from the class of 2012 - long school of medicine, ut...

From The Class of 2012School of Medicine

The University of TexasHealth Science Center at San Antonio

Editor:Shira Amdur, MSIII

Publication Cover Design:Katie Reppa, MSIII

published by the Office of Academic Enhancement

®

Letters Third Year Student

to a

There’s always the possibility that we will come to a new understanding and to perceive the

body as a primal mystery and therefore sacred.Again and again, in patients deformed or ravaged by disease, we are stunned by a sudden radiance.

This is not always comforting; there is terror in occasions that lift the veil from the ordinary world.

Letters to a Young Doctor, Richard Selzer MD

Forward ......................................................................................... Pg. 6Allam, Arti ..................................................................................... Pg. 8Alvarez, JJ ...................................................................................... Pg. 9Anonymous 1 .............................................................................. Pg. 10Anonymous 2 .............................................................................. Pg. 11Anonymous 3 .............................................................................. Pg. 12Anonymous 4 .............................................................................. Pg. 14Anonymous 5............................................................................... Pg. 15 Bloomer, Tyler .............................................................................. Pg. 16Burau, Keith .................................................................................. Pg. 17Camero, Fred ................................................................................ Pg. 18Chang, Andrew ........................................................................... Pg. 19Chen, Dennis ............................................................................... Pg. 20Choi, Sooyeon ............................................................................. Pg. 21Christensen, Kevin ..................................................................... Pg. 22Christian, Elaine .......................................................................... Pg. 23Corona, Hille ................................................................................. Pg. 24Crozier, Matt ................................................................................. Pg. 25Davila, Karla .................................................................................. Pg. 26Desai, Viren ................................................................................... Pg. 27Dudley, Chris ................................................................................ Pg. 28Edeen, Richie ............................................................................... Pg. 29Edwards, Jeffrey .......................................................................... Pg. 30Fielding, Sheridan ...................................................................... Pg. 31Ford, Leila ...................................................................................... Pg. 33Gambill, Lauren ........................................................................... Pg. 34Geoffrion, Tracy .......................................................................... Pg. 35Gurgiolo, Cassandra .................................................................. Pg. 36Harrington, Ashley ..................................................................... Pg. 37Heller, Tyson ................................................................................. Pg. 38Hemard, Kristin ........................................................................... Pg. 40Hendricks, Abby ......................................................................... Pg. 41Hurley, Richard ............................................................................ Pg. 43Jackson, Matt ............................................................................... Pg. 44Jivani, Ani ...................................................................................... Pg. 45Johnson, Mark ............................................................................. Pg. 46Johnson, Natalea ........................................................................ Pg. 47Ketner, Liz ...................................................................................... Pg. 48Khademi, Shaadi ......................................................................... Pg. 49Lee, Christine ............................................................................... Pg. 51Lee, Cindy ...................................................................................... Pg. 52Mackie, Emily ............................................................................... Pg. 53Marshall, Kyle ............................................................................... Pg. 54Martinez, Azalia .......................................................................... Pg. 55McIntosh, Andrew ..................................................................... Pg. 57McKean, Melissa ......................................................................... Pg. 58Metter, David ............................................................................... Pg. 59Miller, William .............................................................................. Pg. 60Mitnaul, Larry ............................................................................... Pg. 61Moss, Brandon ............................................................................. Pg. 62Murthi, Shweta ............................................................................ Pg. 63Nava, Ashley ................................................................................. Pg. 64Neal, Catherine ............................................................................ Pg. 65Nguyen, Tien ................................................................................ Pg. 66

Onyirioha, Kimberly .................................................................. Pg. 67Overley, Sam ................................................................................ Pg. 68Parikh, Toral .................................................................................. Pg. 69Patel, Ami ...................................................................................... Pg. 70Peacher-Seany, Annaceci ..................................................... Pg. 71Perry, Ted ....................................................................................... Pg. 72Pientka, Bill ................................................................................... Pg. 73Poage, Cameron ......................................................................... Pg. 74Rodulfo, Nayeli ............................................................................ Pg. 75 Sanders, TJ .................................................................................... Pg. 76Sartin, Chris .................................................................................. Pg. 77Schmidt, Kathryn ....................................................................... Pg. 78Sheikh, Rehman ......................................................................... Pg. 79Stayer, Sarah ................................................................................. Pg. 81Swann, Matthew ........................................................................ Pg. 83Syed, Almas .................................................................................. Pg. 84Thiel, Brent .................................................................................... Pg. 85Todd-Thompson, Kate ............................................................. Pg. 87Tracy, Eric ...................................................................................... Pg. 88Vizuete, Krista .............................................................................. Pg. 89Wait, Eric ........................................................................................ Pg. 91Walsh, Rorey ................................................................................. Pg. 92Ward, Mike .................................................................................... Pg. 93White, Cassie ................................................................................ Pg. 94White, Matan ............................................................................... Pg. 96Whitney, Margaret ..................................................................... Pg. 97Williams, Lindsey ........................................................................ Pg. 98Wood, Lauren .............................................................................. Pg. 100Yang, Ming ................................................................................... Pg. 101Yieh, Leih ....................................................................................... Pg. 102Zhao, Zibin .................................................................................... Pg. 103RAHC - Ahmed, Nabid ............................................................. Pg. 104RAHC - Burke, Christine ........................................................... Pg. 105RAHC - Dayah, Taroq ................................................................ Pg. 107RAHC - Gaona, Carlos ............................................................... Pg. 108RAHC - Hechanova, Martin .................................................... Pg. 109RAHC - Juarez, Jesus ................................................................. Pg. 111RAHC - Kimiagaree, Maurice .................................................. Pg. 112RAHC - Koller, Derek ................................................................. Pg. 113RAHC - Koller, Jessica ............................................................... Pg. 114RAHC - Marshall, Bryt ............................................................... Pg. 115RAHC - Melia, Beth .................................................................... Pg. 117RAHC - Millstone, Michael ...................................................... Pg. 119RAHC - Taylor, Zach ................................................................... Pg. 120RAHC - Yurcheshen, Rachel .................................................... Pg. 122

Table of Contents

Dear Students,

Congratulations for successful completion of your basic science curriculum and welcome to maybe the most exciting, challenging, and perhaps angst-provoking year of your life!! Do not think this is the end of your basic sciences, because you will utilize your basic science knowledge every day for your entire career. As you anticipate your next year, perhaps your greatest fears (some rational and some irrational) will focus around the Surgery Clerkship. I know, because I had some of these same fears when I began my Surgery Clerkship over 25 years ago. Those fears included being chronically fatigued, having long work hours, having no time to study, not knowing expectations, receiving criticism from a surgical chief resident or faculty, making mistakes that will hurt patients, not knowing enough information, having no technical skills, being “pimped” on surgical anatomy, contaminating instruments in the operating room, standing for long hours in the operating room, being hungry, falling asleep, fainting and vomiting in the operating room, getting stuck with a needle, having little time for relationships and hobbies. I want to offer you a few words of advice to reduce your anxiety as you begin your Surgery Clerkship, in order to become a successful, competent medical clerk.

First of all, take a deep breath and relax! At no other time in your clinical career will surgical residents and faculty know that you have little clinical experience and few technical skills.

Second, read as much as you possibly can about the patients for whom you will care. Read everything about them-not just simple descriptions of the operations that you will perform on your patients. Find a classic surgical textbook that you enjoy reading in order to develop a sound foundation of surgical knowledge. Have a good grasp of surgical anatomy and the pathophysiology of the surgical disease. Faculty will certainly quiz you about anatomical findings in the operating room, so brush up on your anatomy before you scrub into the case. After you have acquired a solid fund of surgical knowledge, go the surgical journals to begin to develop an evidence-based approach to the diagnosis and treatment of surgical disease. When a resident or faculty member asks you a question about a surgical topic, and you do not know the answer exactly, provide an educated guess- you will be surprised how much you have learned in the past two years!! If you absolutely do not know the answer, just swallow your pride and state so, but also affirm that you will research the topic that night and provide a brief review on rounds that next morning.

Third, become proficient in basic bedside surgical skills. You will require these simple bedside skills no matter what career path you ultimately choose. There is no better or safer way to learn simple surgical skills than under the direct supervision of surgical housestaff and faculty. You do not want to become “paralyzed” during your internship because you did not master basic surgical skills during your Surgery Clerkship. You do not want to be in the position to have to consult the Urology service to place a routine foley catheter in your patient because you did not perfect that skill in medical school. If you do not feel comfortable to perform a bedside procedure, just say so, and there are many healthcare providers to assist you. Fourth, learn how to perform a focused history and physical exam on a surgical patient and to present this patient to the surgical team in a concise and coherent manner. If you notice a change in your patient’s surgical condition, by all means do not hesitate to inform a supervisor on your surgical team.

Fifth, develop a diagnostic and a therapeutic plan on your surgical patient every day and do not rely on the surgical team to offer that plan for you; the development of a logical daily assessment and plan on your patient will likely be one of the most difficult skills for you to master over the next year.

Sixth, approach your patient as if you are the primary (the “only”) physician caring for your patient. You will get to know your patient and his/his family members intimately, and you will realize not only his/her surgical needs but also his medical, psychological and social needs in a cultural context.

Forward

Seventh, appreciate an inter-professional approach to the delivery of healthcare for your patient; this approach will likely be the way you provide healthcare after your training in the future. Eighth, eat breakfast every morning, because you will never know when a “routine” 30- minute long cholecystectomy actually becomes a 4-hour long liver resection, and wear comfortable shoes in the operating room because you might be standing for several hours in one position.

Ninth, do not take constructive criticism too personally, but use it to improve your approach to patient care. Hopefully the residents and faculty will provide a balanced assessment of your exceptional qualities and areas that need attention.Tenth, just because you are on a busy surgical rotation, do not neglect your relationships and hobbies that are important in your life. Prioritize what is important to you and find that critical balance to maintain satisfaction and happiness in your personal and professional life.

Finally, approach each rotation with incredible enthusiasm and active participation as if you will pursue that discipline for the rest of your life. Keep your eyes and ears open, and you just might have a radical change in your career path. This certainly happened to me on the General Surgery rotation of my third year Surgery Clerkship. With a degree in Microbiology, I always assumed that I would pursue residency in Internal Medicine followed by a fellowship in Infectious Diseases until I got to my Surgery Clerkship, when I had a sudden, drastic shift in my career plans near the end of my third year, and I made an appointment with my Clerkship Director Dr. Kaminski to discuss how to secure an internship in General Surgery.

Once again “Welcome aboard”!! I look forward to working with each of you on the Surgery Clerkship!!

Robert M. Esterl, Jr., M.D.Professor, Department of Surgery, Transplant Center Surgery Clerkship Director

8

Letters to a third-year student from the class of 2012

Letters to a Third-Year

I was having dinner with my aunt, uncle and cousins this past weekend, and I told them I had to go home early because I was on 24-hour call starting the next morning. My aunt got excited, and said, “Oh, you sound so professional!” I laughed, and said, “It sounds glamorous, right? Well, it’s really not when you are in there.”

It’s funny - the first few times you are on call you like saying it. “I can’t, I’m on call that weekend.” “I’m post-call and ex-hausted.” “Call was crazy yesterday!” It feels so doctorly and official and, well, cool. Then, it becomes part of you, and you and all of your friends in medical school with you realize what this fancy word truly means. In the ER, it often means being showered by bodily fluids via natural and traumatically created orifices. It means trying to take care of patients who are out of control. It means poking, prodding and sewing itty, bitty and big, huge babies. It means no food, no water, no sleep and staving off your own bodily functions for the sake of others’ blood pressure, stability and complaints.

As I performed 5:30 a.m. chest compressions on a 55-year-old man with an open chest who was coding after being hit by a bus and then found to have a dissecting aneurysm in the ER, 23.5 hours into the busiest day of my life, blood on my arms, beads of sweat on my forehead, I counted, watched his blood pressure go up, and thought, “This is it, baby. Life and death are literally in your hands,” and I gave it everything I had from physical force to prayer. When they finally called his time of death, after a bedside pericardial window and thoracotomy and bags and bags of transfused blood, I knew we had done everything within our means for him. I felt defeated, humbled and saddened, and wondered how his loved ones would take the tragic news and how they would recover, as I ran to get an ABG on the next trauma that had been airlifted in.

My crisp, clean white coat is now stained with its sleeves rolled up. My nares undoubtedly harbor MRSA. I’m just waiting for my next PPD to convert. The glitz and glam image of this quintessential experience of doctoring has fallen away, giving way to fact - this job is so real.

By Arti AllamClass of 2012


9

Dear soon-to-be Third-Years,

So, a little bit about third year. First, I don’t think there is anything anyone can say that can precisely describe what the year ahead of you is going to be like. We all have different perspectives and expectations going into third year and, thus, entirely different experiences to share. However, I think nobody will disagree with me when I say that it is the most challenging and rewarding year yet. Now, having said that, I want to share with you some practical advice that will hopefully prepare you for some of the difficult times ahead.

1. Never show up late! This one seems like a given, but it’s a rule that can easily be forgotten. Some attendings are just looking for a reason to mark points off your evaluation so just always make sure that you’re at least 5 minutes early.

2. If an attending tells you to do something and a resident then tells you to do the exact opposite (like cutting clothes in a trauma), ALWAYS go with what the attending wants you to do. Otherwise, you will have to deal with their unmerciful wrath.

3. Don’t judge patients. They have enough going on in their lives, they don’t need another person talking down at them. Also, there will be times when you hear others belittling patients in some form or another. In circumstances like that be the bigger person and just walk away (or if in the OR, just keep your mouth shut). Remember that everybody was born with faults and that includes you.

4. Ask questions. Everybody knows that as a third-year, you don’t know jack. This is the only point in your career where there are no dumb questions, so ask away. However, always make sure to ask them at an appropriate time.

5. Your iPhone is a great source for quickly looking up information while on the go. But never use your iPhone in front of your attendings unless they allow you to do so. To them, it looks like you’re texting and not paying attention to what’s going on.

6. If in the OR, don’t just stand around, always volunteer to help the nurses and techs prep the patient or with anything else they may need help with.

7. Listen to your patients. Your duties third year will often be minimal and you will sometimes find yourself with a lot of free time on your hands. If you’re not studying, get to know your patients. Many times these patients don’t have any sort of social support, so having someone to converse with can mean a world of difference to them.

8. Try not to compare yourself to your teammates or other medical students. You already have enough stress in your life, doing so will only lead to you being overly critical of yourself. Forget everybody else and focus on you, primarily your strengths and weaknesses and how you can improve on them. Periodically talk with your attendings about how you can go about making these changes.

9. Learn to let criticism roll off your back. When you’re starting off, it’s easy to get flustered when you’re criticized for doing something wrong. Try not to worry about it; it happens to everyone. You’ll see that the residents have grown very thick skin over the years and are pretty much professionals when it comes to this rule. Learn from them.

10. Lastly, don’t forget to have fun! This experience, in my opinion, is unlike any other. Never again will you have the opportunity to do the things you’ll be doing third year. So definitely take full advantage.

Good luck with all your future endeavors and I look forward to seeing you in the wards!

J.J. Alvarez

10


If you aced everything the last two years and made a 245 or even a 220 on your Step, move on.

I started out 3rd year with Dr. Keeton’s uplifting lecture sharp in my mind. Even though I only made a 198 on Step 1, I had decided I would use this year to start over. Forget how I had done these last two years or the Step and move on up in the class ranks. What actually happened was nothing like that. Unfortunately, I guess I didn’t realize just how much you needed to study for the shelf exams because you don’t see everything on the wards. My second rotation was Family and I just used Case Files like everyone else. Then, I failed the shelf by a point. (*My other lesson was this: If you are having issues with a resident, talk to the clerkship director. You won’t get in trouble, the resident won’t ever find out about it, and it will save you a lot of stress and grief.) Surgery came after and I got smarter. I bought Case Files, but also got a question book to review information and two detailed text books. I didn’t ace the shelf, but I did make a B on the test.

Lesson: Things are not going to just fall into place for you, especially if they didn’t the first two years. Listen to yourself and do what you need to do. I hadn’t done so well last year or on Step 1 and these should have been clues I needed to study more and use more detailed books. However, I was trying to do what everyone else was and it just wasn’t working.

I came to school with dreams of being an orthopaedic surgeon. Clearly, this is out of the question now. For those of you who are in similar situations, this doesn’t mean you’ll never get into a residency program or be happy. There are transitional or preliminary years you can do if you can’t get into a residency you want the first time. Yeah, Dr. Clare will try to scare the pants off you because she’s just trying to be “realistic and practical.” There are things you aren’t competitive for anymore, but that doesn’t mean you’ll never be a doctor or a good one at that. I’ve heard stories from people in advisory positions about students who fail Step 1 three times and are now in an anesthesiology residency program or barely pass Step 1 and 2, made C’s in all their 3rd year rotations and are going to a psych residency program in California.

Find something you love. If it’s something you can’t attain directly, do a transitional year and work your a** off. Apply again the next year. Look into community-based programs. You might have to go to a part of the country you don’t want to. This year, you can start by rocking your personal statement and do everything you can to impress your interviewers next year. Lastly, there are plenty of people who leave one type of residency program and go into others because they weren’t happy (I’m not recommending you making this your plan).

Maybe you think this letter is too personal, but people are always putting on fronts about how well they do in school. If your story is anything like mine, I hope I give you some comfort and help you realize you’re still going to be a doctor when May of 2013 comes.

Anonymous


11

Dear MS3,

Congrats on making it out of the lecture hall and into the hospital. It’s fun, scary, and leaves you longing for the safety of 3.104. Third year is a veritable cornucopia of emotions, the predominant one of which is frustration: frustration over the chaos, the confusion, the lack of feedback, the vague feedback when it does eventually come. The hours are often long and, as tired as you are when you get home, you still have to open your books and study. It’s amazing what they expect you to know, and how quickly they expect you to figure it out. Without taking the time to teach you. The whole time, of course, you feel like a bumbling idiot and keep waiting to be exposed as an incompetent moron and a ginormous fraud. Yeah, third year is a colossal pain in the ass.

But then there’re the patients. And isn’t that what it’s supposed to be about? Sure, there are the annoying ones, those who make a bad day worse. Like the drug-seeker who knocks on the workroom door every 8 minutes asking you for his vicodin to help his back pain (the back pain so crippling that he can barely walk to the door of the workroom, q8minutes, to ask you for his vicodin). Or the smoker who swears up and down he wants to quit smoking—and then runs off for a smoke break. But never mind the annoying ones, because it’s always the very special few who stay with you throughout the year. There was the dying little old lady who may or may not have realized how much the cancer had spread: when I went to tell her that I was rotating off her service and say goodbye, her family was there, and they’d heard all about me. I was floored to learn I was family-conversation-worthy! In a good way!

And then, on the most grueling rotation of the year, at a time when I was feeling beyond useless, I met the pregnant 14-year-old who had been too scared to tell her family she was pregnant; she’d kept silent when they’d said she’d gotten fat. I simply did what I was supposed to do as a medical student—doing a good H&P, awkwardly patting the kid’s shoulder, and generally contributing very little to her care. I was caught off-guard the next day when her mother, in the midst of her shock over her daughter’s pregnancy, actually stopped me and thanked me for all that I had done. Embarrassed, I smiled and reminded her that I was only a student and hadn’t really done anything. She responded, “But you were kind to us. And that meant a lot.” At that moment, I didn’t think any compliment could mean so much; yet, by far, the greatest compliment of all is the trust that your patients will put in you. They will look into your eyes and tell you about their darkest moments (the army officer who put a gun to his head but somehow it malfunctioned), their most embarrassing secrets (the immigrant who prematurely ejaculates when he “makes the sex”), and every degree in between—and they will tell you these things all because of your white coat, short though it be.

So that’s pretty much the sum total of 3rd year: you’ll feel utterly inept but keep truckin’ on in the hopes that maybe, just maybe, somewhere along the way, while you are so busy studying for the shelf, that you can somehow contribute a modicum of something useful to somebody. And when the year winds down and you look back and a few life-altering (yours, not theirs) patients stand out in your mind, you’ll realize that you might have had a little more significance than you’d thought. Just hold tight to that—especially during the first week of each rotation—when you’re wondering if you’ll ever figure it out.

