Medicine From the Trenches

More updated blog

2011-11-11T10:06:00.004-05:00

I have an more updated version of this blog at Wordpress (Click on the name of this post to access it. Feel free to go over there and read posts that were done later. This site tends to have troubles on a regular basis thus I don't have as many updates here as on the Wordpress site. Both blogs have the same name but the other site is more stable. Enjoy.

It's Medical (or any other professional )School orientation Week

2011-10-22T20:16:00.002-05:00

Well, you made it into medical school! Congratulations on that accomplishment but resist the urge to look around and size up what you believe is the “competition”. Your fellow classmates are far from your competition. They are a bit like your family in the sense that they are going to annoy you in the years to come. Additionally, you have no control over their identities or actions (waste of time to be annoyed with them) and you will come to appreciate them when they bail you out of a struggle or provide “comic relief” when the stress is causing you to lose part of your soul. In short, you inherit a bunch of brothers and sisters who will travel the experience of learning with you. Take a minute to take in the atmosphere, test out the “vibe” that you get from your class and enjoy orientation because it’s one of two periods of time that medical school will be totally enjoyable. Once the classes start, the work begins. Many orientation sessions will have loads of information for you. Just like your coursework, get this stuff mastered! The check in and schedule is most important so that you know where you want to be and when you need to be there. This is also a time when you realize that you need to spring for a 140 db alarm clock without a snooze button for those days that you just can’t hear the one with the buzzer. My “super alarm” was my best friend on many a Monday morning when I was in medical school. By general surgery residency time, I found that I didn’t need it as I woke up when the curtains rustled; surgery makes one a light sleeper by necessity. You also do not want to get into the habit of hitting the snooze because you can’t hit that beeper once you get into practice. In short, you have to get up and get rolling on the first alarm. You will also need comfortable walking shoes and a car with a trunk so that you can carry home all of those books that you will buy, or in my case inherit, from your upper-class advisers. I watched in amazement as a few of my classmates carried what looked like a “house” on their backs as they marched to the underground or bus stop to go home. I drove during orientation week so that I could get my “loot” home comfortably. If you haven’t done so, get all of the stuff that you need for your apartment (crib/loft) arranged and unboxed. I can’t emphasize more, how little time you are going to be spending there during first year but you don’t want to waste any time trying to arrange things when you need to be studying. Orientation week for medical school is also orientation week for getting your housing together too. Make your place as efficient as possible. Stock up on “the noble necessity – bathroom tissue” , soap, deodorant, ramen noodles- can be enjoyed in 2 minutes 1,000 ways, laundry detergent and most important for me, coffee. If you don’t purchase at least a semester’s supply of the necessities, it will be during exam week when you have no time that you discover you have no TP! Don’t let this happen. (If you have a roommate, put a couple of extra rolls under the foot of your bed so that you always have a stash in emergencies). I will also recommend finding a 24-hour gym that is close-by because you never know when you are going to get an hour for a workout. My biggest mistake in medical school was not keeping in good physical condition. Regular aerobic exercise diminishes stress and just makes you a more efficient student. It also helps to keep your immune system polished (drinking tap water helps too) and ready to fend off your classmates’ viruses and bacteria that they will try to share with you. In short, driving yourself to burnout is less likely if you have a means of working out. You don’t have to have an elaborate routine just 30 minutes or so of walking on the treadmill plus 30 or so minutes of weights. I can’t tell you how much weight work helps to keep you focused on your studies. I have learned that fact after many years of teaching and practice. Take the time to pump some iron for your sanity and your health! Go to all of those social events during orientation. They may seem stupid but you want to get to know as many of your fellow students as possible. No, you are not running for office (don’t run for office unless you know you can get your class work mastered well- our class president didn’t do so well first year and being a class officer is pretty meaningless for residency so don’t take a chance on this) but you want to have a cordial/professional relationship with everyone in your class. Resist the urge to form cliques (many students do this by ethnicity) because your future colleagues are going to be every ethnicity and color and you have to work with them. Get along with everyone and have a sunny relationship with everyone even if you have a family at home. You need to be able to work with your classmates on projects and in the future on the wards. It’s also your classmates that will cover for you when you need to take that sick kid to the doctor or leave early because there’s an emergency. Go to those social events and get to know everyone. I met my best friend from medical school while we were in a line to shake hands with the deans at the Deans Reception. We studied together, cried together and graduated together. Even today, I miss those great times that we had even though we thought we were suffering. The greatest thing about my best friend is that she spoke to everyone in the class and worked easily with everyone. She is truly a gifted person. Make sure that your study area at home and at school is well equipped (plenty of note paper, pens and highlighters) and easily accessible. Don’t seek out the darkest and most remote area of the library (too dangerous) and don’t seek out the most popular area ( you won’t get much accomplished). Find a place where you and a couple of like-minded individuals can study (watch each others stuff when you need to use the facilities) and get something accomplished. I found that I studied best at home (not an option if you have a family that will compete for your attention) with a couple of beagles at my feet. My “facilities” were next to my office and any telly, video games and other distractions were far away. Once a week or so, I would do a group study with my study partners but not until I had mastered my work (see my post about my study habits). As I have said in other posts, the two times that you can truly enjoy medical school are during orientation week and during fourth year after you match, unless you haven’t taken Step II. Orientation week is a time to get to know as much as possible about your school, your classmates and how you can set a strategy to navigate the next year or two. I can’t encourage you more strongly to read all of the information in those handouts and student handbooks so that you know where things are and know who to contact if you have trouble. If you are given course syllabi (we were), look though them and get an idea of how much work you are going to need to set aside for your courses. Planning and organization are two of the most important tasks for medical (or any other professional school) success. Have fun for this week because the classes are going live too soon!

Why Students Fail USMLE Step I ( or any of the steps)

2011-09-20T04:51:00.001-05:00

False sense of security Every year no matter what medical school a student attends, some people are going to fail one or more of the USMLE Steps. (This can apply to COMLEX as well.) I have heard students say that because they attend school X that has a 100% pass rate, they are assured of a pass. Well, that pass rate for School X is characteristic of the class that it applies to. If you are not a member of that class, you have no assurances. Your medical school attended is no assurance of anything other than they have met the standards set by the LCME (Liaison Committee for Medical Education) and that if you have passed your coursework, you will be eligible to sit for your USMLE/COMLEX exams. With that being said, you have to understand and be proactive if you want to pass and score well on licensure exams regardless of school attended. In short, passage and performance of these very important exams is dependent on how well you prepare for these exams.

The big mistakes

Many students purchase tons of review books and start memorizing questions, outlines and isolated facts as soon as they have been accepted into medical school. You can’t MEMORIZE your way into a pass on licensure exams because these exam require you to master and understand concepts in basic science, clinical science and application of the concepts to patient care. Just memorizing board review books is not sufficient knowledge to do well. Daily and consistent mastery of your coursework with systematic review will enable you to pass and do well on these exams. Many students discount the importance of their coursework with the idea that they will cram in what they need for a course exam and spend the rest of the time memorizing a board review book for the licensure exam. This is the biggest and more common reason that students fail these licensure exams.

Coursework is too detailed for the boards!

While your coursework is very detailed, your mastery of those details (and I mean thorough mastery) is a very significant strategy for doing well on your licensure exams. It’s the details that enrich your understanding of the basic concepts that will be vital to your eventual practice of medicine. Rather than looking for shortcuts or complaining about the rigor of your curriculum, set a strategy for mastery of your materials and get the job done. As a medical student, I complained about the level of detail in many of my basic science courses but was quite happy when Step I came around and I know those details. The more experience and exposure to the details of concepts, the greater your likelihood of being able to rule out incorrect answers and rule in the correct answer. In short, those coursework details are invaluable both for boards and for “pimp” sessions during clinicals. Get out of the “I will just memorize this” mentality You have to learn to evaluate and synthesize concepts in both basic science and in clinical medical science. For the rest of your career, you will largely be teaching yourself the things that you need to keep a mastery of for your practice. In short, keeping up with medical literature means that you master how to read what you need and how to incorporate what you need into your practice. Where do your learn these tasks? You learn these tasks in mastery of your coursework and in preparation for you licensure boards. Just taking a review course and memorizing everything in a review book will set you up for an unpleasant surprise when you open your score report because you must have a solid knowledge base in order to review for a board exam. Every licensure exam will post a list of key topics to be mastered for the exam. These are never secret and are why books such as First Aid for Step I are so crucial for preparation for USMLE. First Aid contains all of the topics but none of the details. It’s up to you to provide the details and provide the thorough grounding and mastery that you need. This can’t be done in a month-long review course unless you have a solid knowledge base to begin with. The solid mastery that you need can’t be done by memorizing the answers to questions on a website either. While practice questions are good, they are not useful memorization and can give you a false sense of security in the long run. I can’t tell you how many times student Y had told me that they were scoring 70% on Q-Bank but they turn up with a failing score on Step I. Kaplan’s Q-Bank is great but it’s an adjunct to solid study and mastery of basic and clinical science materials (coursework).

Giving Step I more power than it deserves

In today’s world of residency application, residency directors know how much time you as a student have to master the knowledge needed for the USMLE/COMLEX steps. While there will be people who want to take a “year off” to study for Step I in order to insure a high score, this is not a sound practice. Residency directors do not want to see students taking “time off” from medical school unless you are pursuing a higher degree such as MPH or a Ph.D. Utilize the time that you are given wisely and efficiently and you will be able to review completely and comprehensively for this exam within that alloted study time. Residency directors also realize that IMGs also often have years off to study for the USMLE Steps and take that into consideration when evaluating scores from these individuals. This is why IMGs are usually required to post higher scores on Step I than their AMG counterparts in order to be competitive for a residency program. Another caveat for IMGs is do not attempt any of the USMLE Steps if your language is not up to the standards of that exam. You can’t blame lack of language understanding as a reason for failure of Step I. Residency slots are more competitive (more AMGs now) and failure of any steps can be very problematic for an IMG. In short, if you are an IMG reading this, prepare well and be prepared to pass any of the USMLE Steps with at least a two digit score of 85 (even for medicine programs) on one try. Does this mean your are doomed if you are and IMG and you fail? No, but you have greatly decreased your chances of match in the USA and may have shut yourself out of many residency programs (other than prelim slots) because of the sheer numbers of US grads and the lack of categorical slots.

Passing USMLE

•Your first stop is the USMLE website. On that site, you will find the subject lists for what’s covered on the exam and the characteristics of that exam. •Your next step is to thoroughly master your coursework with regular and systematic study (if you haven’t done this in the past, start now). •Obtain the most recent copy of First Aid for USMLE (whatever step) and read it from cover to cover so that you know what tools are available for the particular exam you are taking. •Look into a commercial prep course only if you are certain that your knowledge base is poor or that you know you need plenty of feedback and practice with USMLE-type questions (most US grads don’t need this). •Don’t tell yourself that you can’t get into residency if you don’t get a two-digit score of 99. Chances are, you are not going to get that score even if you follow the exact study schedule of someone who did. •You have to figure out what works best for you, in terms of mastery and review so that you can prepare your best. •If the worst happens and you fail, look at my post “Failing USMLE and how to get beyond it” for strategies for passing on a retry. Remember, USMLE is not the MCAT. You don’t get “do-overs” for this exam unless you fail. If you fail, you have significantly made yourself less competitive but you are not out of the residency game. You will need to make sure you don’t fail any other steps and you need to accentuate other things (excellent coursework for one thing) in your residency application. Plenty of US grads who have failed Step I but gone on to have a strong third year have managed to match into very strong university-based residency programs. In short pick up and keep moving forward. Also keep in mind that wishing and hoping for a pass/high score isn’t going to make it so. Plot a strategy and get busy doing what you need to get the job done. Don’t discount the value of consistent strong coursework performance but realize that you have to have mastery of coursework before you can “review” for boards. Board review is not the same as study for your medical school courses. Good luck!

Standardized Tests

2011-03-29T11:05:00.001-05:00

Standardized Tests
Let’s face it, standardized tests are a “fact of life” if you attend public school in the United States, anticipate attending college/university in the United States, want to enter professional school in the United States and practice any profession (especially medicine) in the United States. These tests are required for medical licensure in every state and most medical colleges require applicants take and score well on the Medical College Admissions Test (MCAT) for admission. These standardized tests need not engender any great “fear” in the test-takers as they are simply tests that are administered (and scored) under some kind of standard conditions. They are tests and like any test, they have characteristics that need to be examined in terms of preparing yourself. Just as you prepare for a course examination, you need to prepare for any type of standardized test that you need to take and score well upon.

Getting your “head” in the game
If you constantly tell yourself that your “bad at” standardized tests, you will fulfill your prediction. You can’t give any standardized test any more deference than you would give any examination in your academic history. Every test tries to measure something and that “something” is what you have to maximize your knowledge of , in order to do well on any test. In short, you survey,prepare, and master the knowledge that is tested on any test under any conditions. Every standardized test has a description which needs to be read, analyzed and used as a guide in your preparation for taking the test. If you decide ahead of time, that you can’t do well on a particular test, you have made your preparation that much more difficult. Any standardized test can be prepared for, taken and mastered by anyone who diligently and systematically prepares for the test.

Timing is everything
Once you know that you have a standardized test (in addition to your course exams), get a description of what will be covered on that particular exam. In the case of the MCAT, there are detailed descriptions of the subject matter for each section of that exam. Download those descriptions when you start your pre-medical preparation (when you start college if you know that you want to enter medical school) and pay close attention to your coursework in order to make sure that you have adequate coursework to cover the subject matter of the MCAT. Make sure that after you download a test description, prepare for the test according to the description and not according to how you prepare for other tests.

If a description says that a test requires that you apply knowledge from a specific knowledge base, simply memorizing that knowledge base is not going to prepare you for that test. In addition to thoroughly mastering the knowledge base, you have to be sure that you master the application of that knowledge base to problem solving. Standardized tests such as USMLE, MCAT and COMLEX have such broad knowledge bases that you can’t hope to memorize every factoid in those bases. You must master the prerequisite coursework (not memorize/cram for each exam) and build upon each courses within that knowledge base in order to apply that knowledge to problem solving.

What about problem-solving?
For many people, anxiety and poor reading skills can destroy any chance that they had of actually answering each question as it comes. If you are thoroughly familiar with the manner in which each test will construct problems, you can greatly decrease your anxiety level and improve your experience and reading skills. You can find reading skills courses (critical reading and analysis) that will hone your ability to pick out the significant parts of any argument, problem, question or survey that will help you extract the information that you need to answer a question about that argument, problem, question or survey. You can practice self-questioning as you read textbooks, newspapers, position papers and peer-journals to learn how to extract pertinent information for problem-solving. Turning off the television and getting away from the social media sites on the computer can free up valuable time for reading and analysis of a wide-variety of journal, texts and other learning materials. In short, you can read and analyze something every day that will hone your reading skills.

Get away from the Powerpoint!
Just attempting to study anything from a Powerpoint summary can be problematic. Professors use Powerpoint to summarize facts which may not be detailed enough for through mastery of any subject matter. If there has been assigned reading from a textbook, make sure that you have completely and critically covered the material. As you are reading, be sure that you look up any unfamiliar words and constantly question yourself in terms of knowledge mastery. If you have a Powerpoint lecture summary, be sure that you thoroughly cover and understand (in the textbook) the material that has been outlined in the Powerpoint lecture. Only after you have completely summarized and learn complete concepts, can you utilize a review-type book for reinforcement of learning. Trying to learn the basics from a review book is not going to give you the in-depth knowledge base that you can use to apply to standardized test problem-solving.

Review courses
A review course is worthwhile if you have a thorough mastery of your coursework in the first place. Just like review books, Powerpoint reviews and other review-type materials, you can successfully utilize these things unless you have had a through underlying knowledge base in the first place. If you are a medical student and you anticipate taking any of the USMLE/COMLEX step exams for medical licensure, you need to have thoroughly mastered your coursework before you begin any type of review course for these exams. This is why review courses are most valuable as soon as you have completed the prerequisite coursework that will be covered in the review. These review courses are not a substitute for thorough mastery of coursework. This same strategy works for pre-med students in that purchasing and taking a review course before you have completed the pre-med courses is largely a waste of time and money.

Finally…
Most standardized tests have a recommended study time frame. If you can’t find this study time frame, make sure that you ask people who have taken (and done well) on a standardized test, how much time they put in. Also be sure to ask a number of people (not just one person) so that you can get an average. Keep the following in mind:

•Don’t tell yourself that you are “bad” at standardized tests because you add to the difficulty of any prep for a particular exam.
•Don’t expect to memorize a review book and be prepared for a particular test or exam.
•Don’t tell yourself that your “whole career” depends on one exam as no exam can totally determine your vocational destiny(influence yes but not totally determine).
•Regular if not daily systematic preparation for the major standardized tests is a sound strategy. Your daily prep can be as simple as practicing your reading comprehension.

Match Week (and the scramble)

2011-03-11T08:36:00.002-05:00

Most fourth-year medical students are eagerly awaiting noon on Monday of Match week to find out if they matched. If they didn't match or matched to a second-year position but not first-year, these is a process called the "Scramble" that they will be taking part in if they do not have a PGY-1 position. The majority of US medical school seniors will match if the process has worked well. By process, I mean that they have ranked places that interviewed them and the places that interviewed them, have ranked them. The computer attempts to match the applicants highest choice with the place that ranked them the highest. Most of the time, the process works out fine but sometimes it doesn't and an applicant will know on Monday if they need to actively look for a position.

There will be a scramble list published on noon of Tuesday that will include programs that didn't fill all of their PGY-1 slots. Some programs will elect to offer positions to people who applied outside of the match. This means that you need to be aware that many programs that you might have applied to will fill from people who have either applied and are eligible to accept a position outside of the match which means that those programs may show open slots but those slots are filled (usually by FMGs who have already signed contracts). The only way to find out that a slot on the scramble list is truly open is to call the program on scramble day and find an open slot. You also need to have your application materials ready to fax/send by e-mail thus you would need to be next to a fax machine or have your materials in electronic form and ready to send if requested.

On scramble day, programs that didn't fill (and want to fill) will have the program director and a couple of faculty, reviewing applications received and ready to make an offer of a contract on the spot. This is why is makes sense to be at your medical school (most schools will have a scramble set up) and have your materials ready to send. On scramble day, some programs that show openings will be literally deluged by unsolicited faxed applications from commercial services for applicants who didn't match. Most of those folks will receive an e-mail that stated that the program will not review unsolicited applications. Some unmatched applicants will spend literally hundreds of dollars with commercial services that will sent applications but be aware that unless you have spoken to a program, they are not likely to review your application.

Many very high-powered and excellent residency programs may not fill for a variety of reasons from clerical errors to not interviewing enough candidates. Every year some places that have national reputations may have openings. Most years, the preliminary spots at many programs will not fill completely because not enough people applied for those slots. This means that a US grad (who is at their medical school on scramble day) stands a good chance of getting into one of those unfilled preliminary spots. Many programs will call deans looking for unmatched candidates for slots which is a great way to snag an open position at a top-ranked program.

The scramble situation is very stressful for those who go through it but the worst case scenario is that an applicant spends one year in a preliminary position and enters the match as stronger candidate the next year having done one year of excellent work. If a candidate accepts a preliminary position, they have to work very hard to be sure that they get good letters and good experience to take into the Match for the next year. Most good program directors will help a preliminary candidate find a categorical position for the next year if they have done an outstanding job with the preliminary year. In short, doing a prelim year isn't the end of the world and can provide valuable time for making good contacts with programs that interest you for the next year. If you know that you will be going into the Match after a preliminary year, be prepared to make sure that your letters and application materials are sent to your medical school for uploading as early as possible. You don't want to risk not matching a second time.

My other piece of advice for anyone reading this post who receives a letter on Monday that says they are going to scramble, is that you need to immediately contact your dean of students at your medical school. You don't want to try to go through the scramble from a remote location without having the advantage of experienced people to help you through this. You need to learn as much about the process as you can in the 24 hours before the scramble starts. Positions, even the preliminary ones, will go very quickly. If you find that you don't have a PGY-1 position after the first 24 hours of the scramble, you are going to need to contact your medical school to let them know. Again, programs that don't fill (or who have open positions) will contact the deans at medical schools looking for candidates first. You want to be sure to let your school administration know that you are looking for a job.

To those that match and don't make the mistake of thinking that you are inferior because you didn't get your first or second choice. If you didn't have to scramble, you are definitely more fortunate that those who end up with no position for the next year. If you ranked the places that you would accept a job and you received a position, you are ready to start your residency. No one who goes through the scramble would ever say that the situation is wonderful but it's part of the experience and with that experience comes wisdom.

Getting the Schoolwork Done.

2011-01-19T08:37:00.001-05:00

This is a re-post of some material from a previous post. Some of my current students have asked about this subject matter and thus, the repost.

"The Thrill of Victory or the Agony of Defeat"
The Drama of Human Competition as the opening lines of ABCs "Wide World of Sports" promised. By now, many students have had their first blocks 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.

What if I fail a whole course, like Biochemistry?
The consequences of failing an entire course in medical school are largely school-dependent. Some schools will want you to retake only the material that you did not pass while others will have you go through an entire summer remediation course. In any event, look at your remediation/retesting as an opportunity to hone this material well. You definitely want a strong knowledge base for your upcoming classes and you will have made some steps toward review in terms of preparation for USMLE. In this light, having to retake or remediate is not totally the worst situation that you can find yourself going through.

Plunge into your review with total concentration on the subject at hand. If you have one course or one area of subject matter, this is easier than if you have multiple subjects to remediate. Your only resolve in this situation is to not miss this golden opportunity to thoroughly master this material. You are not a "lesser person" because you need a second review and keep in mind, that you are reviewing at this point. In most cases, you have learned the material on the first shot but this review gives you insight into the material that you likely previously missed.

I am always more concerned about those students who "barely" passed than the students who failed and are re-mediating. In most cases, the student who re-mediates does not carry a knowledge gap forward while the student who barely passed likely has gaps in their knowledge base. It is those who barely pass that will need the most intensive review and preparation for board examinations. I always encourage students who scored below an 80% to study for and take any optional shelf subject exams if offered by their school. These shelf exams can pinpoint knowledge gaps that can be filled in before taking Step I.

Class Attendance - Is this time well spent for me?
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".

Wasting time and less efficient practices
I 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 (or 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.

Striking a Balance
Finally, one key aspect of medical school, residency and the eventual practice of medicine is that you will have to constantly "strike a balance" between study, personal life and professional obligations. The first semester of medical school will definitely test your resolve to keep working away at your studies until you get them mastered but this should not be at the cost of your personal integrity or sanity. Try to find ways of incorporating some stress relief (physical exercise) and socialization (away from your classmates) into your life. Nothing, including the practice of medicine is one-dimensional and there needs to be balance.

For example, if you are studying in the library and know that you won't make it to the gym, try to walk up at least 8 floors of steps on the days that you don't get to the gym. Take 10 minutes and take a brisk walk around the corridors to get your brain relaxed before you keep "grinding" away at your study materials. Study and pace at the same time while reciting the material to yourself in your own words. Try making some study-drill tapes and drill yourself while you are on the elliptical trainer/treadmill in the gym. Finally, picture that professor's head when you are doing your bicep curls or on the fly machine and pound things out. You will be more relaxed, less stressed and more efficient in your studies. In addition, you can enjoy eating without worrying about gaining weight.

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.

Medical Reading

2011-01-08T16:53:00.001-05:00

Now that I am out of medical school and residency, keeping up with my reading and study has become a major goal for me. I usually keep a weekly log of articles and book chapters that I have completed. For instance, I have been reviewing the medical treatment of esophageal disorders today. In addition to my last evening's read of the appropriate chapter in the latest edition of Sabiston's, I tend to keep my medical reading as up to date as I can. While Sabiston's is a great general surgery resource, I do find that reading in Harrison's Principles of Internal Medicine provides an in-depth review of physiology and pharmacology. I also tend to read from 20 to 30 journal weekly in addition to my textbook reading. The question would be, "Why do all of this work now that I am out of school?"

As a professor, I need to keep ahead of the textbooks on many topics. Human beings are incredibly complex entities that regularly present their physicians with diagnostic dilemmas. I have found over the years, that my diagnostic skills have greatly improved with both experience and reading. I find myself looking forward to my time with the "pulps of medicine" as being able to constantly learn and assimilate information is crucial to me in navigating those diagnostic dilemmas. There is always some new theory or different way of looking at a disease entity that I find interesting. Since medical school, I could never get enough of New England Journal of Medicine or Nature Medicine as a student. One of my internal medicine professors encouraged us to read journal (as much as we could between coursework study) in order to develop an early grasp of the language of medicine. It turns out that old habits die slowly for me which is a good thing in terms of journal reading.

Most weeks I will have an undergraduate student or two drop by my office to discuss entry into medical school. One of the first things that I encourage for these folks (not New England Journal of Medicine or Nature Medicine; these are better utilized in medical school) but just to read a variety of types of literature (scientific and non-scientific) from a scholarly perspective. Regular critical reading encourages regular critical thinking which is integral to the practice of good medicine. There will be plenty of opportunities to read medical journals in medical schools (great libraries online and on site) but training your mind to handle different types of writing is a good skill to have as an undergraduate. Most undergraduate college libraries have a wealth of well-written scholarly journals that are great to keep up with.

In addition to reading the scholarly journals, pick up a couple of newspapers (New York Times, Richmond Times-Dispatch, Wall Street Journal) and read the editorial pages. Most editorials are short and very well-written in the three newspapers that I have listed in the last sentence. The New York Times and Richmond Times-Dispatch are both published online for easy access. In addition to the editorials, compare how major front-page news stories are handled. Do both papers have the same stories "above the fold" on the front page? Look at your local newspaper, even if are from a smaller locale such as the Falls Church News-Press or the Marin Independent Journal to see how your local events are covered and discussed. The Marin Independent Journal is one of my favorite reads along with the San Francisco Chronicle as both newspapers provide a welcome change for my brain as I move through my weekly medical journal reading.

Being able to read efficiently and comprehensively is a habit that can be honed by regular practice. Just as walking/jogging on the treadmill or listening to my favorite recording artist is welcome change from my daily work routine, my journal and newspaper reading are welcome habits that I enjoy. It's great to utilize the social media such as tweeting and blogging but the best reads are still those that explore a subject (medical or otherwise) from a comprehensive standpoint. You won't get a comprehensive view of a topic from Twitter but you will get great opinions from that website. Blogs are also great for both opinion and information but force yourself to think creatively and comprehensively even when you are reading your scholarly journals.

Many people will say that they just don't have the time to do much reading outside of work. I generally find that I can make use of my "down time" when I am waiting for a patient or something else. I always have an article or two in my lab coat pocket for those stray minutes. I do find that I have to "mark my progress" so that I am not reading the same sections over and over. I have a list of my regular journals and then I have the journals that I scan sporadically for a change of pace. Most of the time, if a subject is getting loads of press in one journal, it's getting mention is many journals. Knowing what's "hot" is just one of the great aspects of regular journal reading. I also find that when the Nobel Prize winners are announced, I generally have some knowledge of their work from my journal reading.

If one keeps in mind that it takes approximately 2 to 5 years for something to become established enough in the journals to become published in a textbook, then the utility of regular medical journal reading for the physician becomes important. While I make my yearly read of Sabiston's, Cameron and Greenfield, I find that my journal reading enriches those topics that I encounter in the text. Regular reading when I was a resident, made study for the "in-service" exams much easier than some of my colleagues would find. Residency is the ultimate learning experience because one is learning both from a practical standpoint and from a scholarly standpoint which is the only time in training that you will have both types of learning so intimately connected. Journal reading during residency is an integral part of the process.

If you hang around me for any length of time, you will find that I have a journal article or book chapter in my hand/pocket most of the time. Over the holidays when I was traveling thorough some of the wonderful airports of New York and Chicago, I was able to get my journal and textbook reading off to a good start. Since there is so much waiting involved with air travel, having a good read is a necessity. I keep my Amazon Kindle jammed with .pdf copies of articles and chapters for airplane reading in addition to my paper copies of one or two things (they tell you to turn off all electronics until 10,000 feet). In short, I always have something to read.

I can't (and maybe don't want) to get into medical school

2011-01-06T12:02:00.001-05:00

Medical school has been the ultimate dream profession for many people (or their parents) for many years. In some cultures in this country, only four professions exist; medicine, law, dentistry and engineering. If a person didn't get into one of those professions, then they were seen as a professional failure in the eyes of their parents. For some unfortunate students, not only are they not going to enter one of those professions, they are not interested in the subject matter or practice of one of those four professions. Almost weekly, a parent will enter my office stating that they will "disown" their child if I don't "let" them into medical school. Many of these students will say that they have little interest in the sciences (unacceptable to the parents who are paying tuition bills) and even less interest in medicine. When questioned closely, many of these undergraduates will reveal that their parents would never "allow" them to seek other professions and that medical school is the only choice.

In today's climate of grade inflation and very high tuition costs, the sheer magnitude of maintaining the medical school matriculant average undergraduate GPA of 3.7 is a burden that many are not able to carry. For some students, a very poor freshman year can mean the end of being able to get that uGPA into the average range let alone a competitive range. For others who might enter university poorly prepared in math and science because of attendance in a poor secondary school, getting their academics off to a strong start and keeping them there may be problematic. Along those lines, I encountered a young Latina woman who was valedictorian of her secondary school class (inner city). While she had maintained a very strong academic record at her secondary school, the quality of instruction was extremely poor.She would be the first in her family of very hard-working immigrants whose dream was for her to become a physician so that she could come back to the neighborhood for practice. This was a huge burden for this young lady who was determined not to let her family down. She came to our university will poor study skills, poor reading skills and deficient math skills. He school had no IB or AP courses and offered few academic courses that would prepare her for becoming a biology major in preparation for medical school.

During her first semester, she proceeded to achieve a 2.0 GPA which lead to much discouragement and frustration. When she came to my office for assistance (she was in danger of losing her full-ride scholarship), I immediately contacted the school administration to allow her to shore up her academic skills before proceeding to lose her scholarship. She had determination and discipline but lacked guidance in being able to navigate the academic world (common in many students who are the first to enter higher education). She was allowed to spend the next semester working on basic writing, reading and math skills. Fortunately, she has and always had very strong problem-solving skills which is why she sought assistance when her performance was working in the first place. While she hadn't failed any courses, those "C" grades would not be enough for medical school.

In the next semester, she excelled in her academic remediation. She was able to make great strides and shore up her deficiencies. She learned to put her drive and determination into her studies but she also learned that she was not particularly interested in science and math. Over the course of the remediation semester and summer, she became interested in psychology which she pursued with vigor over the next fall semester earning a 4.0 GPA for that semester. Her reading and writing skills were excellent along with a very strong interest in studying her population in terms of achievement. In short, her interests lay not in medicine but in helping her community and those in her community to be able to achieve in the academic world. She went on to earn a degree in psychology and entered graduate school to earn a Ph.D in psychology. While her family was not happy, she continues to research, study and write articles which have been the cornerstone for closing the gap in Latino achievement in academia. Her most recent achievement was tenure in her department at the state university where she teaches. In short, if medical school is not your dream, all of the drive and push from your parents and family will not provide what you need to get into medical school and practice well in medicine.

Another undergraduate student had come from a family where his mother and father were both physicians. He freshman and sophomore years had ended up netting a uGPA of 2.5. He loved the university life and spent many hours with his fraternity brothers working on extracurricular activities. His father brought him to my office so that I could "talk some sense into him" before he destroyed his future. After a tumultuous weekend with his parents, this student returned to my office resigned to "dig in" and get his work done. As we calculated what he would need to do in order to raise that uGPA, he said that he just didn't have that kind of drive. He said that he would "do his best" because he didn't want to let his parents down. He said that it didn't help that his brother was in medical school and was very critical of his undergraduate performance.

Over the next couple of semesters, his academic performance improved but not enough for him to get his cumulative uGPA above 3.2. He became more and more discouraged. At one meeting, he expressed interest in looking at other careers besides medicine. He decided that he would look into becoming a physician assistant which didn't take as long but would enable him to have a career in health care. While his family wasn't pleased with his choice, after making the decision not to pursue medicine, he was better grounded and had more direction. He finished his undergraduate degree in biology with a cumulative GPA of 3.5 and entered a masters program in physician assistant studies. Today, he loves his job and loves that he can travel while practicing his craft.

I do not advocate trying to become a physician assistant because you can't get into medical school but it is a profession that is worth exploring if you have a strong interest in the practice of medicine but can't spend the minimum of 7 years above undergraduate school in order to enter the profession of medicine. In terms of love of their work, physician assistants have the highest job satisfaction in healthcare and earn a very strong salary which is quite appealing for people who have families whose needs won't allow an additional four years out of the workforce. In terms of academics, the same strong academic skills in reading, writing and math are needed by a PA that would be needed by a physician. I would also caution that the academic achievement to become a physician assistant is just a bit lower than what is needed for medical school with the average uGPA of the PA class that entered our state university being 3.6. In short, getting into PA school isn't that much easier than medical school but the training is shorter which is appealing to many people who have an interest in medicine but do not want the long training period.

Other careers worth looking at are anesthesia assistant which is a physician assistant who does anesthesia and perfusionist. The training programs for this profession are quite competitive but as with PA, the job satisfaction is very high. Anesthesia assistants work with anesthesiologists and provide anesthesia care in a variety of settings. This particular profession seems to attract people who have no interest in nursing and going the CRNA route but have a strong interest in working the operating room environment with anesthesia. The perfusionist runs the heart-lung machine (and extra-corporeal membrane oxygenator ECMO) which is used during cardiac surgeries such as coronary artery bypass grafting or valve replacement. If ECMO is used in a nursery, it is the perfusionist that maintains that machine too. Perfusion technologists earn a very high salary and enjoy very good job security. There are a limited number of perfusion technology schools (and training slots) in this country but for many people who find that medicine is not for them, perfusion technology can be a very good healthcare profession.

For the undergraduate who has applied to medical school more than twice, the chances of getting into medical school will not increase and are likely to decrease. Just reapplying is not enough to achieve admission as whatever kept you out in the first place has to be corrected and upgraded. Every year, the medical school matriculant average goes up along with the matriculant average score for the Medical College Admissions Test (MCAT). To continue trying to raise an otherwise undistinguished uGPA (graduate doesn't count) with one class here and there is a long and expensive process. One poor year as an undergraduate can be overcome but multiple drops and repeats of the pre-med courses (especially organic chemistry, calculus and general physics) do not bode well for medical school admission success. There are just too many medical school applicants out there who have completed their studies without drops and repeats. There are also many applicants who have very competitive uGPA/MCAT scores who will be admitted ahead of those who have a less distinguished record. No amount of research or extra curricular activities will off set a poor uGPA; nor will a high MCAT score do the same. In short, the admission process into medical school is long, unforgiving and quite expensive with little guarantee of success in any given year.

Multiple retakes of the MCAT with final scores less than 30 are going to be problematic for many who desire to enter medical school. One retake of the MCAT if you were ill (or severely distracted) is warrented but several mediocre scores with no or a 1 point improvement will no work will. Not releasing scores on more than one retake with mediocre scores is not a sound practice either. Students who have a less-than-distinguished academic record can't expect to "ace" the MCAT and get into medical school. This is why it takes both strong academic achievement and a strong MCAT in order to achieve admission success. Medical schools want to accept students who show evidence (by undergraduate achievement and scores on the MCAT) that they are able to master a very competitive curriculum. It is far from a certaintly that once you are accepted into medical school, that graduation will happen. In short, medical school is a very strong academic challenge that many of the strongest students find daunting at first. It takes a consistent and high level of scholarship to achieve the performance in medical school that is needed to become a physician. Also keep in mind that USMLE (United States Medicial Licensing Exam) steps are not retaken which means that multiple retakes of exams such as the MCAT do not bode well for USMLE success.

If you find that you are not successful in gaining admission into medical school, you need to do an objective and thorough inventory of why your application didn't work. After your inventory, you need to figure out how and what you can upgrade that will ensure successful admission. If you are on a waitlist, I strongly advise getting the application together for reapplication for the next year as soon as possible with updates and reworking of things such as your personal statement. In the intervening time, upgrade anything that is within your power to upgrade and apply early (exceed every deadline). If you didn't get any interviews or waitlist, then your application need a thorough upgrade (might take more than one year). If you can't upgrade your uGPA (t0 a competitive range) significantly in one or two years, you likely either need to look into a Special Masters Program for credential enhancement (if you enter one of these you need to do well) or look into another profession. Getting a Masters of Public Health (MPH) isn't going to offset a poor uGPA or MCAT nor is entering a Ph.D program as most medical schools require that you complete any graduate work that you start.

Study Skills Part V

2011-01-04T15:17:00.001-05:00

Introduction

This is the fifth part of a series that I have been working on since starting this blog. From time to time, I will keep adding to this material as much as possible. For this installment, I want to "get into your head" for you to get the best results of your work. Previously, I have discussed things like taking notes and organization. You need to keep your studies as organized as possible. If you are working and trying to attend school, your organization skills have to be outstanding.

Adjust your thinking for best results

As you move into the next semester (or next class /group of classes), start working on getting your thought patterns together. There is no class taught at any university or college that cannot be mastered by any student who is willing to put in the time needed to master the material presented. As I have stated in other posts about study skills, consistent and regular study will get the best results for most students. It is extremely rare for an individual to be able to sit down the night before and exam and expect to master everything that is up for testing. If your fellow classmates are telling you that the "last-minute cram" gets the best results for them ("I always get an A when I only look at the material the night before the test."), they are likely lying to you about the time that they are putting in. For some people, lying about the amount of time needed for study allows them to believe that they have a superior mind over the rest of us. Congratulate them and keep to your plan to get your work mastered. What another student does (or does not do) is meaningless in terms of what you need to do for complete mastery of your studies. Keep in your thoughts that the "superior mind" is the one that get the best results period and retains the information over the long term not the last minute crammer who loses the knowledge because it is never in their long term memory.

Rate My Professor and other review sites

Going to sites like "Rate My Professor" might seem like a great idea but remember that most people who post to those "review" sites tend to be the folks who had problems in courses. Not all of the problems that a student might have is due to the professor. Most professors do not gain "academic points" for making sure that most of the students in their courses earn grades of C or less. Most professors do not gain "academic points" for making sure that most of the students earn grades of A either. In terms of teaching, the professor is most likely the most redundant element in your learning experience. A professor should know their subject matter and be able to point students in the right direction for the student to earn their best grade. It is counter-productive to learning at the college level, to expect that your professor is your sole resource in any subject matter. While your professor should be able to help you navigate a subject, you need to have the confidence that even if the professor wasn't there, you could master the subject material. In short, don't attempt to develop any personal reactions to or concerning your professor. Utilize a professor for what they do best which is, being a good resource for things about a subject that you, the student, might need. A professor doesn't care if you "like them" or you "don't like them". Since most professors are tenured, a student's likes or dislikes do not figure in the learning equation one way or another.

Since the professor is essentially a redundant element in your learning; this means that your actual "learning" isfar more dependent upon you being able to incorporate the information into your knowledege base so that you may be able to utilize it. The professor, while being a resource, it not your sole resource or the ultimate resource that will enable you to make the most of a class. If you anticipate application to professional school such as medicine or dentistry, you have to master the building of a solid knowledge base that you can tap for the situations that will present for you in the future such as your Medical College Admissions Test or the Dental Admissions test where you will be asked to apply your knowledge base to any of a variety of problem situations. Being able to problem-solve is a characteristic of an individual and not of any one particular professor or school for that matter. Learn to garner as much knowledge as you can in any particular class with the realization that any professor can provide what you need.

"Weed-out Courses"

I don't know how many times I have head the phrase, Physical Chemistry is the "weed-out" course for a chemistry major or Organic Chemistry is the "weed-out" course for a pre-med student. I have taken both of these courses and frankly, found Physical Chemistry more enjoyable than Organic Chemistry but both were the subject matter of my major which I mastered throughly. I refused to give any course, or subject matter, more deference then it deserved. Physical Chemistry was a great course that allowed me to use my math tools to describe the physical aspects of chemistry and chemical reactions. Organic Chemistry was a course that taught me much about developing synthetic themes and the mastery of carbon-based chemistry (useful for understanding Pharmacology). Since I took these courses as a sophomore in university, I just packed the knowledge from these two courses into my chemistry knowledge base.

As people around me spent hours lamenting how "rough" these two courses would be, I spent most of my time figuring out the best strategy to do well in these courses because I needed the information presented there. There was only one section of Physical Chemistry at my university that was taught by two professors fall and spring semester. In short, I didn't have a choice in terms of professor "shopping" if I wanted to take this course. I did make sure that I had the math background for mastery of the Physical Chemistry course material (I was taking Applied Differential Equations at the same time) and I did make sure that I thoroughly mastered the material presented both in problem-solving and in lecture. In the end, Physical Chemistry was a very enjoyable course that allowed me to apply physics to chemistry and solve problems. The course took plenty of time, especially the lab write-ups, but the course challenged me on many levels which was great. In short, don't have any preconceived notions that a course is going to be "so hard" that you can't perform well. If you keep telling yourself that the course is too difficult, the course will become too difficult.

Your Less than Helpful Classmates

Interaction with your classmate can be intellectually stimulating and provide an important and crucial means to solidifying your mastery of a course especially the science courses. While a great interaction experience is wonderful, in reality, you will encouter classmates (lab partners) who will be happy to allow you to do a bulk of the work while they receive an equal share of the grade for a collaborative project. You, will have to master the skills necessary to get the most out of the project and your less than "helpful" classmate. First of all, you grade depends on your finding a balance that will enable you to get the strongest grade. If your grade is important to you, then you do what is necessary and worry about the "sharing" of project duties later. This means that when you encounter a partner who isn't will to pull an equal share, you don't have all semester to try to "cajole" this person into being a good partner. Sometimes, you have to deal with the "hand" or in this case, the "partner" as best you can so that your work doesn't suffer. Don't let resentment for your partner's lack of participation cause you not to get the best grade possible. In short, sometimes you have to "take up the slack" and do what you know will provide the best grade. It's not "fair" but it get the job done. Just don't let yourself be partnered with the "slacker" under any other circumstances. You can also state clearly why you won't work with that person again unless there are no alternatives.

It's always important for you to keep your grade and work in the forefront of you efforts. I will state over and over for emphasis, "what another student does or does not do is meaningless in terms of your grade." In short, you have to look out for yourself and keep your work at the highest level. As a professor, when I assign group projects, it's very easy for me to see who is the leader, the follower(s) and the slacker(s). Most people do not change their style over the course of one project or one semester. As an educator, I also make sure that every person in a group project is not so dependent on the others in the group that one person who has worked strong and hard ends up "making up for" or "carrying" the slackers. Again, keep your work ethic and don't worry about others unless they are impeding your progress to the point that you can't learn. Under that situation, you need to write down specific instances of the impedements and present them to the professor after you have presented them to the person who is impeding you. Some people are so self-absorbed, that they don't realize they are not pulling their share or that they have become a weak link in an otherwise strong group.

Group Study

Having a study group is a great strategy for both undergraduate or professional school. Some things that make group study efficient are the following:

Keep the group to 4 or less people. Large groups become unmanagable. If you want to collaborate with another study group of 4 or less, then do so but keep your primary group small.
Have a study plan (agenda) for the amount of time that you will spend together. This should be no more than one week's worth of materials. Don't try to do a whole test's worth of review in one study group meeting. It's counter productive to full mastery.
Do your individual study before you work with a group. While other folks can give you a different insight, they can't be the sole source of your learning.
Get away from school if possible. A Starbuck Coffee Shop meeting or group study room in the library is good so that other folks in the class won't disturb your group study.
Distractions and interruptions abound when you and the group have an exam in the near future. Try to find a method of keeping the socialization to a minimum while keeping the study to a maximum. Sometimes having one person write down a summary of a discussion or questions that the group can't answer is a good strategy for getting back on track.

If you get hungry/thirsty and you find that the group is getting "off track", stop while you refresh so that you can get back to working more efficiently. Sometimes, walking around the room or getting a drink can help to clear your mind.
If you are having trouble with some of the material, get your questions stated and answered before you meet with your group. If some of your group members have a stronger grasp of the material than yourself, don't worry about it. This is why group study works well.

Finally, remember that you are the ultimate person who is in charge of your learning. Your coursework is your job and you want to be the ultimate professional on the job at hand. When you sit down to study, give it your best effort. If you are tired and distracted, try to get rid of the distractions, rest a bit and then move to your studies. I can tell you that as a medical student, resident and practicing physician, I had and have to study when I am sick, tired and distracted. I have learned to hone in on what I need to master while tuning out the rest. Learn to master study when you are tired and learn to refresh yourself often. Sometimes your brain just needs a break which means that you divide your study periods into shorter bursts rather than one long session if you are tired.

Strategies for Non-traditonal success

2010-12-09T11:41:00.000-05:00

Being Non-traditional
A non-traditional applicant generally hasn't taken the "traditional" route to medical school application (graduation from 4-year university with application in junior year). There is no particular "higher status" that applying to medical school as a non-traditional applicant will confer. In short, you are in competition with every applicant that applies to the schools that you apply to. The same criteria also applies to your undergraduate experiences and preparation for medical school. In general, many non-traditional applicants are older but this is not always the case. Sometimes an applicant is non-traditional because they didn't attend primary or secondary school in this country but completed university here, worked a couple of years and then applied to medical school in their early 20's. Certainly, this type of applicant is not traditional in any sense of the word but they would not be an "older" applicant as many nontraditional applicants would be.

While there is no age "limit" in terms of admission into medical school, certainly an older applicant needs to be sure that they are physically able to get through four demanding years of coursework and residency which is minimally three years. In today's world, many folks who are in their 40s and 50s are in excellent physical condition and would have no problems with medical school, residency and practice. In my own case, I was over 40 when I applied to medical school and had no problems with school or practice. I was heavily involved in middle-distance running and tended to meet several older classmates on the running track. In short, the older students (a couple of service academy grads, a former olympic gymnast) in my medical school tended to be in excellent physical condition. While many folks in their 20s and 30s would look at those folks who are in the 40s and 50s as "taking up a seat", in general, the older applicants to medical school have no illusions that they need to be in good physical condition while the 20-somethings are often not as physically fit. If you are older, you should make physical conditioning a priority without question.

Keeping in good physical condition (at least 30-60 minutes of meaningful aerobic activity) can spell success in your academics. Physical activity is excellent for stress release and relief along with allowing one to foster discipline in life. It is the consistent and disciplined students who tend to perform best in medicine and in practice. Being able to work long hours (almost any specialty will demand this) will be much easier and better if you are in good shape. I can tell you that in residency, tennis, soccer and basketball along with running stairs became my means of keeping my head clear and my back strong. I played varsity tennis in college and continue to enjoy this activity well into practice. Having a physical activity or sport that can give you a good workout along with some social connections can be excellent. Even golf is good as long as you walk the course (I know the cart is fun but walk the course). Twenty minutes of brisk walk on a treadmill a couple of times per day (listen to the audio summaries of your coursework) can be good for your physical condition and good for your head.

Turning disadvantage into an advantage.
Remove the thought that because you are a non-traditional applicant, medical schools are "hunting" for you. Medical schools do not have to hunt for any type of applicant or accept every type of applicant for diversity. This means that as a nontraditional applicant, you have to be just as competitive as a traditional applicant. Many times, many non-traditional applicants have had less than a great undergraduate record but taking a undistinguished undergraduate record into a competitive range is a very positive asset for a nontraditional applicant. Most admissions committees will look at recent coursework that is excellent and take into consideration that many students apply with a poor freshman year and turn things around for the next three years. While you won't be applying with an undergraduate GPA (uGPA) of 4.0 (and you don't need a 4.0) you will need to be above 3.5 to be considered minimally competitive and in the 3.6-3.7 range to be considered very competitive in addition to a strong score (31 or above) on the Medical College Admissions Test.

With those types of "numbers" out there, am I saying that you don't have a chance? No, that is not the case but I am saying that you need to be realistic about your application when you are posting a uGPA or 3.5 along with a 28 MCAT and expect to be the nontraditional student at most allopathic medical schools. While the osteopathic schools do replace grades and make a good shot for the nontraditional applicant, you still have to do some uGPA "damage-control" if you have several grades of D in Organic Chemistry and have Cs in every pre-med requisite course. For any medical school, osteopathic or allopathic, the numbers are going to be more important and are going to be more important than the subject of the major that you have selected. In short, your application has to show recent can consistent scholarship in some manner. You have to get your academics in the best order that you can and optimize every part of the application along with excellent academics.

Many nontraditional students make the mistake of trying to take too many classes while working full-time. If you need to work full-time, your coursework need to be part-time. You are not going to get any "points" for a less than optimal performance (any grade below B+) in your coursework because you are working and taking a full load. Most allopathic medical schools are going to screen by uGPA which means that you need to make sure you meet and exceed the screen. When screening, most schools are not going to try to look at whether or not you are employed full-time. In short, drop back your courses (even if it take longer) until you can do excellent work in your courses. While you can't allow your family (or yourself) to live outdoors while you are trying to take courses, you can cut back on the number of course hours that you take. If you are dependent on financial aid, take only the minimum of courses that keep your financial aid flowing. If you do well with the minimum, then add more but don't overload and drop in the middle of the semester when you burn out on work and too much of an academic load.

You also need to take into account the demands of your courses. Taking three lab courses in one semester and trying to work full-time is not a sound strategy. When students (traditional or nontraditional) try to overload on coursework and work at the same time, it's not the employment that suffers, it's the academics. Again, it the performance that counts and not particularly the courseload because you are trying to "prove" that you can take many hours like a medical student. Additionally, your pre-med prerequisite courses need to be outstanding with the acquisition of a solid knowledge base for a good performance on the MCAT. For General Chemistry and General Physics, you need to have a very strong math background and thus, make sure you have good college-level algebra/trigonometry skills before you take those classes. If you need a math upgrade (or refresher),then take General Biology and math before you take General Chemistry and General Physics.

If you have a family, certainly there are things that you are going to have to take part in that your more traditional students will not have to deal with. You can become an expert with time-management and make time for the things that mean the most for you or you can resent the fact that you just have more demands. Balancing a family (does not mean that you inform the professor that your child has a play and you won't be getting your assignment done that night) with excellent academics can be a huge positive when it comes to application to medical school. In short, make a schedule that allows you to get your studies done and take time for the people who you love. If you have a son or daughter's play or a ballgame that you want to see, make that your recreation for the week and do your work with your recreation reward in mind. Even better, schedule some physical activity with your child or spouse that will allow you to both spend time and get some benefit from the experience. Never, never use your family or job as an "excuse" for not getting your assignments done on time or doing poorly in a class or on a test. If you set a regular and consistent study schedule (without academic overload), you are likely to be more efficient rather than less efficient.