Best of luck; you’re in for an incredible year! It will profoundly touch you and transform you if you let it—so please do.

Anonymous

12


When I started my third year clerkships, only one word could describe how I felt: terrified. And to be honest, I had good reasons to be. That cruel attending who hates med students? I had her. Being surrounded by bodily fluids and nasty smells? I got puked on (twice). The fear of others seeing my clumsiness? My hands would shake each time I sutured. Too sheltered? A 19-year-old girl died right in front of me.

Many things I was most scared of about third year really did end up happening. But I made it through and learned a lot along the way.

As med students, we’re driven by structure and expectations. This is reinforced the first two years, but during third year, we are suddenly thrown into the entirely new challenge of applying our knowledge. Looking back, I’m amazed at how much I’ve changed, both personally and professionally.

This is the most difficult year of medical school and will really test your patience, strength and capabilities. For what it’s worth, here is my advice.

1. Don’t judge yourself the first few days. A wise person once told us that the goal of each first day of a rotation is just to get through the day and make it home. It sounded pretty dramatic at the time, but, actually, it’s something I have held onto this whole year. First days are rough, and you have a lot of them. You aren’t going to know where anything is or where to go or even what you are supposed to be doing. Everything is new and unfamiliar. It’s almost like a scavenger hunt with clues all over the hospital, but not quite a prize at the end of the game. Just accept the uncertainty and roll with the punches. There’s always an adjustment period, so give yourself a break. As long as you make it home, you’ve done a good job.

2. Be kind to your patients. Although at times it may not feel this way, you actually are important to your patients. Sometimes they may feel more comfortable talking to you than to the residents or attendings. They may not understand everything said on rounds and are usually pretty scared. Med students tend to have more time to reassure them and explain things to them. Simple things, like answering their questions and talking to family members, go a long way. Most of the time, you will never know how much that means to somebody. If you take time for your patients because you genuinely want to help them, you will learn more than any textbook can teach you.

3. Have a sense of humor. You have to be willing to laugh, most of all at yourself. You may pronounce a commonly used drug the wrong way in front of your entire team (hey, it sometimes sounds different in your head!), or you may break the sterile field in the OR and get yelled at by a scrub tech. It’s ok. Everyone experiences these things because it’s our first time on the wards; many people have made the same mistakes. Just brush it off, laugh a little and do your best to move on.

4. Be kind to your classmates. It’s not an easy year, but it is a bonding experience. Your peers most often understand your feelings and what you are going through because it’s happening to them too. Support each other. You’re going to work with people you previously may not have ever spoken to, but suddenly find yourself with every fifth night as you watch traumas come into UH. One of the most amazing, special things about this year is the opportunity to get to know and become friends with some pretty wonderful people after being teammates with them.

5. Stay humble, but be confident. There are going to be times when you feel stupid or you feel like you just don’t know anything, and this is frustrating (to say the least). Other times, you are going to feel like you’re finally getting the hang of things and actually are competent…and then – more than likely – it’ll be time to switch to another rotation. Work hard, but don’t beat yourself up if you aren’t perfect. No one is perfect, even if they’d like you to believe otherwise. We all have things to learn in life. It’s easy to take things personally and harp on your mistakes. Other doctors may not always be sensitive or patient. A big lesson I’ve learned this year is to grow a thicker skin. Not to be completely numb, but tough enough to not let people’s comments bother you and rattle your confidence.

6. Remind yourself why you went to med school. You may have to dig up that essay you wrote for med school admission or look at happy photos from your White Coat Ceremony. Make sure you remember why you are doing this. You have a bigger goal than to survive third year.

7. Be kind to yourself. Continue to do fun things when you have time. Make time for yourself. You will learn to cherish your free time more than ever before. Use it wisely.

8. Let third year affect you. It’s so easy to get caught up in vitals, labs, plans and shelf exams this year. You can immerse yourself in numbers and books and probably get through third year without much damage at all. Or you can stop and think about what you are witnessing. You are privy to an extraordinary part of people’s lives; you know such intimate details about them; you ask them all sorts of personal questions; you see them go through surgeries, illnesses, moments of unspeakable joy and unbearable sadness. These are real people with their own stories in the most vulnerable times of their lives. Don’t underestimate that.


13

9. Get sleep. A tired brain is a stupid brain. Most days, you’re going to be exhausted. Getting up between 3:30 and 5:00 in the morning is never easy. Get sleep when you can.

10. Prepare yourself for what you’re going to see. This is one of the hardest things about third year. It’s difficult when patients who you see everyday have terminal illnesses. It’s heartbreaking when a child who is barely alive comes into the trauma bay. These things have affected me and will stay with me always, shaping the kind of doctor I’m becoming. You may see others around you not even flinch after a patient codes, while you stand there stunned that you just saw someone die for the first time. It’s important to have an outlet to deal with these difficult situations and tough days. No one teaches us how to react to these things; it’s something we experience for ourselves, often without much guidance.

In the end, third year is what you make of it. There are many ups and downs, but you will learn more than you thought possible. Keep your head up and enjoy the journey.

Anonymous

14


“Hello babies. Welcome to Earth. It’s hot in the summer and cold in the winter. It’s round and wet and crowded. On the outside, babies, you’ve got a hundred years here. There’s only one rule that I know of, babies-God damn it, you’ve got to be kind.”

— Kurt Vonnegut

Mr. A. was a 78-year-old man with end-stage lung cancer. He had been comatose in the ICU for the last week and his wife had just made the decision to withdraw lifesaving measures and give comfort care. So appropriately, Mr. A. was moved down from the ICU into a single room on the regular floor of the hospital. In the ICU, the patient had a new, large room, with his own private nurse to attend to his needs and the needs of his family. On the x floor, patient care was not as supervised and the nurses were notoriously understaffed and overworked. The rooms were also kind of sore on the eyes and noisy. Not the picturesque quiet hospital room that we see in the movies when we think of our last moments. His daughter was not happy with the accommodations. She kept calling our team all day complaining about the noise and the lack of supervision. She told us that the nurses only came in once an hour to check on Mr. A. She told us that no one was listening to his lungs and checking his breathing. Our team went to go and visit the family again, and once again explained what comfort care meant. My residents and interns were compassionate and understanding. They did not use medi-cal terminology, talk down to, or show any signs of impatience with the family or his daughter. It seemed like the family was on-board with the plan and understood what was going on. Late that night on call, our team got a call from the nurses on x floor that Mr. A. had just passed away. I had been dismissed from my duties at this time, but was interested in seeing how someone is pronounced dead, and so, even though the patient was not mine, I went with my intern to Mr. A,’s room. When we got back, the family was in tears. We expressed our condolences, gave them the phone number of the case manager to help them with arrangements, and then told them that we had to pronounce Mr. A. The family left and then my resident got a page and had to leave the room for a moment. When she left , Mr. A.’s daughter stormed into the room and began to verbally assault me. She did not see why we had to move her father down from the ICU. She said that we killed her father, that none of the nurses came and checked on him, that no one was monitoring his vitals and that the room was noisy and shabbier than the ICU. Then she began to swear at me and tell me that she hoped that when my parents die that I have to go through what she went through. All the while peppering her tirade with the gratuitous use of several words which I will not repeat here. She was about three inches from my face and yelling at me the entire time. And so I remembered the advice that I had gotten from a book that I had read recently, “In a code situation the first person’s pulse to check is your own”. So I took a deep breath. I resisted the urge to tell the daughter that her father was not my patient, that I was just a medical student, that we explained this plan to her three times. Instead, swallowing all of my pride I told her that I was sorry for her loss and for the experience that she had here. I told her that it must have been horrible watching someone you loved suffer and you not being able to do anything about it. It did not help the situation but it did not seem to make it worse. My resident then finally came back and the woman stormed out. Moral of the story, the hospital is a house of pain: patients suffer, nurses stress, families grieve, attendings vent, and medical students hyperventilate. Be kind no matter what, it might not solve all your problems, but at least it won’t make them worse.

Nervous Medical Student


15

If I could give only one bit of advice for a successful third year of medical school, it would be to be a good person. You are probably thinking that that is the worst advice you have ever been bestowed. “You can’t just become a good person,” you say, “morals cannot be taught.” But I have faith in you that somewhere, deep down inside, you all have some goodness just waiting to rise to the surface. If anything, I hope that this letter will make you conscious of that part of yourself.

It can be somewhat easy to lose sight of your “good side” during third year. You will be amazed by what you see attendings, residents, staff, and other students do and say about patients (and each other). You may even find yourself falling into their sentiments, making condescending remarks about a patient’s diabetes or talking smack about other services. True story: I once witnessed my attending berate an overweight 20-something with a history of leukemia for coming to the ER due to terror and anxiety of returning cancer symptoms, instead of waiting for his outpatient appointment in two weeks—

Attending: Scared-young-cancer-patient, did you know you are overweight? If not, I would like to remind you of that right now. You are very overweight. Don’t you know that you are overweight? Look at you. Do you exercise? What about this exercise?

[Attending mimes pushing motion in front of self.]

It’s called “pushing the food away.”

I hope that most of you are horrified by this exchange, and will continue to be, but too many times I have seen medical students emulating this behavior.

I am, personally, always so acutely attuned to weight berating because of a special circumstance. At the end of my first year of medical school I moved into a new apartment complex and immediately met my cheerful, boisterous neighbor: Debra. We quickly became friends. I would sit in her beautifully decorated house maybe 3 times a week, and we would just talk for hours like old high school friends. On Saturday mornings, you could hear her voice travelling across the apartment complex as she chatted with anyone on the way to their cars or walking their dogs. (She was always sitting on her front porch).

Many a day, she would invite me over for dinner, and she would endearingly say, “This is my Stephanie” when introducing me to her other friends and family. However, one characteristic I haven’t mentioned yet is that she was morbidly obese.No, she wasn’t lazy, she wasn’t weak, she wasn’t dirty, or whatever messed up preconceived notion someone may have about overweight people. She was my amazing friend who had a full life, who decorated her entire house impeccably, who owned a little poodle named Bruiser, and who cooked me dinner on nights after I’d stumble into her apartment, delirious after a full afternoon of studying for pathology. And she also had malignant melanoma. During the OB/GYN-Endo module of second year, she passed away on the 9th floor of University Hospital.

My friend, Debra, had noticed the large lesion on her arm for a few years. She never went to the doctor because she was ashamed of her size, and she was afraid that the doctor would focus on her weight. She didn’t want to be judged or dismissed. When her family finally convinced her to go to a dermatologist, it was already too late for the melanoma.

So every time I hear smack about overweight patients, I think about Debra. Please remember when you are out on the wards that your patients are people, they are just like you, and it is not your job, or place, or right to judge them. We only act as temporary consultants in our patients’ lives. I think that if you can realize this early on you will not only be happier in your work, but also provide the best care for your patients.

Anonymous

16


Dear Third-Year Student,

First and foremost, congratulations as you have now survived the classroom years of medical school and have conquered Step 1. It is an exciting time in your medical career as you make the transition to the clinical years. Before you know it, you will find yourself doing a variety of things, from sewing up lacerations to delivering babies. You may also find that the specialty and reason you went to medical school is not that appealing anymore. On the other hand, you may have no idea what type of medicine you want to pursue, so remember to approach all clerkships with an open mind.

The best advice I received and you might have already heard from Dr. Keeton regarding your third year, was: “Show up on time, do what you’re told, and don’t complain.” Third year will be demanding at times and you will be working with a number of different attendings, residents, and interns that have different personalities, beliefs, and approaches to patient care. There will be instances where it will be difficult to define your role as a medical student. It is important to remember that you and the patient will be the only ones actually paying to be at the hospital, clinic, or in the OR. Also keep in mind that some parts of third year can be described as rites of passage more so than beneficial to your medical education.

Don’t forget about your loved ones. You will find yourself exhausted from both standing all day and talking with patients. There will be days and weeks where it will be dark when you get to the hospital and dark when you leave. Then, somehow you are supposed to find time to study for a clerkship exam. Remember, you need to set aside time to spend with your significant other or family members.

If you ever become burned out or are tired of the UH and VA canteen food, there is always the option of doing a rotation at the RAHC. There are a number of great physicians and opportunities in the Valley. I recommend possibly spending four weeks there during your outpatient weeks on your Medicine rotation or even three weeks during Surgery. If you did not previously sign up to do a rotation there, you can always talk with clerkship directors throughout the year to see if there are any openings if you change your mind. For the guys, when in doubt wear a tie. First impressions go a long way as you might be working with a faculty member for only one day on a rotation and they might be one of many evaluators affecting your clerkship grade. Also, have a pair of scrubs handy in your car during Surgery and OBGYN. During both of these rotations you will be in clinic and sometimes your schedule might change and you will be asked to scrub-in unexpectedly.

Lastly, never be afraid to say that you do not know the answer to a particular question. Attendings will sometimes ask off-the-wall questions regarding a patient’s history, particular disease process, or a syndrome named after someone you’ve never heard of before. Just be sure to tell your attending you will find out the information because you might be asked the same question during the next patient encounter on rounds.

All the best and good luck!

Sincerely,

Tyler Bloomer


17

She’s gone. These were the only two words I could think to utter to myself as I wandered from room to room in the house that I had so recently considered ours. She had left to start a life free from the burdens that were so integral to mine. It wasn’t just the house, or the dog, or the joint bank accounts; it was my concept of someday that she was taking from me. I wish I could say that I handled it gracefully, but I don’t want to lie.

When I was interviewing for medical school the only fear of mine that surpassed failing out was losing Julia. I obsessively gathered words of wisdom at every social welcoming. Along the way I heard a particularly haunting phrase. I was told that, “Medical school does not so much create problems in a relationship, it simply magnifies them.” I knew that she had been poised to sprint since I received my acceptance letter. She was terrified that if she followed me to San Antonio, she would lose her identity and become swallowed by my life…. she followed me anyway. For two years I did my best to finish my daily studying as quickly as possible so that I could rush home to her and try to keep her happy. This ritual fell apart as the boards approached and I spent more and more time with my nose in a book and less and less time with her. One month before I took the STEP, she told me she wanted to leave. I convinced her to shelve the idea until I had the exam behind me and she was kind enough to do so. She left seven days after I took the USMLE STEP 1.

So there I was. Two years into med school and losing the one relationship I had put any effort into maintaining. I was the guy who studied in the quiet of the basement instead of going to lecture where I couldn’t focus. I was the guy who had six or seven friends in class and didn’t even know anyone else’s name. I was the guy who could count, on one hand, the number of social events I had been to. I had heard that during 3rd year, a student’s social ties to his class friends become severed, so in a panic, I started reaching out to people who I had previously exchanged only casual words with. (As an aside, I’d like to anonymously express my gratitude to them here.) After the first month I realized that my classmates were of a higher caliber of character than I had given them credit for. It made me wish that I had not waited to get to know them until it was emotionally essential to me. These classmate-strangers unknowingly dragged me through the year alongside them. I have serious doubts that I would have made it had they been any less than the heroes they were.

The nights were really rough at first. I was in the habit of brushing my teeth while someone chattered on about her day. The company was missed. It can be difficult not to feel sorry for oneself in the midst of such hypnagogic silence. It was on my pediatrics rotation that, for the first time, my thoughts leading up to sleep were of a patient that I was taking care of rather than self-pity. It was not a particularly moving case but it was my first inpatient experience and it occurred to me that while I fell asleep at home, however alone I may have been, my patient was falling asleep in a hospital bed. I had no great epiphany, but it became habit to distract myself with thoughts of the patients I was tending to rather than wallowing in a state of bitter pre-sleep. The nights are now a reminder of how great my life is. I am alive and healthy. I end my day thinking of how privileged I am to be welcomed into the lives of those in need and how determined I am to do whatever I can to help them.

It’s not over as I write this, but I can say with reasonable certainty that I will not be forgetting the bumpy start to year 3 of medical school. I can only imagine that this letter will blur into the sea of my classmate’s letters, but after this year, I have faith that some of their advice will surpass mine in value. Trust that you have good people surrounding you. UTHSCSA selects fine students and you owe them, and yourself, the opportunity to get to know them as much as possible this year. Get to know your patients too. Remember they don’t want to be sick. You are entering their lives in a manner that very few people will be invited to do. It is okay to enjoy the novelty of this, just make sure that their care and comfort come first. This life we’ve chosen takes sacrifice but if you lose something dear to you along the way, keep in mind that you might have lost it even if you weren’t here.

Keith Burau

18


Dear Incoming 3rd-year students:

Congratulations! If you’re reading this, it means you’ve made it through two tough years and the dreaded Step 1! If 3rd year is for you like it was for me, this will be one of the biggest transitions you will have to make during medical school. The days of being in the classroom are over, and now your days will be spent in the hospital, clinic, or, some days, both. The day has finally come where the patients you see are real patients and not standardized. 3rd year is the year where intellectually, I’ve learned the most. Emotionally, I’ve grown the most as well. I’d like to take this opportunity to share some knowledge, stories, and advice with you before you start your journey of 3rd year.

So, first thing’s first: what will be your role? There’s not a clear-cut answer for this, and that’s the point I wanted to make. Every rotation is different. Some rotations you will feel as if your work is so crucial to the efficiency of the team, you don’t know what they do when medical students are not around. And other rotations you will wonder if the work you’re doing is really helping out at all. The advice I have for you is to treat your work as important regardless of the situation. On busy services, most of your admits, notes, and discharge summaries will be revised and used. On others, they might not be, but it shouldn’t be something to get frustrated over. If doing your work doesn’t benefit the team directly, it will benefit you for having practiced and now knowing how to properly write a discharge summary, admission orders, etc. And also, good work hardly ever goes unnoticed, so make sure to try your hardest, and your evaluations will usually correlate.

Next: be excited. Regardless if you have no intent on ever working in a certain field, be excited to be there. Your time there is limited, and this might be the last time you ever see patients in that field. Residents and attendings appreciate excitement, and I encourage you to take advantage of your time on each service and see/do all that you can.

Next: enjoy your time off. There is very little time off during 3rd year, but when you are given some, take advantage of it. If a resident says that you are free to go because there’s nothing left to be done, and all of your patients are stable: go home. Enjoy your time off, and try not to neglect yourself or loved ones.

Next topic: participating in the care of patients is a privilege, not a chore. It’s sometimes easy to forget when you’re waking up at 4 every morning for 6 weeks, and walking in freezing weather (the one month it does freeze), that being there is a privilege. But one thing that I always think of that puts things back into perspective for me is: we have chosen to be here, and the patients have not.

Lastly: don’t stress. The first surgery that I scrubbed into was a thyroidectomy. I was nervous and sweaty as I retracted skin and muscle back while they operated on the gland. I had a poor view, so the attending said: “Fred, why don’t you go stand on the other side, and get a better view.” I walked around trying to avoid touching anything so I would stay sterile. The resident, who was wearing a surgical headlight that was plugged into the wall, was standing on the other side. As I approached the other side and walked behind the resident, I didn’t look down and notice the cord from his headlight. So I kept walking and…. tripped right over it. The lamp flew off his head and luckily the resident’s neck wasn’t hurt. I fell to the floor and “broke scrub.” Clearly, this was a pretty traumatizing experience to someone who’d been a 3rd-year for a total of 3 days, and was scrubbing into his first surgery. Everyone was very nice and no one got angry, and in a couple of days we were laughing about it. So why did I share that embarrassing story? So whenever something like that happens to you, you’ll know that stuff like this happens, so don’t stress.

Good luck with everything and enjoy 3rd year!!

-- Fred Camero


19

Dear Class of 2013:

Congratulations on surviving the monotonous, but important, chapters of medical school, and welcome to the portion of your education that you’ve been waiting for! I know you probably get tired of hearing us say this, but I’ll say it again: this year will be so much better than last year (and I’ll say it again when you become MS4s)! I’m sure my fellow classmates will provide all the advice you can handle, so I thought I’d share a story about an encounter I had and what I learned from it.