On the job
If you are working full-time, your job demands your attention when you are on the job. You can certainly bring a note card or two that you can work on when you are on your meal break but don't expect your co-workers to "take up the slack" because you have a final exam coming up or because you are in school to become a doctor. First, your coworkers start to resent you and your work performance which makes the job more stressful for you. If you are on the job, you need to put in as much mental and physical energy as if you were not in school. Again, cut back on the coursework if your job is very demanding and don't count on breaks at work to be your study time as most people can't get their homework done on the job. Pitch in and be a good coworker/employee while you are getting yourself prepared for medicine. These characteristics will serve you very well when you are both in medical school and in residency.

Studying and getting academics strong
If you have poor academics from an earlier attempt at university work, take your time and get As on your retakes. Taking Organic Chemistry three or four times with Cs is not going to get you into medical school. The retakes will be on your record and don't bode well for an acceptance. Before your start to prepare yourself for medical school (uGPA "damage control" or not), sit down with a counselor and take a good and objective look at your study skills and academic knowledge base. Do you need to upgrade your reading skills? Do you need to upgrade your math skills? Do you need preparation in critical thinking skills? In short, you need to have good communication (reading, written and spoken English), good critical thinking (math and logic) and a good academic base to show that you can get through a challenging medical curriculum. You can acquire these skills at any time but you need to get them. Take some time and put yourself in a good position to get the most for your tuition dollar.

As I stated above, there is no "hurry" to get into medical school. If you acquire strong academics, you can enter professional (medical, dental, law) at any age. Take your time and get what you need. Medicine is a very long-term goal. It's a bit like having 100 pounds of excess weight to lose. You are not going to be able to get that much weight off in two weeks even if you drink only water for that period of time. You are not going to turn a poor academic record around in one semester but you can start right this second to sit down and work out how you are going to achieve the excellence that you need. With any long-term goal, you can "tick off" the daily strides that you make toward it. Write down everything on everyday that you have done to get toward your goal even if it's "studied and mastered all of the synthetic reactions for alcohols" . Also, don't forget to reward yourself for keeping on a straight path to your goals with excellent performance. Also, don't forget to "forgive yourself" if you weren't perfect in everything that you attempted. Being an obnoxious perfectionist will lead to burnout rather than excellence which is the real "key" to nontraditional sucess.

My medical school interview went badly...

2010-12-06T00:44:00.000-05:00

You have just completed your interview day for medical school. You had such high hopes for the day and right now you feel as if you have been “kicked in the abdomen”. What can you do to “fix” the situation? You tried to “salvage” the encounter with the interviewer but nothing seemed to work, now what’s going to happen? All of that work that you did on your application comes down to a huge disappointment with the day. You keep running the session in your mind and you can’t make any sense of where things seemed to get off track. My first piece of advice is to stop replaying the interview in your mind.One thing that is generally true about the session is that you are far from an objective observer of the situation. You were a participant and your mind was on the questions that you were asked in addition to a “hearty dose” of nerves about the whole situation. In short, stop playing the situation. You are done and there is nothing for you to be ashamed of thus, you did your best. If you haven’t attended your first interview, here are some possible scenarios and how to deal with them.

The apparantly disinterested interviewer or the interviewer who is in a hurry
You sit down in front of this individual who is shuffling the papers on the desk (likely your application or his/her evaluation score sheet). He/she never makes eye contact with you or even worse, he/she leans back in the chair, looks at you as if you just landed from another planet. They begin to “pepper you” with questions that you can’t seem to answer or they interrupt your answers. They keep looking at their watch as you start to answer a question or clarify your answer.

For you, take a deep breath and listen to each question carefully. If you interviewer tries to rush you, don’t be rushed. Think about your answer and speak clearly. In short, you “take” charge of the interview situation by slowing down instead of being pushed into delivering an answer that you didn’t intend to deliver. It’s your interview and most of the time, the interviewer will to move to your pace, albeit with some resistance. This doesn’t mean that you count to 100 before you speak or count to ten between words but it means that you don’t rush your answer because the interviewer has rushed the question. Sometimes interviewers will look for candidates who can keep control of themselves and the situation under these types of circumstances. Resist the urge to panic but do something to get your nerves under control.

Practice strategy: Take a deep breath quietly and make sure that you don’t take too long to answer questions. Tape yourself answering some routine questions such as “tell me why you want to be a doctor” or “tell me about yourself”. You can almost bet that you will get some version of these two questions so make sure that you have a clear answer to these. Look at yourself in a mirror dressed in your interview clothing. Do you look relaxed and confident? Make sure that this is the case.

The interviewer who asks “ethical” situation-type questions

Some candidates make the mistake of trying to “read the mind” of the interviewer and say what they believe the interviewer “wants” to hear. Give your opinion on whatever question is asked. If you don’t have an opinion, then don’t try to “fake” an opinion. You can state, “I have actually never considered that situation but here’s a similiar situation that I have considered”; then go on to relate your experience or opinion about a situation. In most ethical questions, try to make sure that you are not taking a position that could wind up hurting another individual (or yourself). Unfortunate things happen to good people but do not make the mistake of trying to read your interviewer or trying to give what you believe might be a “popular” opinion. It’s also good to have some examples of how you formed your opinion too.

Practice strategies: Do some research into some current but controversial issues and form some well-researched and well-thought out opinions. Do some research and reading of points of view that are opposite yours and be ready to state these and why you disagree with them. Be able to calmly and objectively discuss a controversial subject such as abortion rights with respect for opinions that differ from yours. Healthcare reform is a popular topic that can be researched so that you have an opinion.

The interviewer that asks scientific questions
If you don’t know the answer to a question, don’t try to “fake” it. If you have completed a scientific research project, you need to know every aspect of your research (including the things you didn’t work on) along with its implications. Most of the time, you are going to be interviewed by a basic science professor who is quite familiar with scientific literature and current biomedical research. Don’t get caught up in not knowing the most about any project that you have listed on your application. If you are asked a question that you can’t answer, then state your case honestly. Certainly, do not embellish your role in a project more than what you actually accomplished. If you only maintained a cell line, then know everything about that cell line and how it fit into the project overall.

Practice points: If there have been recent papers by members of your research group, know these papers well even if you didn’t work on the projects. Be sure that you can explain your role in any research project completely and in depth.

By all means, when your interview is over, keep the following in mind:

•The worst case is that this interview provided you with valuable experience.
•You are not objective enough to grade your interview. What you may experience as “bad” is likely your nerves getting the best of you.
•Don’t rehearse and try to recount every word that came out of your mouth. Every person is more likely to remember 10 negatives for every 1 positive thing. In reality, the positives always outweight the negatives but you won’t remember them.
•Everyone is nervous. Unless you tripped over the waste bin and fell into the arms of your interviewer, your nerves didn’t “get the best of you”.

Before any interview, practice in front of a mirror. Have a friend read questions to you and watch your expressions. You can even have a friend tape you answering questions such as “Tell me about yourself” or “why do you want to become a physician?” You should have some “stock” answers for these questions anyway. You can write out answers for these types of questions because they are often asked.

Needless to say, be polite to every person that you meet. You are “on” as long as you are on that campus. Ask questions of students and have one or two things to ask your interviewer but don’t make the mistake of bragging or belittling your fellow interviewees. This can backfire in more ways that you would believe. Many times, secretaries have be invited to give input into admission interview day behaviors of the candidates. Be sure that your behavior is outstanding and professional in every way. Words like “please” and “thank-you” can go a long way in distinguishing you from your peers.

New Intern Practices (lists and listing)...

2009-12-24T13:47:00.000-05:00

I am going to relate some of my practices as a new intern. I certainly learned from the best (my love and infinite respect to J-Ro wherever he is) and have generally kept up with the solid patient care practices that I learn from day one on the job.

Lists

Every good intern needs to have some kind of list procedure and I was no exception. Placing those little square boxes beside things to do and frequently checking my list became the "bane" of my existence on the wards. As a newly minted intern, my principle job was to make sure that every facet of patient care was done and assessed in a timely manner. I developed the practice of carrying both a clipboard (clip kept small pieces of paper from falling out) and blank sheets of paper. I would have a master list of patients that were under my care with Post-It sticky notes for things that I had to add to the lists in a hurry.

Daily Routine

When I first arrived in the morning, I pulled up my patient list and busied myself with checking the latest lab values. I scheduled my hospital arrival time based on service and the number of patients that I had signed out the night before. I knew that I would get at least one or more new patients and thus, on a service that contained a large number of patients with complicated diagnoses (or needs), I arrived earlier and on services with more long-term patients, I could arrive a bit later.

I would list my labs, check any imaging studies from the day before (or the middle of the night) and circle them in red (I always carried a 4-color pen or bright pink highlighter). I would want to make sure that the results and plans from these results were in my notes and orders for the day. Sometimes, lab results and imagining study results would indicate the need to change plans for the patients for the day. This is why these were the first things on my list.

My next tasks were generally to check with the night charge nurse for the things that needed immediate attention. Since the charge nurse knew that I was usually the first on the wards, he/she didn't have any problems letting me know anything that needed immediate intern attention from overnight. In general, the intern that was covering would also have reported to me but occasionally, there was a slight difference in the reports between these two people. I also make a concerted effort to get sign-out from the covering intern as soon as I could so that they could take care of their own patient load and I could get "cracking" on my daily duties. This is a good characteristic to have.

By the time my chief resident (and fellow on some services) arrived on the floor, I could hand them a patient list with the immediate problems (and my handling of them) circled in red. We could then start morning rounds with me (or a medical student) presenting the patient outside of the door, going inside for a look at the wound/incision, and any additional care options that the chief might want to add. These things were carefully noted and checked by me as I was responsible for everything aspect of bedside care on the service. A medical student could follow a patient or two but the intern has to be sure that everything is checked, double-checked and done.

Right after rounds

As soon as rounds were finished, I would quickly enter any orders that needed to be entered and head off to the OR for cases that had been assigned to me by the chief resident. Usually, unless there were loads of ward patient care duties, I could get to the operating room to do a case or two. I would check the schedule the night before to make sure that I had done my anatomy and surgical atlas work for any of the PGY-1 level cases. I didn't want to miss any of the "pimp" questions that I was bound to be asked over the incision during these cases.

If patients were likely to be discharged, I developed the habit of dictating a pre-discharge note that I only had to dictate an addendum to when the patient actually left. This meant that I could enter my discharge orders and scripts, pre-dictate the discharge and then release all of the information and scripts as the patient was leaving the hospital. Since these decisions were made during morning rounds or shortly after discussion with the attending, this turned out to be a great practice but one had to keep good records of patient numbers and what had been pre-written/dictated. There was nothing that prevented me from grabbing an order sheet, writing some discharge orders and keeping those orders on my clipboard (dating them when needed).

I also made it a point to go and observe any studies that were being carried out on my patients whenever possible. There were procedures like gastrografin swallow studies and upper gastrointestinal studies that were great to observe in "real time" along with the radiologist. I also made sure that I reviewed all of the CT Scans, cath reports, angiography studies and other studies of patients that were admitted the night before for surgery. I reviewed as much as possible in terms of their care in clinic and why the decisions had been made to take them to surgery. In short, I wanted to be there and get to the bottom of every patient detail as much as possible. Much of this type of investigation work was done on call based on my notes from clinic.

Do you actually know the most about your patients?

I have to say in all honesty, that my best skill as an intern was to know more about what was happening with my patients than anyone else on the service. Most of the time, the nursing staff would call me when a patient went to radiography so that I could slip over and look at their studies. The radiography techs and transporters were also happy to let me know when they had picked up a patient, especially at night. I always wanted to get in and see for myself, what the studies looked like even if it meant that I would lose some sleep. I knew that I would rest better when I had tracked down my studies; knew the results and had discussed them with the chief that was on call so that any plans could be done.

Sign Out

One of my colleagues replaced my folded paper system with an Excel system that I still use today. On this system, we kept a running log of patients, locations and things to do and check. An intern covering my system could easily check the sign-out sheet (done by printing out Excel sheet) or check our files on the service computer. I always kept this backed up on a jump drive too.

I never signed out anything that I could do or check before leaving. I knew that the night float intern would have a huge patient load ergo, I made sure that all admissions and post-operative checks were done by the time I left. Unless a patient was still in recovery (in which case, I checked on them anyway to fill anticipated needs), I didn't sign out discharges or new admissions. If I had to stay a bit longer, then I stayed a bit longer (signed out earlier) and updated the night float just as I left the hospital.

There is no substitute for making your own rounds and checks in the late morning between cases, in the afternoon to see that everyone got home OK and just before signing out to the night float (or receiving sign-out if you are on call). It is things that are signed out that are most often missed. On-call folks get busy and emergencies come in that will delay things. In short, I tried not to sign out anything that I could do by phone or that was routine (should have been done earlier in the day). My regular walking around solo rounds usually kept me on top of things.

Going off service

Another very nice thing that I always accomplished was an "off service" note that summarized the care of a long-term patient. There were many times when a patient (especially a burn patient) had been hospitalized for months. When I received such a patient, I wrote a summary of care up to when I started and a summary of the care while I was on service. If the patient died or was discharged a couple of days after I left the service, my "off service note" would assist the new intern in doing an accurate dictation on that patient. This type of note would also help them get up to speed when they came on too. I always appreciated when someone did this for me and readily returned the favor. An "off-service" note is one of the best things for good continuity of patient care.

First Semester of Medical School (it's over and done)...

2009-12-21T16:56:00.000-05:00

For many people, the first semester of medical school is complete. By today - barring being snowed in and delayed at one of the east coast airports - you are on your way or at home for the holiday break. Many folks worked harder this first semester than in any aspect of their previous academic endeavors only to find that they didn't do as well as they wanted or anticipated. The good news is that the semester is over and the bad news is that you have to go back and face second semester in a few short weeks.

My first piece of advice is to take a bit of time to assess what worked (and didn't work) in terms of getting the material mastered for this past semester. There is little use in anguishing over grades (you get what you get when you get it) or what you "could have done". You put everything regardless of good or bad, behind you and move into the next semester renewed. If you failed, it's behind you until you have to re-mediate. If you passed, it's behind you and you have to move forward. That's one of the great things about medical school in that it carries you along at a relentless pace.

As you take stock of the things that worked well for you, see if there is something that you can do to enhance your efficiency. You are going to have to be more efficient in the upcoming semester and into next year so why not take a look at what you can "tweak" to make better. If you are totally satisfied with your work, still look at adding some activities such as physical conditioning or stress relief. Trust me on this one, stress can come out at any time in medical school no matter how well you are doing. Having some kind of a stress relief plan is a good thing. Even if you walk around the block a couple of times, it will just relieve some of the stress.

Resist the urge to try to study for Boards during this holiday. You NEED rest and relaxation. If you feel that you must do something, then have a cursory look at First Aid for Step I but there is little that you can do that will make any meaningful "dent" in what you will have to review after next year is done. Your best prep now is rest and relaxation. Don't even try to use these next couple of weeks to "read ahead" for the next semester. Work on a plan for increased efficiency but you know that you will have ample time to study for the next semester of coursework.

Take this time to catch up with old college mates who have gone into something besides medical school. I found this practice most fulfilling because they wouldn't allow me to "talk shop" during our get-together. I could hoist a brew or enjoy the holiday lights without feeling compelled to study something or plan to study something. If you were fortunate enough to complete your Gross Anatomy course, relish in the fact that you can burn those formaldehyde-scented scrubs now. See, there is always something to put behind you. If you are not done with Gross Anatomy, well, you are at least further along that when you started.

I also used the holiday break to catch up on some of the latest movies, non-medical reading and other nice non-medical pursuits. Even today, as I have completed submitting grades and evaluations for the students that I teach, I am contemplating the movies that I will catch up on this week. I have some holiday clinical duties but as I have posted in past posts, I actually enjoy the hospital during the holidays. The patients are grateful that you are working in addition to the wonderful decorations everywhere. I love to take a couple of minutes to sniff the branches of the huge lobby Christmas tree just to get that holiday feeling. I also enjoy hearing the Christmas carolers strolling the halls to serenade the few patients who are left in the hospital.

In short, take the time to enjoy your time with your family and friends, to celebrate that you have gotten through your first semester and to face the upcoming semester with some anticipation. Try to remember that this whole "medical school thing" is a process and not a commentary on your worth as a human being. My bet is that you are far more complicated than your studies.

If you didn't get the grades you wanted or feel that everything you have learned has "leaked out of your brain" relax because that hasn't happened. You definitely know more than you think you know. Every medical student feels that they are forgetting everything that they have learned. You may not remember every tiny detail but the neural pattern is there and can be recovered with a bit of review. In short, relax, that knowledge is in there and will be there for you. Next semester will build upon what you went through this semester but isn't dependent upon you having done a "perfect" job with this semester's material. You will have another shot at anything presented this semester next year and for Step I study. Again, this is why you can relax right now.

Finally, to those who may have to re-mediate, put off the self-flagellation. You have learned what not to do so concentrate on thinking about what you will do differently. Assess what worked and resolve to hone that what worked for you. Don't be ashamed and don't keep running thoughts around in your mind that you have closed any doors to having a fine medical career. You haven't closed off anything. Remember that the vast majority of medical students will have something to face in the future that will cause a hiccup or a step-back. If you had your hiccup now, you are done. Put it behind you and know that you are going to move forward to enjoy a great career.

Happy Holidays!!!!!

Doing Well in your Cardiothoracic Surgery Rotation

2009-07-03T18:00:00.001-05:00

Many times, third-year medical students will have to spend a portion of their required surgical clinical clerkship on Cardiothoracic Surgery. This portion of your surgery clerkship can provide a good informational background for anyone going into medicine, pediatrics or surgery. For the medicine, emergency medicine and anesthesia folks, you get first hand experience with the actions of pressors such as dopamine and dobutamine and other cardio pharmaceuticals in the postop management of these patients. You see the real-time effects of agents like nipride and nitroglycerine because most cardiac surgery patient will have pulmonary artery catheters in place in the immediate post-operative period. For those anticipating entering pediatrics, you will get a chance to see some of the effects of the congenital heart disease entities and how repairs are undertaken. For those entering the surgical specialties, you can develop an understanding of some specialized surgical techniques in addition to becoming familiar with the surgical intensive care unit.
Approaching the Rotation
The first step in any clinical rotation is to have good reference materials so that you understand the language that these surgeons will be using. For cardiothoracic surgery, I strongly recommend the following: Essentials of the Surgical Subspecialties by Lawrence, Cardiac Surgery Secrets by Solotoski or Handbook of Patient Care in Cardiac Surgery by Vlahakes. Any of these books will provide a solid background into the types of pathology that you will encounter in your rotation. The Lawrence book includes good sections on the thoracic elements of this rotation which are not included in the other books. In addition, you need the usual pocket books such as the Pocket Pharmacopeia or Epocrates which may be used to look up dosages of medications and the Maxwell Book which outlines SOAP charting, brief operative notes and discharge summary writing.
The players on any cardiothoracic service are the Cardiothoracic attending surgeon, the resident or fellow surgeon, the intern and you the medical student. You need to understand your role as both a member of the team and as a student of medicine/surgery. This means that in many cases, this busy service will require that you become very proactive in terms of getting the information that you need. You should thoroughly understand the following for every case that you encounter on this service (or any service for that matter):

• The relevant pathology of the underlying disease entity
• The relevant anatomy of the underlying disease entity
• The “gold-standard” of diagnosing the disease entity
• The accepted treatment of the disease entity
• For surgery- the surgical approach and performance of the operative procedure
• For surgery – the postoperative disposition and management of the patient

In the case of a patient that is undergoing a coronary artery bypass graft procedure, you need to understand the indications for the procedure, how the diagnosis of coronary artery disease was obtained (how to read the cath report), where is the disease (in which arteries), the relevant surgical anatomy, how the case is done including the operative approach, how cardiopulmonary bypass works, the effects of the cardiopulmonary bypass pump on the patient and how these effects are managed in the postoperative period, how to read and interpret data from the pulmonary artery catheter, where the grafts for bypass were obtained and how they were utilized and the care of the patient both in the intensive care unit and on the postop ward before discharge home. You should also know why the patient is discharged on certain medications and what you may expect to see and evaluate in the clinic when the patient returns for postoperative care.

Armed with that knowledge, you should make sure that you observe (you probably won’t be actually scrubbing in these cases)the preparation for anesthesia, how the chest is opened and closed, that you see how the grafts are harvested (done by a surgical resident) and how that wound is closed, how the grafts are sewn I place (best to use the camera overhead for this observation rather than try to look over the shoulder of the surgeons, how the pacemaker wires are placed, how the patient is placed on and taken off the cardiopulmonary bypass pump, how the chest tubes are placed in the chest cavity and how blood is evacuated from the chest cavity when the sternal wires are placed. Placement of the sternal wires is also a good opportunity for you to observe an interesting procedure.

After the case, you should accompany the patient to the intensive care unit and you should carefully note and observe the data that is obtained from the pulmonary artery catheter, the arterial line and the 12-lead ECG. You should look at the pre-operative ECG and compare the two. Another good exercise is to note where the grafts were placed and the number of minutes of pump time and any circulatory arrest time. You thoroughly familiarize yourself with the preoperative workup and the postoperative course of every patient that is on your service. Look at things like electrolyte replacement, ventilator weaning, urine output and transfer from the intensive care unit. This is also a good time to learn how to remove chest tubes and arterial lines. You should observe the conversion of the pulmonary artery catheter to a central venous line but leave the rewiring duties to a resident. If you anticipate entering a surgical subspecialty, you might observe these procedures but you should never perform these procedures as a medical student.

In addition to the routine patients, you may get an opportunity to observe some trauma that involved the cardiothoracic service. You may see the repairs of lung lacerations, penetrating cardiac injuries and the relief of cardiac tamponade from a traumatic injury to the chest. It is always interesting to see a patient who is admitted to the emergency department with a stab wound to the chest, knife in placed, rushed off to the operating room where the object is removed and the repair completed with survival of the patient. These are some of the most interesting cases. You may also see how damaged cardiac valves are replaced and how congenital heart defects are repaired. All of these cases are under the practice of a cardiothoracic surgeon.

The thoracic cases may afford you an opportunity to scrub in on the procedures. In the case of the video-assisted thoracic (thorascopic) lung procedures, you will have a good view of lung pathology. You can follow the patient from biopsy (in the case of a tumor) or chest wall abnormalities/problems through the repair. These cases will have interesting anatomy and will have excellent postoperative observations and challenges that will teach you many good skills. You can learn about chest tube management and the physiology of the chest cavity. You will also learn about pain management and the prevention of major postoperative complications as these patients may often be a challenge in terms of pain relief. You may get a chance to observe a thoracentesis or placement of a chest tube.

This rotation can teach you many important skills and hone your ability to understand the critical care of patients. It is an excellent learning opportunity for you. You may not get much hands-op operative experience but you can be invaluable in the post-operative care of these patients.

Memorial Day at the Veterans Hospital

2009-05-25T17:39:00.001-05:00

Typical Wound Rounds

It was one of those typical wound rounds days at our VA Hospital. We made our (the complete vascular surgical team) over to the long-term care wing of the hospital to do our weekly check of patients who didn't have formal vascular clinic appointments or who were bedridden with chronic wounds. The mid-level practitioners would put names of patients on a list at the nurses station for us to check. The patients who were ambulatory or wheel-chair bound would return to their rooms so that we could check them as we made our way down a T-shaped hallway with two long wings. The entire process generally took from 2-4 hours depending on how many patients to see and how extensive the wounds were and what care was needed.

The hallways

Most of the rooms down these hallways were semi-private (2 vets to a room) with a ward (4 vets to a room) at the proximal ends. At the end of the hallway were the private rooms for those vets who were in isolation for infections or for those who were too loud or ventilated and would not be amenable to sharing a room with another vet. The rooms at the far end of the hallway, though private, had views from the window that rivaled any 4-star hotel. They overlooked the front grounds of the hospital and the baseball diamond. Flying in the breeze was the state flag, the POW-MIA flag and the flag of the United States. The entire VA complex sat upon a hill that overlooked the surrounding town and mountains in the distance. No matter what time of year, the views were spectacular and I always paused to admire nature's show for these men who had given so much.

Chronic Wounds

We made our way from room to room. Many of these patients were post toe amputations and needed wound checks. Others were diabetic with foot ulcers from poorly fitting shoes or injuries that they could not feel and thus the wounds had become infected. Many of the vets were long-time smokers and diabetics with peripheral vascular disease from smoking and neurovascular disease from their diabetes. Some were despirately trying to "keep their feet" while others had both lower extremities amputated starting with the toes, then the feet and finally the leg above the knee. With each room change, there came a new challenge or a new evaluation. We removed dressings, evaluated vascular supply and made recommendations for each patient. With each week, I grew to know these patients and to learn to predict whether the wounds would heal, or an intervention was needed, or progression to limb amputation. Sometimes it wasn't wonderful to tell a patient that he would lose his foot but a good amputation with a well-healed stump could mean a return to ambulation and increased freedom. It was the progression of things each week.

Moving toward the end of the hall

This week, we decided to divide the duties with the interns doing post op checks and the more senior residents examining those patients who needed evaluation for possible surgical interventions. I elected to see the last two patients who were bedridden and in isolation for MRSA (meth resistant stap aureus). I knew that these guys had extensive wounds that would take some time inspect, debride and re-dress. I loaded my pockets with enough bandages for the dressing change and left my coat on the cart outside of the door as I donned the yellow isolation gown, a mask , gloves and shoe covers. I greeted my first patient and set to work removing the old dressings. We had ordered that dressings be changed every six hours on this patient but it was clear that his dressings were being changed daily instead of three times daily. How was this wound going to heal? It's the wet to dry dressings that debride the wound and help to clear the necrotic tissue that would promote healing. I chatted with "George" as I completed the inspection and dressing change. I left my initials, the date and time on the outside of the dressing. If this was still here in the AM (I had planned to stop in early and check), I would be writing an incident report. If George was to keep his leg, this dressing needed to be changed. For George, a very pleasant gentleman who was post stroke, this was limb salvage.

The last room

I moved into Fred's room after I cleaned up and washed my hands from George's wounds. It was now well past dinner time and the sun was low in the sky. Fred's bed was facing the beautiful setting sun. Fred had congestive heart failure, diabetes and emphysema. He was a small thing gentleman with bright blue eyes that still held a twinkle when you greeted him with "Semper Fi". Fred had been a marine and by his looks, a real scrappy guy. I always chatted about baseball with him and he loved the company. Sometimes he sang "Take Me Out to the Ballgame" off key as I worked on his infected decubitus ulcers. Twice we had taken Fred to the OR for surgical debridement where we cleared away foul-smelling dead tissue down to the bone. Fred had little tissue left on any of his pressure points and had been failing rapidly.

Today, Fred appeared to be dozing quietly in the setting sun. I touched his hand which was wrinkled and warm. I noticed that Fred wasn't breathing and had likely died a few minutes earlier. He looked peaceful and happy as the sun's last rays of the day were settling on him. On the ball field, one of the local town teams was finishing up a game. Most likely, the last thing that Fred saw was his beloved baseball and a beautiful May sunset. To the man who had given so much so that I could come and dress his wounds, God had given one last baseball game in sunset.

There are thousands of veterans in hospitals around the country presently. They love company and they don't care if you are not related to them. They are very appreciative of everything that we do for them. Many times, the interns and medical students would complain about wound checks but for me, they are the highlight of my week. I might make a difference that will allow a vet to keep his feet or I might be reminded of how special these guys are and why I love what I do and have the opportunity to do it because of them

Do I really NEED to take an MCAT Review Course?

2009-04-12T20:12:00.000-05:00

You have completed your pre-med coursework with no grade less than B+ and a majority of A grades. You feel that you have a solid grasp of the material and the concepts presented in your pre-med courses. Do you really “need” to take a review course for the Medical College Admissions Test (MCAT)? The answer to that question depends on whether or not you are good at solving the types of problems that are presented on the MCAT. If your knowledge base is good, then taking a review course that emphasizes knowledge refreshment is largely going to be a waste of money for you. If it’s been a few years since your pre-med coursework, then getting your knowledge base up to speed is your first priority and thus a knowledge upgrade type of review course may be the key to a strong score on this very important admissions test.

How are your problem-solving skills?
You can quickly find out how well you solve MCAT-type problems by downloading one of the retired exams and working the problems under actual testing conditions. If you are finding that you are struggling with these types of problems, then try to find a review course that gives you plenty of strategy and experience with problem-solving. Problem-solving is often the main gap in the education of most pre-med students. With many undergraduate institutions placing more emphasis on “rote memorization” rather than application of knowledge to problem-solving, pre-med students may have earned high grades in science coursework with little training in how to apply those skills to new situations. Even the so-called “ranked” universities can be seriously lacking in terms of making sure that students have problem-solving skills. Many times these skills are utilized most in coursework like Calculus and applied Differential Equations; courses that many students avoid because of rigor or lack of math background.

How are your reading skills?
In this age of electronic media at every corner, many students have lost the ability to produce (and evaluate) good writing. Many students view the analysis of literature, primary resources and scientific papers as the torture of producing research papers and as a “necessary evil” of obtaining an education. Many professors routinely pass out PowerPoint lecture slides that contain the bare minimum of facts/information that students attempt to memorize verbatim without regard to analysis or research beyond what they have been handed. These processes have tended to rob many students of the skills needed to evaluate information sources and information. While Wikipedia may give starting points for a wide variety of subject matter, many students will often use the “cut and paste” function for research paper writing rather than spend some time evaluating a cross section of resources. Reliance on quick media resources is a great starting point but this reliance can’t be the end point of your information evaluation and gathering skills. Learning how to evaluate the primary literature is a valuable skill that you should have acquired in your undergraduate training regardless of major course of study.

The sections of the MCAT – Biological Sciences
This section will test and evaluate your mastery of General Biology with some Organic Chemistry thrown in. While it may seem strange to put these two subjects together, organic chemistry is largely the most concept application course that is taught in chemistry. Organic Chemistry relies on your understanding of the chemical properties of carbon as an element to solving problems across a wide variety of conditions. Many students hit a major roadblock with organic chemistry because there are many problems that can be created to test your knowledge of carbon chemistry. Trying to sit and memorize every problem that you were presented with in organic chemistry is not going to be very helpful but making sure that you know the concepts of carbon and its chemistry will enable you to solve any problem that you are presented with.
In addition, many student mistakenly believe that they must “take a course” in every type of subject matter that is covered on the MCAT. This could not be further from the truth. A good comprehensive General Biology course will give you the knowledge foundation to apply concepts to the problems that the MCAT will present in Biology. You don’t need specific coursework but you DO need to be able to do some creative thinking in the application of your concepts to novel experiences. A good comprehensive General Biology course will cover physiology, botany, zoology and ecology. Thus, you don’t HAVE to be a biology major to have exposure to the subject matter but you do need to have a grasp of the concepts of a good comprehensive General Biology course. Being able to synthesize and build upon a basic knowledge base are the types of skills that you will use in medicine thus your ability to do these types of problems will be measured by the Biological Sciences section of the MCAT.

The sections of the MCAT – Physical Sciences
This section tests your ability to solve quantitative problems using concepts that you learned in General Chemistry and General Physics. These types of problems are often answered by being able to apply order of magnitude type strategies rather than working though an entire problem. Students who thoroughly know quantitative relationships presented in their coursework will tend to do well on this section. Between General Chemistry and General Physics, the quantitative relationships of many concepts can be probed and tested. It is practically impossible to rote memorize every type of problem that can be presented in these courses but having a sound knowledge of quantitative relationships in addition to being able to apply those relationships can bring success in this section.

The sections of the MCAT – Verbal Reasoning
This section of the MCAT can often be very difficult to improve or prepare for. Being able to analyze critically the reading passages from a wide variety of sources and disciplines generally takes years of careful practice and skill building. Preparation for this section should have been occurring over students previous years of study in practically every subject. College coursework in the humanities with strong achievement can also hone these skills. In addition, good readers are always good writers and thus, the writing section of the MCAT is likely going to mirror the Verbal Reasoning section of this exam. Can you consistently read and learn from your text books and journals? This is a very valuable skill to take into medical school with you as medicine will require a lifetime of learning and the acquisition of new knowledge that will be outside of a classroom.

Some final thoughts…
Finally, the review courses are expensive and time-consuming. You have already paid thousands of dollars in tuition and book purchases in order to master your coursework. Do you actually NEED to pay a few thousand more for a review course of that work? If you didn’t master what you needed the first time around or if you find from doing a few practice retired MCAT exams, you are struggling with this test, and then perhaps a review course can make a difference for you. You should thoroughly investigate the materials offered and you should thoroughly understand what the courses are offering for the fees that they charge. You should also be prepared to master some of the material on your own as many of these courses are taught by people who have a variable ability to teach others. Doing well on the Medical College Admissions Test may not translate into being able to teach others to do well on this exam.
The Medical College Admissions Test is one aspect of your application to medical school. This test requires solid and thorough familiarity with the mode of testing and a solid knowledge base that must be applied to the problems asked on this test. Several retakes of this test do not bode well for medical school admissions. You want to be prepared and take this test one time. With this test being administered 22 times annually, you also have more options in terms of being able to time your preparation for this exam. The important thing to realize is that you don’t want to take this test unless you are thoroughly prepared at your own pace. This is not the time to listen to your peers tell you how much or how little time they needed but the time to set the study schedule that works for you.

Burn Surgery

2009-04-11T11:12:00.000-05:00

I was the resident in charge of the burn unit and working on my daily notes for the patients that were currently residing there. There was a 19-year-old who had suffered severe inhalational burns and brain damage after the carburetor that he was cleaning with gasoline caught fire from a static electricity spark. There was a 70-year-old who had fallen asleep with a lit cigarette and sustained 25% full thickness burns to his upper torso. There was a mother who had burned her hands and face when she opened the door to her house, smelled gas and pushed her children to safety just before her house exploded. All of these patients require intensive care, intensive wound management and attention to every detail of their progress and condition. Also, some of these patients were in the process of being grafted which required operative timing and preparation.

The call came in just before lunch that a 39-year-old highway construction worker was being flown in with 96% partial and full-thickness burns to his body. This man was working in a manhole when he accidently hit a steam pipe that ruptured. He was wearing steel-toed boots which kept his feet and lower legs from the burns but just about every place else on his body was burned. This would be a major trauma to this young man and this would predict months of recovery if he would be able to recover from such a traumatic blow. In the case of burns, the patient doesn’t stop in the Emergency Department but come immediately to the Burn Unit where the staff can start treatment as soon as possible. At stop in the Emergency Department would delay initiation of the treatment unnecessarily and would expose this patient to infection because the Burn Unit is far cleaner than an open Emergency Room. He would arrive in less than 30 minutes.

The nursing staff set up one of the evaluation rooms: scrubbed stainless steel tables lined with sterile liners and warm water for removal of any clothing that might be adherent to the skin. In the field, most paramedics know that burned clothing will hold heat and continue the burn process unless removed from the skin. They will make sure that any smoldering clothing is removed and will wrap the burns in sterile dressings and drapes. The patient’s airway will be protected and two large bore intravenous lines will be inserted so that fluids can be infused as quickly as possible. The paramedics had indicated that they had inserted three 16-guage lines into this patient and has already infused 1.5 liters of fluid. The patient was intubated, stripped of clothing and wrapped completely to prevent fluid and heat loss because of the burns. They had done an excellent job in the 15 minutes since the patient has been burned. They were 15 minutes out from the hospital.

The man arrived and we quickly set to work debriding any scorched skin and clothing from his wounds. I inserted a cordis intravenous line into his internal jugular vein for even more fluid infusion and extra IV access. We also induced a pharmacological coma for pain relief (about 60% or his burns were painful partial thickness and the other 30% were full-thickness (not painful but devastating). His face was swollen and red; his hair was gone; singed by the steam. It appeared that the pipe exploded, he inhaled the hot gas and turned to his left while covering his face. His left arm and back had the full thickness burns but his eyes were in good condition. I used an ultraviolet light with dye to assess corneal damage and found none. His ears were singed red with large blisters that wept fluid. His chest and legs had partial thickness burns that needed to be debrided too. Three nurses helped me start the initial debridement process while the respiratory therapist made sure that his ventilation was taken care of.

Full-thickness burns cause the skin to take on a leathery appearance. Since all layers of the skin are totally destroyed, this leathery eschar would need to be removed. Just under this layer would be a layer of ischemic damage that would be lost unless proper fluid resuscitation had been undertaken. Our patient had an IV rate of 1,950 ml/hr in the first 8 hours because of massive fluid loss. We didn’t want to get behind and cause further damage. After the first 8 hours, we cut the IV fluid rate back to 980 ml/hr for the next 16 hours. Overall, our estimate was that our patient was 31,000 ml of fluid down because of the extent of his burns. In addition, his body was massively stressed by the injury to his lungs and fluid loss from there. He was fortunate in that he had been in excellent health before this accident. We were able to hold blood pressure and urine output adequate in the first days after his accident.

My attending burn surgeon arrived after the patient had been in the unit for about 20 minutes. He helped with the debridement and wound evaluation. Our patient was fortunate that he didn’t need an escharotomy (incisions made to release burned skin so that the patient would be able to breathe/be ventilated). After 35-minutes, we had infused several liters of IV fluid, placed the patient in a pharmacological coma for pain relief, undertaken mechanical ventilation and cleaned/dressed his wounds. My preceptor surgeon and I sat down with the nurse assigned to the patient to plan for covering this patient beginning the next day. We also had antibiotics started and had placed a feeding tube for liquid nutrition which is so vitally important in burned patients. This young man would be in a hyperdynamic state with the ultimate demands on his body both physically and nutritionally. In addition, we would need to start to cover his burned skin as quickly as possible. Our first cover would be donated cadaver skin.

Cadaver skin would be a good cover to start with but the patient’s own skin would have to be harvested slowly as he healed. As soon as donor sites would become available, we would use them and would harvest. On our first assessment, the backs of both calves were not burned along with his right upper posterior thigh. These would be harvested first. We would start on hospital day 2, harvesting skin from the donor site and covering the full thickness burned areas with cadaver skin. The patient’s own skin would be meshed and would be used to cover the partial thickness areas. We would also perform a tracheostomy as he would require mechanical ventilation at least two week and possibly three or more. He had been fortunate in that he had not inhaled carbon monoxide but he did inhale heated gases which had caused some lung damage. We hoped that this would heal and we would come to see that this damage was minimal in the next week.

At the first surgery, our team consisted of seven people: the attending surgeon, the chief resident, an intern, a nurse practitioner and three medical students. Our attending surgeon set about further debriding the burned areas after anesthesia had been induced. I performed the tracheostomy creation while the intern and nurse practitioner harvested and meshed skin for beginning the coverage. Once the recipient sites had been properly debrided and prepared, the meshed skin was applied with everyone having an opportunity to do some suturing. In the coming weeks, he would undergo more of these coverage procedures as his body rejected the cadaver skin and the donor site would allow more harvest. In all, it took about three weeks to get his would covered with his skin and to keep the donor sites healthy and thriving.
In addition to coverage, keeping infection at bay and nutrition, we had the challenge of pain relief. At first, we kept the patient strongly sedated. As his lungs began to heal, we gradually cut back on the sedation to allow him to breathe on his own. After 2 ½ weeks, he was doing well and we removed mechanical ventilation. At this point, he was able to talk with his family by covering his tracheostomy tube. With is grafts and tubes, we could see that the greatest joy for this young man was having his family gathered round for encouragement. When he was pharmacologically comatose, his wife made tapes of their children singing for their father. The nurses would play these during the daily would care and dressing changes. Any person who entered his warm room (to prevent heat loss) would have to dress in sterile garb and wear a mask. In addition, the massive facial swelling started to resolve after about a week so that his children could see him from the door. His wife had carefully prepared them for the sight of seeing their father in bandages from head to toe.

When I left my burn rotation after two months, I would stop in to see him from time to time. He said some of his first memories had been of my voice and the staff speaking with him and encouraging him. During his dressing changes, we had sung (recommended by our music therapist) along with his children and that this had been of great comfort to him. He also said that he didn’t remember having a huge amount of pain until near the end of his recovery when he started to have difficulty with some mild contractures. He continued physical therapy and when I saw him one year later, he looked fantastic. One could tell that his arms and torso had been burned but the plastic and reconstructive work that had been done on his face and ears was very nice. He was upbeat and looking forward to changing careers. He had decided to go back to school to get a degree in counseling so that he could help other burned patients. The staff in the burn unit said that he would often visit young men who were burned to tell them his story as he was recovering. He said that he thought that recovery for a younger man was especially difficult.

I still remember what this gentleman looked like when he came in and often had to look at the portrait that his wife had supplied so that we knew what he had looked like before his accident. We also saw the incredible love and support that came from his family and parents. He had brothers and sisters who took turns sitting with him and reading to him while he was comatose. This was a very close-knit family who prays for and supports each other. We saw the incredible determination in this patient and in others that have undergone this type of extreme stress and life adjustment. All of these patients taught me the value of appreciating how easy it is for me to do something as simple as walk across a parking lot or sip a cup of coffee in the morning. Often it takes weeks and months for a burned patient to even get out of bed.

And finally, taking care of burned patients is the ultimate team effort. The surgical procedures take multiple hands and personnel who have the goal of getting the burned patients covered as soon as possible. In addition, the nurses, nursing assistants and environmental services personnel in the burn units are invaluable. They have some of the strongest work ethics of any area of the hospital. If the environmental services folks were not dedicated to their jobs and doing a job well, the infection rate in these units starts to climb. Every single person “counts” when it comes to getting this massively injured patients back to health.

Working and attending college...

2009-03-29T14:31:00.000-05:00

Potential lethal combination?
Many students find themselves in the unenviable position of HAVING to work and attend college at the same time. This a a potentially lethal combination in many ways. First of all, when something starts to suffer, it generally isn’t the job and second, burnout is a strong possibility. Both of these problems can be potentially avoided if you cut back on your coursework if you find that you must work full-time. If you are a full-time employee at most jobs, you have minimal time to study in between and thus, you can’t take on a full-time course load that includes pre-med lab courses. Decide that you are going to take your time and do well in your courses while leaving yourself plenty of time to rest from both coursework and employment. No medical school admissions committee is going to give you “brownie points” for trying to do a full-time course load along with full-time employment especially if your uGPA (or postbacc) work has suffered.

Recharging your batteries
You need time to digest and assimilate the material that you are learning in your pre-med coursework. Rushing through these classes with last minute “cramming” is not going to leave you with enough time to get the material in your long-term memory so that you can apply it on the Medical College Admissions Test. You need to be able to see the subtleties of what you are studying in addition to having some time to let your brain just rest. Again, rushing through your coursework makes MCAT review on the other end a total chore instead of a progressive process that will lead to success. Take your time, recharge your brain (even take a semester off if necessary) and then come back refreshed and ready to work at very high level.

Damage control
If you are retaking courses or attempting to take additional postbacc work to enhance your application, you need to do well without exception. You can’t keep posting mediocre grades and retaking courses with the expectation that eventually you will get that A and get into medical school. If you have significant prior poor coursework to overcome, take your time and remediate one course at at time. Pair a more demanding course like Physics with something less demanding like English/Psychology. Again, if you have prior poor coursework, you can’t afford to either do poorly in your recent coursework or drop courses because you have overloaded yourself. Slow, steady excellence will bring the success that you seek.

Keeping some perspective
If you have a family to support and take care of, be sure that you allow plenty of time for them. Working, attending class and then diving for a nap on the sofa or heading for bed is not going to do much for your relationship with your loved ones. They need your undivided attention and you need to interact with them for your sanity too. Let your loved ones be your much-needed and much-desired break from your schedule. They generally don’t expect your to be on your best behavior but only want you in your basic form. Allow them to see you, hang out with you and take you away from the grind of work/study on a regular basis. You grades will be better, you will be happier and you can keep yourself reminded of why you seek your goals in the first place.

Setting goals and achieving them
The whole key to finding success in the medical school application process is keeping your eye firmly on your long-term goals. I have stated in other posts that the process is like having 100 pounds of weight to lose. It isn’t going to happen overnight and you must take small steps on a daily basis to stay on track. It’s easy to get off track by the demands of work but you can’t achieve your goals by letting this happen. This means total organization and total commitment to the task at hand, be it work your studies. If you are at work, you give your work your full attention. When you attend class, you give your classwork the attention that it demands. It’s neat to be able to multi-task but most people are not able to work at a high level and achieve those A grades that you need for medical school admission at the same time. Again, if you work full-time, don’t expect to attend school full-time. If you attend school full-time, don’t expect to work full-time. The end result is that you wind up doing both things at a mediocre level which won’t allow you to achieve your goals.

Finally…
There are no “points” for getting this process “almost” right. The level of academic achievement that is demanded of a potential medical student is getting higher every year. The MCAT is getting more competitive as many students are taking prep courses and spending more time preparing for this exam. You can’t expect to be competitive next year with this year’s work because the bar will move higher. If you are attempting to upgrade your credentials, then you need to do a complete overhaul and put up some good academics (even one course is better than nothing). Don’t expect to be the exception to any of the rules in this process. You are not generally in a position to be objective about yourself and your abilities. Make sure that you get some honest and objective advice. Trying to self-evaluate is like asking your Mum if you are a great kid. Of course, she’s going to answer in the affirmative but it’s far better to get someone who doesn’t know you, to look over your things (like a good academic adviser who knows the pre-med climate). Allow plenty of time for getting your work done at a high level and you will see movement toward your goals without sacrificing your employment records, your sanity or your soul.

Venting

2008-12-28T20:08:00.000-05:00

I remember doing a case with one of my favorite attendings. This person was a colo-rectal surgeon who would talk through out the case. I was an intern at the time but I remember him saying that his talking was just “venting” and that he hoped it wouldn’t bother me. I looked at him with amazement because his “venting” was putting to word, many of the thoughts that I was having as we went through the case. I had felt honored to be able to scrub this case with him because usually, one of the chief residents would have taken this case but everyone was tied up and thus I asked if he would mind if I scrubbed with him. He said that he was happy to have me there.

The Teaching

He explained the fine technical points from skin to skin allowing me to mirror many of the things that he was doing. He pointed out anatomy and explained why he loved mobilizing the rectum and why colo-rectal surgery was always a rush for him. I was mesmerized by how fascinating going through this case was. In short, I was being treated to the first of many one-on-one mentor-trainee sessions with this young colo-rectal surgeon. His enthusiasm for his craft and his ability to teach me what he found amazing was delightful. From that point on, I always held a special reverence for colo-rectal surgery.

He marked out the incision line for me and handed me the scalpel. He showed me how to make sure I had just the proper amount of tension and counter tension as we entered the abdominal cavity. He showed me how to explore the abdominal cavity and how to palpate the liver for cancer mets. He pointed out the fine points of living anatomy as we located the tumor that we knew we would be able to resect.

His next lesson was how to put two ends of bowel together. Today, he said, we would do a hand-sewn anastomosis. Sure the stapler is nice to use but once in a while, a hand sewn anastomosis is a good thing to do. He showed me how to resect the section of colon leaving plenty of margin and the fine technique of location the numerous vessels that fed this wonderful organ. Again, the living anatomy is a wonder to behold and being able to see how this tumor would be removed was great.

We carefully sewed the remaining ends of the colon together using Lembert stitching. He talked, he vented and I watched and listened. Together we completed the case and at that moment, I understood why operating on the colon is both fun and something of a challenge. I had to always keep the anatomy in mind, the technique perfect and move in an efficient manner. I remember laughing at him describing the “big honking vessels” that we would be ligating and why one doesn’t want to even think about ties not holding. He said that when he started residency, he would lose sleep over thinking that his ties were not secure.

Technique

One of the great things about doing a case with an attending like my colo-rectal professor is that he does vent the things that go over and over in my mind. Are my ties secure with every knot? Are my hands going in the right direction? Have I identified the vessels correctly and ligated them using proper technique? After all, surgery is a practice which has to take place over and over for years. Even now, year’s later, when I don’t have to think about every suture or every tie, I still mentally revisit some of the cases that were turning points in my training for various reasons.

There isn’t anything magical about surgical technique but there is something magical about having the knowledge, background and education to use that technique properly. This is what I learned across the table from my colo-rectal professor. He vented and I listened to all of those pearls that he would verbalize. For me, his venting was golden and some of the best teaching that I ever encountered. He was an extraordinary teacher and he would often tell us that if he was in our position, his venting would drive him crazy. Well, that was never the case for me. His venting made me see the artistry of colo-rectal surgery and why having impeccable technique was paramount for these patients.

The best teaching

It’s no accident that the lessons that I remember best came from my first two years of surgery. By the time one reaches third year, there is a comfort level with being in the operating room. The lessons of my first two years were magical and have not left me. Those late night cases with the chief residents, moving through the abdominal cavity on a laparoscopic case or the first time I was able to close the abdominal cavity and feel confident that I had done this correctly, were memorable for me.

I was fortunate to be exposed to some of the greatest professors of surgery under a variety of circumstances in addition to having some of the best chief residents who were willing to give me their best too. There is much joy in this type of learning and a great amount of joy in venting.

Getting Through the Semester (or what if I fail something).

2008-11-23T12:31:00.003-05:00

“The Thrill of Victory or the Agony of Defeat”

The Drama of Human Competition as the opening lines of ABCs “Wide World of Sports” promised. By now, many students have had their first blocks 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.

What if I fail a whole course, like Biochemistry?

The consequences of failing an entire course in medical school are largely school-dependent. Some schools will want you to retake only the material that you did not pass while others will have you go through an entire summer remediation course. In any event, look at your remediation/retesting as an opportunity to hone this material well. You definitely want a strong knowledge base for your upcoming classes and you will have made some steps toward review in terms of preparation for USMLE. In this light, having to retake or remediate is not totally the worst situation that you can find yourself going through.

Plunge into your review with total concentration on the subject at hand. If you have one course or one area of subject matter, this is easier than if you have multiple subjects to remediate. Your only resolve in this situation is to not miss this golden opportunity to thoroughly master this material. You are not a “lesser person” because you need a second review and keep in mind, that you are reviewing at this point. In most cases, you have learned the material on the first shot but this review gives you insight into the material that you likely previously missed.

I am always more concerned about those students who “barely” passed than the students who failed and are re-mediating. In most cases, the student who re-mediates does not carry a knowledge gap forward while the student who barely passed likely has gaps in their knowledge base. It is those who barely pass that will need the most intensive review and preparation for board examinations. I always encourage students who scored below an 80% to study for and take any optional shelf subject exams if offered by their school. These shelf exams can pinpoint knowledge gaps that can be filled in before taking Step I.

Class Attendance - Is this time well spent for me?

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”.

Wasting time and less efficient practices

I 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 (or 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.