J was a little boy battling osteosarcoma. Every time the cancer seemed to be gone, it would pop back up at a subsequent visit. However, when I met this brave little boy, the cancer had been in remission for a while and everything was going well, even though he had lost a leg via amputation during the process. In clinic, J was complaining of a dull backache with tenderness at a specific location in his thoracic spine. Concerned, the attending and I looked at his routine CT and discovered a compression fracture of his vertebra, knowing this was probably secondary to metastasis from his original cancer. Going back into the room to deliver bad news was one of the hardest things I’ve had to do, and as the attending was describing the findings, I could see the parents fighting to hold back tears. Finally, the attending asked if they would like to see the CT findings in the radiology room and told J we would be right back.

As I was about to shut the door on my way out of the room, I had second thoughts. J was probably already scared and leaving him alone would be inappropriate. The attending would probably wonder where I was, but I decided to turn back in and keep him company. As I started to chitchat with him, I could sense his frustration as tears started flowing down his cheeks. He expressed how much he hated cancer and how bad he wished it would just leave his body, but the main reason he was crying was because he was sick of hospitals. He wanted to be with his cousins at home. He didn’t want to miss school so that he could see his friends. He just wanted to be a normal kid. When the parents came back into the room, it was obvious that they had shed some tears as well.

Later, the parents would thank me for giving them the chance to release their emotions, giving them a break from having to be strong in front of their son, and this was a reminder that even the smallest of things can go a long way. As you go through your 3rd year, you’ll realize that there are many questions you can’t answer and so many different ways you can mess up. However, time is the one thing you have that residents and attendings don’t. Yes, a lot of these interactions go unnoticed by those that have power over your grade, but you will make a difference simply by listening, answering questions, or clarifying things your patients didn’t understand. It’s easy to get jaded and detached as you progress through medical school, but I encourage you to seek out opportunities to make a small differ-ence and remind yourself why you went into this profession.

Best of luck,

Andrew Chang

20


Dear Third-Years,

Congratulations on successfully slogging through 2 years of lectures, labs, working conferences, and Step 1. I’m sure many of you felt like this day would never arrive. I’m also sure you’re all experiencing a unique mix of emotions thinking about your first day on the wards that run the gamut from pants-wetting terror to heart-pounding excitement. Just keep in mind, as big and bad and scary as 3rd year seems, everyone makes it through. You’ve all heard stories and wondered how you’ll be able to get to work at 4 a.m. or study after a 15-hour work day or deliver a baby or calm down a schizophrenic patient. There is no good answer to these questions; you will simply find a way. Medical students are nothing if not resilient and whatever challenges are thrown at you in the next year, you will meet them, just like you met all the challenges over the past two years. You will learn a lot about yourself, you will grow as a human being and a physician, and you will push yourself to new limits. Try and approach every rotation with an open mind and they will be that much more rewarding. I think it was Dr. Keeton who told us to treat every rotation as if it was the one we were going to go in to, which was great advice, plus that’s what you’re going to be telling all your residents and attendings anyway.

There will be difficult times, frustrating times, and times when you question why you’re doing what you’re doing. On one of my many 5 a.m. mornings on ob/gyn, I went to go see one of the post-partum patients. This young lady was 21, had just delivered her third child, and had a heroin addiction. So at 5 in the morning, I woke her up and introduced myself, she mumbled something about how awful it was that they made me come in so early in the morning. I smiled and nodded in agreement, and she exclaimed: “I hope they at least pay you well for it!” I laughed and told her that actually I suppose I was paying them to do this. She just started laughing incredulously and told me that she was sorry for me. After I finished checking on her, I left the room and couldn’t help but laugh to my-self, thinking about the irony of this 21-year-old drug addict with 3 kids feeling sorry for me because she thought I had made such poor choices with my life to get to this point.

But that’s part of the charm of third year. Third year is about the patients. They will make you laugh, they will make you cry, they will frustrate you, they will teach you, and they will inspire you. Try to always keep in mind that these are real human beings who are scared and suffering. This is harder than you might think. Your professional curiosity will frequently get the best of you and you’ll get excited when you hear about a patient with a disease you haven’t seen yet or a crazy trauma case. That isn’t bad or anything, but don’t lose sight of the goal of treating the patient, not the disease. Be caring and compassionate, and remember that while you chose to be at the hospital, your patients did not. Your patients will certainly appreciate the time you spend with them, and hopefully, you’ll appreciate the time you spend with them too.

Best of luck to all of you!

Dennis Chen


21

Dear Third-Year Medical Students,

Congratulations! Finishing the first two years of medical school is truly an achievement indeed! Now moving on to another chapter of your life. Welcome to the year that you’ve been waiting for and studying for – time to be doctor! (well maybe I should rephrase – more doctoresque than you have ever been) J

Let me go ahead and say upfront that 3rd year truly flies by in the blink of an eye. It feels like yesterday when I sat down in my bed to read the letters that my upperclassmen wrote to my class. Now sitting back and reflecting upon this past year, I just have a few words of advice for you as you embark on your journey to becoming an extraordinary physician.

1. Make it a habit to be thankful for something each day.Like any habit, this takes time and practice. The established rule before was that it takes on average 21-28 days to develop a habit, but latest research says 66 days to truly condition yourself. Hence, I say start this your very first day! I can tell you firsthand this is not the easiest habit to form, especially on days when you are tired, frustrated, and beat down. There are days where you feel like nothing you do is right, feel unnoticed or even undervalued, or feel you will never amount to the doctor you aspired to be. However, once you form this habit, you will find things to enjoy about the steps along the way despite your circumstances. Remember it is not a right but truly an honor to be in the position that you are in. Be thankful that patients see you as a doctor already and that they truly appreciate you when you answer their questions, listen to their stories, and spend time with them. Although you won’t believe me right now, you will spend more time with a patient than any other health care provider has. This is a very special privilege of the doctor-patient relationship, so be thankful for that! 2. Don’t complain.Complaining can become a habit as well. It unfortunately has a huge role and impact on not only you but also any team or rotation you are on. Some residents will keep you there longer than you need to be. You will be the “black cloud” and work longer hours than other medical students. You will have to do things that neither the residents nor you want to do. You will have to take care of difficult patients who think it is their right to get the most attention and best care possible. All these expectations including working long hours, learning everything about your patients, and studying for shelf exams are tough. However, complaining will only make things worse. Your desire to learn and to be involved with your patient’s level of care will decrease. You will need to decompress and call a friend to complain about the day from time to time but don’t bring it to work with you every day. You will just make it worse for everyone else.

3. Maximize your learning.This is the first and last year in a clinical setting where you can ask almost any question to anyone. The advantage you have at a teaching hospital is that you have so many people including the nurses, techs, residents, and attendings you can ask and learn from. Ask the EKG tech to show you how to place the leads correctly. Ask the resident what the ABG means. Ask the OR tech if you have proper OR etiquette or are suturing correctly when the resident is gone. Ask the patient with a significant clinical finding if you and other students can come by later to listen to the murmur or carotid bruit, etc.

4. Enjoy the camaraderie of your colleagues.Remember that student who always sat in the far right 4th row that you never talked to or saw outside of the lecture halls? One of the things I enjoyed most was meeting classmates that you never knew existed before! Get to know your classmates and help them out when you can. There will be rotations where you will work with people who are more knowledgeable and some who are less. I promise you will be in both of those shoes some day along the course of your career, so always be humble and be thankful when you are in the position to help someone. Lastly, don’t think that residents are a different class of people. I’ve become really good friends with some residents I met along the way. They are just as human as you are and fun, awesome, and loving people too!

Everyone has different advice and words of wisdom to give, but no matter what, take time to think about who you are and what you value from time to time. Remember you are intelligent, capable, and competent medical students despite how you feel some days. Develop good habits early on and enjoy the start of this fantastic career you have ahead!

Sooyeon Choi

22


The third year of medical school is when your medical education truly begins. My first day of third year was on cardiothoracic surgery, overwhelming to say the least. We finished orientation and within 30 minutes I was on my way to the airport in an ambulance, a few hours later I was in Arkansas to harvest a set of lungs. I finished my first day of third year at midnight after watching a bilateral lung transplant and having traveled to Arkansas in a private jet. Every day has not been quite that exciting but each day I feel blessed to be a medical student and to receive the education that the third year of medical school offers.

Third year offers a myriad of different facets to your education; it solidifies your basic science, strengthens your understanding of pharmacology and reminds you of your desire to serve others. It teaches you to be resilient when you get reamed by the attending or chewed out by the nurse who didn’t get enough sleep. It allows you to become close friends with fellow classmates that you hardly knew and makes you excited to see another medical student in the hospital just because you know they understand. There are days that you think you are going to change the world and days that you think you want to give up. Days that you feel you made a difference in your patient’s life and days the patient asks you to leave because they don’t want to talk with a mere student.

Third year provided a lot of first-time experiences for me, I remember the first time I performed CPR on a patient, the first time they pronounced someone dead in my presence, the first time I pushed the button on the defibrillator and the first time I was there when we told the family their mother had an accident…or that their daughter or son had cancer. I will never forget my feelings three days ago when I saw them wheel away the darling five-year-old girl that passed away and listened to her mother cry in pain for her loss. And how could I forget the time that a nurse asked my opinion about the patient, or the time my first patient said thank you, or the laughter amongst classmates as we talked at lunch or on our way to OB clinic, or the mixed feelings of finishing one rotation and moving on to the new unknown.

I have made more friends this year than any I can remember. I have learned more than I expected, about every aspect of life, from medicine to personal relationships. The third year of medical school is a wonderful time and a challenging time. A time where we get to put our money where our mouth is about our desire to help others, a time where you get to face your own emotions amidst lack of sleep and stress of grades. Third year is the year you begin to learn how to really become a doctor.

Kevin Christensen


23

Dear Third-Year,Congratulations on making it through the first two years of medical school. You will now be experiencing the real life of a physician with no more vacations, no more spring breaks and no more real weekends. As is true for all types of experiences, your experience during third year is what you make of it. They can be on different ends of the spectrum for each individual. All I can offer are a few words of wisdom that I’ve gained during third year that may provide some insight as you begin the journey of your career as a physician.

Third year is the best time to maximize your learning experience. Your medical knowledge will rise exponentially. Take every opportunity to ask questions and be involved in every medical decision dealing with your patient. If you don’t know why a specific test was ordered, if you don’t understand why an electrolyte abnormality is occurring, if you don’t know why a certain antibiotic is used over another one: ask, ask, ask!!! If you never ask and just pretend to understand why a patient is being managed the way he is, you will be struggling when the time comes for you to manage patients on your own. Third year is not the time to be shy or worry about being embarrassed. This is the time to put yourself out there, show that you are interested in learning and interested in every decision that is made regarding your patient. No one will ever fault you for asking too many questions or being eager to learn.

Learn how to do a physical exam well. This will be the last year when you have an excuse as to why you are taking an hour to perform a history and physical. You definitely don’t want to be a sub-I or an intern taking an hour to examine every patient; it is imperative that you learn to become efficient. Learn what normal is like so you can recognize when something is abnormal. During rounds if you hear that a patient has a palpable mass, fine crackles, a murmur, or expiratory wheezes, go listen to him! Remember – don’t be shy! Third year is completely team-dependent. The type of experience you have will be solely based on how you function as a team and how much of a team player you are. Be flexible! You are bound to work with someone that you would rather not interact with, but remember that you are a professional and you must act professionally. Be courteous! Don’t overstep a teammate so you can receive a “better evaluation.” Be respectful of your fellow colleagues and realize that you are all going through the same thing and everyone ultimately has the same goal.

Don’t complain! No one wants to be stuck working with that someone who is constantly complaining. Be the person that others want to have on their team. Always have a positive attitude. If you are rotating on a service that you absolutely hate, just remember that there is an end to the rotation and you won’t be stuck doing this for the rest of your life. So just try and enjoy the experience while it is available to you.

Spend as much time as you can with your patients. As a medical student, you’ll always have downtime to go back and visit with your patients while everyone else on the team is busy. Your patients will greatly appreciate it and it’s the best way for you to practice your skills in developing an adequate doctor-patient relationship.

Don’t be afraid to provide ideas on how to manage your patient. This is the ideal time for you to suggest any ideas and not worry about harming any patients. Always test your knowledge; it’s the best way to eventually become confident with the decisions that you’ll make when you are the sole physician responsible for your patients.

Most importantly, HAVE FUN!!!! There will come a point during the year when you will be completely over third year…but when that time comes, remember: you’ve made it this far and it’ll all be worth it in the end. Stay motivated, be yourself, be professional, smile and enjoy the journey of third year.

Best wishes,

Elaine Cristan

24


Dear Third-Year Medical Student,

On one of my rotations, I met a 63-year-old lady with long-standing diabetes. Her diabetes had gotten so uncontrolled over the years that her kidneys shut down and now required dialysis three times a week. She had been on dialysis for about 4 years and was doing well as long as she kept attending her appointments regularly. When she didn’t, she would feel very sick and have nausea, dizziness and weakness. So when she came into clinic that day, I was surprised that she wanted to stop the dialysis. She said she knew she would die if this happened and that her appointment that day was to say goodbye to her doctor, whom she had been seeing for more than 20 years. She only asked if it would be painful and if it would take long. She had spoken with her children and decided that after 4 years, she was tired and felt that being on this treatment for four years had finally taken its toll on her. Everything had revolved around her dialysis schedule. It made her so tired that she could not do anything the next day and by the next treatment, the process would start again. Each treatment took 4 hours. She was very limited in her activities and was not able to care for her husband, who was also debilitated and eventually required nursing care and finally, hospice. She could not travel or take vacations. She could not do housework or go for walks. She relied on her daughters to drive her to appointments and the grocery store because she was unable to drive herself. She had suffered 2 major hospitalizations for infections from her arteriovenous graft. Over the past year, with each trip to her appointments, she realized she didn’t want to be on dialysis for the rest of her life.

To be honest, I did not know much about dialysis treatment before this. I only knew that it was the only treatment for renal failure, short of a kidney transplant. I did not know how long each treatment took, how many times a patient had to do it each week, the side effects after treatment, the complications that can occur and really, how debilitating it was. Now, different patients respond differently to dialysis treatment and may actually still be able to live a mostly normal life. My patient was not one of those patients. Her quality of life had significantly dropped so that she finally decided she had no life left to continue. Over the years, it had taken most of her strength to be able to do basic things around her house and finally, the will to continue her treatments.

This was my first encounter with a patient who willingly decided to stop a life-saving treatment and knew of the consequences. Not many patients make that decision. In the first 2 years of medical school, we are introduced to medical and ethical issues. We have discussions and small groups, and we form opinions without ever having real experiences of having patients battling with these issues. For me, hearing my patient say she didn’t want to be treated and knowing she would eventually die was difficult. On one hand, I wanted her to live; on the other, I didn’t want her to suffer. In the end, it wasn’t my decision. I can’t say I’ve met too many patients with major ethical and medical dilemmas like her as a third-year medical student. But I don’t imagine it gets any easier.

H. Corona


25

My Letter to a Third-Year

Let me start off by saying congratulations for finishing the Step 1! It is most definitely a challenging experience and you should be very proud of what you have accomplished thus far. I hope you are all not sufficiently burned out at this point, but if you are, it is OK, because I was too, as were most of my class-mates.

As you find yourself at a most liminal of moments, I imagine you are filled with great uncertainty at the nebulous concept of third year rotations. I can’t say for sure how exactly rotations will affect each and every one of you. As our school is composed of students possessed of different talents and aptitudes, the third year is bound to impact everybody in a unique way. In addressing you all in this moment, all I can do is share my experience which has been one of peaks and valleys; however, through it all, I rediscovered and learned anew the principles and convictions that brought me into medicine in the first place, and I continue to stay motivated in pursuit of the most noble of endeavors.

Upon beginning my third year, I was under the notion that my days of cramming through review books and being judged on my ability to take tests were over; however, in my misconception, I began to realize something greater about the medical profession. As Dr Esterl told our class, even the best of intentions can be harmful in someone who does not possess the proper knowledge. I began to finally see why I had just gone through 2 years of late nights suffering through texts of a wide variety. The truth is that medicine is an ever-evolving field, as you will come to find out from elder physicians who love to talk about the “good old days.” Thus, a commitment to lifelong learning is essential to living life as a successful physician. Though my days of burning the midnight oil over a text and taking standardized test may never be over, I understand now that it serves a higher purpose for the benefit of our patients.

Many of you may have no idea what you want to do and many of you may know exactly what fellowship you want to pursue, both of which are fine. However, in undertaking this third year, it is important you take a step back to understand what the lay public thinks when they hear you are a doctor. More than likely, they won’t even know what the name of your subspecialty means, however they will know you are a healer. No matter what field you may choose, that will not stop neighbors from asking you every little question about anything that may bother them, however you may have already realized this by going home for breaks! Though a gynecological oncologist throughout my life, my father has served as a neonatologist, pediatrician, infectious disease specialist, endocrinologist, radiologist, emergency medicine physician, dermatologist, orthopedist, psychiatrist and any other subspecialty you can think of to our friends and family. Keeping this in mind helps me truly see the true value in each rotation, however disinterested I may be in the actual specialty.

Perhaps the most beautiful aspect of medicine is to indiscriminately heal others without judgment or scorn. We all have preconceived notions about who our patients are that many of us have accrued from portrayals in the media and stereotypes in clinical vignettes. However, behind every alcoholic with cirrhosis, homeless man with an aspiration pneumonia and gang member with a gunshot wound, there is a real person who is hurting. This person, like you, also has a story of who they are and how they got there, and in you they see a chance for redemption. A physician is someone who will not judge and not act disgusted with them for being there; rather, someone who can heal them in their time of need and provide them hope for a better future. It is this beautiful aspect of medicine that motivates me and I hope reaches you as you enter this new phase of your education.

Matt Crozier

26


Dear Friends,

Congratulations! You are about to embark on one of the most exciting years of your medical education. Third year of medical school can be one of the most stressful yet rewarding life experiences; it can be the turning point in your journey of becoming a doctor. From delivering a baby to performing a thoracentesis to assisting in laparoscopic procedures, I had the best time of my life!

I started my path with Pediatrics; I remember Dr. Petershack’s enthusiastic words on our orientation. The one thing I can tell you is that kids are not little people! Enjoy pediatrics, you will see that everyone is nice, always in a good mood. Family center rounds, although overwhelming at first, they can be very interesting and a truly positive experience, not only to you but also to the parents.

My next step was to move forward with family medicine which was a great introduction to internal medicine. For both rotations the best advice I can tell you is to read as much as you can and stay interested. There is a very systematic approach to medicine applied here and it can be easy to get overwhelmed when dealing with patients who have chronic problems. Put the worry aside and learn from day to day and let the big picture come together.

Surgery was next; I learned how much I can function without sleep for over 24 hours. Trauma surgery is where I got the least amount of sleep, but it was a small sacrifice to make. Here time is measured in seconds, and seconds can mean the difference between life and death. You will have the opportunity to staple or suture a laceration, place a central line and see the nurses fighting each other at the end of the shift.

OB/GYN is great; it brings me joy to talk to expecting mothers. This is the one rotation where patients will ask the most personal questions. I truly enjoy the dynamics of this field from going to clinic and participating in the care of complicated pregnancies to assisting in deliveries. I truly love the variety in clinical setting.

Through the year, try to remember who you are as a person. Revisit the reasons that made you choose medicine as a career, while also not forgetting about the simple things in life that make you happy. If exercising makes you feel re-energized, keep doing it!The key things to do are to study as much as you can, sleep when you can, take breaks when you can, and learn to be humble and improve everyday. It is ok to say “I don’t know,” these words can mean “teach me.” It is better to face the gaps in your knowledge and fix them. This is the time when you will decide what kind of medicine YOU want to practice. Don’t leave any stone unturned.

Sincerely,

Karla DavilaMS3


27

It’s easy to feel underappreciated in the hospital as a third year medical student: during my band of students’ night calls in the trauma pit, every little mishap was reflexively blamed on “one of the med students,” while every commendable action was considered “not possibly done by a med student.” After several daily episodes of “PIMPing” during the day on surgery, a few students would meet every night to help out on trauma call. And usually, our requests were ignored, and our questions were inappropriately answered. We were expected to perform our mindless duties of transporting patients to the CT scan while writing a history taken primarily by a few residents. With this reality, many of us suppressed our desires to be proactive and to lend a hand in need. But every now and then, we were recognized for our actions, and these moments kept our passion for medicine alive.