Striking a Balance

Finally, one key aspect of medical school, residency and the eventual practice of medicine is that you will have to constantly “strike a balance” between study, personal life and professional obligations. The first semester of medical school will definitely test your resolve to keep working away at your studies until you get them mastered but this should not be at the cost of your personal integrity or sanity. Try to find ways of incorporating some stress relief (physical exercise) and socialization (away from your classmates) into your life. Nothing, including the practice of medicine is one-dimensional and there needs to be balance.

For example, if you are studying in the library and know that you won’t make it to the gym, try to walk up at least 8 floors of steps on the days that you don’t get to the gym. Take 10 minutes and take a brisk walk around the corridors to get your brain relaxed before you keep “grinding” away at your study materials. Study and pace at the same time while reciting the material to yourself in your own words. Try making some study-drill tapes and drill yourself while you are on the elliptical trainer/treadmill in the gym. Finally, picture that professor’s head when you are doing your bicep curls or on the fly machine and pound things out. You will be more relaxed, less stressed and more efficient in your studies. In addition, you can enjoy eating without worrying about gaining weight.

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.

Failing Step I and how to get past this

2008-11-22T14:42:00.003-05:00

For many second year medical students, the prospect of taking USMLE Step 1 is looming "large" on the horizon. You have completed three semesters of pre-clinical science and the first step toward licensure as a physician rapidly approaches. Along with the exam and its preparation comes the thought of what will happen if you fail this exam. Statistics show that somewhere around 1/4th of people who take this exam, will not pass on the first try. While failing this exam happens, it's better to consider that 3/4ths of the people who take this exam will pass.

So what happens if I fail?

If you fail, you generally have the option of re-taking the exam. Most medical schools in this country will have you do some remedial work and will have you sit for the exam a second time will little consequences other than damage to your ego. If you fail Step I once, you can still practice medicine and you can still graduate from medical school. You have likely knocked yourself out of the moderately competitive to competitive specialties but you can still have a very satisfying career in the less competitive specialties.

The first thing that you have to do, if you open your test score report and find that you have not passed, is immediately figure out where you were deficient. The USMLE score report comes with a breakdown of where you lost points. You should immediately start your review in your weakest subjects/items. The next thing that you want to do is speak with your Dean of Education so that you can get an idea of the time frame that you have to submit a passing score. Some schools want a passing score on Step I before you can begin third year clinical rotations and some will allow you to complete a rotation that you have started.

Don't make the grave mistake of attempting to do clinicals and study for Step I. If you failed this exam once, you need to put your entire attention into a thorough and adequate preparation for this exam. You can't afford two failing scores here and thus, drop/delay your clinical rotations until you have passed Step I. It's not going to be easy or quick it terms of preparing for a retake so don't try to rush this process. As bad as one failing score looks, two failing scores can really kill your chances for a solid residency match.

Get the idea out of your head that you "are not good at standardized tests" or "that your career in medicine" is over. You just cannot afford this type of thinking. Your whole attitude needs to be focused on the task at hand, which is, passing Step I. If you cannot focus for a couple of days, then take that time to relax but depending on your school's schedule, you likely need to get back into the study mode fairly quickly. Take some time to come to terms with your non-passing score but don't let a non-pass set you into a "tail-spin" that prevents you from doing your best on a second attempt.

The other mistake that many medical students will make is believing that because they were able to do well in their medical school coursework, they are a "cinch" to pass Step I. This is not always the case as since I have been involved in academic medicine, it's not always the students with the weaker academic records that fail but those who have a "false sense of security" because of their academic record. Make no mistake, Step I takes some preparation and review no matter how you scored in your coursework.

Another thing that you likely need to do is enlist the assistance of your Dean of Academic Affairs. There is no medical school in this country that has never had a student fail Step I. Your Dean of Academic Affairs can offer some assistance in getting your study methods on track. There may be great resources available at your school that you will be able to access since you have a failure on Step I. Be sure to find every resource (many likely free) that is available to you.

Another mistake that many students make is looking at the pass rates of a previous class and thinking that there is no way that you can fail. If the Class of 2008 has a 100% pass rate and you are the only member of the Class of 2009 that fails, that 2008 pass rate hasn't helped you much. Passing or failing Step I is a personal matter and not class (or school) dependent. Either you have prepared well and performed well or you have not. These are individual characteristics and not school characteristics.

What kind of residency can I get with a failure on Step I?

If you pass on the second try, score some solid performances in your clinical rotations and perform well on Step II, you have a shot at a very good residency. No, you are likely not going to match into Derm, Ortho, Rads and Ophtho but you have a shot at solid programs in just about everything else if you post a good performance in things after your failure. Sure, it's not the best situation that you have failed this very important exam but your career is not over. There is still a substantial amount of "medical school" in front of you that will provide an ample opportunity to show that a non-pass on Step I (on your first attempt) was an aberration rather than a characteristic of how you perform. Some options may not be there for you but more options exist than you would believe. You simply have to get this behind you and move on with what you have left.

Getting and keeping your head together

Again, your first priority is to do whatever you need to do to pass this exam. You cannot afford to wallow in blame but need to gather your reserves and get busy. Sure, it seems like everyone you know passed without difficulty but you didn't pass and you have to pass this exam. The thing "is what it is". The reality is that while this hurts; it's not fatal. You can take this opportunity to learn what kind of reserve you have and how to thrive in adversity. These are characteristics that any residency program director would be happy to have in an incoming resident. Get your thinking together; enlist the help of your Deans and get this exam behind you. Performance on one license exam does not define your entire medical career unless you allow this performance to define your and your career. Sure, it's important but in terms of percentages, most people pass comfortably on the next try and move on to good clinical rotations and residency spots.
Final Thoughts

If you find that you failed Step I, get your resolve together to:

Get in contact with your academic Dean and Dean of Students.
Find out what options are there for you to allow you to focus on getting ready for your retake.
Put that non-pass into perspective and behind you; what have you learned "not" to do?
Get the idea that your "medical career is over" and that you can't match into a good residency program out of your head.
Prepare efficiently and properly so that you do not find yourself failing your re-take (or any other licence step ) exam.

This is not about you as a person, physician or anything else. You simply didn't pass Step I and you resolve to prepare and pass on the retake.

Playing the Waiting Game and Keeping Your Sanity

2008-10-03T09:38:00.002-05:00

Timing

You scrambled around and made sure that every one of your writers of your letters of recommendation did their respective jobs. You started your Personal Statement early and left plenty of time for editing and corrections. You started to fill out your AMCAS application as soon as it was available and you made sure that there were no mistakes. Finally, on the first day that you could, you pushed the submit button and the “waiting game” started. You had heard that in every circumstance, early application is the best strategy for success in getting into medical school. So now, you find that it’s early summer, school is out, and you are in for the wait.

Starting the Wait

Your next hurdle is to receive word that your AMCAS is verified. This can take six weeks or more if there were no mistakes or lost transcripts and can often take much longer if things are not moving efficiently. This step has to happen and it can cause worry if things are delayed. I can tell you that, in terms of medical schools, early summer is a non-time in terms of admissions. Most of our time is spent on getting the current class underway and gearing up for the start of receipt of new applications. For us, that early lag of time between when you can submit your application and verification is vacation time, organization time and just plain much-needed down time for us in terms of application review. It is also the time when we try to put the finishing touches on the class that is set for the new year.

The best strategy for you at this period is to make a folder for each school that you have applied to. In this folder, you will place copies of your personal statement, copies of any completed secondary applications one they have been received and completed and copies of any correspondence that you receive from that school. You can also put an envelop on the front of the folder with a copy of your itinerary once you have made travel plans for your interview. In any event, start making the folders and securing a safe place for them.

The next thing to do is make and Excel spreadsheet. On that sheet, you should make a book for each school that you have applied to. You will eventually log every date and every receipt of correspondence that you will receive. You columns should go something like date received, date sent, and date of school’s receipt. (Needless to say, anything that you send to a school should be sent by certified mail with receipt notification). Repository services such as Interfolio will also post dates of when they send your materials and when they were received. You definitely want to make sure that you keep your application materials and correspondence with each school very organized and safe.

Plan B

Plan B is what you will do if you are not accepted. In the business of medical school acceptance, nothing is a certainly except you won’t get accepted to a school if you don’t apply there. Acceptance, even if you have submitted an application with a 4.0 uGPA and 45 MCAT is not assured for anyone. It is wise to have a carefully though out and planned Plan B. From experience -mine and others- the more elaborate and complete your Plan B, the less chance you will have to use it. Start planning and working on you Plan B.

Financial Aid Forms

Right after you have submitted your AMCAS, you should begin and complete your FAFSA forms. You will need to obtain a financial aid transcript from every school that you have attended whether or not you received financial aid. If you are not applying for scholarship or financial aid for medical school, you can skip this step.

When you complete your FAFSA, have the results sent to every school that you have applied to. This will save you time in the long run. If you are not accepted, having your financial aid information sent is not going to make a difference one way or the other. If you are accepted late, having your financial aid information already in place can save plenty of headache when school starts.

Senior Year

If you are an undergraduate, you want to plan a strong senior year. I know that “senioritis” sets in and you are tempted to want to coast because you are done with MCAT and done with the majority of your courses but don’t do this. Take some seminar courses and expand your knowledge base or take some research courses and pick up some valuable skills. My senior year of university was spent writing and presenting my honors thesis work. This was actually great experience for me and propelled me into the world of research scholarship. Use that senior year to shore up any possible deficiencies that you might have and to finish strong.

This is also a prime time to begin a solid exercise program. My biggest regret in medical school was that I didn’t stay in good physical condition. If I had kept up with my conditioning, I would have been an even more efficient student and a student with far less stress. Take this time to start and hone a solid aerobic exercise system that you can complete in 30 minutes to 1 hour each day. It can be as simple as taking three 10-minute brisk walks or climbing a couple of floors of stairs until you work up to 14 floors daily (only up direction counts). Even today, I make sure that I do at least 14 floors up every day. I can find steps pretty easily and do a couple of floors between cases or when I need a break from my desk.

Early Fall

By this time, you should be keeping your senior coursework strong and completing all secondary applications within one week of receiving them. Another thing that you need to do is go to a professional photographer and have some professional head shots taken of you in your interview attire. You will need these for many secondary applications and you will need them later for things like USMLE application. Don’t use a cheap “Passport photo” service. These cheap services will take photos that make you look like you have been in prison. Use a professional photographer and groom yourself as if you were going for interview. That secondary application should look polished and professional. Once you have chosen a good photo from the proofs, have several passport-sized sheets made and keep these in a safe place.

Again, as soon as you complete and post a secondary, make a copy and place this in the folder for that school. It’s a good idea to make a copy of everything that pertains to each school including things from their website (names of deans of admissions, names of admission coordinators) along with dates of any phone conversations. Also place copies of any e-mails that you have received for each school.

Interview Time

Most schools spend July and August reviewing applications and interviewing Early Decision applicants. You can expect to receive notification that you are complete but not much more information from your schools. Early Decision applicants have to be notified by September 1 so their applications are processed first. After the first couple of weeks of September, some of the earliest regular applicants may be notified of acceptance by some schools. If you receive a notification of invitation to interview at this time, this is great but don’t read anything into not receiving an invitation to interview. At this point, it is way early and you should be either working on Plan B or working diligently on your coursework. In short, don’t start obsessing about timing.

Many schools will not even begin interview session until late October and early November. Again, if you applied in early June, it will have been a long time. Don’t get crazy and don’t begin to call schools. If you have received a “complete” notice, then you wait. Find something else to do. If you have an interview notification, then work on your travel plans and logistics. Elsewhere on this blog, you will find posts about traveling to interview.

If you haven’t heard from any school by the end of October, consider applying to more schools. If you were in the very early applicants, you may need to broaden the number of schools that you have applied to. A major mistake that many applicants make is overestimating their competitiveness for medical school. If you are not securely above the averages for matriculants (uGPA 3.65 and MCAT 31) then you likely need to add more schools. If you are above those averages, you can hold but you probably should have head from schools by now. If not, make sure that your application materials have arrived.

Holiday Time

You applied early and haven’t received any interview notifications. Yes, it’s easy to fall into the trap of being depressed but this is the time to plunge into the holidays and not get insane. Yes, I know that it’s only your future here but you cannot do anything more at this point. I will repeat in all caps for emphasis, YOU CANNOT DO ANYTHING MORE AT THIS POINT. If your application is complete then you have to wait. It’s a good time to plan your trip home for the holidays and take a breather from coursework.

January and February

These are very heavy interview months. You may find that the interview invitations will roll in at this time. Again, there is still plenty of time to receive an interview and receive an acceptance. This is also a time when many of the early interviewers will begin to receive acceptances. If you have done a couple of interviews but received no acceptance, don’t panic here either. Again, work on and finalize your Plan B.

If you are a dedicated reader of The Student Doctor Network, don’t obsess over the fact that others have been accepted but you are still waiting. Timing is out of your control and dependent on things like the number of applications received by the schools that you have applied to and the competitiveness of those applications. The only thing that you can do at this point is WAIT (dread).

March and April

By the beginning of April, some folks will find themselves on wait lists and without an acceptance. This is not entirely a bad situation though you may want to make a decision as to whether you will begin to collect the things you need for reapplication. If you need to do things like re-take the MCAT, you need to have gotten started on your study and planning for the test. You can’t wait too late and you can’t do a re-take without some significant review and preparation. The worst thing that you can do is post an MCAT retake with a mediocre score.

If you are on a wait list, remember that there is a huge wait list movement on and after May 15th. May 15th is the date when people cannot hold multiple acceptances. I always advise folks to release acceptances as soon as they have either been accepted by their first choice or when they have made the decision as to where they want to attend. I released my acceptances by the third week of February because I had made my decision. I am sure that five people were grateful that I did that because they were able to get in that year.

May and later

In general, after May 15th, you are not likely going to gain acceptance. There are exceptions, especially the schools with rolling admissions but by this time, you should either have an acceptance or gathered your materials for reapplication. You can look at my previous post on when to give up on application to medical school but if you don’t have an acceptance by now, you likely need to take an objective look at your competitiveness and do some application upgrading.

If you need more coursework, this is a good time to get registered for post bacc work. If you are planning to enter a SMP (Special Masters Program), then you need to get busy fast. These SMP programs have deadlines too. In short, these may become your new Plan B and you need to get to work. If you are on a waitlist at this point, it will not hurt you to go ahead and plan on reapplying. Sure, you will lose the money of submitting your application but if you are not accepted off of a wait list, you will be happy that you reapplied early.

If you reapply, change everything that you can change about your application. Do not apply to the same schools with the same application materials. We do compare old and new applications. If you were unsuccessful and submit the same unsuccessful application materials, you are most likely not going to be successful next year either. The average matriculant uGPA and MCAT scores have always gone up. Also, unless a school tells you that you need more extracurricular activity, you likely don’t need to add more here either.

Finally

You may want to look into the following:

1. Getting the services of a professional pre-med counselor. For nontraditional applicants who have been unsuccessful, this is money that will be well spent.

2. Taking more undergraduate coursework to raise your uGPA. If you are significantly below 3.5, you likely need a year or two of more coursework.
If you have an MCAT score below 28, you need a re-take period if you are applying to allopathic medical schools.

3. Making sure that you have applied to a wide range of schools. If you only applied to schools in the Northeast, you may want to go out of that region. You need a minimum of 10 schools if your are a strong applicant and 15 to 20 if you are less than competitive.

4. Don’t thumb your nose at osteopathic medical schools. If you are under the averages for allopathic but your uGPA is above 3.2 and MCAT above 27 but less than 30, you stand a good shot at osteopathic medicine. If you get into osteopathic medical school, you can have the same career as attending allopathic medical school. If you want to be a physician, they are definitely the way to go.

Medicine From The Trenches

2008-07-26T14:25:00.001-05:00

Why I chose Surgery (Part 1 and Part 2)

2008-07-18T12:48:00.003-05:00

Part I (an earlier post)
I can vividly remember starting my third year of medical school. My school chose our third-year schedules for us and I remember some of the angst of my fellow classmates when our schedules were posted during the summer between our second and third years. I was in the midst of a wonderful Pathology fellowship that I had received for scoring very high in my Pathology course. I was assigned to various Medical Examiners offices and to the Pathology Departments of a couple of very large teaching hospitals. I had been spending the summer doing everything from crime scene investigation to transfusion medicine to bone marrow transplant. It had been a great summer. I was very strongly considering Pathology and Transfusion Medicine as my specialty.

I stopped by my Dean of Academic Affairs office and was told to wait for my USMLE Step I scores. The school had received them before I had received them. I took a deep breath because I really hadn't prepared myself for facing the prospect that I might have failed that test. I sat in a chair outside the Dean's inner office and ran a couple of scenarios as to what I would do if I had failed. I would quickly sign up for a retest and I would only miss one rotation at the start of third year. Since I was doing Pathology, I could study in between cases and get my preceptors to help me with covering the material.

The Dean came out and handed me a sheet of paper. I had to just sit there in disbelief. Not only had I passed, I had done extremely well. I was on my way. It was hard to hold back the tears of joy because I had studied about two and a half weeks for Step I. My fellowship had the requirement that I take Step I by the second week in May and my last exam from second year was on April 28th. I would be starting third year and I would be starting third year on Pediatrics with one of my best friends as my rotation partner. Life was good... I found out later that two people from my class did not pass USMLE Step I. It was very sad because one girl ran down the hall screaming and sobbing when she received her score. That put loads of people on edge.

I started third year on Pediatrics. It was a good rotation and I received Honors. I really enjoyed taking care of patients and I was very popular with the residents because I could place IVs and draw blood. I had also spent loads of time with an excellent pediatric pathologist so I knew my congenital defects inside and out. I could interpret cath reports and I was quite comfortable in the Pediatric Intensive Care Unit. I had been a Pediatric-Perinatal Respiratory Therapist before starting medical school so the interns found me quite useful.

My second rotation was Psychiatry. This was one of my best required clerkships. I knew that I wasn't going into Psychiatry (you know these things early) so I was free to enjoy the rotation and pick up anything that I could. My preceptor was an excellent Consultation-Liaison Psychiatrist who exposed us to everything from the wards for the criminally insane to hard-core substance abusers to schizophrenics and other stuff. I earned another Honors grade and got some excellent experience. I learned above all that I was not crazy, my friends are not crazy because I spent loads of "quality time" around people who were genuine crazy.

My third rotation was Family Medicine. I had a great preceptor who even delivered babies. This rotatations was entirely office based but I learned to do prenatal exams and care for entire families. I also learned how and when to refer which is great stuff to know. My preceptor was extremely brainy and "pimped" me on just about everything. Turns out this was a good test for USMLE Step II because we either discussed or I had to report on most everything in Family Medicine that was on the shelf exam or on USMLE Step II. I received Honors for this rotation but decided that I really did not enjoy being out of the hospital too often. I also did not enjoy the slow pace of the office.

Holiday break came and I was happy to be done with shelf exams and rotations for five weeks. I knew that Surgery was coming up and my friends had warned me to be ready for two months of pure hell. The rotation is designed so that you spend your first month on General Surgery on one of two services: Trauma or General Surgery. I drew Trauma out of the hat and I received the condolences of my classmates. I figured, "you can do anything that you want with me but you can't stop that clock." No matter how bad, in four weeks, it would be over.

I was hooked on Surgery from my first case. It was a total colectomy with four females operating. My chief resident was female, the junior resident was female, the attending was female and I was female. We talked about shoes and Chanel suits during the case. I tied tons of knots and helped the junior resident close the incision. It was heaven. I found out that I loved Trauma and I couldn't wait to be on call every third day. I had the time of my life and I loved everything about surgery.

My next month was spent on ENT and then on Cardio-thoracic and Vascular Surgery. I scrubbed every case that was assigned to me and many cases that were assigned to some of my colleagues. I became hooked on Vascular Surgery during that rotation. I loved the detective atmosphere on Vascular and loved taking care of the patients. My chief resident on Vascular taught me some great pearls about making sure that even with an amputation, fashioning a well-constructed stump can make the difference between ambulating and not ambulating for the patient. It was great stuff.

After Surgery, I rotated through OB-Gyn. I hated everything about this specialty. This rotation became my only High Pass during third year. I just couldn't get into delivering babies and I wasn't thrilled with tubal ligations. I wasn't thrilled with spending too much time in the clinics and offices. The one bright spot was the Gyn surgeries which I excelled at. I learned the surgical anatomy like a sponge but I knew that this was not going to be the specialty for me.

I finished up on Medicine and Neurology. This would be my final sixteen weeks of third year. I was fortunate to have medicine last because this made study for USMLE Step II a snap. I totally enjoyed Medicine and Neurology but my heart was back in surgery. All of my Pathology experience really paid off because I aced these rotations and moved onto fourth year.

My faculty adviser was chairman of surgery and helped pave the way for my entry into this specialty. I was also co-president of the Surgical Society during my fourth year which also helped. My USMLE scores were good so this helped too. I had some awesome interviews and I landed at a great residency program. My experiences began there and they keep on.

As I continue to write, I will be posting more of my experiences.

Part 2 Why I chose Surgery.

As I moved through medical school, I knew that any specialty that I would enter had to have the following aspects:

Ability to have long-term relationships with patients
Ability to see every type of patient under a variety of circumstances
Practice in office, clinic, hospital, intensive care, operating room and emergency department.
Ability to handle a wide variety of clinical conditions
Ability to deal with both acute and chronic conditions
Ability to perform many procedures

The only specialty that met all of those requirements for me was Surgery. I also loved the aspect that I had to utilize my knowledge of both medicine and physiology to the surgical patient both preoperative and postoperatively. This was very appealing for me. I also utilize pathology and biochemistry to a great degree especially in my teaching of surgery and surgery practice. Again, this made surgery a very attractive specialty.

I definitely started out in residency with a strong interest in vascular surgery. Not only were the vascular surgical patients among the sickest in the hospital on any given day, I also loved seeing the immediate aspects of my work. Once you increase blood flow to an extremity that had previously been lacking blood flow, you see the immediate effects both good and bad. I also liked becoming very familiar with wound care and the healing of chronic wounds.

I had heard about the "surgical personality" and that some surgeons were very difficult to deal with but that never became a factor in my choice of specialty. I don't care if the devil himself is teaching me if the teaching is good. Fortunately for me, that was rarely the case and my knowledge base expanded exponentially with every year of training. Good teaching is good teaching and good faculty allow you to grow and learn from both them and your mistakes in a constructive manner. I also found that I could profit from the mistakes of others at time too.

The other factor that did not deter me from surgery was the horror stories that I had heard about the residency experience. Yes, sometimes I had to work long hours but those long hours yielded some of the best teaching of my life. Yes, I did miss parties and social events but that happens with any aspect of medicine and comes with the territory. Physicians often work long hours taking care of patients who are sick. If you don't like to take care of sick patients, medicine/surgery is not the career for you.

Finally, I have a very good life. I do something that is very interesting and I give my patients 100% at all times. I have encountered some physicians who were psychotic, neurotic, dishonest, unprofessional, racist, sexist, anti-Semitic and just down right stupid. The interesting thing is that I am none of those things and my life is good. Good will goes out from me to my patients and it come back to me in droves. Yes, I work very hard and under extreme conditions at times but I have been blessed with an even temper and a love of my fellow humans.

If you choose a specialty, choose for what you know that you will enjoy doing in most aspects for the rest of your life. If not, you have many years of misery ahead of you. Conditions of practice will change and your income is largely based, not in how hard you work, but on what third-party payers are willing to pay for your services. If you can't deal with this aspect of your chosen profession, get out as soon as you can.

If you choose a specialty because the rest of your classmates were in awe of you, you are likely going to be very unhappy in that specialty. Specialty choice is personal and your classmates will not be entering residency or practice with you. You, and not your classmates, will be the person at 0400h who is admitting that patient with the chronic condition, thousands of medications and multiple needs. You have to love that aspect of medicine/surgery as much as you love the other aspects of medicine/surgery.

Finally, you have to be a ethical and honest person. Showing up at the church door every Sunday does not make you a moral person if you know that deep inside yourself, you couldn't be honest with yourself, your patients or your colleagues. You may not "like" everyone that you work with or work on but you have to have respect for them and give them your best. In short, you can't be having a "bad day" unless you are on vacation. If you are prone to allowing external influences to influence you internally, you are going to have a difficult time medicine/surgery.

Especially with surgery, you will find yourself multi-tasking, juggling six or seven balls at once, shifting up and shifting back on a daily basis. That's the nature of the work and the challenge of the work. If you can't do this, surgery is going to be tough for you on a regular basis. In short, I have never had a day that was strictly "routine" unless I was just teaching for the entire day.

Finally, take some time and get to know yourself and your career needs because after all, this is YOUR career. Your parents, your significant other, your classmates or anyone outside of yourself, can't make this decision for you. You have to know your competitiveness for certain specialties (forget derm if you struggled with every aspect of medical school including boards) and you have to have a good idea of how competitive you are for programs within that specialty.

Also, remember that while residency is when you will hone your skills, it is a short period out of the length of time that you will actually practice those skills. Again, I heard that surgical internship was the worst time on earth but I actually enjoyed my experiences during internship. I heard that surgical residency was the worse time on earth but it wasn't. No residency program is going to be perfect but unless you encounter dishonest or illegal activity, you can live with residency. The clock is always ticking and time passes (quickly in most cases).