I was on the first week of my Neurosurgery service, when a patient with a massive subdural hematoma from a motor vehicle collision was rushed to the operating room. The residents began evacuating the hematoma carefully, and at first, the patient maintained his vital signs appropriately. But suddenly, within thirty seconds of acquiring an air embolism from a central venous line, his blood pressure dropped to 30/0. Just as suddenly, twenty pulses became tachycardic while pressures became hypertensive: the staff grew apprehensive as they witnessed the patient’s life dwindling.

As the only medical student in the room, I was called on to begin chest compressions to keep the patient’s organs oxygenated. It was my first time performing chest compressions on a live human being, but I remembered how we were taught on mannequins to compress at a rate fitting the beat of “Staying Alive.” I began pumping away, sweating within three minutes and exhausted within five. I shuddered at the idea of a patient dying with my own gloved hands on his chest and continued pumping for an additional ten minutes. I heard in the background the neurosurgeons shouting, “Where is all this blood coming from?” and the anesthesiologists screaming, “His blood pressure’s still shot!” All I heard in my head was “Staying Alive.”

After fifteen minutes of chest compressions, the patient’s blood pressure miraculously recovered. I stepped back, still wide-eyed, desperately hoping the patient would survive. As I watched, the attending anesthesiologist walked over to me and asked me, “Hey, what’s your name, Kid?” After answering, I expected to hear some sort of critique, but instead he said, “Congrats, you just saved this patient’s life. You can have dinner with us tonight.”

I’ll admit it, I smiled. Seven weeks into the surgery rotation, I, for the first time, felt appreciated. Times like this make third year as great as it is. I would hope every student has the opportunity to realize the impact their work makes.

Viren Desai

28



You know that white coat that you got before first year, when your friends and family all came into town to celebrate your entrance into medical school? Well, it’s not just a stiff, awkward, uncomfortable jacket that you pull out every couple of weeks, to awkwardly wear into the CSC to fumble through history-taking and physical exams with SPs, and it’s not just a symbol of your membership in the medical profession, albeit at the most junior, short-coat level. It’s so much more:

- Your white coat can come in handy as a backpack replacement. Seriously. On a lot of rotations, you might not even need a backpack. Your white coat has seven pockets; if you also include pants pockets, plus maybe a shirt pocket, that’s a lot of carrying space. And you’ll have plenty of stuff to load up, if you so desire: stethoscope, reflex hammer, penlight, tuning forks, scissors, sutures, papers (a LOT of papers – rounding sheets, to-do lists, random notes), notepads, pocket references, phone, keys, wallet, pens, Kleenex, hand sanitizer, eyedrops, Chapstick, snacks, water bottles, and even some conveniently-sized review books. Just make sure you hit up Spectrum frequently enough to keep your trapezii in shape!

- Your white coat can double as a blanket on those long, cold nights in the hospital on call. Just remember, falling asleep carries the same curse as saying “it sure is quiet around here…” Speaking of sleep: no matter how little you sleep or how hard you work, your interns and residents almost certainly sleep less and work harder than you do; help them out and they’ll help you out.

- Your white coat comes equipped with a dirt/liquid attractant property. No matter how careful you are, your white coat will pick up some random stain the first day after you wash it. But don’t despair, and definitely don’t give up washing it. Once it starts to smell, or builds up the neckline grunge, you’ll know it’s time. Added bonus: if you wash it often enough, it might even start to soften up a little bit.

- Your white coat comes equipped with some sign, visible only to attendings, that blinks “I don’t know anything about this topic! Quiz me about it!” on rounds. Make sure you’ve read about your patients, both about their disease and how they are doing in the hospital. And remember that it’s OK to say “I don’t know” – after all, you’re a medical student. That’s when attendings get to teach, which is usually one of the main reasons they are here and not at a non-teaching hospital. Learn by doing, learn by failing, learn by trying. What you lack in knowledge or skills, make up with effort.

- Your white coat says to your patients, “I am your doctor. I am taking care of you.” While everyone else in the hospital might know what the short white coat means, your patients see you as their caretaker, their confidant, their healer. Take advantage of the fact that you are assigned fewer patients than anyone else on your team; you have so much more time to get to know your patients personally. You won’t even know the depths of that connection until that moment when you’re the one member of the team that can convince your patient to let their morning labs be drawn, or to take their medicine, or to go to their follow-up appointments.

- Your white coat will serve to remind you of every patient you take care of this year; faces and names will replace mnemonics as your way of learning medicine. While your white coat might feel at times like an incredible burden, remember that you are privileged to wear it and that it gives you access to learning experiences that will shape the rest of your life.

Enjoy third year, and don’t forget your white coat!

- Chris Dudley


29

Get ready for constipation. Seriously. That nice study and coffee drinking schedule from STEP prep time is over.

Never turn from the instrument stand with scissors in your hand already reaching towards the field. Turn. Look. Cut.

Don’t talk bad about the residents, you never know which one of the others in the room is their spouse.

Especially don’t say negative things about faculty.

Sometimes the attending will be wrong, often the resident will be wrong. That’s it.

Make a note of all those “When I’m a resident.. I’m going to/not going to…” You’re going to be a resident pretty soon.

The shock you have in July about how it seems like the interns seem to know about patho-phys wears off by December when you realize you have forgotten the same things.

Seriously, constipation.

It doesn’t matter what you study, just study. Anything relatively up to date is going to have the necessary info. The amount of time you put in is what’s going to make the difference.

I feel weird calling the residents by their first names, but get the feeling I am regarded as being cold when I continually address them as Dr. So-and-so. Don’t know what to tell you there.

Remember the residents and faculty who you thought were great and try to do things like they did them.

Don’t tell them about your constipation.

Write down everything you see on the EMR – labs, imaging, notes… Even the normal values. Who knows what you’re going to be asked about?

Take advantage of the food at Methodist or CSRCH. Free food is delicious.

Be nice to the pit bosses – they’ll let you do the fun stuff

Don’t mess with a recently intubated airway during a trauma. That is apparently frowned upon.

It’s not Crohn’s, it’s not IBS, it’s not colitis. It’s just constipation. Eat some prunes.

Once you decide what you want to be when you grow up, start writing your personal statement. It will be easier to put into words when you have just decided. Plus this is likely to evolve over time, continually work on it.

Touch your patients. Hold their hands, pat them on the leg or back, sit on their bed, ask where they are from, tell them jokes, answer their questions.

The best way to look good is to try to make your team look good. The best way to look bad is to try to make yourself look good.

Richie Edeen

30


Letter to a Third-Year

I had been on the service for only 1 hour, but when I came by to see him he had been admitted for 3 months. A fifteen-year-old boy lay in the hospital bed, unable to speak due to the tube in his throat that was allowing him to breathe. He had been diagnosed with a craniopharyngioma three-and-a-half months ago and had undergone surgery shortly thereafter to remove it. He had lost some of his vision before the surgery and sadly it was not completely restored after the procedure. The surgery also left him with a diagnosis of panhypopituitarism. A high school freshman, with his whole life ahead of him, had suddenly been relegated to the hospital wards with no end in sight.

He received daily doses of steroids and DDAVP to correct his metabolic imbalances, as well as a dozen other medications. Every one of his nurses and doctors was extremely caring, but this boy was still suffering from extreme sadness and depression. While his friends were playing basketball and opening Christmas presents at home, he was stuck in a cold hospital watching the neighborhood Christmas lights from his window sill. Further complicating his condition was the fact that his sodium level had to be stable for at least 2 weeks before he could be transferred from the hospital to a rehabilitation center. Predictably, his sodium level was extremely difficult to control, hence the reason for his 3+ month stay in room 837 of the east wing of the hospital.

In most other places in the hospital, time is at a premium. Nurses, doctors, staff, janitors, technicians, and medical students are frantically trying to care for all the patients and finish their work as efficiently as possible. But in this child’s room, time seemed to stand still. I saw interns spend 30 minutes reading Christmas cards to him. I watched as nurses would change his clothes and turn on his favorite movies. Staff physicians, doctors of more than 20 years’ experience, would stop their rounds to touch his hand and let him know that everything was going to be ok. Indeed, it was a surreal experience to spend as much time talking with the patient about his birthday presents as we spent talking about his electrolytes.

Slowly, our little hero began to recover. One day he was awake enough to give us a “thumbs up.” The next day he smiled at us. When his tracheostomy tube was removed, he was finally able to say “hello.” And as tears welled up in his eyes, a very heartfelt “thank you” emerged from his mouth. But all we could say in return was, “No, thank you.”

It is a known fact that patients can teach their health care providers many things about life and even medicine, but I would imagine that it does not happen as often as it could because of our hectic schedules, lofty demands from both our superiors and patients, and our narrow focus. We spend vast amounts of time learning how to treat pneumonia, but we only have one or two classes that teach us the importance of having a conversation with our patients that doesn’t include questions about their productive cough. Surely there is enough room in the practice of medicine for a doctor to do both.

Third year of medical school is perhaps the only instance where you will have the ability to spend adequate time talking to and with patients. Yes, you will have to present patients on rounds and watch procedures and go to the OR and spend nights on call and deliver babies and fill out requirement forms…the list goes on and on. While all of those things are indeed important and necessary, none will leave as lasting an impact on your emotional and scholastic memory as the time you spend developing relationships with your patients.

The thing that separates good doctors from great doctors is the desire to know and personally care for each individual’s needs. And while mediocrity can be attained overnight, greatness is a lifelong pursuit not easily gained. I encourage you to pursue excellence in all areas of medicine – research, scholastics, surgical skills, and anything else that arises. But do not forget to be excellent in your relationships with your patients, because you never know when a 15-year-old can make a lasting impact on your life.

--Jeffrey D. Edwards14 March 2011


31

Three years ago it was bestowed upon me, as it was to you just one year later, in due ceremonious fashion, a short white coat... the symbol of our forthcoming years of training to become a doctor. My coat at least was sized “small,” unisex in design, but fit my short frame like a little girl all dressed up in daddy’s jacket. I hope yours fits you a little better.

This year me and my white coat made the transition, as you too are about to, from the security of the classroom and the comfort of curling up at home with a 10-lb book (images of our first two years of medical school) to the hospital. Still students, still learners, but immersed nonetheless in an entirely new pace and culture of learning on our feet and at times eating/sleeping only when you can and not when you want. But, you also get to be a part of people’s lives. The 82-year-old with hematochezia is no longer a vignette on an exam. He’s Mr. K. You’ll meet his family and hear his story... see his fear and pain with your own eyes. And, praise the Lord, you’ll be a part of the team seeking to alleviate that. For me, it was hard to convey my initial excitement at being given such a privilege...

But somehow, over the course of these long and grueling months, some things began to change. The crispness of my white coat, that symbol of the professional and dignified journey I was undertaking, is long gone (really, when am I ever going to have time to iron it, or forbid, starch it?), and it now carries a sort of dingy, well-laundered hue, marred by ink stains, stubborn coffee stains, and I-honestly-don’t-want-to-know-what-that-was stains.

But the pockets... it’s the pockets that have undergone the greatest transformation of all. Once neatly containing a stethoscope and a few pens, now all seven pockets are fully loaded with a clipboard of papers, loose papers that no longer fit in the clipboard, four different badges, at least two reference books, pens in varying levels of functionality, a granola bar I forgot about, stethoscope, penlight with a dead battery, and my phone that I tell myself is only there so I can look up medications and other such clinically relevant information. It’s the strangest thing, but though these coats are very helpful in accommodating lots of supplies, they’re designed in such a way that the weight of ALL of it somehow eventually bears down squarely on the back of your neck and shoulders... What are we to do with this? What are we to do when excitement becomes exhaustion, and we’re surrounded by pain, burdened with the pressure of performance, and overwhelmed by the long road that lies ahead? And truly, I don’t have a great answer. Rather, it seems these are not the right questions to ask at all. You see, at the root of all these queries is a “me”-focused mentality: how this makes me feel, how my needs aren’t met, how my paradigm of justice has been disrupted. There are times every day when I have to force myself to stop my programmed history and physical checklist of questions and my “how fast can I say it all this time” review of systems to simply look at the person in front of me—to set aside my harried schedule and desire to “get this done quickly” to just listen. Here I begin to understand that the art of healing is much deeper than mere physical ailments. As Dr. Henry Maudsley once said, “the sorrow that has no vent in tears may make other organs weep.” Also, I have to realize that I cannot “save” everyone. I was completely flummoxed and heart-broken to realize that no amount of study, research, or pain-staking attention to detail was enough to bring complete healing in all cases. I still believe a commitment to lifelong learning is one of the most crucial responsibilities each of us bear, but I also have to know deep in my heart that life and death are not ultimately in my hands. I believe, more firmly now than I did nine months ago when I began my clinical rotations, that my role in medicine is to be a means, an educated and well-trained vessel, of God’s ultimate healing in others’ lives. To carry any pressure above this is more than another human can bear. This rest in the sovereignty of God does not give me an excuse for laziness or recklessness in the hospital or clinic—by no means! Instead, I see it as Dr. Heinrich admonished the class of 2012 during that very ceremony where our white coats were first placed upon our shoulders: “You never know when a miracle is going to happen, so you’ve got to work hard to be ready to usher it in when it does.”

There are still times when I feel, as you also may someday, the weight of the white coat as a burden too heavy to bear, experience hours of frustration scrubbing at stains on the pockets and sleeves that won’t lift, and days when you can’t wait for the end of the day to take that white coat off, throw it in the backseat, and go home. But with a commitment to joy, an eye to look for the personhood of those around you, and for me, a firmly rooted conviction in the true Healer, we can move forward, unafraid to see, serve, and care for those around us. And, when I take time to remember these things, I am obligated to be humbled, inspired, and grateful for this journey... in some ways, to be that same little girl in an over-sized white coat, with a whole lot yet to learn. I wish you much joy for the days to come! Have fun--you’ll do great.

32


Sincerely, Sheridan Fielding UTHSCSA Medicine Class of 2012


33


It’s difficult to give advice about your third year of medical school, because it is an entirely different experience for each person. The only guarantee is that third year will be full of ups and downs and in the end you will be surprised at how much you learned and how quickly the time passed. With that said, there are a few things I can think of that you should find helpful in general.

First, sometimes you just have to consider making it home at the end a success. There will be days when you feel like you couldn’t do anything right, but it doesn’t do anyone any good to take those moments home with you. Consider each failure an opportunity to have improved your clinical skills and knowledge, learn from it and move on.

Second, a solid, well thought out, efficient oral presentation can make you look like a rock-star, all other things aside.

Never complain around your faculty or residents, even if they seem to be inviting it. I was once asked by an attending on one of my post-call days how I was doing and if I was tired. My response was that I felt great. He stopped for a second and told me with a smile that while that wasn’t the answer he was expecting, he was glad to hear it because, “nobody my age, wants to hear anybody your age complain about being tired.” You might also find that saying out loud that you feel great, even when you don’t, will often actually make you start to feel great. If you have a bad attitude and start thinking it’s going to be the worst day of your life, it probably will be.

On surgery – learn how to suture and tie knots before you’re asked to do it in the operating room. I kept a shoe lace tied to my scrub pants and would practice my knots and read Surgical Recall every spare moment I had while at work…in between surgeries, while walking from one hospital to the next, during lunch. It paid dividends during pimping and in the OR and it meant I had less to do when I got home.

Try to know everything you can about your patients. Your patient may be getting a cholecystectomy today, but if he has a history of a pancreatic cyst don’t be surprised if you get asked questions about pancreatic cysts. The same goes for the medicine wards. All is fair in pimping and chances are you’ll need to know it for your shelf and the boards, even if it doesn’t happen to have a huge impact on your patient at the moment.

The third year of medical school is an exciting time because, for the first time, patients, nurses and others will start to look to you for answers regarding your patients’ care. You will, of course, have a safety net of interns, residents and attendings, but don’t rely on them for the answers. Try to come up with your own plan (it will get easier as the year comes to an end) and then run it by them. One of my pediatric attendings said it didn’t matter to her if we were right or wrong, but she wanted us to come up with a differential and treatment plan by ourselves, and she would take us from there. You will learn much more that way.

The third year is also challenging because gone will be the days of getting out of lecture by noon some Fridays and you can no longer assume that the weekend means two entire days off. There will be “mornings” you have to wake up so early that you can’t help but feel like it’s still the night before and there will be nights you get home so late all you can do is drag yourself inside and collapse on the couch. You survived the MCAT, you have survived two years of medical school and the Step 1 exam, and you will survive third year and hopefully feel more knowledgeable, capable and confident by the end of it. You will also have days that make you remember why it’s all worth it. Whether you do a thorough history and physical and pick up on a significant finding that your resident or attending initially missed, or hold the hand of a scared patient, as a third year you have an important role to play.

Last, but definitely not least, don’t forget about your life outside of the hospital. You can (and should) make time for your loved-ones, your hobbies, and your health.

Best of luck!

Sincerely,

Leila Ford

34


Letter to a Third-Year,

It’s hard to believe as I am writing this, that I am in my last rotation of third year. This year has been amazing and has gone by so quickly. There is no way to predict or to prepare for what your third year will have in store, but if it is anything like mine, it will be full of ups and downs. Moments that you will cherish for the rest of your life and a few that you will wish you could forget.

You will laugh, with your colleagues, with your residents, with your patients and when you accidentally drink your attending’s coffee. He won’t event hold it against you, he may even laugh also as you spit it out because of embarrassment and because it has too much Splenda in it.

You will cry. Maybe during your surgery rotation. Maybe alone in the bathroom of University Hospital. But it will be OKAY. You will survive that day and the rest of the rotation. You will appreciate what you learned in that moment when all you want to do is go home and crawl into bed, but you wash your face and scrub back in.

You will lose; your patients. Maybe on pediatrics, where death feels unfair and cruel. You may visit the butterfly room alone in Santa Rosa afterwards and try to imagine what that mother is thinking. Say one last goodbye to that three-year-old who never had a fair chance. Then you will walk down the hall and try again to teach the six-year-old with a bone infection how to swallow pills using tic tacs and Halloween stickers with googly eyes.

You will make mistakes. You will overlook important labs or miss huge and obvious physical exam findings. You will always forget to ask something that, in retrospect, seems like the most obvious question in the world. But you will get better. Every single day you will improve and you will realize that someone pointing out your mistakes is a necessary step in developing into a competent and qualified physician.

You will change someone’s life. You will talk to patients more than anyone on the team. You will inevitably explain something they never understood. You will ask a question that no one had taken the time to ask before and you will unlock a history they have never felt comfortable sharing. As medical students, we have the opportunity to know our patients on a deeper level than anyone else on our team. We have the time to spend talking to them. When we are residents with twenty patients to see and 10 minutes to spend with each, we will not get to hear the stories of pain, of healing, of suffering and of happiness and we will miss them.

You will fall asleep. On rounds, in the pit, in your car in the parking lot, standing up during a kidney transplant at 2:00 a.m., and even occasionally in your own bed. I hear fourth year is better though. I’ll let you know when I get there.

You will learn more than you ever imagined possible even when you do not realize you are learning. You are surrounded by incredible, caring, and compassionate people every day. Your residents, your attendings, your fellow students, the nurses, techs and secretaries and, most of all, your patients, will teach you about life, death, healing, hard work, and also a little medicine.

You will grow as a person and begin to see your own potential. You will realize that the “C” on your transcript from first year really does not matter (seriously), and that you are meant to be here. Even if you failed a pathology test... or two, you are still capable of becoming a great doctor.

I hope your third year is every bit as happy, sad, energizing, exhausting, confusing, simple, rewarding, and beautiful as mine has been.

Good luck!

Lauren Gambill


35

It’s All About Attitude

I understand exactly how you are feeling right now. Whether you are scared, excited, nervous, unsure, or confident, I understand how you are feeling because in the last year, I have felt all of those same emotions, often simultaneously. Third year is nothing if not overwhelming and surprising. It presents constant challenges yet at the same time may be the easiest and most natural thing you have done since starting medical school.

As you prepare to enter the clinical years of your education, you are going to get more advice than you want or need. So rather than dispensing more of the same, I am going to tell you how to be happy while doing well in your rotations. The most important thing you can do third year to assure success and happiness: have a good attitude.