Residency requires hard work and hard study. In my case, during my first two years of residency, I studied far more than at any point in medical school in addition to getting my work done. At times, I was "bone tired" but I made myself read and study (minimally for 30 minutes daily). No, I didn't get to the gym as often as I would have liked and I didn't hang out late at night (outside the hospital) but I did live pretty well and my significant other saw as much of me as he could stand anyway.

You Can Go Home Again...

2008-07-12T15:55:00.004-05:00

This is going to be one of those posts about a nice experience that I had in the last couple of weeks. A few weeks ago, I was covering for one of my colleagues who was out of town at a meeting. He asked me to stop by an outlying hospital to check on one patient that he had there. This patient was going to be hospitalized for at least another four of five days and I was happy to look in on him for my friend who would do the same for me if necessary.

The patient was out of the room having a diagnostic study completed in the radiology department. A very distinguished gentleman was patiently waiting for him to return. He sat in one of the chairs at the bedside with a magazine on counter-terrorism (spy business). The magazine immediately caught my eye as someone I had known many, many years ago, was an expert on counter-terrorism and a writer. I introduced myself and said that I was the covering physician for my colleague who was out of town. The gentleman said that he was told that I would be the covering physician and introduced himself as a relative. I told him that his loved one would be back from radiology in a couple of minutes and that I would wait.

I also mentioned my old friend who was a writer and who was a counter-terrorism expert. It turned out that this gentleman knew my friend's writings very well. Their paths had crossed many times in the past. He was also able to tell me that my friend had moved to another state from when I knew him and that I should get in touch with him. I made a note on my "rounding sheet" with my friend's name and about that time, the patient returned from radiology.

A week or so went by and my secretary asked me about the name on the rounding sheet. "Was this a new patient?" she asked. I had to laugh and tell her "goodness no" but the name of someone that I knew in my "other" life long before medical school and even before graduate school. I told her of my life before college teaching and medicine and said that I had thought about the person from time to time but had no contact. I told her of the patient's relative and she looked up my friend's phone number, leaving it on an index card on my desk.

Last Sunday, while I was finishing up some of my paperwork, I called my old friend. He was not available at that time but he returned my call about 45 minutes later. I must admit, I was very happy to hear my friend's voice. He sounded much the same but was a very nice reminder of how everything in my life has prepared me for this profession. I believe that he was surprised that I had entered medicine and surgery because they were so far away from my previous life but I am reminded of how small our word is and how much one phone call from an old friend can just be one of the nicest things to happen.

I hope my friend's life has been as rich and rewarding as mine. There isn't a day that goes by that I don't pinch myself to make sure that I am not dreaming. I really love my work and taking care of my patients. I am honored that they place their lives and health in my hands and I never find this job routine. Even something as simple as doing a favor for a friend who was out of town has brought just a little extra joy in my life and the renewing of an old friendship that I thought long past. Enjoy the little things in life as they are precious.

Personal Statement 101

2008-05-17T13:39:00.000-05:00

Writing a personal statement can be a daunting task for many people who are not familiar with the process. By definition, a personal statement is something over which, you have total control. This is your area in the application process to make sure that any evaluator has a complete understanding of your ideas. Unfortunately, many people have great difficulty with expressing their ideas in a clear and concise manner. The key here is that your ideas give a complete and clear picture of you as an individual person.

Characteristics of Well-written Documents
Any well-written document contains an introduction or presentation of a hypothesis, evidence to support that hypothesis and a conclusion. If you have clearly stated or presented your case and evidence, the conclusion should be very easy to write and should stay in the mind of the reader. Unfortunately, conceiving and writing an introduction is the most difficult portion of personal statement writing for most people.

A well-written document is easy to outline or present in outline form. This is why starting with an outline is not a bad strategy for writing any document from personal statement to term paper. Outlines should be logical and should help your ideas from from one to the next as you present your evidence or data to support your original thesis or hypothesis. Most people mistakenly place too much information in their outline which makes their document difficult to understand after it is written. Your outline should be brief and should leave plenty of room for you to "flesh out" your evidence.

A well-written document contains good grammar and word usage. If your reading and writing skills have been "dumbed down" to the state of text messaging and sound bites, you are going to have a very difficult time getting your skills back up to a standard that is acceptable for a university-educated person. Being able to understand and utilize text messaging is quite useful in today's world of electronic communication but make no mistake, trying to use the same methods of communication to a professional school admissions committee that you would use to your "chums" is not a good strategy. A better strategy is to become literate in every level of writing and communication.

Getting Started
To get around the difficulty of getting started on your personal statement, write down a list of words or phrases that describe you as an individual. You can certainly start anywhere with anything such as your "likes" and "dislikes", your favorite activities, activities that you enjoy daily or do not enjoy, or persons that have strongly influenced you. This "idea" list need not be detailed but should be as descriptive or related to you as possible.

For example, if you listed your Uncle Andy as the person who had a strong influence on you, then under a subheading, list the characteristics and you and Uncle Andy share in common. If you can't list any, then Uncle Andy did not have much of an influence on you. If Uncle Andy was the person who helped you through a difficult struggle, then list some of the specific things that Uncle Andy helped you to gain insight that helped you through your difficulties.

Do not list autobiographical data such as I was born in Las Angeles California on December 1,1983 and grew up in San Jose. I am certain that a couple of hundred folks were born in LA on that date and several million have grown up in San Jose. Those are not unique factors though growing up in San Jose may have had a profound influence on you as a person but you have to list the things about growing up in San Jose that have molded you into the person you are today.

Were there any sentinel events that shaped you interest and drive to pursue medicine as a career? Many people have gone through a life altering illness or experienced the emotions of the illness of a loved one. If you use this type of experience to weave your personal statement, you have to be sure that you carefully weave this event into your character and experience. It is your experience that you need and want to elucidate.

Take Your Time with this Document

Writing your personal statement is something that needs to take many drafts and many revisions. It's a good idea to allow a minimum of five people (who know you well) to assist you in the editing of this document. If one or two of your personal statement readers are excellent writers, then you will be fortunate indeed. Allow them to objectively critique your document and allow them to change things. It is definitely certain, than you cannot be objective when you are attempting to write about a personal issue. This is where a good editor can help you clearly express your ideas and thoughts especially if they know you well.

The last thing that you should do is send your personal statement for edit to someone who does not know you or copy a personal statement from a website or service. By sending your personal statement to a stranger, you run the risk of them plagiarizing your material. You also give up some measure of your privacy which may come back to cause problems in the future. If you copy a personal statement from another person or allow a "service" to write your personal statement, they may be writing the same statement in the same style for several people. This can leave you open to plagiarism which will "tank" your chances of getting into medical school.

Admissions committees have plenty of resources for detecting plagiarism at our disposal. Don't take the risk or leaving yourself open to this type of error. It is far better to write your own statement, in your own style than to copy anything or allow anything to be written for you that you present as your own work. While ghost writers are common in today's world of celebrity authors, if you are not a celebrity, then you should not use a ghost writer.

Specialty Selection and Matching (Part II)

2008-05-08T17:10:00.001-05:00

This post is a continuation of the previous post and will feature more aspects choosing a specialty and matching into that specialty.

How competitive are you for your chosen specialty?
Medical student love to entertain the idea that once they have graduated from School X or School Y, they are going to be sought after for by program directors across the country. This might be true if you have done extremely well in your studies and on your board exams but in general, program directors look for people who have a solid work ethic, have an interest in treating patients and have the academic ability (as evidenced by performance in medical school/board exams) that they are going to be able to master the knowledge that the specialty demands.

If you have done the “bare minimum” to get through medical school and have just above the minimum pass on your board exams, you are not going to be very competitive for high end university programs or the surgical specialties. Many of the high end university non-surgical specialty residency programs are not going to be interested in you if you have attended medical school overseas unless you have multiple publications and extremely high board scores (even in that case, Americans who have graduated from medical school in this country are likely going to have an advantage.) Every program director in this country is looking for the best potential residents out there period. It is your job, no matter what your medical school performance, to convince the program and faculty that you are well suited for them.

Along those same lines, every program that interviews you is not going to rank you. If you have applied for residency and received under 10 invitations for interview, it is likely that you are not going to match into that specialty unless you either apply to more programs and to a greater variety of programs across the board. This situation usually happens when a candidate is marginal for a particular specialty and applied to high end programs only in that specialty.

If you are again, not a particularly distinguished graduate of your medical school, apply to programs across the board (community and university affiliated). Make sure that you have received at least 10 solid interviews in those programs across the board. There is nothing wrong with applying to some “reach” programs but you need to apply to some “non-reach” programs too. On the other hand, if you have applied to 20 programs and you have 20 interviews, you can probably cancel some of your later interviews as long as you have enough programs to rank the ones that you would seriously want to be your future residency program.

Some of the things that you need to take out of the equation are the comments from your fellow medical students. Everyone “hears” things about programs but if you visited the program, had a great interview experience and feel that you loved the program, location and all vibes, then rank that program. Even though you only get to see what the program “wants” you to see on interview day, unless you felt there was something very sinister that remained hidden, your impressions about a program are generally fine.

Program Problems
Programs that have undergone a leadership change are not necessarily bad programs. Sometimes leadership changes are the “shot in the arm” that a program needs to go from good to excellent. If you happen to interview at a program that has a recent change in leadership, look carefully at the enthusiasm for training and education of the new (or interim) program director/chair. If enthusiasm is lacking, avoid the program.

Programs with a large turnover of residents are definite red flags. If you see a program were most of the people who start do not finish there, something is wrong. It may be problems with workload, administration, resident support, working atmosphere or any number of things. Be sure that you ask any program about the percentage of people who start that finish. If they change the subject or even hedge on this question, mark them in the “questionable” category.

Programs that use the resident staff as “assistants” rather than programs that are dedicated to resident education and professional advancement are also problematic. Residency is teaching and the attending staff should have some strong teaching ability. A good measure of this is how the residents conduct themselves during your interview day. They should be unhurried and available to you for questions. They should be able to answer your questions without hesitation. Make sure that you speak with a good cross section of residents at every training level especially the PGY-1s and the ones that are about to graduate from the program. Speak with the lab residents too.

Places that have very poor facilities can also be a major problem for you. Try to see where the call rooms are located and if they are private and clean. As a resident at any level, you do not want to share a call room with either medical students or other residents. As an on-call resident, you should have meals provided and a place to keep your things such as a locker. Residents are employees but they have a crucial role in the running and management of hospital patients. If the rule is that the attending calls the resident, tells them what to write and then completely manages the patient while the resident does the paperwork and discharge dictations, you are not going to have a good learning experience at that program.

Some Final Thoughts
Application for residency is NOT the same as application for medical school. Program directors know that if you have finished medical school, passed your boards without too much difficulty and have a good work ethic, you are likely going to be a good resident. You don’t have to “pad” your curriculum vitae with things like extracurricular activities and club memberships but you should have good solid interest in the specialty that you hope to enter.

You should also have a very objective assessment of your competitiveness for a particular specialty/location. If you are not competitive, research (only if it is meaningful) can help you a bit but all of the research in the country (with the exception of a Nobel Prize) will not get you into Dermatology if you are in the bottom half of your class.

Also, don’t choose a specialty because your father and grandfather expect you to be a particular specialist. If they were orthopedic surgeons and you would rather die than be in the operating room, then don’t choose orthopedic surgery. You will be miserable and you will likely become a miserable orthopedic surgeon. If you love family medicine, then carefully choose good family medicine programs that seem to be a great fit for you both program size and location.

Matching and Specialties

2008-03-25T14:33:00.007-05:00

This is likely to be a multi-part posting but I thought that I needed to start to address this topic at some point. Speciality choice can be quite difficult for many medical students because some schools never quite spend much time on how to choose a speciality. This choice can be a source of life-long misery or it can become like a marriage with deep and passionate love in the early years only to be replaced with a wonderful familiarity that is both surprising and satisfying at the same time.

The wrong way to choose a speciality is based on what you will believe will be potential income. While it's generally true that surgical specialties are better paying than primary care specialities, this is not always the case especially if you find that you just don't enjoy surgery and surgical procedures after a while. Anesthesia has become very popular in the sense that people feel that this speciality pays well and had less hours than surgery but a description of Anesthesia as "hours of boredom punctuated with seconds of sheer terror" can be pretty accurate at times. Many people find that this aspect of anesthesia far outweighs any monetary rewards.

Another wrong way to choose a specialty is by how wonderful your medical school experience was in that particular rotation. While you may have loved your residents and interns, you may have not loved the patients that you were treating. This can make for a miserable residency experience and an even more miserable practice experience.

As you rotate through your required third-year clerkships, you may want to pay close attention to the types of patient that each speciality treats. Do you enjoy a long-term relationship with your patient and handling of chronic problems? If this is the case, then family medicine and internal medicine may be of interest to you. Do you enjoy treating only female patients? This brings to mind OB-Gyn but you may find yourself drawn to internal medicine with a track in women's health.

Do you enjoy procedures? You may want to investigate the procedure-heavy specialties such as anesthesia, radiology, orthopedic surgery, ophthalmology and invasive cardiology. You might also place any of the surgical specialties in this category. Finally, do you enjoy the outpatient treatment of patients? This might lead you to emergency medicine as EM spend most of their practice time dealing with outpatient issues with a bit of trauma thrown in. Dermatology is also a specialty that has far more outpatient care than inpatient care. Psychiatry can also go into that category.

Pathology tends to appeal to individuals who love to study tissues and medical problems. Pathologists do not treat inpatients and pathologists perform few procedures other than those pathologists who subspecialize in tissue banking and transfusion medicine. If study and evaluation of tissues and medical problems are appealing to you, look into pathology.

Another way NOT to choose a speciality is by what your classmates have to say about a particular specialty. Don't be drawn into the "the smartest people in medical school go into derm so derm is the best specialty". This might not be the case for you if you don't enjoy the scope of practice of the dermatologist. While dermatology is a competitive specialty, you may not enjoy much about this speciality other than the look on your classmates faces when you announce that you want to pursue Derm.

The telly shows such as "House", "ER" and "Scrubs" have also tended to glamorize certain specialties. Do keep in mind that telly watching is for entertainment purposes. There is little reality to any of these shows no matter how compelling the characters and patient situations. These shows are written by people who are generally not in medicine with input for practitioners. These shows are written with entertainment factor built into them. Most of actual medical practice is not entertaining.

As you study through medical school years one and two, you are creating the foundation upon which you will enter your third year. It is during that third year that you will be exposed to different specialties and their patients. It's good to keep an open mind during third year. Do not feel pressured to decide upon anything if you don't have an idea of what type of specialty might be of interest.

I can tell you from experience, that I generally liked every rotation that I encountered during third year. Basically, I enjoy the practice of medicine and patient interaction. I saw plenty of very interesting pathology and patients on OB-Gyn but I didn't particularly find this specialty appealing other than how I could learn to differentiate pelvic problems from abdominal problems in the course of seeing patients.

I loved my Psychiatry rotation and found the expertise of my preceptor far greater than any clinician that I have dealt with to date. I developed a very strong appreciation and high degree of respect for that multitude of psychiatrists out there that just do a good job taking care of their patients. While psychiatry was not for me, it was an awesome rotation that brought a depth of understanding as to how many medical and surgical problems might present with psychiatric symptoms.

As you go through first and second year, take the time to join one of two specialty exploration/interest groups at your medical school. By joining these groups, you ca expose yourself to residents and attendings that can assist with your exploration of their specialty. It is participation in these types of specialty interest groups that can allow you to keep your focus when you feel that you just can't look at another histology slide or review another article for biochemistry.

Also keep in mind that certain specialties do require a high level of academic achievement in medical school. I have often spoken to medical students who have struggled with a course or two in medical school who feel like doors have closed for them because they won't be competitive for a dermatology residency. My first inclination when I speak to theses folks is to find out if they actually understand the scope and practice of dermatology. If they do have this understanding, are there other less-competitive specialties that will satisfy many of their need? In the vast majority of cases, the answer is yes.

Finally, as a close to this little essay which is like a part one of this issue, if you know that you are not particularly competitive for a speciality that you feel you can't live without, spend some quality time with the program director/department chairman of that specialty at your school. Try to figure out if you have some options that can increase your competitiveness for said specialty such as research. There might even be a possibility of finding a program or two in that specialty that might be in a less desirable location and therefor less competitive.

Don't listen to anyone except yourself when it comes to your needs in terms of the practice of medicine. In the end, it doesn't matter what you classmates say about the specialty that interests you. It's how you feel about what you are interested in practicing and your suitability for said specialty. It's also about your attentiveness to your academics/boards too.

If you had a slow first year, try to have a strong second year. If you had a weak second year, then try to have a very strong third year. In short, you can decide at any point, that you are going to upgrade your work ethic and performance.

Dealing with patients you might not "like" for whatever reason.

2008-03-13T12:47:00.000-05:00

I received a call about a consult for placement of a temporary dialysis catheter in the Medical Intensive Care Unit. When I arrived I quickly scanned the chart (coagulation profile, patient’s medical information etc.) and entered the room of the patient who needed the temporary dialysis catheter. Just before I entered the room, one of the resident physicians pulled me aside and said, “This guy weighs 500 pounds and let himself get to this point. On top of that, he smells. I just want to warn you to have your gas mask ready”. He laughed and I “thanked” him for the information and entered the room.

Lying in the bed was a 500+ pound gentleman who was restrained and mechanically ventilated. In one hand was an intravenous line which was leaking intravenous fluid. He had a very large abdominal pannus (apron of adipose tissue), multiple scars on both arms and both legs with both legs having open venous stasis ulcers that had become infected. I walked up to the bed and spoke to this patient to explain to him that his kidneys were failing and that he was going to need to have a dialysis catheter to help them along. He nodded to me but I wasn’t sure he could understand. I explained what I was going to do and that it might be uncomfortable but I would use as much local anesthetic as needed.

The nurse told me that the small intravenous line in his hand was not going to be adequate and that it was the only source of IV access that the patient had. It was tenuous at best. I asked if the patients family was present and the nurse said that they were in the waiting room. I told the nurse to gather the equipment for both a central venous line and a temporary hemodialysis catheter insertion while I went to speak with the patient’s family.

The patient’s wife was sitting in the waiting room with her daughter. She was tearful and spoke lovingly about her husband. She said that as he gained more and more weight, he became immobile. Finally, she said that nothing could get him out of his room and that she had difficulty getting him to comply with medications for diabetes and hypertension. She said that he would become angry and depressed when she attempted to help him with his personal hygiene or care of his venous stasis ulcers. I explained the need for the central venous line and the temporary hemodialysis catheter. I also explained the risks and benefits of the placement of these lines so that she could make an informed decision. She asked me to do what I could to help her husband get back to health.

After washing my hands and washing the areas of the patient where I intended to insert the catheters, I used a portable ultrasound machine to locate both the subclavian vein and the femoral vein. Both were fairly deep because of the large amount of subcutaneous fat that was present in this patient. I was able to mark off some landmarks and get to work. With the aid of a couple of nurses, I used adhesive tape to tape as much of the patient’s fat out of my way so that I could get to my intended target. After 30 minutes, I had inserted a central venous line into this patients left subclavian vein after taking about 20 minutes to carefully prepare the site. The more time I spent in prep, the easier it would be to get the line in under the best and most sterile conditions. I also had asked the nurse to give the patient a small amount of sedation so that the whole experience would be a little less alarming.

I then turned my attention to the femoral vein. Since temporary hemodialysis catheters were very large, I chose a long catheter and moved closer to the inguinal ligament as the vein would be larger there. As with the subclavian vein, I used a large amount of adhesive tape and three nurses to hold this gentleman’s large fat pannus out of the way. I inserted the line and had great blood flow and return. I also carefully secured the line with locking tape and sutures. I wanted to make sure that the patient would not be able to easily “pull” the line if he became disoriented and unrestrained. I also gave the local anesthetic plenty of time to take effect as most patients are pretty still if they are comfortable.

After a chest radiograph to confirm that my lines were in good position (with no pneumothorax), I phoned the nurses to let them know that the lines were safe to use. I also had “blocked” the hemodialysis catheter with an anticoagulant and thus I let the hemodialysis department know that this line was ready for use. I spoke with the patient’s family and let them know that the procedures, while taking a couple of hours, had gone well.

For the next three days, I went into the intensive care unit to check on the those lines and make sure that they were working fine. I spoke with the residents who kept congratulating me on “getting the lines in the whale” and laughing about this patient’s body habitus. On the third day, I didn’t see the joke and I didn’t see where calling this man a “hippo”, “whale”, or anything other than a sick patient was necessary. I asked them why they felt obligated to demean this gentleman that they didn’t really know (because he had been intubated) and they were charged with treating.

One of the residents said that he just doesn’t like “fat” people because they don’t take care of themselves and won’t follow his direction. He said that they could follow a good diet, exercise and not end up using up our precious health care resources for something that they “did to themselves”. Another resident said that he could “stand” the smell of the venous stasis ulcers and that he had to get out of the room as quickly as possible. While I appreciated their honesty, I couldn’t help wondering why they didn’t have a problem with treating an alcoholic or a drug addict who had become ill because of self-inflicted abuse of a substance. I had encountered some “skin popper” IV drug abusers who had multiple cutaneous abscesses that smelled far worse than a couple of venous stasis ulcers.

I find it difficult to blame the patient for their disease. In my mind, just as a diabetic can’t make insulin, a morbid obese patient has a metabolic problem that is not under their control. By the time a patient winds up weighing 500 pounds, all personal control is lost. If you couple the massive weight with psychiatric disorders such as depression, one finds a very difficult and challenging patient with multiple problems that need to be addressed. I can’t just afford to “like” or “dislike” any of my patients because they need my help and not my judgment.
Two weeks later, I received a call from the hemodialysis unit secretary. The nephrologist wanted me to stop by the unit so that I could “speak” to this patient. He was off the ventilator and was not going to need hemodialysis as his renal function had greatly improved. When I saw him, he said that he remembered my speaking to him in the ICU. I was amazed that he would remember me with his condition but he remembered how I explained everything that I was going to do for him and how I spoke to him with respect.

I later heard from his attending physician that he entered a rehab center and was on his way to losing 100 pounds. His hypertension was greatly improved and his diabetes was managed by diet. Though he had a long way to go, he was moving along on his journey. Hearing this made me remember why I went into medicine in the first place. It is simply to help people regain their health.

I can’t make judgments on my patients because “there but for the grace of God, go I”. I have been given the privilege and opportunity to touch the lives of thousands of people. I have also been given the trust of those thousands to also have only the best of intentions when I treat them. This is what makes medicine like no other career on earth.

What do you want from a career in medicine?

2008-02-03T11:33:00.000-05:00

I am often asked why I decided to pursue a career in medicine; starting at a later age and with many demands both mentally and physically. Quite simply, I knew that I would enjoy those mental and physical demands because I love working with my patients to identify and help solve their health problems. When a patient walks into your clinic, office or you encounter them in the hospital, the most amazing relationship develops that you will ever experience. A person walks into your life and puts their health and trust into your hands. This trust means that you give your best knowledge in terms of figuring out their needs and meeting them.

Too many people will confuse what they see on the telly (House, Dr. Kildare, Gray’s Anatomy,Ben Casey, Scrubs, ER) with what is the actual reality of being a physician. There is little “glamor” in this job but there is loads of personal satisfaction in winning those hundreds of little “victories” that you will win over the course of a day. There is also the knowledge that if the health care system continues along the road that it has taken, you are going to make less money for every day that you work in the practice of medicine. The question that you need to ask is “am I willing to work this hard for this career?” If you can answer this in the affirmative no matter what the future holds, then likely you will have a satisfying career in medicine.

In no other career are you asked to be out of the work force for essentially 8 years just to be able to enter a job where you will be making less than minimum wage with an average educational debt of more than $150K. In no other career is your income totally dependent on the policies and regulations of private industry, government regulatory agencies, Congress and state governments. You have no control over what reimbursement will be for your services (those reimbursements have been cut every year in the name of holding down costs) while your costs of maintaining your practice have continued to increase dramatically.

Primary care (Internal Medicine, Family Medicine, Pediatrics and OB-GYN) have seen their ranks shrink in popularity among graduates of American medical schools for a number of reasons not the least of which is the extremely high costs of medical education, rising interest rates on loans and decreased pay. Those people who are yet to enter medical school and those who are yet to graduate face even more challenges in terms of just being able to make a living (purchase a house, pay off educational loans, open a practice). If you are not yet in medicine/medical school, you are likely (unless you enter the armed forces) not going to be able to afford to enter primary care because of past educational expenses. Along with that, add the fact that if you are not a very strong performer in medical school, you won’t be eligible for residency in one of the “money” specialties and thus, you will be scrambling to make a living even if you are able to get into medical school.

The American Medical Association has been extremely slow to organize and speak for the needs of the young physician. Most of the people (and I am thankful for their efforts) that are able to lobby, have been established physicians in specialties such as opthalmology who can afford to take a day away from practice because their loans are paid off and their homes are purchased and their children have their college education paid for. They have little in common with the newly minted physician who has a young family, a 10-year-old car from residency and a $2,000 a month loan payment in addition to rent (mortgage if they are lucky)and office overhead expenses. I remember my cousin, who is a neurosurgeon state back in the early 1990s that she had to make a minimum of $10,000 per week in order to keep her office door open. I am sure that number has increased (increased malpractice costs and office costs) while her payments have been decreasing. In the face of this, why would anyone want to enter this career? How would anyone afford to enter this career?

The answer to these questions are not easy but they are expensive both in time and energy. The truth of the matter is that you had better know as much about the day-to-day practice of medicine before you enter your pre-med curriculum because by the time you have finished your first two years of medical school, you have racked up too much debt to be able to do anything else. Little is taught about practice management/investment/finance either in medical school or residency. Medical school prepares you for residency and residency prepares you for practice.
Some people want residency programs to include more about practice management, marketing and finance but along came the 80-hour work week restrictions and thus, most residency programs are still scrambling to make sure that they can include all of the experiences that residents need to learn just to practice let alone add to what they need. The business of medicine is very complicated and growing more complicated daily with policy changes at both the federal and state level. It takes many hours to keep up and keep yourself informed.

This gets back to what do you want from a career in medicine? Financial/job security isn’t out there anymore. Definitely respect and admiration are not out there anymore. Hard work, long hours of study and personal and financial sacrifice are definitely out there and ahead. i caution anyone to look long and hard at this career because it’s not easy and there is no relief on the horizon. Be very, very sure that you have a realistic idea of what day-to-day life is like for physicians who are coming out today and not what you see on the telly. None of those shows are remotely close.

When should I "give up" on applying to medical school?

2008-01-20T12:16:00.000-05:00

Introduction
I was speaking with a group of undergraduate pre-med students who asked me when I thought someone should “give up” on seeking admission into medical school. My first inclination was to say that if medical school and medicine is your “dream” you should never “give up”. I thought a bit about what might be behind the question and I thought it might make a good essay topic for my blogs.

“Should”
I have never been a person who dealt in “shoulds” in terms of what might be the best situation for anyone’s life and life pursuit. If you want something and if really desire something, then pursue that “something” and make sure that you are in the best possible situation to achieve your goal. Any realistic (and the emphasis here is on realistic) goal is achievable in taking small steps daily toward it. Certainly, you cannot possibly reach anything if your are not moving “toward” it.

Long-term
The pursuit of admission to medical school and medicine is a bit like having more than 100 pounds to lose. You have to be consistent with your work on a daily basis or you are not going to see results. This means that everything “counts” and you can’t afford to “slack” or you won’t reach your goals. Your undergraduate work is an opportunity to set yourself up with solid and disciplined study skills that can take you into medical school and beyond. It is also an opportunity to learn how to learn and master coursework. Just as daily exercise and diet modification will lead you closer to losing that 100 pounds (ounces at a time), daily preparation/study and mastery of your coursework will lead you closer to your goal (one semester at a time).

As you have probably heard, this is not a “sprint” but a “marathon” and like a marathon, you can’t just lace up your running shoes and expect to finish a 26.2 - mile race without some daily training and preparation. If you are not comfortable with long-term goal achievement, then use your undergraduate to obtain the characteristics that will make you comfortable with long-term goal achievement.

Overcoming difficulties
There are plenty of physicians out there who didn’t start off strong as an undergraduate. Perhaps they had some maturity problems or perhaps they just didn’t have the academic skills for the pre-med coursework but the important thing is that they kept their goals in mind. If something is not working for you in terms of getting your coursework mastered, then change it.

You can decide at this very minute -even if you are on the verge of dismissal- that you are going to turn your academics around “by any means necessary”. The process of doing this “turn-around” can be a huge asset in terms of making you competitive for medical school but you have to be successful. Just thinking about getting your academics together (like dreaming about losing 100 pounds) won’t make it happen but taking some active steps toward changing your methods will get results.

Many students have gone from extremely low undergraduate performances to getting themselves competitive but the process is not easy or short. Again, it’s back to the daily and consistent work with constant checkpoints to make sure that you are keeping on track. Enlist the assistance of any study skills courses at your school; enlist the help of peer tutors; enlist the help of a good academic adviser. In short, get help from any resources that you can find. Often, your school’s counseling service can help you identify resources at your school that can help you. You have to take the first steps and be willing to make some changes. Why not make the changes because what you are doing is either successful or it’s not?
Just remember, undergraduate “GPA damage control” is a long and expensive process. If you know this going in, then you can prepare yourself for the long haul. Again, medicine is not a sprint, it’s a long-term goal.

“Deal-breakers”
There are some things that are very, very difficult to overcome. I place things like academic dishonesty, felony convictions and substance abuse problems. Most medical schools, even if you are sitting there with a uGPA of 4.0 and an MCAT of 45, are not going to be very interested in you with these things in your background. If you have a substance abuse problem, get it taken care of long before you anticipate entry into medical school. There are excellent substance abuse programs out there and you can’t hide from your problems forever. Medical school on any pharmaceutical substance (other than pharmaceuticals prescribed by a physician within the guidelines of established medical practice) is expensive and heading for a crash either physically or legally. Neither of these are things that a prospective medical school would like to deal with. In short, take care of what you need to take care of and educate yourself so that you can handle life without drugs of any kind. If you “think” you have a problem with tobacco, alcohol, uppers, downers and any other illicit substances, then you have a “problem”. Get your “problems” solved as soon as they are identified.

Living in the “Real “World
You are going to read (and hear) stories out there about John or Jane X who got into Medical School A or B with a GPA of 2.5 and an MCAT or 20. Those John and Jane X’s are very, very unlikely to be real people. The average uGPA for medical school matriculants in 2007 was around 3.65 and the average MCAT was around 31. This means that the further from those average on the low side that you are, the lower your chances of admission. Admission to medical school with a uGPA of 2.5 is not impossible but it is improbable since the uGPA averages have been increasing every year. Get your uGPA as high as you can period. Get the highest MCAT score that you can period.

There are also folks out there who would believe that if you are an URM (Underrepresented Minority) in medicine, that you can get into medical school with drastically lower GPAs/MCAT. This is simply not the case because you have to have something in your application that shows you are capable of mastery of a challenging medical curriculum. If you are a URM and far below the uGPA/MCAT averages, then you likely don’t have a competitive application. Do what you have to do, to make yourself competitive and be prepared to take some years to get this done. I don’t care what your ethnicity/race is, you still have to be able to get through medical school if admitted. Admission is no guarantee that you will complete medical school. If you uGPA/MCAT is low, get yourself competitive by whatever means you have at your disposal.

But when do I “give up”?
You must answer this question for yourself. Preparation, application and matriculation in medical school is a very expensive process. How much time and money do you have? If you are a re-applicant, what you have you done to significantly improve your chances of admission? Just reapplying to medical school to “show them that you really, really want this” is not enough. You have to make some improvements on your application before you spend that money to reapply. Again, take a realistic look at what might have kept you out and get it improved.

If your application didn’t work this year, rework everything that you can rework before you submit for a future year. If you are reapplying to the same schools, you especially need to change and improve everything about your application that can be changed. Get fresh letters of recommendation, rewrite your personal statement (I don’t care how wonderful you believe it is, it didn’t work) and take more coursework if your uGPA is very low. Retake the MCAT if that is holding you back. (Beware though, retaking the MCAT and scoring lower can be a death blow). What ever you do, be sure to make it an improvement and not a change for the worse.

Looking at other career options
Some people believe that if they explore other career options such as physician assistant, nursing or physical therapy, that they are somehow giving up their dream. Nothing could be further from the truth. Explore other careers and have a realistic appraisal of how competitive you are for those careers. You may find that one of those careers better suits you in the first place from the standpoint of time of schooling to what your actual interests/motivation for medicine might be.

I am not advocating for anyone to seek to be a physician assistant, nurse or physical therapist because they “couldn’t get into medical school” but I am advocating that you should have a career back-up that you can love and pursue. You may not be competitive for physician assistant, nursing or physical therapist or you may not be interested in these great careers but you can’t make an honest decision without career exploration first. You may find again, that these careers are a great option for you and a better option than medicine.

Parting thoughts
Finally, be willing to let any of your advisers take a long and hard look at your competitiveness for medical school. If you don’t get in, get input from any and every excellent resource that you can find. Your goal is success on reapplication and you want to do everything that is within your grasp to ensure your success. Only you can tell when it’s time to move on to another career option and it’s YOUR life to live as you wish. Enlist any and all help that you can to get what you both need and want out of life.

The pursuit of becoming an excellent physician is a long goal. There will be people along the way who will tell you what you “can” and “cannot” accomplish. If you know yourself, and have faith in yourself, you know that you can accomplish anything that you want. You have to be willing to “run your own race” and take care of your own “needs”. There are as many routes into medical school as their are medical students.
If you should decide that you don’t want to pursue medicine, then that’s the best decision for you. Don’t let your life’s dream be anyone’s other than your own. It takes a fair about of courage to stand back, take a realistic appraisal of where you are and make the decision to move on to something else.

The other thing to consider is that getting into medical school does not have an age limit. Just because you decide not to continue with the pursuit next year does not mean that you can’t do something else and revisit medical school application three, four or even ten years down the line. As long as you have the desire, the stamina and are willing to earn competitive credentials, then give yourself a couple of years to decompress before you dive back into this process. If something doesn’t “click” for you in 2006, it might “click” in 2009 because you are a different person with a different perspective.

Shadowing Me

2008-01-06T14:22:00.000-05:00

Some people have asked what may be expected of a pre-med student who is shadowing a physician. I thought that I would write a bit about what I provide and expect on this shadowing experience. The expectations of the physician and the experience of the shadower definitely vary but I hope that this description provides those who have not shadowed with some things that might make the experience better.

Legal Matters
I have a confidentiality sheet that all pre-medical and medical students must sign before shadowing me. It outlines the confidentiality rules such as you may not disclose the name, condition or any other identifying information of any of the patients that you encounter during the shadowing experience. It also outlines that your may not write on any patient document while in the hospital and it outlines that you will observe all rules and regulations as you are directed by the staff of the hospital. These rules are for protection of the privacy of my patients and are pretty clearly outlined before you come to the hospital.

Dress
I ask that shadowers dress in business attire for the experience. This includes suits for males and suit or dress and jacket for females. I don’t ask for white coat because I seldom wear one. I have a badge that identifies you as a Student Observer that you will wear on your jacket along with a name tag. My patients expect that you will be professionally dressed and they are made aware of your presence. If I am going to be doing any procedures that you will be observing, I obtain their permission before you are allowed to observe anything. The staff is quite aware that I have shadowers from time to time and are very helpful in terms of making you feel comfortable. They understand the process and are happy to help me make sure that you have a good experience.

What I expect you to do
I expect you to have some expectations of what you want to achieve in participating in this experience. You should write down a few objectives and have these ready for me to go over with you. Are you there to learn about my specialty? Are you there to learn about the practice of medicine in 2008? Are you there to discuss your chances of admission into medical school? Are you there because you need an additional letter of recommendation for medical school? In short, jot down a few objectives for your visit and have them handy.

I expect you to bring a copy of your Curriculum Vitae (resume). If you have a photo attached, so much the better but I take a digital photo of you and place it with my copy of the signed Confidentiality sheet. If I am writing a letter of recommendation, I like to look at the photo and make sure that I remember the person correctly. Sometimes people will ask for a letter several weeks after their shadowing experience and I like to make sure that I remember the person.

I also like for you to bring a copy of your Personal Statement (PS) and the medical schools that interest you. I usually read your PS before we begin the day and I often offer tips for making the document stronger. I also can provide some information about specific schools that might be helpful to you. I can also suggest particular schools that might be a good fit for you too. Again, I add your PS and schools list to the folder that contains the documents that I have mentioned above.

The Day
I usually have people shadow on a day that I am in the hospital ,clinic and teaching. While it’s a long day, it usually gives the shadower a good experience. I usually have folks come on the day when I am not on call and have a lighter procedure day. I want to you see some cases but I also want you to have plenty of time to ask questions and understand as much about my practice as possible. I also will send you a list of the cases that I have scheduled and a brief description should you want to do some research before you observe.

Over lunch, which I provide, we usually discuss your career plans and I answer any questions that you might have. Again, I usually have taken a look at your CV, PS and schools list. If you are yet to take the Medical College Admissions Test (MCAT), I usually offer some tips about preparation for this very important exam. Since you will likely sit in on one of may classes, I usually give you a copy of my lecture notes so that you can follow along. The class is a great time for you to meet some of my pre-clinical medical students or some of the third-years that are on my service. They usually have loads of hints and suggestions about application to medical school.

When the day is done, usually about 5 pm (just before evening rounds), I usually go over any questions that you might have and any expectations that you have of me that we haven’t gone over during lunch. If you need a letter of recommendation, I ask that you provide a deadline for me so that I can make sure that you letter is out in a timely fashion.

Most shadowers get a chance to participate in morning rounds, a few cases, in my clinic and sit in on a class or lecture. I think that while the day is pretty full for you, it gives you a fairly realistic idea of what this profession involves. After all, this is your shadowing experience and you have a short period of time to make the most of your experience. I also feel that you need to have exposure to the daily routine of what I do so that you can compare your shadowing experience with me to others that you might have. Again, this gives you a more realistic experience.

Finally, I do have people who come back for a second day sometimes. These folks usually have shadowed me early in their undergraduate career and now want to spend a little more time working on buffing their application before they submit it. I certainly do not ever have a problem with this. I definitely recommend that people shadow at several stages in their undergraduate career as sometimes the shadowing experience can hone your desire to pursue medicine if you were unsure the first time around.

Good sources of names of physicians who will allow you to shadow are the local medical societies in your locale. Most local medical societies will have lists of physicians who will work with you. I know that in many large metropolitan areas the city medical society will make all of the arrangements for you. This was how I was able to shadow several physicians before I entered medical school.

Another source of physicians who will allow you to shadow would be any medical schools that are nearby. You might contact the individual clinical departments of the medical schools which may be able to match you with the name of a physician or two that would allow you to shadow. Other resources are your family or personal physician who may provide this service or know a colleague or two that might allow you to shadow.

The important things to do are:

Have a list of objectives that you want to accomplish on this visit.
Find out what the dress code will be, what time you are expected to finish and what the daily agenda will be.
Have a copy of your CV, personal statement and list of schools if possible (attach a small passport-sized photo) to your CV.
If you need a Letter of Recommendation, be sure to provide a deadline, an address as to where the letter should be sent and if the letter is going to an individual or a committee.

The last thing is to enjoy your experience being mindful of the person who is allowing you to shadow them. This means being mindful of the confidentiality of their patients and send a letter of thanks when you are done.

Academic Excellence

2008-01-05T15:25:00.000-05:00

For many people in both medical school, graduate school and undergraduate school, this is the beginning of the second semester (or quarter). If you are new to your academics, then you finished the first semester/fall quarter with some academic achievements (good or bad) and learned some things about yourself. Since this blog is about strategies for success in medicine (getting into medical school, staying in medical school and other things associated with medical school), I though I would post a note or two about making changes that can enhance your Academic excellence.

Doing well in academics is something that can be mastered with practice. It comes out of having a strong and solid approach to what you have to master in terms of knowledge and it comes out of having a high comfort level with the learning process. If you always feel that you are somehow “not going to be able to get everything learned” or that ” the course is too hard”, then your beliefs can become a self-fulfilling prophecy. There is no task, no matter how great or how formidable, that cannot be approached by taking small steps every day until it is conquered. You have to be willing to “chip away” on a daily basis and note your progress on a daily basis in order to see that you are handling the larger task in smaller steps.

Let’s take Organic Chemistry for as an example. At the beginning of the year, your professor hands you a syllabus that outlines the lecture schedule, laboratory schedule and exam dates in addition to what is expected in terms of how you will be graded in the course. Usually your grade is the result of your grades on some combination of exams and projects. Armed with this information, the first thing that you need to do is make a master subject calendar of lecture topics and test dates. Also include things like “one week to Exam 1 ” and “2 weeks to Exam 1″ along with “3, 2 and 1 week to project due” so that when you look at your calendar daily, you know exactly how much time you have to master the knowledge for the material on your exams/projects.

The next thing to do is look at your reading and problem assignments each week for your lectures/topics. Some topics have many problems and some don’t have so many problems. Divide and conquer here by looking at the amount of time alloted for each topic. This should give you a good idea of the importance of each topic. Your textbook is a good resource in terms of looking at how much time and space it devotes to a particular topic. For example, look at functional groups of organic compounds. This is a topic that can be divided into families with the simpler families being presented first and the more complicated families being presented later. You can use your text to add upon your knowledge base.

The other thing that you want to do is be sure that you are prepared for each lecture. Don’t go to class with the idea that you can sit there, listen to the lecture and learn what you need for mastery. You need to know something about the topic before you hear the lecture. The best way to do this is to read about the topic before you hear the lecture so that you know something about the items that will be presented. Don’t every walk into a lecture “cold” as 50% of your actual studying can be done in your preparation for you upcoming lecture. The other 50% comes in your digestion of both the reading and lecture in addition to any problems that were assigned.

A point about problems and problem solving. With any problem that you are given, try to figure out what learning concept is behind the problem. For example, look at the wording of a problem and then review the concept that applies to that wording. Consider the problem, in diabetic ketoacidosis, glycerol is primarily used for what? To answer this problem, you need to know something about the biochemical derangements that take place in diabetic ketoacidosis. In diabetic ketoacidosis, the patient is acidotic which implies that ketone bodies have been released and have lowered the pH of a patient’s blood. What else do you need to remember? You need to remember that while the blood sugar is high, the patient does not have adequate insulin which allows glucose to enter the cells and undergo glycolysis and be used for fuel. That leads you to thinking about why the ketone bodies are out in the blood stream in such high quantities in order to cause acidosis. This because the brain primarily, needs to have a constant fuel supply and in the face of a huge amount of glucose in the blood, none of it can be used by the brain because there is no insulin to allow the brain cells to take up the glucose. Now what do you need to know about diabetic ketoacidosis in addition to the above and that is that fat is being catabolized into acetyl Co-A that is being used to make the ketone bodies and that the fat comes from the breakdown of stored triglycerides into fatty acids and glycerol. The fatty acids can undergo beta oxidation to acetyl Co-A and then shunted into ketone bodies but the glycerol goes to the liver as a substrate for gluconeogenesis or the making of glucose. In the face of large amounts of glucose in the blood, the diabetic can’t use that glucose to feed their brain and thus they are making more glucose in addition to ketone bodies which are acidic. This is the concept behind this problem and why you need to approach problems like this or questions like this from many different angles rather than just memorize the answer. You have to be able to master the concepts so that in any manner you are questioned, you can figure out the correct answer not attempt to rely on you memory.

The next thing that you must think about is that you have all of the tools that you need to master your coursework under the conditions that work best for you. Don’t compare yourself to anyone in your class. Some people are visual learners (tend to sit in the front of the class) and some folks are aural learners (tend to sit in the back to avoid aural distractions). Most folks use a combination of both visual and aural and thus learn best when they utilize both methods. If you are a visual learner, then make a brief outline of the material to be covered in lecture and take a note here and there. Don’t try to write down every word that the professor says but watch how the material is presented and fill in your notes later. If you are an aural learner, listen to the lecture and take a note here and there. Listen for inflections in the professor’s voice. Listen for key phrases such as “in summary” or lists of important topics. If you worry that you will miss something, take a small digital recorder with you and record the lecture. You can then upload it to your lap top and it’s there if you need to review concepts.

In short, if you have managed to get through first semester, you have every tool that you need to excel second semester. You may need to adjust some of your study habits or you may need to fine tune others. The important thing is not to dwell on what anyone else in your class does but to do what you need to get the results that you want. There is no class invented that could not be mastered because after all, someone had to come up with the facts and concepts for the professor to present. Don’t go into any of your courses with preconceived notions that the course is too “touch” or is a “weed-out” course. The coursework is there for you to master and you have to figure out how you will master it.

Another common mistake that many students make is relying on their perceptions of the professor’s like or dislike of them personally. No one who is lecturing actually cares about you as a person. They don’t have a personal relationship with you, and if they do, it doesn’t matter in terms of the presentation of the material to be mastered. The material is there and it doesn’t care about you or the professor or whether or not you “like” or ”dislike” the subject matter. If you spend the dollars in tuition, then that alone should be enough for you to have a vested interest in mastery of the material that is presented. In short, you need to get your tuition dollar’s worth out of this class for whatever reason. Whether you ”like” or “don’t like” the way the professor talks, looks, or anything else has no relationship to how you deal with the material that is presented. The professor is not your main source of knowledge but someone to help you navigate (by their experience) though mastery of this class.

Finally, you can decide in this very instant, that you will change your “thinking” in terms of how you approach your coursework. You can approach your coursework from a point of fear and trepidation or you can approach your coursework from the standpoint of “hit me with your best shot because I can hit it back and score”. You can decide to toss old habits of trying to “cram” at the last minute and replace them with solid organization and daily study. You can decide that you will either adapt a lifestyle and study style that will allow you to become an excellent scholar or you will continue to do what you have been doing that doesn’t get the academic achievement that you want. The key point is that you are the complete master of your thoughts, actions and reactions.

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

2007-12-23T12:22:00.000-05:00

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.

Timing
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.

A Memorable Patient

2007-12-14T18:15:00.000-05:00

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.

Thanksgiving

2007-11-22T10:43:00.000-05:00

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.

Selecting Medical School Applicants for Interview

2007-10-31T11:55:00.000-05:00

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.

Some Perspectives from Teaching students

2007-09-30T10:51:00.000-05:00

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.

Getting Through the Semester

2007-09-28T10:21:00.000-05:00

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.

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

2007-08-31T19:06:00.000-05:00

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.

Surgical Clerkship 101 (Part 3)

2007-08-12T13:12:00.000-05:00

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.

Surgical Clerkship 101 (Part 2)

2007-08-11T11:36:00.000-05:00

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”.

Surgical Clerkship 101 (Part 1)

2007-08-10T14:04:00.000-05:00

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.

Gross Anatomy (Revisited)

2007-08-05T11:09:00.000-05:00

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.

Study Skills Part IV

2007-07-31T10:06:00.000-05:00

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.

Strategies for Mastery of Organic Chemistry

2007-07-17T13:52:00.000-05:00

For many pre-medical students, Organic Chemistry represents a monumental hurdle that must be crossed painfully. This need not be the case if you can change your "thinking" about organic Chemistry. I will be the first person to say with great conviction that I was not a "carbon-friendly" chemistry major but I had a passionate love of the subject matter of chemistry and organic chemistry was but one more course that added to my knowledge of the subject matter that I loved. I ended up performing very well in Organic chemistry even though it wasn't my favorite course in chemistry.

Organic Chemistry is the chemistry of carbon-containing compounds. It is not the basis of Biochemistry, though both chemical disciplines share carbon as a component for many of the compounds that are studied within each discipline. O-Chem is centered around carbon and the special characteristics of carbon-containing compound families while B-Chem generally looks as structure, function and characteristic reactivity of macromolecules that contain carbon. This is why I could happily study B-Chem in graduate school and not be a particularly "carbon-friendly" chemist.

O-Chem starts out with the special atomic characteristics of carbon that are responsible for it's bonding and reactivity. There are plenty of explanations of reaction mechanisms that must be mastered and absorbed as these basic reaction mechanisms will present themselves repeatedly as you move through the course. Rather than look at them as abstract and in isolation, learn them and be able to recognize them as a recurring theme as new carbon-containing families are presented. In short, you should be able to look at the way electrons behave in the various mechanistic schemes and apply that knowledge to new reactions as you encounter them.

O-Chem has a specific vocabulary that includes terms like nucleophile, electrophile, substitution, replacement, degradation etc. It is a very good idea to keep a list of the new terms as you encounter them and make sure that you understand them within the context of your o-chem study. One of my techniques was to take class notes on the left side of my spiral notebook. The right side was reserved for adding notes from my textbook and for working problems. I also kept a running tally of terms by leaving the last ten pages of my spiral notebook clear and using those for listing new terms and their definitions. I would circle in red, the new terms that I had defined in my notebook glossary as they were mentioned in my notes.

O-Chem requires daily study while you are taking the course. You need to review the previous lectures and notes, preview the next lecture and study the current lecture notes within the context of how they fit with the assigned reading and problems. Always look at an o-chem problem by making a note of the concept that the problem will be illustrating. Every o-chem problem or synthetic scheme has a concept behind it. Make a practice of noting these as you work the problems and studying the concepts as you work the problems.

O-chem also builds upon previous principles. For example, as you are introduced to the simple alkane family of compounds, the characteristics of this family should be compared and contrasted to the alkenes, alkynes, aromatics and other families as they are introduced. Make yourself get into the habit of reviewing summaries and characteristics of each old family as new families are introduced. This will greatly help you with synthetic schemes and problem-solving.

Before you go to lab, you should sit down with your lab book, write out a simple outline of each experiment with a listing of the steps that you will be doing. You should do any pre-lab exercises and review any topics in your text as they relate to your experiment. Many organic labs require that you answer post lab exercises, write up a report and submit these for grade. Look over your post experiment questions before you begin the lab so that you can be sure that you have obtained the proper observations that will enable you to answer these questions easily.

If you are required to keep a laboratory notebook, make sure that you include the following:

The purpose of the experiment
The experimental procedure
Your data (tabular form is a good way to present this
An explanation of your data that includes possible errors
Any spectra (NMR, GC, Mass Spect that you obtained
A summary of your observations

Don't record data on little scraps of paper! Those little paper scraps can get lost and your grade will suffer. Get used to preparing for each experiment and recording your data directly into your laboratory notebook. I used to take photos of my experiments as I went along and pasted these directly into my laboratory notebook so that my instructor knew exactly what my reaction setup looked like as I progressed through an experiment. I also pasted my NMR spectra and GC results directly into my lab notebook with annotations and directions to my conclusions about their appearance.

As you encounter a new family of compounds, look at their reactions and usefulness in synthetic schemes. Again, you may want to keep a running list of characteristic reactions of each family as they are presented. With each lecture, link to the previous lecture and study a whole weeks worth of material and data on the weekend.