Now I must be honest: this year will be difficult. There will be days when you wake up in the morning and dread going to the hospital. Days when no matter how much you have studied or how smart you think you are, you will feel like a giant idiot on rounds. You will likely be so exhausted that you will fall asleep sitting in a lecture, or if you are anything like me, standing in a surgery. You will be worked to your breaking point and still be expected to study when you get home. You may have patients who are ungrateful for the generous care you are providing; those who make all your hard work feel as if it does not matter. It is possible that you will work such long hours that you will not see the sun for days at a time. You might get yelled at by someone you respect. Do not let these negative experiences distract you from the fact that this is an unbelievable job. There will probably be a day where you correctly diagnose a rare disorder in a patient. You could find yourself shocking a heart out of V-fib, doing an emergent intubation, or saving someone by holding pressure on their arterial bleed. You will become comfortable presenting patients to your attending. You might have the chance to teach a wide-eyed first-year student shadowing in the ER how to participate in a trauma call. You could have the satisfaction of the surgery fellow scrubbing out, leaving the entire sternotomy for you to close on your own, saying, “Okay, I know you’ve got this.” You will have a patient tell you that they think you will be a great doctor someday. We all came to medical school for these moments.

From my experience, the key to navigating the emotional, physical, and educational roller-coaster of third year is to remind yourself that this job is amazing and let your attitude reflect that understanding. Wake up in the morning and emulate the doctors you are trying to become. Do not fall into the trap of thinking that no one is watching because you are “just the third year.” Everyone is watching and the subtleties of how you carry yourself this year will matter. Your attitude towards your patients, residents, classmates, attendings, and toward yourself will be your lasting impression. Be someone that your patients can trust. If you go to work every day looking like you just rolled out of bed and hate your life, I can guarantee that others will notice. Even on days when you do not love the third year experience, fake it, because you might be surprised when pretending to have a positive attitude toward your work can actually manifest itself into a true sentiment. Pretend that you are not tired, not frustrated, and not overwhelmed and you might find that it relieves the burden of those emotions. On your rare days off, spend time doing things you really enjoy with the important people in your life so that you are refreshed when you go back to work. Try to be exceptional every single day, not because it will get you good evaluations or a good shelf exam score, but because your patients deserve more than mediocrity and you deserve to enjoy the process of taking care of them.

So get excited MS3s, because you are entering the most rewarding part of medical school. When things get rough next year, as I am sure they will, remember how you felt right in this moment. Be reminded of how fortunate you are because in the end, you will all be doctors and, from my perspective, it doesn’t get much better than that.

Tracy Geoffrion

36


Congratulations on surviving the first two years!! This next year will remind you of why you wanted to be a doctor. You can finally use all that book knowledge you thought was useless and share it with your patients! Most residents and faculty have so many patients and so little time, which makes you the perfect person to explain the intricacies of managing chronic disease. You’ll be surprised to find that many patients don’t know what meds they’re taking or why they’re taking them. You’ll have diabetic patients that are non-compliant with their ACE inhibitors and statins because they “don’t really have high blood pressure or high cholesterol.” And you can be the one to share with them all of the protective renal and cardiovascular effects of those drugs that you learned in Dr. Keeton’s class. Your patients will really appreciate your willingness to sit down and talk with them.

There will be wonderful days where you remove a central line and then get to explain to the patient’s family that their loved one is ready to be discharged home. You’ll catch babies, I&D abscesses, tap fluid, and suture up wounds. There will be many “aha” moments where you’re listening to a patient’s heart, hear a murmur, and then your attending confirms that it’s not just your imagination. On these days you’ll feel like a real doctor and life will be good.

Unfortunately there will be some agonizingly low points, for example when you’re just getting off call after a long day of feeling useless and being yelled at. You’ll need thick skin, especially during Surgery. At times you’ll wonder why you ever wanted to go to medical school just so you could live like an indentured servant, spending the better part of your youth cooped up in a tiny hospital room with endless paperwork to complete. However, these days will be outshined by some of the amazing experiences you’ll have.

A few tips for 3rd year:

Try to do a rotation in either Corpus Christi or the Valley. The palm trees and near-by beach will make it feel like a mini-vacation. Usually the hours are much better at the RAHC and everyone is more relaxed. I was lucky that I got to spend about half of my clerkships in San Antonio and half somewhere else. The traveling back and forth is a little tiring, but once you’re there, it’s totally worth it. And you definitely broaden your experience in healthcare delivery by working in different towns.

When presenting your patients to residents and faculty, always have an assessment and plan. Even if it seems like they couldn’t care less, they still have to evaluate you on your assessment and plan, so it’s a good idea to cover all your bases. And at the 3rd year level, really the only bad plan you can have is no plan at all.

For books, I really liked Case Files and Pre-Test for every clerkship. The information seemed stick better for me with Case Files as opposed to textbooks or reference books, and Pre-Test is a great tool to practice questions right before the Shelf Exam. You’ll probably need to supplement these with other resources for some clerkships, especially Surgery and Internal Medicine, but they’re a great start.

You’re going to love 3rd year! Best of luck and many blessings!!

Cassandra Gurgiolo


37

Letter to a 3rd-Year,

Surgery was my very first rotation, and I went into it having absolutely no idea what to expect. I was on a team with one other medical student, 2 interns, a 2nd-year resident, and a chief resident. One morning while pre-rounding with a few of the residents, we visited a patient, Mr. H., who had been there almost 2 weeks following a liver transplant. Soon after the surgery, the patient developed an ileus, and was unable to digest food or have a bowel movement, for unknown reasons. Mr. H. required an NG tube and was allowed only ice chips and small sips of water, both of which he would frequently request more of. The patient was put through a whole battery of tests looking for a possible cause for the ileus, all of which had turned up with no helpful information. The next study on the docket was an endoscopy that was scheduled for the afternoon. The study required him to be NPO until it was completed. NPO meant he would no longer be enjoying his ice chips and water for the rest of the morning.

During rounds, we asked him all the customary morning questions like, “have you passed gas this morning,” “are you in any pain,” “do you have any questions”…and so on. The patient had one request from us that morning— more ice cubes. I could tell his lips were chapped and his mouth was dry as he answered the questions. The 2nd-year resident quickly answered him saying, “Oh yeah, of course, I’ll get those for you right away,” with a sarcastic tone. The patient looked relieved, and the team turned and left his room. The resident failed to tell him he wasn’t allowed any more ice cubes or water for the rest of the morning. When we got outside of the patient’s room, the resident said to the rest of us, “Yeah right, this guy is NPO, he’s not getting any ice cubes today.” He and the rest of the residents chuckled while I stood in shock. The other residents were not going to question this resident, and I especially did not feel I could question my resident’s actions at the time…I was just a medical student. Instead, we were going to let this patient sit in his bed thinking we would be back with his ice any minute. This was the first time I had been ashamed to be a medical student and the first time I was ashamed to be a member of this surgery team.

I still cannot imagine how it must have felt to be in his situation and to wait for something that would never come, to wait for something that one of your physicians has promised you, a person whose entire job is based on caring for you. Ice is such a minor thing when you think about the daily difficulties that a transplant patient goes through, but to this particular patient, ice was one of the only things he could enjoy. I think the patient’s dignity was thrown by the wayside and basic human courtesy was denied to him.

I hate that this is the story that I am passing on about 3rd year. I wanted to write about one of the many positive experiences I have had during third year, but this particular encounter is something that I think about frequently. I replay this visit over and over in my head and think about all of the things I should have said, the things I should have done, and the things I would do now to make sure something like this never happens again. Medical students are sometimes the only voice that a patient has, and because I was too afraid to question authority, I failed to speak for him that day. I will regret that for a long time.

I hope that if you come across a situation like this, you will have a better idea of how to act and react. I wish I had been more prepared.

In all honesty, 3rd year has made all of medical school worth it, even when I think about the few bad experiences I have had. The good ones still outweigh all of the bad. I continue to learn awesome things from patients every single day. Good Luck!!

Ashley Harrington

38


It was the first five minutes of my first overnight trauma call for the General Surgery clerkship, and the pit boss was showing me how to use the student pager. Just as he was about to demonstrate what the green button does, the pager began to beep…a beep with which you will become all too familiar. It’s the beep-beep-beep that signals the imminent arrival of a new trauma patient.

“Oh, perfect!” exclaimed the pit boss to me. “This will be a great opportunity to show you how it works. When the pager goes off, you simply push this button to read the details on what’s coming in, and scroll down or up. So our page here reads:

‘Pedi vs MV 10y/o M GCS 3 CPR en route’.”

I looked at the pit boss blankly, as if to look for a translation of what that meant, and noticed that he was wearing a rather grave expression.

“You know what,” he said, “this is a real serious trauma. Why don’t you observe on this one… and try to stay out of the way.”

As I waited for the trauma victim to arrive, I noticed that the Chief of the trauma surgery department (who I was told only shows up for the worst trauma cases) had come down from his office and was already barking out orders. Even though I knew my job was to stay out of the way, I decided to put on some gloves, just in case things should become so critical that they might need the help of a third-year medical student.

As the patient was rolled in, I began to piece together the meaning of the code I had read off the pager’s display. A Glasgow Coma Scale (GCS) of 3 means essentially that a patient is on the brink of death. The ten-year-old boy had been struck by a vehicle, and, upon arrival to the trauma bay, he appeared cyanotic and lifeless.

The team sprung into action, and even before an IV access had been put into place, the Chief spun around and shouted, “I need the tallest medical student on chest compressions right now!” In spite of already knowing myself to be the tallest student in my class, I nevertheless looked around the room frantically, hoping to find a medical student taller than I. Thank God I had put some gloves on.

“You, let’s go!” he said, looking at me. And without thinking, I found myself over the patient, hesitantly but willingly doing my best to give CPR as I had been taught: 100 chest compressions per minute, to the beat of the song “Staying Alive.”

Inside of 30 seconds, the team had intubated the patient, placed an IV access in two locations, hooked up the AED, and was getting ready to perform a left-sided thoracotomy in order to check for bleeding in the thoracic cavity and manually massage the heart if need be. After another 30 seconds, the team had entered the chest cavity and I was beginning to feel more comfortable in my role. “Maybe I will have the honor of helping to save a life,” I thought to myself, as I did my best CPR right next to the action. But as the chest was opened up, blood came pouring out at an alarming rate. The chief took a quick look inside and searched with his fingers as if to attempt to stop the bleeding, but then he said something that I didn’t quite understand. Well, I understood what he said, but what he said didn’t seem to fit just then.

“Is anyone opposed to calling this one?” He waited for a response as the team continued to pour fluids into the IVs and search for signs of life on the monitors.

“Time of death: 6:15,” he said.

Somehow, I didn’t think that that could possibly be it. How could death be an option so soon? Only after everyone around me had stopped what they were doing did I begin to slow my chest compressions until I too finally stopped and backed away from the stretcher.

Nurses and staff began cleaning up, people went on attending to other patients, and eventually pagers began ringing again with the beep, beep, beep of the next incoming patient. There was a definite sense of loss on everybody’s faces in the trauma pit, but nobody really had time to digest the tragedy that had occurred. Things just went on. I finished my overnight shift the next morning at 7am and went straight home to my bed. Later, over dinner, I finally had time to think about what had happened. I thought about how the chief


39

had requested the boy’s name after pronouncing the time of death and how he had asked where the parents were so that he could talk to them about what had happened. I thought about the parents and the heartbreak that they must be experiencing. And I replayed the images of that night’s events in my head. I picked up the phone and called my mom. She answered, but before I could get an explanation out, I erupted into tears.

Death is something that you will all likely encounter during your third year, as well as many other emotional experiences. And, of course there will be plenty of good things to celebrate as well. My message and advice to a third-year would be to embrace these experiences; seek them out even. Get involved with not only your patients’ medical conditions, but also take time to ask about their emotional condition. Instead of just asking if they’ve experienced any side effects from their meds or whether they’ve had a bowel movement in the last 24 hours, ask them if they have any concerns that they would like to bring up with the treatment team. Be sure to acknowledge their strength throughout their hospital course, and, if a family member is present, always thank him for being there because that is likely where the strength is coming from. Third year is your chance to learn those things that they say can’t be learned in a classroom or from a textbook, so learn those things. Don’t hide behind a clipboard when the attending goes out to the waiting room to address the family, and don’t get yourself “stuck” in front of a computer writing a progress note when the surgeon is on his way out to tell a spouse that cancer was found. Sit in on family meetings where they discuss palliative care for a loved one, and don’t resist those emotions that come your way over the course of things. When you are preoccupied with studying for shelf exams, it is sometimes easy to forget what is at the core of our profession: the human condition. Dedicate your time not only to science, but also to humanity. All experiences can serve a purpose in training and development, and our emotions do also play a role in treatment and diagnosis. In the words of the great physician-writer Sir William Osler, “The physician needs a clear head and a kind heart; his work is arduous and complex, requiring the exercise of the very highest faculties of the mind, while constantly appealing to the emotions and higher feelings.”

–Tyson Heller, MSIII

40


During the first and second years of medical school, when things got tough, I always found one piece of advice from upperclassmen to be very comforting: “Just wait until you get to third year. You’re going to love it. You’ll finally get to do what you came to medical school to do.” These words of encouragement helped me through the seemingly endless rounds of exams and the marathon of studying for the USMLE Step 1. Like most students, I started third year with high hopes and high expectations.

The first day of my first rotation finally arrived. For me that meant it was my first day on the cardiothoracic surgery service (Note: If you happen to have that as your very first rotation – brace yourself for a rough ride. You WILL survive). I arrived at 5 a.m. in the surgical ICU at the VA and found my intern. I introduced myself and he glanced at me with, bloodshot, frantic, sleep deprived eyes and said, “Uhmm… Go examine Mr. B in room 1 and be ready to present him.” I nodded eagerly like an excited bobble-head toy, pulled out my newly purchased mini clip board, and stepped through a pair of glass doors to see my very first patient of third year. The room was dark and filled with monitors. Mr. B was intubated, sedated, and had so many lines going into his body that I couldn’t count them. I cautiously stepped up to the bed and attempted to start the exam by rousing the patient – no response to sternal rub. I tried to auscultate his heart and lungs - all I heard was the roar of the ventilator. I stood there in the darkness by Mr. B’s bed and thought “ACES has not prepared me for this. Shit.” As I was having this revelation, my intern stalked into the room, flipped on the light and grunted, “Are you done?” I stood there frozen and before I could reply he continued, “Good. I need you to go get all the lab values for our patients before we round at 6:00.” It was 5:55….

You will have days like my first day. Days where you are overwhelmed, sleep deprived, and find yourself wandering around the hospital wards with no clue of what is going on. Days where you will be disappointed in yourself because everyone told you third year was amazing but you hate your life. You might begin to think that all fourth year students are delusional and that maybe they have blocked the third year experience from their minds in the same way that a woman who has gone through labor will continue to get pregnant. What I want you to remember during third year is this: it is OKAY not to like everything you do next year. Really. Do not feel guilty about it or think that you’re a failure as a medical student. You will learn a lot even in your misery. The best advice I was given for those days when you don’t want to be at the hospital was to fake it. Pretend you love it. Remember when Dr. Keeton told you to show up early, leave late, and be happy? Do it. Your attending and residents will notice it, your classmates will appreciate it, and your patients deserve it. Yes, you might have bad days. However, you will also have many amazing days during your third year rotation and many experiences that will make you feel blessed and honored to be a future physician.

Good Luck!

Kristin Hemard


41

Thursday February 24, 2011

Dear Third-Years,

Congratulations! You’ve made it through two of the hardest years of medical school (and Step 1). You should feel proud of what you’ve accomplished. Some of you may be thinking, “What is she talking about? I thought third year was supposed to be the hardest.” Well, that’s what I thought when I was in your place and to be quite honest, I was pretty freaked out about the prospect of 48 weeks of torture. But let me put some of your fears to rest. Third year is not the horrible, no-joy, stress-fest some people make it out to be. I’ve actually had some fun this year. I’ve seen my family (who live in Chicago and Tulsa!). I’ve gone out to dinner with my husband. I’ve even been to a few movies! A lot of third year is about attitude and time management. A good attitude can actually get you pretty far in third year! You do need to know the basics, but if you have no clue how to do a fundal height or how to talk to a psych patient about their Matrix delusion, that’s okay. That is the point of third year, to learn. There will be some tough times, but that is true of anything. The important thing to remember during those times is that you will not be a third year medical student forever! There will come a time when you will no longer be addressed as “medical student” or “you.”

When I was in your place what I really wanted to know was, “What will each rotation be like?” What I’ve learned over the year is that everyone’s experience is so different. It depends on what particular attending you have, which residents are on when you are, who your fellow third years are, and your own attitudes toward the rotation. There’s not a lot you can do to change most of these factors, but you do have control over your own attitude, so try not to worry about the rest. Approach each rotation with an open mind and take all advice you hear with a grain of salt! And remember, whether it’s a positive or negative comment, always consider the source.

Surgery: I had this rotation first and was really nervous. I have no intention of becoming a surgeon, but I actually liked surgery! (Again, a lot of it is attitude and willingness to help.) Yes, you will have to stay up for 24 hrs for trauma call, but you can do it! I had never stayed up that long before in my life (in fact, I really, really love sleep) but I was able to do it. If I can do it, so can you! We were given the Pestana packet to study. It is helpful; however, you should NOT rely on it as your sole source to study for the midterm! Study the weekly cases Dr. Esterl gives you and read ahead to the cases for weeks 9-12 (trust me!). Working weekends- depends. Technically you don’t get them off, but I happened to have rotations where I had most weekends off except for days when I had call. Also, a few baked goods or snacks can go a long way to boost the morale of your teammates and pit boss during trauma call. J

Psych: I did my rotation at SASH. It’s a really good place to see severe pathology that you may otherwise not get exposed to. If you’re not at SASH, don’t worry, you’ll still get to see a lot! You get weekends off, unless you have call that day. They are pretty flexible with call though and if you need that day off you can usually switch with someone. I used First Aid and World question bank. I thought the World questions were easier than the actual test.

OB/GYN: It’s not that bad! I liked it because I was able to see and experience one of the great miracles in life: birth. (That is also what I reminded myself when I was really tired and getting burned out.) You also get weekends off! You don’t have call, but you have night float where you go in from 6:30pm- 7:30am for four to five days. I used Blueprints and uWise (ob/gyn gives you access to this site- it’s really good for questions, use it instead of World if you only have limited time).

Peds: I want to be a pediatrician, so I loved peds. However, one of my attending s was a lot more intense than most pediatricians. Unfortunately, I didn’t follow my own advice and listened to other peoples’ views instead of being open-minded. Once I actually worked with her for a few days, I realized she was very good and really enjoyed my time with her. For the two weeks you’re on outpatient you have weekends off. For the four weeks you have on inpatient you work one weekend day and take a short call one night a week. I used Case Files and PreTest.

Family: I’m in the middle of family right now. I’m doing private practice so I have weekends off except for the two weeks I’m on inpatient. For inpatient you work one weekend day and take a short call each week. I’m using Case Files and PreTest.

Medicine: I haven’t done this rotation yet. By the time you read this I’ll be done, so if you really want to know, email me. J

Third year is stressful, exciting, and fun. Just remember, lots of people have gone through third year before you and made it. So can you! And if you start to get burned out, just know that it’s natural and will pass. Try to remember why you went to medical school in the

42


first place and know that you’re not alone, everyone feels like that at some point during the year.

Congratulations and have a wonderful time!

Sincerely,

Abby Hendricks


43

Stuff I learned during 3rd year:

1. Never stop reading - You’re going to have long hours every day, and you’re going to be tired most of the time. That’s just something you’ll have to live with. If you can pick a book, stick with it, and divide the number of pages by days in the rotation, you can manage the reading that must be done before the shelf. Books can be checked out at OAE, so take advantage and save money.

2. Start doing questions early – I would always ask the brightest students in my class what q-bank helped them the most on the shelf exam, and then I would start doing questions every night before bed. Even if you only get through 20 questions in a night, that is still 140 a week. You’ll be shocked how simple things like that really pay off before your shelf exams. Check out Pre-test apps for iPhone and iPad.

3. Be nice to everyone – You’d be shocked how someone you meet in the hallway turns out to be the chairman of this, or the director of that. Don’t be crude with your pals in the halls; it can really come back and bite you.

4. Be a team player – help out, volunteer, teach each other, bring snacks, tell jokes, have fun.

5. Get to know your patients – We had a patient on our service that had fever of unknown origin and had been admitted three times for the same diagnosis. On his third admission, he was assigned to my resident, so I picked up the patient. I talked with the patient at length, performed the exam, and was about to leave, when he mentioned that he had a sore bottom. I performed a rectal exam, and there was an abscess. Because I spent time getting to know the patient, he told me what was wrong. I looked like a hero when all I did was listen.

6. Find the bathroom on day 1 – Trust me, it’s helpful.

7. Watch online videos of procedures – There are lots of online videos from NEJM on how to perform procedures in the hospital. Watch them several times, know what instruments are required, and memorize the steps. If you know how the procedure works, you’ll be ready when someone asks you to do it.

8. Get comfortable doing a basic H&P – This seems like a basic thing, but really it’s the heart and soul of diagnosis. If you can remember what to ask and what to look for, you’ll do so well. It takes lots and lots of practice, and each new patient is a chance for you to improve your history taking skills.

9. Let people know your interests – if you tell your team you’re definitely not interested in something, they might be cool with that, and they may not. I’m not encouraging you to lie, but I’m definitely encouraging you to keep an open mind. I liked Obstetrics going into the rotation, and made it clear I was interested in Obstetrics, and as a result, everyone treated me like a future Obstetrician. My rotation and learning experience was better because of it.

10. Have fun – Some parts of 3rd year are definitely less fun than others, but overall it’s a privilege and an honor to be in the field we’re in. Have fun and come to work with a smile.

Regards,

Richard Hurley

44


Hello Friend,

You’re ready for this. All your time in the lecture halls and library has brought you here and now your third year has arrived. I promise that, although you are not fully prepared, you are as prepared as you can be for this tumultuous year. Our school does an excellent job of producing apt clinicians, and you will be no different. I wish I could offer you some sage advice that would elucidate all the subtle keys of doing well during third year. The problem is that you already know how to excel third year. Working hard, never complaining, and arriving early really are the meat and potatoes of doing well this year, but I’ve expounded upon some of the details that were important to me below.

Keep reading. Everything starts with this. Always seek to enhance your clinical intelligence. Attendings and residents will primarily asses your fund of knowledge and attitude come evaluation time. If you are well-read, you will be more confident, relaxed, and easier to get along with. You can spend your time really learning and asking advanced questions instead of just playing catch-up. You will be able to actually converse and enjoy your teammates instead laying low and quietly hoping you don’t get pimped. Read about your patients’ diseases: the tangible association will help you remember this information better; plus it is the most likely source of pimp questions.

Be friendly. Especially with your fellow students. You will meet and work with members of your class that you never really interacted with before. You will be impressed by how talented and helpful they can be. Make each other look good. Talking yourself up reeks of arrogance, but casually highlighting a teammate’s achievements makes them look good and helps you appear humble and observant. They will return the favor. Also, make your residents look good in front of your attending, this will pay dividends I promise. On some rotations, you will not be evaluated on your individual clinical acumen, but on how well you function with your student teammates and how easy you all can make things for the residents.

Remember who you’re here for. The patients. It’s a real honor that you have been given. There are many who would do anything for the hallowed privileges that you now hold. Respect your patients and be their advocate. They are the reason we are all here and none of this matters without them. Stop by the bedside in the early afternoon just to check in and talk to them. Do some things for your patient, not because it will help your grade, but just because it is the right thing to do.

Open your mind. Approach each rotation as though it may very well end up being your chosen specialty. The days will go by more quickly, you will have more fun, and your enthusiasm will show…this means your superiors will appreciate your interest and allow you greater autonomy.

When ready, act like an intern. Especially the second half of the year (or earlier if you’re ready). Really know your patients. Carry fewer patients but do everything for them. Ask to write their orders and just have your resident approve them. Field phone calls from other teams regarding your patients. Write their discharge summaries. Confidently state your plan for them on rounds in the morning. Even by just managing a couple of patients in this manner, you’ll be way ahead of the curve. Your residents will love you for this and it will show in your evaluation. Plus, for the first time in your life, you will start to feel like a real doctor.

Don’t sweat the small stuff. Despite your best efforts, you will find this advice impossible to follow early in your third year. It’s our nature as medical students to overanalyze and second-guess, but as the year progresses, you will realize that the way your attending phrases his questions or the facial expressions of your chief resident really have no correlation with their opinion of you as a student. If they seem upset, they are probably just having a bad day. Their world is much bigger than you. If you have a question or something to contribute to conversation, speak up provided you are courteous and respectful. Finally, when your work is done and you are released…hit the door running.

All the best,

Matt Jackson


45

Dear Class of 2013,

You are here! You ‘re finally going to be able to take care of patients… something that seemed so distant in the future is now only a few days away. Third year is exceptional! You get to help patients and learn from them. You’ll finally feel like a real doctor. Take this opportunity to talk to the patients and help them out as much as you can. In return, they will brighten your day. I had a patient who I had taken care of in the ER for a dislocated shoulder. Although I vaguely remembered his face since I was running from one patient to the next, he definitely remembered me. A week later I was rounding with my doctor in a different hospital where that same patient worked. He approached my attending and asked her if I worked with her. After my attending told him I was her student, he said something I will never forget. He mentioned to her that I had taken excellent care of him. He told her how I made him feel comfortable about the care he was given in the ER and then he winked at me and said, “You will be a great doctor one day.” These are the moments that will tell you that all the hard work is worth it. During these moments you will realize that every painful hour you spent reading one subject after another during the basic sciences years was worth it. You will also realize that the lack of sleep and the continuous stresses of clinic and studying are worth it. Most importantly, these moments will be the ones that will drive you to be your best during third year.

I’m not going to lie. There will be times when you feel exhausted and overwhelmed, ignorant and clumsy, small and insignificant. Despite that, third year will be an amazing experience. Just remember: what you put into third year will be exactly what you get out of it. Go to work and be enthusiastic. Offer help and ask questions and always make sure you learn something every day.

This year will fly by for you. It doesn’t seem like it now but, trust me, it will. You are halfway to your goal of becoming a doctor and, before you know it, you’ll be wrapping up your last rotation and giving advice to the class of 2014.

For those of you coming to the RAHC:

Take this opportunity and embrace it. Ask the attendings if you can help in procedures. Show eagerness to learn and in turn they will be eager to let you participate in the patient care. Remember that you came down to the Valley for a more hands-on experience and if you show initiative you will get it. I got to scrub in on some pretty spectacular surgeries, including a removal of a schwannoma, extraction of a foreign body from the rectum, and a hysterectomy of a uterus didelphys. You may have heard rumors of us RAHC students having more “study time” but that is not always the case. There will be long and hard shifts for all the rotations. Don’t slack off on studying for the shelf exams, although it will be tempting. Keep up with the material because you may not have as much time to study towards the end of the rotation. Also, take the time to get to know Dr. Valdez, Janie, Angie and Julie. They are there for you and they are always willing to help.

Finally, I’ll end with a quote fitting for your journey this year:

“I hear and I forget. I see and I remember. I do and I understand.” - ConfuciusWork hard and you will definitely go far! Good luck!!!

Ani Jivani

46


My top 10 list for success in 3rd year:

1. Keep your priorities straight – no matter how much you want to impress your resident or attending, in the long run it doesn’t matter as much as how much you impress your family and friends

2. When you are on any given rotation, be there – this means when you are at work, treat it as the privilege it is, give it 100% of your attention, don’t bury your face in the books, get up and do something

3. Be yourself – just like when interviewing to come to this school you were given that advice, it still sticks, people want to know you, not the textbooks you have been studying from

4. Have fun – the practice of medicine should be fun, don’t forget to laugh everyday, it is amazing how you can soften a hardened attending with a good joke

5. Be your patient’s advocate – yes, this is typically the nurses’ job but you have more time than them, patients will love you and your attending will see that you are an excellent student even if your fund of knowledge does not suggest it at times

6. Take advice from everyone – pretty much everyone you work with knows more than you in at least one aspect of life or medicine; you will miss out on a very important part of your education if you do not listen to those who know more than you. It is also pleas-ing to people to think that you are actually listening to them when they are talking to you, not to mention polite.

7. Enjoy time off – a free weekend is your best friend. It’s okay to not study every minute of the weekend.

8. Make friends – you may end up doing residency here, and if not here somewhere. It will be important to have the housekeeping, techs, nurses, midwives, students, interns, residents, and maybe even attendings to be on your side.

9. Do as much as you can – just think of each rotation as the last time you will see some of this stuff before you start out on your own, the more you do the more you learn

10. READ! – Yes, along with all of the other things you can do this is so important. At least one hour a day for the rest of your life.

Even when you finish training you should read, so it’s just a good habit to get into. It doesn’t matter what you read just as long as it is medically related.

Mark Johnson


47

Dear MS3,

Congratulations on being done with the first half of medical school, you are almost there! Third year only happens once, so take it in, this is the first step towards your career as a real doctor. This advice is mainly common sense, but I think it is beneficial to hear:

1. Be proactive- Ask to scrub in, put in lines, intubate… nobody is going to hold your hand, so if you want to make the most out of your time then you have to be assertive. People are usually very willing to let you get involved, you just have to ask.

2. Ask questions- You are the only one who will determine how much you will learn during third year. This is the one time in your medical career where you really are not expected to know that much. Don’t be afraid to ask questions out of fear of “looking dumb.” Take advantage of this time, because you don’t want to be a fourth year and not know the answer to something, because you will look dumb. And, if you find somebody willing to teach, take advantage, this is a gift.

3. Keep an open mind- You will likely be surprised by what rotations you do and don’t end up liking. My best advice is to approach everything like it is your specialty of choice- people will notice your good attitude and hard work.

4. Be a team player- A lot of third year is based on your ability to adapt and work well with others. If you can’t play well with others now, then you definitely won’t under the stress of residency, and people will take note. Somebody always has it worse than you, especially the interns. When you can make somebody’s life easier, just do it. And don’t ever make one of your teammates look bad, it’s just poor form!

5. Have a good attitude- Third year is an extremely difficult year, where you will be working long hours, and feel like nothing you do is contributing. Please just remember that though there may be tough times, not many people have the opportunity to do the things we do. Never forget you are extremely privileged to be in the medical field.

6. Have a life- It is very easy to let a regular day become eat, work, and sleep. You need to do something fun at least once a week, otherwise you will go insane! Work out, have a beer with friends, whatever, just try and maintain some balance in your life.

Best of luck and have fun, you are going to do great!

Natalea Johnson

48



Congratulations on making it this far! I wish I could tell you how to navigate the journey ahead of you, but there are truly no words to prepare you for the amazing life/death/birth cycle that you will become intimately involved with this year. Instead, I would like to offer you some advice for surviving the first day:

1. Be kind to the janitors. They are your best source of information early in the morning, especially when you are lost at a new hospital.

2. Don’t freak out if none of your new team members responds when you page. Chances are your phone has a different area code and you can’t even page someone. Wait patiently and ask around until you find one of your residents.

3. Ask about how often you can wear scrubs vs. professional clothes.

4. Find the bathroom and the cafeteria!

5. Don’t be afraid to get your feet wet. At least go introduce yourself to one patient and remember why you started this crazy journey in the first place.

6. Try to smile and get excited for the year ahead!

Best wishes,

Liz Ketner


49

With just two rotations left in third year, I find myself looking back on my experiences this year. Time has flown. Like anything else, third year has had its ups and downs. There were moments of sheer exhaustion, moments of inadequacy and doubt, moments of sheer frustration. And then there are those rewarding moments that remind you why you chose medicine, leaving you once again motivated and re-charged to move forward. From every experience, there is something to be learned. I’ve learned many things this year. If you have those down moments remember that you are not alone. Here are a few things that may be reassuring as you get on the rollercoaster that is third year.

1) Don’t let people or unpleasant situations bring you down. You will have attendings or residents who will try to intimidate you and minimize your abilities. Nurses and staff can even be mean or unfriendly. Everyone has bad days, and there are some people who just aren’t nice. That is by no means a reflection of you and your capabilities. Sometimes they are biased or may judge you just based on few interactions they may have.

2) Just keep moving. Don’t let a bad day get in the way. There’s always tomorrow. The more you keep trying harder and doing your best, the better you will feel. Sometimes when you look back you realize things were not as bad as you thought they were in the moment. The further into third year you get, the better you become at brushing things off.

3) A smile goes a long way. I found myself sometimes unaware of the facial expressions I put out to the world. Always do your best to look enthusiastic and happy to be wherever you are. It can make all the difference. Even people that seem a little rough around the edges will soften up. Even if you may feel great, make sure to always show it so that it comes across to those who are around you. They will always remember if you were pleasant to be around.

4) Don’t compromise your confidence. There will be times where you feel really lost and confused, especially towards the beginning of the year. You will find you spend a good portion of the beginning of every rotation just finding your way around and how to meet expectations. It’s part of the experience. Always say things with confidence, and showcase your abilities. Let them know you care enough to put in the effort. Sometimes lack of confidence can be perceived as lack of ability or enthusiasm.

5) Take initiative. Even if you feel totally confused and have no idea what’s going on, ask. Show that you can be self-directed. Even if you don’t do things correctly, they usually will appreciate that you care enough to do things without being told. Even if you are on the shy side of life, be assertive. Don’t let opportunities pass you by or go to someone else because you were afraid to speak up.

6) It’s okay if you don’t know. You will soon find that even though you learned loads of information in first and second year, much of your learning in third year will be more clinical and you will be learning it for the first time. Initially you may get lost in the lingo, abbreviations, lab values, but you will find your way. Don’t be afraid to ask questions along the way because you think it will show how little you know. It’s better than nodding when you have no idea what’s going on. Believe me, at some point you will have that “aha” moment where it all makes sense.

7) Don’t be afraid. I always found myself unduly anxious before the start of every new rotation. You sometimes feel that just when you get comfortable in a rotation, it ends. Some rotations can initially be scary, i.e. surgery or OB-GYN. You have to stumble your way around the OR, what to do/not to do, how to remain sterile, etc. Just embrace it. Part of being a third-year is not knowing. At the end of the year, you will marvel at how much you’ve learned. You can think back to some awkward experiences and laugh, knowing you’ve come a long way.

8) Sleep, a lot. There are times in third year, where all you can think about is laying down in your bed. In the early morning hours on trauma call, when you are going on your 16th hour on general surgery, when you are forcing yourself to get up at 2 a.m. to be on time for rounding. All you will want to do is sleep, but somehow you muster the strength to get yourself moving. On that same token, go to bed as early as you can before a work day and catch up on your off days. On rotations when you get home late, you will feel compelled to study and be prepared for the next day. You’d be better off getting more rest. I can remember times where I got home at 10, knowing I had to be up at 2, and I just went straight to sleep. I’d even forgo eating sometimes. It’s worth it.

9) Eat whenever you have the opportunity. Your days will be fast-paced, and not every rotation is going to have regular breaks for mealtimes. You may find yourself scarfing down a granola bar before running off the OR. Always be prepared with snacks, as you may not always have the opportunity to go buy food. It’s just how it goes sometimes, so anticipate it.

50


10) Take your evaluations with a grain of salt. Evaluations will be subjective. There will be moments where you thought you did poorly and you find yourself pleasantly surprised with how well you were evaluated. Then there will be rotations where you work so hard, do everything right, take initiative and go above and beyond your role as a medical student only to receive a mediocre evaluation. No big deal. Some attending just won’t give high scores regardless of what you do. Some of them won’t put in much thought and just write a general one-liner that they write for everyone. Some won’t write anything. It’s just a matter of luck sometimes.

11) Everything comes to an end. Even if you are totally miserable on a given rotation, the good news, there will be a last day. It WILL end. Sometimes that may be the one thing motivating you to get through the day and that’s okay. I remember being on cloud nine my last day of surgery and so happy to be freed of the OR. On those kinds of rotations, you’ll be even prouder that you got through it and did as well as you did. Sometimes you may even have enjoyed them, even if you know you definitely won’t go into that given specialty. There will even be some rotations you wish could go on forever.

12) Make the best of it. You will probably hear this from everyone but your experiences third year will be very “team-dependent.” You sometimes encounter a team dynamic that is really challenging while you witness other students having the best time with their team. It happens. The attending, residents, and interns can make all the difference. Sometimes it may just be related to how different personalities come together. Don’t let them adversely affect your experience.

13) Go into every rotation with an open mind. I had many rotations I completely enjoyed, contrary to what I initially may have thought. Don’t go through the beginning of the year saying to yourself, “Well when I get to this rotation, then I’ll enjoy myself.” Some people spent the year hating every rotation, only to find they didn’t end up loving the one rotation they thought was their specialty of choice. You leave yourself regretting not giving each one a fair chance. Just be happy, the time is going to pass by regardless. You might as well pass the time in good spirits.

14) At the end of the day, it’s about the patients. As a third-year, you start experiencing the clinical side of medicine and you immediately love that you are not stuck in a lecture hall for hours on end. The problem is, you still have shelf exams at the end of every rotation and it’s easy to get caught up studying and worrying about your grade. That can easily take away from your experience. Don’t forget that a huge part of the experience is learning by doing. Yes, you need to impress the attendings and residents and, yes, you need to study, but don’t forget about your patients. Some of your best experiences third year will be the connections you make with them. And remember, the end goal is to learn to be a good clinician so use these experiences to your advantage. You won’t be a student forever.

15) Enjoy yourself. I had a college professor and mentor who used to tell me, “Smile, life is good!” I completely agree. Don’t let the stress get to you. It’s never as bad as you think. Those tough moments give you thicker skin. You become more eager to come out of your shell and you’ll be surprised at how much better things get as the year goes along. You only go through third year once, and there are some rotations you will never do again, so just enjoy the ride!

Shaadi Khademi


51

Hello, Class of 2013!

Congratulations on becoming half-MDs! Third year is a whirlwind of emotions; one moment you may be basking in the glory of your first successful intubation (which is definitely NOT as easy as it looks!) and the next sulking in the corner because you showed up to preround on your patients at 5 a.m. and no one gives you the opportunity to present your findings (or remembers that you exist). My emotions and interest level certainly waxed and waned throughout this year, but as I begin the final countdown to fourth year, I look back with fondness and a teensy amount of PTSD as I reflect on the immense amount of knowledge and experience I have gained this year. While I still feel inadequate and oftentimes downright useless, it is amazing how much one can learn when thrown into a real-life situation outside the classroom.

Random pieces of advice I can offer:

1. Sell yourself as the bright, helpful, responsible, and friendly student ready to help out your team. This does NOT mean show up every day with 10 articles on CHF expecting to show off your wonderful search engine skills. No, your resident or attending does not have time to sit down and listen to you present all your articles and no, this will not make you look good unless you know every single detail in those articles and are ready to answer questions. This may also upset your fellow classmates who may feel inadequate and establish a sense of competition that is completely unnecessary. Do offer to go check up on your patients in the afternoon or help your intern deliver prescriptions or look up labs for your teammate that overslept.

2. Borrow books from the library, OAE, or friends. You save $$$ (add it to the residency application fund!). Do invest in a yearlong subscription to USMLEWorld; you can use it throughout the year for practice questions and then feel halfway prepared to take Step 2 without even having to study.

3. Don’t be disappointed if you are assigned to a team with no one you know. I have worked with many classmates that I never spoke to or even met during the first two years that have turned out to be some of my greatest, most supportive friends this year. It is rare to find the one team member you simply clash with, and even then, just remember you will only be with them for a few weeks and it’s not too hard to keep things professional.

4. Don’t lie and don’t be afraid to say “I don’t know.” I have found that if I admit my shortcomings, people are much more forgiving and willing to teach me what I don’t know.

5. Smile! It works wonders with patients and helps maintain a positive team atmosphere.

6. Third year can be lonely, especially when you are working by yourself. Don’t forget to keep in contact with your friends. Have dinner together when you can, trade stories, and vent with people who understand completely what you are talking about.

7. There is no need to bury yourself in books after you get home every day. Shelf studying can be saved for the last half of the rotation (any earlier and I promise you will forget everything you have already read). Don’t neglect yourself. Work out, go grocery shopping, watch TV, and sleep when you have the chance.