O-chem is a preview and practice course for many of the courses in medical school. The manner in which you approach your o-chem will be good practice for medical biochemistry, pharmacology, microbiology and pathology. These medical school courses build heavily on their introductory concepts just as o-chem builds upon the concepts that are presented at the beginning of the course. Like o-chem, these courses require daily mastery and will increase your vocabulary exponentially.

What you cannot do with o-chem or any other pre-med course is decide mentally that you cannot master this course or that it's a "weed out" course in which the professor is out to "destroy your career". No professor has the time or energy to care about working to destroy any particular student. While there are good professors and poor professors, the material to be mastered in o-chem or any other subject, does not change. Don't let your feelings about a particular professor distract you from the business of learning.

Learning to tune out your fellow classmates i.e. those who whine, complain and otherwise attempt to distract you, is another good characteristic to develop. Some immature folks are going to brag that they "never study and get As" or that "the professor doesn't give As" or my personal favorite, "you can't possibly earn an A because you are not that smart". Don't buy into any of this stuff. Look at the course syllabus as soon as you get it. Look at the requirements for each grade and decide that you will meet them. At the first sign of trouble, get some help.

Check out the O-Chem help site at Frostburg State University. This site is under construction but can be an excellent adjunct to any o-chem coursework. Use the site as a tool not as a substitute for attending class and working your assigned problems. The URL for the site is: http://www.chemhelper.com/ This site requires registration but has a message board, discussion forums and plenty of resources for any o-chem student. In addition to this site, there are likely others too including possibly one at your school so utilize them as you need them.

Don't underestimate the value of attending recitation sections and tutorial sessions. These sections/sessions are great opportunities to get your questions answered or reinforcement of your knowledge of the material as you learn it. Don't skip these sessions and don't skip class. Utilize the office hours of your professor and make an appointment for a consultation at the first sign of trouble. Don't wait until a couple of days before the exam to seek help.

Keep up with your homework and studies. Again, I cannot overemphasize the importance of keeping up and not getting behind. Few people fail or do poorly in o-chem because they cannot understand the material. Most people struggle because they get behind and cannot catch up. Don't get behind and don't skip class. If possible, get ahead of the class and stay ahead. If something comes up that takes time away from your daily study, take care of it quickly and get back on track. If you are taking o-chem during the summer, skipping even one day of study can be a "deathblow" to your total course performance.

Finally, get a copy of the Biological Science Topics for the MCAT(o-chem starts on page 12 of this document) and make sure that you are systematically checking the topics off from both your General Biology and o-chem course as you go along. This document can be downloaded at : http://www.aamc.org/students/mcat/preparing/start.htm Go to the Tests Sections and download the topic lists (pdf documents) for Biological Sciences, Physical Sciences and Verbal Reasoning. These three documents can help to keep you on track as you move through all of your pre-med coursework.

Getting off to a strong start

2007-07-15T05:29:00.000-05:00

After the heady experience of orientation, it's time to get to the business of medical school. The classes will start, syllabi will be handed out and lectures will be available for download. It's time to "Go Live" and get off to a strong start. At this point, you should have your living arrangements settled (at least for the first semester) and you should have a pretty fair idea of how your class time will be utilized during the first semester. Now, you have to get into some kind of a routine.

As I have mentioned in other posts, you need to be thoroughly prepared for each class before you enter the classroom. The volume of material will not allow you to sit in lecture cold. This preparation means having your text/syllabus reading done before you hear the lecture. In addition, you need to have thoroughly mastered the previous lecture's material before you move into the current lecture's material. Gone are the days of sitting down on the weekend and learning the previous week's work. Studying and learning are daily "friends" once you reach medical school.

You are going to hear differing opinions on class attendance. Some schools have mandatory attendance while others don't care except for the occasional mandatory session. If you have signed up for a problem-based learning curriculum, you are going to be subject to mandatory attendance. In general, if class attendance is optional, attend class until you find that you are more adept at mastery of the material on your own or when you feel that your learning is being slowed by the lecture.

When students are sitting in lecture, they are listening to the lecture material being presented in an aural manner. Their isn't much mental processing of the material unless you have a base to which your are mentally linking as the lecturer presents the material. Most of the "learning" of the lecture material will take place when you go home and review the lecture presentation.

Some students will sit in lecture and "personalize" the material as the lecturer presents. This is generally a distraction and leads to those "sometimes annoying" classroom debates between one student and the lecturer. When I was a freshman medical student, these debates would generally occur during out psychiatry lectures when the professor would present a controversial theory or treatment. There was always one or two students who felt the need to be the "moral pulse" of the class. The rest of us learned to tune out and tune back in once the lecturer got back on track. Most experienced lecturers are adept at redirecting but occasionally, these interludes could go on for several minutes leaving me time to pour a fresh cup of coffee (or water) or take a breather.

For many students, taking notes seems to be oppressive. Don't fall into this category. There are very few notes that must be taken for the most part. Don't fall into the trap of thinking that you need to take down every work that comes out of a lecturer's mouth. When this happens, you become more clerical than engaged in information acquisition. You need only write a word here or there as most lecturers will have downloadable handouts/slides. Once you reach the point of figuring out how the lecturer approaches the subject matter, you can take a word here and there to direct your learning later on.

If you are a participant in a problem-based learning curriculum, you will have to become adept at linking medical concepts. I can tell you that by the time your first two years are done, you will become nauseated at the mention of the words "learning issues" and "learning goals". While problem-based learning (PBL) is admirable, sometimes one or two group members - usually the loudest and less shy - can dominate conversations or delay progression. At this point, an excellent facilitator (another word that will bring on nausea) will intervene but sometimes the group dynamics can get in the way of obtaining the information that you just need to learn.

Other things to think about are time-management in general. Yes, there are only 24 hours in the day and you will need to sleep at some point. I did find that after a couple of weeks, I could actually study when I was tired and that more coffee was not necessarily going to keep me awake. Having and keeping a fairly detailed daily schedule that included timing for the necessities of life (sleeping, eating etc) was helpful but there are going to be some days when the schedule is going "out the window" and your time will be spent in less productive ways. (You want to try not to have too many of these types of days). When this happens, forgive yourself, forgive the person (s) who wasted your time and get back on track as soon as possible.

Getting enough sleep is going to become something of an experimental journey for you. Resist the urge to listen to people who say that they "go for days on 1 hour of sleep" or the people who say "if you are sleeping 8 hours a night, you are not studying enough". Both of these are extremes and you will find that some the amount of sleep you "need" is just that, the amount that you "need".

If you are drowsy most of the daylight hours, you are probably not getting enough quality sleep. If you are drowsy when the lecture hall is too warm and dark and the professor's voice is monotone, you are normal. If your sleep quality is not good, be sure that you are getting enough "de-stressing" (physical exercise is good for this) or getting enough rest (being overtired can disrupt your study efficiency).

If your sleep pattern is disrupted, try some good sleep hygiene such as getting in bed at the same time every night. Don't try to read or study in bed (keep the bedroom for sleeping and recreation). Don't have a television in the bedroom (Ok, but un-plug it). Avoid coffee, tea and high caffeine "energy drinks" within four hours of bedtime. Avoid exercising before bedtime as it can disrupt your sleeping patterns as do naps of more than 45-minutes in the afternoon.
Be sure that your bedroom does not contain molds and too much dust. If you have allergies, these things will decrease your sleep efficiency and disrupt your sleeping patterns. Clean and dust your bedroom on a regular basis. If possible, wash your pillows monthly too.

Finally, forgive yourself if you find that your don't have everything together perfectly for the first set of exams. Adjusting up or down is part of the adjustment phase of medical school. You are definitely going to find that some subjects will demand more of your time and some will demand less. In the beginning, keep up with everything but generally give the time where it is demanded most.

Don't try to "explain" your schedule or study needs to anyone. Every medical student is different. If you can get through the semester, get the material mastered and get some stress relief on a regular basis, then you have gotten off to a strong start. Your family is not going to understand the pressure of your daily routine so don't expect this understanding. Your classmates will understand and your professors (to a certain degree) will understand but searching for "understanding" is largely counterproductive outside of medical school.

Start strong and finish strong but in the first few weeks, just get the start under your belt. Largely the study skills that you have brought with you from undergraduate/graduate school will work in medical school. Do realize that you are human and will make mistakes. At the beginning, there are no fatal mistakes so use this time to "ratchet up" or "ratchet back" until your reach your optimum.

The best words of advice that I received as I started medical school were "you create your own success and you create your own luck". Don't overanalyze and above all, don't be afraid of the task that is in front of you. You will adjust and you will have some successes. Overall, you just have to be willing to make adjustments daily and adapt.

Orientation Week

2007-07-01T09:29:00.001-05:00

You have received your acceptance letter and sent in your deposit. You now know where you will be attending medical school in the fall -or should I say late summer. The next step in your adventure will be Medical School Orientation Week. Why does it take a week? How about Orientation Day and then you can get to the business of getting started with first year of medical school.

Orientation Week usually starts out with some type of "check-in". In my case, the Dean of Students called names from a roll. We had previously been warned that if we were not present for roll call, our "seat" would be given to the next person on the wait list. Needless to say, everyone was present and accounted-for that morning. Following roll call, there was the obligatory introduction of the Deans. This was followed by a speech given by a speaker that was chosen by the second-year students the year before.

By the time the introductions and speeches were over, the greater part of the morning had disappeared. There was a meeting of your second-year advisers (second-year medical students) who would share their advice on navigating the curriculum. This meet-and-greet was filled with horror stories about certain professors and warnings about behaviors to avoid. With some of the tales of woe, I wondered how anyone survived the first year and made it into second year.

My own second-year adviser was a lovely but quite young lady. She was the daughter of a registered nurse and was very enthusiastic about all of the adventures that she had experienced in first year. She and her tight-knit group of friends, gathered us together and spoke to us (their advisees) as a group. We were able to get the benefit of a collective experience rather than single reports. This turned out to be a blessing. My second-year adviser also led me to her car where she presented me with a cardboard box of old exam, used and filled-in course syllabi and her books from first year. "I started putting this together for year after my first exams last year", she said almost apologetically. I was speechless but thanked her profusely. That box turned out to be one of the major keys to my success during my first year. I happily passed on her stuff and mine to my two advisees when I became a second-year student.

After our meetings with our second-year advisers, it was time to get our photographs done for the student directory. We lined up and had out photos taken by the medical photography service. Following the photo for the student directory, we were taken to the Student Services building for photo identification cards. Our physical examination papers were collected along with our immunization records as we moved from Student Services to student health. Once we had accepted admission to medical school, we were told to bring proof of immunization and undergo a physical examination by a physician. (My uncle took care of this for me, had his office staff copy my records and put together a nice package).

During the evening of our first day, we were bused and car-pooled to a local park where the second-year students had prepared a cookout for us. This was our first introduction to the wonderful world of "free-food" in medical school. Our first day of orientation ended around 8pm.

On the second day, we were introduced to our microscopes and course syllabi. Each of us was issued a microscope (if you didn't have your own as I did ) and were issued thick syllabi for Biochemistry, Gross Anatomy, Introduction to the Practice of Medicine and Psychiatry. In addition, we were given a couple of hours to purchase books (already furnished by my second-year adviser). We also had lockers issued (I could actually stand in my huge locker) where we could store our necessities. On this day, the student health department singled out students whose records were not complete and gave them strategies for getting their immunizations and records done. This meant downtime for me. At the end of the day, free pizza courtesy of one of the student organizations.

On the third day, which turned out to be a Thursday, we were treated to a morning meeting with Financial Aid and Student Organizations. The Student Organizations had set up tables with sign-up sheets for us to join groups. I signed up for the American Medical Association and new organization called "Students with Families" (a non-traditional student organization). The afternoon was spent organizing our class and electing temporary class officers. We elected temporary officers because we actually didn't know anyone and would elect permanent officers later in the year. I actually volunteered to become the Vice-President for Education in charge of note-service because I had some experience from graduate school with running a note service.

The Dean's Reception was held on the evening of the third day. This is where I met my best friend from medical school. Over the four years, we would share triumphs and tragedies but it was at this reception that we met the various Deans up close and shared a line or two of conversation. In addition, there was more free food and an opportunity to wear something other than our jeans and T-Shir's that had become our orientation outfit.

On our last full day of orientation, we had information sessions from the chairmen of various departments. This gave us an opportunity to mingle with the faculty. We were also introduced to the school's computing system and issued laptop computers if we didn't already own a suitable laptop. Again, that locker was getting full. For students who were not immune to Hepatitis B, there was the first in a series of three Hep B vaccination shots (thankfully, I could bypass this step too). On the evening of our last day of orientation, there was a White Coat Ceremony where we were cloaked in our white coats by graduates of our medical school and issued the Hippocratic Oath.

Orientation had taken the better part of a week. Many of us were not ready to just get down to the business of attending classes and adjusting to the course schedule. Our syllabi need to be filled in and mastered, our textbooks read and highlighted. On the next Monday, we would be "going live" in terms of our classwork.

Over the first week, I came to have a list of things that I could not do without. These things were carried in my backpack and spread on my table in front of me during lectures. These were:

My laptop computer for downloading power-points and the professors writing on the "smart board".
My pens of four colors: black for notes, red for emphasis, green for projects and blue for notes from the text book.
My Easy Reader book stand that held my looseleaf notebook that contained pages from my textbooks that were cut and 3-hole punched.
My highlighters in four colors: bright yellow, pink, green and blue.
A micro tape recorder (now replaced by a digital tape recorder) for making sure I didn't miss anything if I fell asleep in class.
A sweatshirt as the lecture room was always freezing even if the outside temperature was above 100F.
My travel coffee mug and a thermos of fresh coffee (Starbucks was a short walk from the lecture hall).
A liter-bottle of water (kept me awake in the afternoon).
My Walkman (now replaced by an MP-3 player).

These were my daily companions during first and second year of medical school. Even today, I always read and study with my pens and highlighters handy. My Easy Reader book stand is also with me as is my Sony Viao laptop computer for making notes and reading the myriad of PDF documents that I have downloaded.

Other things that I would learn but not mentioned during Orientation Week, was not to worry so much about not doing well on my first set of exams. I more than passed every exam but I saw many of my classmates head into a "tail-spin" after receiving their first failing grades. On our first Gross Anatomy exam, 85% of the class failed the exam. For some students, this was their first failure ever and they had difficulty shaking it off and moving on. In my case, I remembered that my wonderful second-year adviser had said, "You are going to encounter something that will give you problems, ask for help and put your failures behind you fast.". She also encouraged me to help my fellow students who as she said, would "become colleagues that I would refer patients to in the future". She was right because the more I helped my fellow students, the higher my grades became.

We all survived that first semester but we lost a couple of students at the end of second semester. One of my classmates decided that he wasn't going to spend another moment doing that much studying for anything. Another had illnesses and just wasn't able to keep up with the material. In the end, we all experienced the molding that would mark us as physicians.

White Coat Ceremony

2007-06-25T20:46:00.000-05:00

During orientation week at my medical school, the last night of the week is reserved for the White Coat Ceremony. This ceremony is where the incoming medical student has a physician place their white coat, shake their hand and where they are officially welcome into the practice of medicine. This ceremony marks their first taking of the Hippocratic Oath (with a re-take for the practicing physicians).

There is usually a nationally recognized speaker - for my year is was Benjamin Carson, M.D., chief of pediatric neurosurgery at Johns Hopkins- who sets the tone of the entire program. I have heard White Coat Ceremony speeches by Former Surgeon General Jocelyn Elders and other nationally known physicians. Every time I attend one of these White Coat Ceremonies, I am reminded of why I went into medicine in the first place and the "humanism" of my practice.

Even today, in 2007, the infant mortality in Mississippi is higher than in many third-world countries. In New Orleans, many patients with chronic diseases such as hypertension and diabetes face an uphill battle to find adequate primary medical care for simple maintenance of their conditions after Hurricane Katrina wiped out many clinics in the poorer neighborhoods. In Appalachia, the complications from untreated hypertension have left many without renal function who have to rely on hemodialysis three times each week.

We still have a health care system in this country that shuts out large populations who either do not have jobs that provide health insurance or jobs with health insurance benefits that are woefully inadequate. Many of these people avoid seeing a physician when early intervention could likely make the difference between remaining healthy or progressing to a chronic state of illness that will be life-changing.

Obesity is rampant in all segments of our population yet the morbidly obese face discrimination and ridicule by hospital staff, physicians and large segments of society who see them as lazy and responsible for their condition. In most cases, morbid obesity comes from lack of access to foods that are lower in fat and higher in nutrition because of cost or lack of knowledge. After gaining a large amount of weight, even walking around the block becomes more than many of these people are able to achieve.

When I think about attending the White Coat Ceremony at my medical school this year, my focus will be on how we can raise the quality of delivery of health care across all segments of our society. It is my belief that preventive medicine needs to be practiced more than interventional medicine. The poor, the morbidly obese, and those who lack knowledge are among the most difficult patients that any physician will ever treat.

The morbidly obese are a rapidly growing segment of our collective patient populations with problems such as non-healing venous stasis ulcers, lymphatic dysfunction, obstructive sleep apnea, early congestive heart failure, depression, Type II diabetes of the young and predisposition to thromboembolism. Even a relatively minor surgical procedure such as an appendectomy becomes a major undertaking in a person who weighs more than 300 pounds let alone 400 - 500 pounds. I have watched my colleagues deliberately avoid treating morbidly obese patients who have sought their care because they didn't want to deal with the possible complications.

Morbid obesity is showing up in middle school, junior high and high school with some individuals weighing so much, they become unable to attend school. In the cases where these morbidly obese individuals are able to attend schools, many physical education classes are unable to accommodate these children who desperately need to learn how to exercise and eat properly in order to undo 200-300 pounds of weight. In most cases, these children do not need to be subjected to gastric bypass surgery but need simple education and good food choices along with making aerobic exercise a regular activity.

With every patient, we as physicians, need to look toward preventive medicine and patient education. To do otherwise, keeps us on a path where health care costs will continue to sky rocket and soon, too costly for most people to be able to afford. It is up to us, as physicians, to lead this country back to basic good health for every segment of our population.

My First Week of Medical School

2007-06-16T11:04:00.000-05:00

Many people have asked me, "What was medical school actually like?" "What was you day-to-day schedule?". I will attempt to describe my first day in medical school from the time I woke up to the time I fell asleep in this essay.

I woke up at my usual time of 4:30AM. I was raised on a farm and getting up early is as much a part of my life as brushing my teeth every morning and evening. I am fortunate that I actually have always had less of a sleep schedule than most of my buddies and thus, I generally awaken around 4:30AM without the need of an alarm clock. I also roll out of bed and hit the shower while my single cup of "Joe" is brewing.

Over coffee, I usually catch up with the newspaper (online) and then I headed out the door for my walk to the subway station. This walk generally took about 20-minutes and was a built-in source of exercise for me for the first couple of weeks of medical school. My coursework on the first day consisted of Introduction to the Practice of Medicine Class at 8:AM- 10AM, Psychiatry at 10AM to noon. Lunch was from 12 noon to 1PM. Afternoon was Gross Anatomy Lecture from 1PM-3PM and Gross Anatomy Lab from 3PM to 5pm.

All of our lectures were in 50-minute blocks with 10 minutes of break in between each lecture. This allowed us to get a drink, walk around and prepare for the incoming lecturer. It also allowed the media person to set up in between the lectures as our lectures were available for download and all PowerPoints were down-loadable from out seats. Most of us took notes on the Powerpoint slide sheets or just listened in class.

Our syllabi had been handed out during orientation so that we knew the objectives and content with each lecturer. We also knew which textbook readings were to be covered. My Introduction to the Practice of Medicine course had a syllabus that contained an outline of the lecture. There was no text reading for this opening lecture that included the duties of a physician, how to fill out a death certificate and how to gather and interpret vital statistics for a locale such as birth rates, death rates and rates of disease.

With all of my syllabi and text books, I would remove the covers, take the books to Kinko's and have the bindings removed. I would then have three-holes punched and I would place these sheets in large 3-ring binders. I had a binder for each course. In the evening before each course, I would remove the syllabus sheets for that course, remove any textbook pages that I thought I might need and place them in a small 3-ring notebook along with sheets of lined notebook paper (for taking notes). This was the notebook that I brought with me to school. I would have the subject matter divided by separators so that I had all of my information with me for the day.

I would download my PowerPoint slides and place copies of these in my subject notebook when I got back home for the day. My lecture notes (or copies of note service) would also go into each subject note book. My textbook pages would go back into that textbook three-ring binder.

On my first day, I took notes and placed them in my Introduction to the Practice of Medicine binder when I arrived home at the end of the day. For psychiatry, again, the lecturer had no slides but discussed Erickson's stages of development and Piaget. I took notes but knew that detailed explanations of these subjects were in my textbook.

For Gross Anatomy, I had the text pages with me and made notes in the margins of the material presented by the lecturer. I also made a few notes on photocopies of my Netter plates for use in our lab. During Gross Anatomy lab, I had my list of structures that I had made from scanning the dissector. I had also reviewed the relevant plates in my Netter atlas and had made photocopies of these plates. My photocopies were stapled to my list of structures.

In our first Gross anatomy lab, we studied the bones of the vertebral system and skeletal structures. We were also given instruction in how to work with the diener to keep our cadavers in good condition for the entire semester. We were also introduced to our cadavers and our tank groups (each was six people).

After lab was over, I took the subway back home (45-minutes) and walked from the subway station to my house. I then took an hour, made dinner, ate and begin to study and review the material from the first day's lecturers. As I studied, I made notes an questions in the margins of my books, syllabi and note sheets. Since most of my notes were typed, I printed these out and placed them in my subject binders. I also studied and memorized the relevant bone structures using my bone box that was issued to me during the first day of Gross Anatomy laboratory.

My next task was to preview the notes for the next day's subjects and do any readings/problems that had been assigned. After my previewing, my textbook pages, relevant notes and syllabi pages were placed in my daily notebook which went into my backpack. My next days courses were Biochemistry, Microbiology and Microbiology lab.

My day ended about 11 PM and I hit the bed because I knew that my next day would be starting at 4:30 AM. Since Tuesdays and Thursdays were shorter days (class started at 8AM but ended at 4PM) I actually had an extra hour on these days. We also had a Microbiology Discussion session on Tuesdays and a Biochemistry Case Discussion session on Thursdays where we would discuss clinical cases from the standpoint of these subjects. Our instructors would bring a case, present it and then we would discuss these cases in detail from the standpoint of the basic science involved.

When we started to actually dissect the cadavers, my Mondays, Wednesdays and Fridays included 2-3 hours of dissection in the evening after class was done. I would get some dinner at school and then get into the dissection laboratory to study and complete dissections. The extra dissection/study moved my bedtime back to after midnight on these nights.

I also studied in the dissection laboratory and with my study group on Saturdays. We would have an early breakfast (at one of the nearby churches to help them raise funds) and then study and quiz each other until noon. We would then study and quiz each other in the Gross Anatomy lab after lunch and generally until 3 or 4pm. After that, we would do another group session in Biochemistry and Micro and then head home around 8pm.

Sunday's were generally my day of rest. I would spend a couple hours in the evening putting together my materials for my Monday classes but most of my studies would be completed in the time that I had put in Monday through Saturday.

If this amount of study time seems extreme, it was extreme in some ways. I would not stop until I felt I had mastered the material. I also made the crucial mistake of neglecting my physical conditioning in favor of my studies when I should have incorporated my studies into my physical conditioning routine. I ended up gaining a considerable amount of weight but my grades were excellent. At this point in my life, I know that I have to strike a balance and now I am in excellent physical condition with no neglect to my academics/reading.

Medical school was all about balancing my studies with my life. I learned to multi-task and I learned how to focus on getting things mastered and completed. I also learned the value of discipline. My schedule didn't allow much "downtime" but the "downtime" that I had was utilized to an ultimate degree.

It becomes easy to procrastinate in medical school because the days are long and the material seems voluminous. I fought procrastination by asking myself, "Why are you avoiding getting on with this task?". Since I never had a good answer for this question, I just broke the task into smaller tasks and checked them off until they were done.

As I have said in other posts on this blog, the telly went by the wayside. I would spend a bit of time on Sunday scanning the log for shows that might be of interest. I would program my recorder for the shows of interest and watch them the next Sunday if I felt like a bit of relaxation. In most cases, my relaxation became hanging out with my classmates and the telly wasn't much entertainment. I still tape shows that I love or documentaries that might be of interest to my students as I am teaching more these days.

Other things that tended to waste my time in medical school were phone conversations. I seldom use my telephone more than 5 minutes per week and tend to use e-mail communication more. I also pick and choose the meetings that I attend. Many times, academic committee meetings can be a total waste of time and energy and thus, I pick and choose whenever possible. If something is mandatory, the organizers generally will time the meetings around the schedules of those folks who are attending.

One of my medicine professors encouraged us to read the case reports in the New England Journal of Medicine every week from the first day of medical school. He said that we might not understand all of the aspects of each case but that this habit would prove invaluable as we moved through the curriculum. He was totally "on the money" with this one. I can't tell you how studying and reading these cases helped me on all steps of USMLE and in residency too.

Medicine requires that you read and keep up with the journals of your discipline. I strive to read selected articles in New England Journal of Medicine, Journal of American Medical Association weekly. I also read American Surgeon and Archives of Surgery regularly along with Nature Medicine (excellent articles to be found in this journal). I keep a computer log of the articles that I have read and their sources. This keeps me current with the literature as much as possible.