Books I thought were best for each shelf, in the order I did my rotations:

Medicine: MKSAP is the ultimate question book. Step Up to Medicine is an ideal textbook to use as a guide.

Psych: First Aid is all you need. The End.

OB/GYN: Case Files and Blueprints. Everyone raved about the ACOG UWise questions, but I didn’t find them that helpful.

Peds: PreTest questions were very similar to shelf questions. Case Files is great for basic pediatric issues.

Family: Nothing really helps. Sorry…I felt that I could’ve not read anything and still gotten by with the same result. There are a million AAFP questions available online, but I didn’t think they were all that helpful.

Surgery: Just started this one, so I have no clue!

Good Luck!

Christine Lee

52


Dear Rising 3rd-Year,

Congratulations on making it halfway through your medical school education. After the long nights memorizing anatomy and days spent attempting to understand physiology, you will finally have the opportunity to use your knowledge and skills on real patients. Embrace your enthusiasm, work hard, read, and NEVER complain. Be a team player and always try to make your residents look good. Hopefully, my advice below will highlight some of the important things to have/to do during certain rotations.

Internal Medicine: Get there early every day so you have plenty of time to pre-round. Prior to rounding, always ask the overnight nurse whether your patient had any problems overnight. You will find that making friends with the nurses can go a long way. Carry Pocket Medicine with you and use it to read about your patient’s varied conditions. Remember to look up all the medications your patients are taking and know the MOA, class, uses, and side effects. To do well on the shelf, do as many Q-bank questions as possible. If finishing tests on time is problematic for you, consider doing timed practice tests.

Pediatrics: Pediatricians are probably the happiest and most easygoing doctors I’ve had the pleasure of working with. In your pockets, keep a card with normal ranges of pediatric vitals, a small squeaky toy, and some stickers. When rounds and notes are done, take some time to go play with some of your patients. Not only is this fun and a good way to build trust with your patients, but also your interns will appreciate your enthusiasm.

Family Medicine: You will see patients from every age group and socioeconomic status with every possible complaint. Love your patients and learn to do a complete HPI quickly and efficiently. Read Case Files, but know that the shelf will have some odd questions you will be unable to answer. The hours will be lighter during this rotation, so rest well and study.

Surgery: Practice suturing and knot tying. Visit the Johnson Center where you can learn to drive a laparoscopic camera or practice suturing on dummy limbs. Make friends with the scrub techs and they will give you opened unused suture. When rounding in UH, keep gloves, alcohol pads, a suture removal kit, 4x4s, and fluffs in your pockets. Learn to present each patient in 1 minute or less. Sleep when you can and remember not to take it personally when you are yelled at. The night before a surgery, read Surgical Recall.

Psychiatry: Know your AMSIT and use the First Aid to study. Take your time with each patient.

Best of luck,

Cindy Lee


53

Dear Third-Years,

Congratulations! I know it seemed like this day would never come! I also know that there is most likely a nervous energy in the pit of your stomach. Trust in your education and know that you are well-prepared for this upcoming year. I know this book is filled with advice and it can seem overwhelming. Please take what we have to say to heart. All of our advice has been either passed down to us or figured out by us the hard way.

Approach each rotation enthusiastically and with an open mind. There will be, without fail, rotations that will completely surprise you. You will find interest in things you never knew existed. An added bonus to this is that your evaluations (aka the majority of your grade for most rotations) will reflect the amount of interest you showed. Every physician chose their specialty because they feel it is the best in all of medicine. It is not rocket science to realize the student who shows interest and eagerness to learn about their specialty will get better evaluations than the student who has already decided it is not for them and is counting the days until it is over. (Not saying there weren’t times I was literally counting down the hours until I was done, however, I never let it show. Also, being busy passes the time much more quickly than staring at a clock.)

BE A TEAM PLAYER! This may be the most important of all. Carry your weight and help each other out. There will be a day when you are sick, exhausted, brain-dead, delirious, or a strange combination of these and you will appreciate your teammate taking the initiative to do that physical exam or take the complicated patient. Always remember to do the same for them. When teams work well together many wonderful things happen…. 1) you get your work done and they let you go home!!! 2) you are a happier person at the end of the day and 3) once again the added bonus of evaluations saying things like “works great in team environment etc, etc, etc.” This is what you should strive for because every residency program wants to make sure you can work well with others and that you haven’t forgotten those important lessons of kindergarten.

Get to know your residents. They are the key to surviving your rotation. They have inside information about most common pimp questions, useful books and residency questions in general. They can be your primary source of education. Don’t forget to repay the favor. Always ask what you can help with and remember, if you are tired, they are tired, because their schedule is worse than yours. Spend time with your patients. You will hear this frequently throughout the year but really take advantage of everything your patients can teach you. You may not know every pertinent question to ask on a given service but you will be amazed (as will your resident/faculty) at the amount of information you can gather by simply listening.

Don’t forget why you came to medical school. Don’t lose sight of what drew you to medicine. I spent my first 3 weeks of 3rd year in the SICU. Patients had multiple tubes/wires/hoses in various body parts; often the only history was the EMS report and most straddled the fence between life and death on a daily basis. It was overwhelming to say the least, but (after the panic attacks subsided) I loved it. One of my first patients was Mr. O. who came in as an unknown after being hit by a car while crossing the street. His level of consciousness alternated between withdrawing to pain and grumbling on a good day and no response on other days. He was in bad shape. He had multiple fractures and no one could figure out why he wasn’t waking up. I continued to talk to him daily about his progress, test results, etc., even on the days I got no response. His wife was frequently by his bedside and the more I learned about them, the more attached I became. I watched changes made to his ventilator and eventually his extubation. I assisted with his chest tube placement, removal and then replacement. I watched imaging and EEGs come back inconclusive, yet he remained unresponsive. 2 weeks after I left the SICU I heard that he began to improve and was eventually discharged. I saw him across the UH cafeteria 3 months later. He was walking with a cane but looked amazing! I didn’t approach him because I knew he would not know me. It didn’t matter; all it took was seeing how far he had come and how happy he was to remind me why I could never be satisfied with another profession. The long hours I spent attempting to understand his ventilator settings only for them to be changed by the time I presented on rounds, the time I spent talking to a man that, at best, would only grumble at me, and the several times per day I would yet again make sure his GCS had not improved suddenly became worth every second. Mr. O. taught me a great deal about medicine and he never even spoke an entire sentence to me.

Enjoy this year! It goes by quickly so hang on! Never forget how hard you have worked to get here.

Emily Mackie

54



Congratulations on completing the second year of medical school. Each year is great but they continue to get better! Third year is a blast and goes by very quickly; enjoy it while it lasts. As I begin to plan for my fourth year and reflect over the third, I wanted to share a few things with you. This whole book is filled with advice, so I’ll be brief.

• First, remember that there are other things in this world more important than your third year of medical school. Don’t assume that the hospital revolves around you and your education. Have patience with others and always wear a smile.

• Find happiness in where you are and don’t feel entitled to anything.

• Be involved with something that is completely unrelated to medicine. Find a church and get connected. This gives you perspective.

• Don’t stress over the order of your rotations; it will all work out.

• Find something to learn or get better at every day.

• Everyone has their own opinion; take advice knowing that your experience may be different

• Enjoy where you are.

• Don’t complain; it’s not attractive or professional.

• Be punctual; it is attractive and professional.

Best of luck,

Kyle Marshall


55

Congratulations “Shiny New Green Nameplate Owners!” It’s difficult for me to reflect back and think about what to write as advice for upcoming 3rd-years when I can hardly believe my own 3rd year is quickly coming to an end. I remember hearing, “it is the best year and the worst year all at once,” and now I understand what they meant. Here are some emotions, lessons, and advice I learned along the way.

• Become a morning person! I used to be such a night owl, but you can’t do that third year. I remember how lame I felt going to bed at 11, then 10…then “Sweet, it’s 9, time for bed!” You will always thank yourself the next day. You can get to the hospital earlier, be more prepared, and have the energy for hours in the OR or hours or Medicine rounds. In third year, you will do more before the sun rises than you have ever done in your life. Also, when you get home from Trauma call you will literally whisper sweet nothings to your pillow because you are so happy to see it.

• Get there early! For this, I am mainly talking about inpatient. It doesn’t matter how much time you give yourself, or even if you only have one patient, you will still find yourself looking up a value or report last minute, realizing you didn’t ask the patient a certain question, or you haven’t had time to read about whatever in your “Green Book” or “UpToDate” so you don’t sound clueless when presenting to your attending. Having enough time is golden; it makes you look well-prepared and relatively intelligent, so don’t screw yourself.

• On that note, you will sleep in one morning and wake up with “an impending sense of doom” that you wish was an aortic dissection because you would almost rather that be happening than showing up late to work. It will be ok. Alert whomever you should, get your butt there asap, and be super helpful that day. And I won’t ever forget an extremely nice gesture a teammate did for me. I was running late and when I arrived my teammate handed me a paper with my patient’s vitals, lab results, imaging notes, etc so that I wouldn’t have to look it up and could quickly go and see my patient before rounds. It instantly relieved my anxiety when I arrived and, thanks to my teammate, I was prepared for rounds that day.

• You will make friends with classmates you have never spoken to before! In third year, there is an underlying camaraderie that develops. It is easy to make friends with your teammates, etc. but you will find yourself excited to spot a fellow third year that may be on a different rotation and both of you will smile, wave, or make that wide-eyed “I’m so tired, when will this be over but I’m trying to be alert and interested” look. Whatever exchange you choose it basically means “I can relate,” and that connection feels good.

• On presenting: there is a systematic way to do a good presentation, and you will see how that differs between each rotation. Learn from the residents and emulate what they do. Once you know what you’re supposed to say and how to say it, don’t break from that format. Present your objective data first and save interpretations for the end.

• Procedures: So that old adage: “See one, do one, teach one” it still exists. Obviously not with open heart surgery but you know what I mean. Once you have seen something once; be ready to say “Yes I’d like to do that!” when the resident or attending asks if you’d like to perform a procedure. And don’t let nerves make you say no. Use that nervous energy to help you be extra focused and want to nail it on the first try: like the many ABG’s I succeeded at first try J I have gotten to do a pretty good variety and amount of procedures as a medical student (they wouldn’t ask you if they didn’t think you couldn’t handle it). Also, if it is a slow night on Trauma call or if you do the ER rotation, you can always ask to draw blood up front, or ask nurses if there are Foleys, NG tubes, or IVs that need to be done. Ask and you shall (usually) receive.

• Trauma call in a nutshell: know when to help and know when to get out of the way. Bring snacks for your buddies or order in dinner; it’s a good time. Figure out who likes what roles on the team. Trauma call is exciting, challenging, and sometimes shocking. Have fun!

• Emotions: you will go through a lot in third year. You will be exhausted, nervous, proud, giddy, upset, excited, bored, interested, etc…. It can be hard to make time for yourself this year. By the time you get home, there are only a few hours left in the day and you literally have to choose the one thing you are going to do: study, workout, or do laundry. The truth is after a while you get worn down. I am a super easy-going person at heart and there was definitely a period during the year where I was just sucked dry of energy and overall “bummed out.” Find the time to call your family, eat dinner with friends, and see a movie with your significant other. Some nights have to be “no studying” nights or you will go crazy. And reach out to your fellow classmates; if things are getting rough or you had an emotional experience with a patient or a stupid moment in front of an attending, there is no one who understands more.

56


• Being a third-year is a privilege. You worked hard to get where you are; be proud of yourself and keep up the hard work! Many of the sights that you will see this year and the experiences you will share in are something that the majority of people don’t get to be a part of; that is special…and that is why you chose Medicine. Best of luck! Have fun because it goes by way faster than you think!

Sincerely,

Azalia Martinez


57

Dear Class of 2013:

You have just finished the worst part of medical school…by far. Congratulations. Nothing compares to the challenge of forcing yourself back to the library, or First Aid, or USMLEWorld over and over and over again, day after day after day. If you are anything like me, you probably can’t wait to get in there and figure out why you’ve been spending so much time with your head in a syllabus. So, I’m here to tell you that it only gets better from here. Third year is really great (and so much better than the first two), but it’s important to approach it with an open mind and a willingness to adapt.

I can almost guarantee that you don’t know what you want to do, even if you think you do. Of course, there are exceptions, but for most, you just can’t understand what a field of medicine is all about until you have experienced your third year. I bring this up because I think it is important to go into each rotation with a blank slate. That is to say, with the assumption that you don’t know what it’s going to be like. I offer this advice because I think you will be happier in your day-to-day work and more exceptional in your performance if you keep your pre-conceived notions at bay. Most importantly, you don’t want to rob yourself of an opportunity to find your calling by marginalizing an experience from the beginning.

In my experience, the single most important thing you can do during your third year is be inquisitive. Asking thoughtful questions is the best way to show that you are critically thinking, have read about your patients, and are interested in what is going on. Don’t let the position you are in – the bottom of the totem pole – prevent you from engaging in discussion. You want to make your presence known and the best way to do so, while remaining tactful and respectful of your junior position, is to ask thoughtful questions. If you do the obvious (be punctual, work hard, don’t be a jerk, etc) and find a way to be inquisitive you should be able to succeed in any environment. The second piece of advice I have is not to worry about how everyone feels about you all the time. When you think, “man I think my resident thought I was a jerk today,” they didn’t. The residents are busy people, with a lot on their minds, they are not putting your every move under a microscope, and you shouldn’t either. It’s so important to just relax and work hard at whatever your role might be on that rotation. A strong work ethic and friendly demeanor can really carry you. Finally, spend a little extra time with your patients when you are looking for something to do during the day. Not only will you become a better clinician by simply getting to know the people you take care of, but also you will occasionally pick up on something that everyone else missed.

The best part about third year is the feeling that your relationship with your patients and with your colleagues is starting to mature. It really changes who you are and how you feel about yourself. You start to realize that real life is right around the corner and that the bubble of the classroom is finally starting to float away. Most importantly, you start to feel comfortable with that notion.

Congratulations on making it to this point and best of luck in the coming years.

See you around,

Andrew McIntosh

58


First of all, congratulations on completing your basic science years!!! Yeah!! And welcome to third year! Third year is full of new experiences. You’ll meet new people (perhaps even some classmates you didn’t know before) work with wonderful residents and staff on your different services, see interesting procedures and work up unique patients and cases. It will be challenging throughout, but incredibly rewarding at the same time. To try and help you navigate third year, here are a few tips that I learned along the way.

I think the most difficult thing about third year is balancing your time. Of course, we’ve all made it through first and second year, which required a lot of “balancing,” but what makes third year so different is the amount of time that you will spend either preparing for or actually doing clinical duties….and then to top it off, you’ll need to come home and study for the shelf exam at the end of each rotation (of course that is on top of your normal daily activities). Some rotations will be worse than others…and you’ll literally only have time to eat and sleep (i.e. surgery.) Others will be a bit more flexible and provide you with weekends off or more reasonable work hours. It is important that, whichever rotation you are on, you take advantage of your free time outside of your clinical responsibilities and your downtime while “on the job.” Always bring something that you can study while at the hospital, because there will usually be time that you can read throughout the day. When you’re not at the hospital, don’t forget to spend some time doing the things you enjoy (i.e. spending time with family or friends, exercising, etc.). You will definitely need some downtime to unwind and relax so try and squeeze that into your schedule when you can so you don’t become a big ball of stress!

Ok, so basically all the shelf exams are hard. Some will be harder for different students so don’t freak out if someone tells you, “The [insert clerkship of choice] shelf is the hardest exam ever!” Just try and prepare as much as you can for each shelf. Questions, questions questions seem to be the key for most people. Of course, since the exams are so hard, the best way to make up for that is to do well on the clinical side. Usually your clinical grades help to pull up the exam grades, so that it all works out in the end for your final grade.

Most importantly, enjoy third year! It’s when you finally get to experience all the stuff you wrote about in your admission essay for why you wanted to be a doctor in the first place. Approach each rotation with an open mind, even if you know you don’t want to do it, and realize that you can always learn something from that rotation…and, who knows, along you way you may find out you really love some specialty you never even thought about before. So have fun and good luck!

~Melissa McKean


59

Dear 3rd-Year Medical Student,

Two years down and two more to go. Be ready this coming year to put more hours in than you have yet in medical school. It’s your chance to prove to yourself and everyone else that you know your stuff and have what it takes. Don’t worry about what order you got stuck with for your rotations; in retrospect, it really doesn’t matter. Just be happy, cooperative, and a team player whatever rotation you’re on. Following are a few of the things that I learned over the year that I wish I had known before:

1. Your main goals for 3rd year should be to learn how to get a good history and physical, how to write efficient yet complete notes, and how to present effectively. Get these 3 things down and you will look like a rockstar.

2. Read about your patients’ diseases if you get the chance. To really learn medicine well, you need to both read about disease and have patients with the disease. As the great William Osler put it, “To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”

3. Don’t complain. We are tempted to play the game of “who has it the worst,” but this is a trap. Nobody is impressed when they hear you complaining, whether they are residents, faculty, or your fellow students. Also, if you convince yourself you have it bad and start listing everything that makes you upset, chances are you will end up feeling even worse. Just make the best of it and keep working. If you have to, complain to your family or your dog.

4. Learn from everybody you can, not just the residents and the faculty. This includes the nurses, PAs, techs, and NPs. Many rotations, you will end up spending quite a bit of time with all of these people, and what you’ll find, more often than not in my experience, is that if you are interested in what they’re doing and ask them about it, they’ll take the time to explain it to you, teach you something, and are even likely to let you do it. This was particularly the case with minor procedures like starting IVs, putting in Foleys, drawing blood, getting ABGs, placing art lines, and putting in NG tubes. It also gives you the chance to show them a level of respect and they end up treating you nicely when you ask them.

5. Make sure to be respectful and nice to the nurses and your life will be a whole lot easier.

6. The shelves are harder than you think, so start studying early. This isn’t to say that if you don’t begin on Day 1 of the clerkship that you’re doomed to fail, but rather that if you’ve waited to the last minute you will end up hating yourself for it. Plus, as you’re studying for the shelf, you may even learn something that you get pimped on over the next day or two and look like a med student rockstar. Double Bonus. USMLEWorld questions and Case Files series tend to be very helpful on just about every rotation. Medicine has almost too many questions (1400+) while Family has zero. For Family, there is a series of online questions that the clerkship registers you for that are supposed to be fairly representative of the shelf.

7. Don’t be too shy to ask to get food or drinks, except for maybe on rounds. Nobody can get much work done when they’re hungry or thirsty.

8. Try to make the most out of every rotation even if you know it’s a specialty you don’t want to go into, because it may be the only time in your life you will ever get to have those experiences. And who knows, you may be wrong and end up actually liking it.

9. Like Dr. Keeton said, be on time. Every time. You don’t want to be remembered as that kid who was late.

10. As cliché as it sounds, be yourself. People will eventually be able to tell if you’re being fake. If you like to crack jokes it’s fine but just make sure the time, place, and tone are appropriate.

While I know this is a seemingly long list and much of what I said here seems to be common sense, just get through it. Third year has long hours and you are no longer truly in control of your own schedule. However, it is also the only time in your life that you will have this amazing learning experience and be allowed to do/learn much of what you will. Don’t let a bad attitude or laziness ruin your experience regardless of your grade.

Sincerely,

David MetterUTHSCSA, 2012

60


So you think you can dance?

Great.

Unfortunately (or fortunately… depending on your moves), that’s not what 3rd year is about.

Economists often ask their students a quasi-trick question, “What is the most valuable resource?” Eventually people arrive at the correct answer: time. The 3rd year of medical school will make this clear to anyone who feels otherwise. A typical day could be 10 to 12 hours long; assuming a hopeful minimum of 6 hours of sleep, a remaining 6 hours are set aside for commuting, studying, eating, friends, and free time. Needless to say, time management is invaluable during 3rd year.

A few principles will benefit students on rotations: be early, smile, and always say, “Yes.” Granted, there are some exceptions to the third principle; however, the first two are generally infallible.

Despite the above principles, there is no single guideline to success. What you gain from any given experience will be related to your rapport with the people you work with and learn from—including your classmates. Importantly, always be cognizant of how your every action might be interpreted by your superiors and peers—for example, if there is a single task assigned to all of the students on a team, at the very least one should proactively offer to share the burden of that task so that nobody feels denied an opportunity to excel. This may sound trivial, but this is the type of workplace issue that can tear a team apart.

Throughout the year you will be inundated with the notion that you will learn the most from your patients and spending time on the wards. There is truth to this, however I feel time with patients is more of a reinforcement exercise for things I have learned while reading books for a clerkship. Since shelf exams carry significant weight, do not forget to get back to basics and study books. One way to think of it is that your books prepare you for your shelf and your patients prepare you for patient care.

Aside from books used to study for each rotation (which depends on what you feel works best for you), advice for individual rotations is somewhat superfluous since the quality of your experience depends heavily on how you and your team work together. When studying for shelf exams, pick a strategy and go with it… your friends might choose a different approach, but do not let any insecurities grow into self-doubt. Be confident in your approach.

All of the above thoughts are in no particular order. They simply stem from my experiences during 3rd year as I inadvertently lived by the edited philosophy, “All things in moderation; except studying.”

Have fun—learn much—laugh more.

Best of luck!

Will Miller


61

Dear soon-to-be 3rd-Year,

Rejoice and take a deep breath. Third year is upon you. Your knowledge will be tested and you will be presented with many opportunities to grow. Rather than regale you with rotation-by-rotation advice, I will give you the things I’ve found most helpful during the year. Besides, any rotation-specific pearls I’d have for you would be outdated before you get to the rotation.

You make the rotation: There may be difficult personalities on a given rotation, but you can make it better or bearable for yourself and your classmates with a great attitude and strong work ethic. Even tough rotations and personalities can be launch pads to teach you about yourself. You do not have to suffer abuse or mistreatment, but the occasional brisk response is part of learning to be in medicine.

Keep family close: Your time does not feel like your own at certain points, but my big sib’s advice always to make time for your family proved a life saver. Despite the difficulties of the day, venting to family and getting some perspective helped me to refocus my energy on solutions or workarounds to make my time productive.

Smile often: An intimidating attending once asked me why I smile so much. At the time, I smiled, because I was realizing this was not the specialty for me -- but I realized I was still learning a tremendous amount. You may have days where you must look for things to smile about. They may be non-medical things. Find them -- even if it’s picking up that dusty guitar for 30 minutes before bed.

Enjoy your classmates: One of the beautiful surprises of the year is how much fun you have with classmates with whom you’ve spent little time. During long hours in the trauma pit many hilarious stories are shared and friendships are forged.

No complaints: We really have a great opportunity to challenge ourselves with sub-i or intern level work. Much of what you’ll see and do you may never do again. Have fun! This really is the best year of medical school so far.

Larry Mitnaul (MSIII)

62


April 7, 2011

Somewhere among the constant pimping, occasional reprimands, feelings of insignificance and inadequacy, sleep deprivation and cafeteria food, it’s easy to lose sight of why we became doctors. Most students, I believe, chose medicine to help those at their most vulnerable: people lying helpless in a hospital bed at the mercy of a sea of white coats who seem to have a monopoly on the knowledge of sickness and health. We forget that everyone, no matter their role, is working towards the care of the patient. It’s easy to get discouraged when you feel that your work doesn’t matter. It’s easy to become complacent knowing your attending dismisses your ideas. But remember, medicine is about caring for the patients. And everyone on the team, no matter how great or small, shares in this effort. Even the lowly medical student has the potential to make a difference. You may not feel significant. You may not feel appreciated. But if you work hard to give your patients the best possible care, you will be a valuable and valued member of your team.When I started my general surgery rotation halfway through the first semester, I was warned about one OR nurse in particular who disliked medical students and didn’t hide her feelings about the matter. My first day on the service, I walked into the operating room and was greeted with my first task: “Call the resident because the patient is ready to go.” When I sheepishly told the OR nurse I didn’t have the resident’s pager, she replied, “You should. You’re on the service now.” For some reason, I took this as a call to action. I rushed back to the work room to find my list of phone numbers, but when I returned I wasn’t greeted with a hero’s welcome. Instead, I was reprimanded for leaving the operating room without letting anyone know where I was going: “If you don’t know how to do something, just own up to it.”

Throughout the remainder of the rotation, there were many more opportunities for correction. I was told to wear a bouffant cap because my hair was too long. For the rest of the rotation I looked like the lunch lady while doctors with longer hair than mine had on surgeon’s caps. I was also scolded for not taking a more active role in getting patients ready for surgery: “I don’t know why you medical students put on gloves when you just end up standing around anyway.” When I tried to take more initiative by asking if she would like me to bring in the patient’s bed, I was told, “You should know the routine by now.” But through it all, I remained polite and continued to help out as best I could. By the end of the rotation, we were no longer combatants but soldiers to the same cause. I realized she was only looking out for the best interest of the patients and wanted me to take my role seriously. And she realized that I was doing everything I could to help. I can’t say that we became close friends or had sweet parting words, but we gained a mutual respect for each other.

In addition to feeling underappreciated, it’s easy to feel insignificant during third year. Medical students have the least experience and the least responsibility. Our notes often go unread. Our plans are occasionally dismissed. But we can’t forget that everything we do makes a difference. On my psychiatry rotation, I was assigned to a patient with mania and delusions of persecution. It’s not easy to treat a patient who distrusts the people in charge of his care, and nothing we were doing satisfied him. But everyone on the team was compassionate and considerate and did their best to work with him so that he had a voice in his care, even if it wasn’t the final word. On his last day in the hospital, he took out his journal and asked if everyone would sign it and write a parting note. His request was one of the most touching experiences of my third year. As medical students, we may not have a major role in the medical and surgical treatment of our patients, but we can impact their care in other ways by being a welcoming smile or an ear to listen.

In parting, third year will be challenging and exciting. You are on the cusp of your clinical years and get a glimpse of the road in front of you. There is much ahead to look forward to and much behind you have overcome. Amidst all of the stresses and competing desires, don’t forget your patients, the reason you are here to begin with.

Brandon Moss


63

Dear Third-Year Students, Congrats on making it halfway! This next year will fly by and every person you meet will likely offer their 2 cents on their own clinical year experiences. So, in true form, here are my own pieces of advice that I’ve found to hold true over the rotations thus far.

1. Never trust your own mother – Don’t take anyone’s physical exam or radiographic interpretation as truth. See it with your own eyes. And if you have no idea, take a field trip. (The radiology department is surprisingly encouraging of med students!)

2. Learn on the fly – Somehow, the busier you are, the more quickly you can make yourself learn. Try not to rely only on UpToDate. Broaden your horizons to STAT!Ref, PubMed, and other library databases (even access these on your phone or through a VPN connection). Any little bit of research before presenting your patient will help make you stand out.

3. That sense of entitlement – Your friends/family outside of med school will not love hearing about your 80-hour week on Facebook, week after week. It’s not a contest. Life gets easier when you relax your expectations of a time to get off of work, or which holidays you’ll get off. The best part is, at the end of the day, you still have no real responsibilities and are able to just purely soak up your environment.

4. Find your motivation – Even after the worst day of the semester, try and find something small to give thanks for. Remembering the privilege of witnessing a kidney transplant or holding a 29-week preemie’s hand will make waking up at 3:30 a.m. (just a very little bit) easier.

5. Don’t let your skills slide – You will find the resident who will do a 20 second physical exam over the patient’s clothes, and call it a day. You are not that resident, and your daily notes are not busy work… think of it as a dry run for intern year. Keep up those good habits as long as you can!

6. Pay attention to your patients – They care how you react when you walk into the room, or if you yawn during morning rounds. When you’re not as busy as the rest of your team, offer the patients something each day: an explanation of what’s going later, an ear for them to voice their complaints, or perhaps a slice of pizza (with permission) after an emotionally exhausting day.

Hold on to your hats. This year will be crazy and amazing all at once! You may question your career choice at least once (or twice or… three times). But it all works out somehow.

And as a final parting thought, realize that life’s too short for UH cafeteria food 3 meals a day. Good luck!

- Shweta Murthi

64


Dear 3rd-Year Medical Student,

Congratulations, you have successfully completed over 80 hours of graduate level work and have nothing to show for it. Ok, I’m kidding. Now is when the fun begins, but don’t get cocky. You likely have a great knowledge base; maybe you even aced Step 1. That doesn’t matter now. In the next year, you are going to learn more than you ever thought you could. Much of what you learn is going to make you wonder what the heck you’ve been doing for the past two years. The truth is, at this point you don’t even know enough to know what you don’t know. See what I did there? Hang in there; read lots; sleep when you can; and try not to anger anyone. At the risk of sounding repetitive, here are a few quick tips:

1. Be assertive. Not aggressive, people don’t like that. The bottom line is even though you are the lowest of the low on the totem pole, you are still training to be a doctor. That’s kind of a big deal, but don’t let it inflate your ego. Just keep that in the back of your mind when you have one of “those days.” And by “those days,” I mean the ones where the fact that you’re out of milk brings you to tears.

2. Declaring your specialty. It is perfectly acceptable to tell those that ask, “Well, I’m still keeping my options open.” It is NOT acceptable to tell them you want to go into their specialty if you are not seriously considering it. They can smell it a mile away if you’re not genuine. If you’re as indecisive as I have been, tell them everything you’re considering and just be prepared to get funny looks. Hey, at least you’re being honest.

3. Brain Farts. You will likely be put in at least one uncomfortable, nerve-racking situation each day, but count on more than just one. Get over it now. People are going to ask you questions to which you don’t know the answer. Actually, sometimes you may even know the answer but may just forget everything you know for a moment. It’s okay. Take a deep breath. Few people will actually tell you you’re stupid, some may think it, but it’s okay. No one person is going to get you into or keep you out of a residency position.

4. Aspiring lady surgeons. If you don’t already have thick skin, develop it now. ALL of surgery, no matter what the specialty, is male-dominated. You will likely be exposed to raunchy jokes and stories. Get used to it. Now isn’t the time to storm out of the OR because someone has a potty mouth. Unless someone is physically assaulting you, get over it. (Having instruments angrily thrown your way because you’re slow doesn’t count, by the way.) Don’t be afraid to tell the surgeons if you want to have 10 kids, either. You’ll still fit in the surgery world if you act like a lady.

5. Take care of yourself. We are all gluttons for punishment; we wouldn’t be here if we weren’t. However, sometimes you just need to take a “me” hour, night, day, whatever. Realize that if you work 12-hour days, you can’t work out, cook dinner, clean, study, and still get 8 hours of sleep every night. Mix it up a bit: sometimes you’ll need to go to the gym and skip the studying. It’s okay, you’ll still be a good doctor. Sometimes the best time to take a break and reset is when you’re incredibly behind. For example, the half-days before NBME Shelf exams were always my most relaxing days. This may seem ridiculous, but at this point, the fate of your grade is likely already sealed. Might as well get a good night’s rest, it may be your only chance on certain rotations.

I hope some of you reading this found it to be helpful. This year is going to be both amazing and incredibly rough. Some days may be better or worse than others. Keep in mind that each day you are growing as a future physician and are one step closer to your dream. Good luck, and we look forward to seeing all of your fresh faces on the wards!

Sincerely,

Ashley Nava


65

Dear MS3,

Starting the third year of your medical career is a bit like starting first grade—truly exciting and utterly terrifying. The exciting part you’ve got covered. I will try to ease your apprehension by giving you a few tips I wish I had known before I started third year.

1. Show up early on your first day of EVERY rotation. Mama was right when she said you can only make a first impression once.

2. Be nice to everyone, and they will (probably) be nice to you. If they aren’t nice, don’t take it personally.

3. On the days you wake up and go to work and your little friend “motivation” is snoozing comfortably in your cozy bed, FAKE IT.

4. Get your work done early and offer to help others. This gets you a great “team member” score, and if there isn’t anything to do, you may get sent home early.

5. If you have downtime, study. This means when you go home, you can actually do something you enjoy.

6. Whatever keeps you mentally sane (i.e. exercising, cooking, reading) keep doing it cuz NOBODY wants to become a patient on the UH psych ward.

7. Be prepared for the moment you make a complete idiot out of yourself in front of your team. It happens to everyone, and it will inevitably happen to you.

8. PIMPing is part of life as a medical student. The point is to ask you questions until you finally get one wrong. Hint, Hint: you can NEVER get all these questions right.

9. When your teammate is being PIMPed, help them out if you can. This is good KARMA.

10. You are in control of your own education now. Not every attending will teach, so don’t wait, and start reading early, especially for Medicine and Surgery.

11. You will ALWAYS get yelled at when driving the camera. This is because the surgeon wants you to read his mind. I am not psychic, maybe those of you with ESP will fair better in this endeavor, but speaking from experience, you probably won’t. Again, part of life as a medical student. Don’t take it personally.

12. Lastly, this year can be whatever you want it to be, and your attitude can make all the difference. Put a smile on your face. You will be amazed at how quickly you can change someone’s day, and maybe even someone’s life.

This year you will realize how much you have learned in two years, how much more you have to learn, and how much information you can actually cram into your brain in 54 weeks. But, this is also an opportunity to learn something about yourself—so embrace every moment you can and enjoy the ride. Cheers and good luck!

Catherine Neal

66


Letter to a Third-Year

Dear current underclassmen and future classmates of mine:

I don’t think I’m wise enough to offer many useful pieces of advice to you guys about third year. Many of the things I was told, which you probably have heard, are indeed true. Read a lot about your patients. Try to be punctual, which means not being late or too early. Treat everyone you encounter with due respect. Most importantly, please be kind to your patients. I had no idea how much trust they put in physicians in general until I met Mr. Rolling Stones. The experience I had while taking care of him changed my attitude towards medicine.

It was my third day on Medicine wards at Santa Rosa. Most of my inpatient experience up to that point had been post-op care and management of surgical complications. This was my first case of a rare, mysterious disease. I met Mr. Stones and learned that he had endured three months of muscle pain and edema in his shoulders and extremities. His physical exam did not indicate how sick he was. We performed a “million-dollar” work-up on him to figure out a diagnosis. Meanwhile, his symptoms were somewhat controlled with medications. Many consults were placed to Neurology, Rheumatology, Hematology, etc.

Over the next few weeks, Mr. Stones developed severe dysphagia, bowel ileus, and fulminant cardiomyositis, from which he passed away. When I learned the sad news from my resident, my body froze in agony – as if a knife was being drawn through my heart. A powerful sense of betrayal came over me. I had told Mr. Stones he was going to improve soon and that the team would do our best to find that which made him ill. I diligently researched any possible diseases he could have. Polymyositis, inclusion body myositis, scleroderma, etc. But none fit his presentation perfectly. I felt betrayed by the Great Power above who lead me to have faith in Mr. Stones getting better. At the same time, I felt guilty about having made false promises that I could not keep.

Then I remembered that Mr. Stones once made a comment to my resident about how good I was. I could not believe it, so I asked him for clarification. Mr. Stones said he appreciated the time I took to sit and chat with him about his life. I was half-curious, half-wanting to ease his worries. Honestly, I did not know what else to do for him. My knowledge and experience were limited. I had all the intention in the world to cure him – I just did not know how! In that way, I think I did not truly betray him. Mr. Stones will remain with me for the rest of my career. His story will remind me to work hard at developing exceptional diagnostic skills so that I will never lose another patient.

Sometimes medicine is learned through losing people we care about. But this perhaps is what drives us to do a better job every day. I encourage you to care about your patients. They will trust you. It is a huge responsibility, but one that teaches you to develop passion and hopefully will lead to many improvements throughout your career.

Take care,

Tien Nguyen (Currently Class of 2012 – graduating with Class of 2013)

PS: Private information about patient and clerkship location was changed for privacy protection.


67

Mrs. H. was an 82-year-old Hispanic female who was taken to the emergency department by family members because at home she was with low oxygen saturation and few upper respiratory symptoms. She had just recently been discharged less than a week ago after going through her first round of chemotherapy for MALT lymphoma. After gathering up information on Mrs. H., I walked into her room and was surrounded by six, maybe seven family members. The feeling in the room was hard to go unnoticed. I remember feeling a bit nervous and scared for them because I could see they were scared, nervous and obviously concerned for the well-being of their mother, grandmother, and friend. I’ve cherished my experience with Mrs. H. because it has taught me so much about patient-physician interaction in the presence of language barriers. As obvious an obstacle as it was, the relationship that I built with Mrs. H will be a constant reminder of the importance of humility and compassion we as third-years should embrace.

Mrs. H. was a Spanish-speaking only patient and my Spanish was absolutely subpar compared with my other classmates working down here in the Valley. With all forces against me, I didn’t use my lack of a sound Spanish vocabulary to limit my interaction with her. Much of what I got from her current and past medical state was from her sons, daughters, and grandkids, but I made much effort to interact directly with her. According to them, she was sweet, compassionate, understanding and has been a tremendous help in the family for so many years. It was very hard for them to cope with the fact that her energy level in the past few months had drastically changed for the worse and that she continue to become more somnolent. I began telling them how important it was that they brought her into the hospital because the labs had shown marked increase in her white blood cells and a high grade fever. I explained to them what the team and I planned to do in order to best manage her care while here in the hospital.

Each day I’d come and check up on Mrs. H. and before speaking with her family members I always made an effort to communicate with her. Our conversations would of course be limited to me saying “Como se siente” and her responding “poquito bien.” Then I would continue throwing a few words out here and there: dolor, popo o pepe, esta comiendo. With each word I struggled to say, she forced a smile. Her smile told me that she knew I was trying and that she appreciated my effort. Then again, it might just have been pure comedy for her! Each day it was something new and I could tell she appreciated my effort even though her responses were minimal. The lab work, three days into her stay in the hospital, showed improvement but clinically there was no change in Mrs. H. She continued to lack energy. As the days progressed, she ate and spoke less and slept more.

As a third-year, sometimes you may feel as if your presence or contribution to a patient’s care is irrelevant or minuscule. But it’s the time spent when talking and interacting with your patients and creating a sense of comfort for them when you matter the most. After a week of following Mrs. H, my Spanish vocabulary doubled! I vividly recall being very excited to showcase my improvements to Mrs. H. The night before, I sat in front of a mirror and practiced a few sentences. I wanted to ask her when she gets out of the hospital what would be the first thing she’d want to do: “que quisieras hacer cuando salgas del hospital.” Sadly, I didn’t get to tell her that. That morning, excited to see her, I went straight to her room. Getting there, I hadn’t realized that she’d been moved to a bigger room the night before. Seven hours after the transfer, she expired. It was one hour before I’d arrive.

Many students have come up to me wondering how I’ve made it down here in the Valley not being able to speak Spanish. Not every patient I’ve interacted with spoke only Spanish but, yes, the majority does. I say make the effort. If you want to be a good doctor and get to know your patients in order to assist in their well-being, make the effort. Mrs. H. was a sweet woman. Although the time I spent with her was short, I’ll never forget it. Medical school makes the effort in teaching us about breaking bad news and helping family members and patients cope. But, we’re not taught on how to deal with bad news when it affects us. We are medical students but we are humans first. Be willing to hurdle through obstacles and let nothing come between you and your patient. Language may be a barrier, but there is no amount of barrier that should keep you from showing compassion and humility to your patients. Make the effort!

Kimberly Onyirioha

68


As I spoke with Mr. S., a man that had been deemed “severely demented” in numerous prior chart documentations, about his experiences at Pearl Harbor, I was captivated. He vividly recounted the events as if they had occurred just days ago. I never would have thought I would find him with apneic breaths just hours later.

He was admitted for Urinary Obstruction and secondary Acute Kidney Injury to our medicine service at the VA Audie Murphy Hospital. I knew him only for a few hours before he coded the first time. Our team was on call the day Mr. S. was admitted to our service. He came in around 3:00 p.m.; I did the inaugural medical student H&P and spoke with several consulting services about their plans for the 88-year-old veteran. Urology sounded optimistic about his chances of regaining complete kidney function; good “thing for him he came in when he did,” they said… I must now disagree .

Although Mr. S. had a creatinine of close to 10.0 with massive bilateral hydronephrosis, was 88 yo and obviously weak, none of the nurses seemed too concerned. I must say that usually the nursing staff at the VA is great and what happened next was an exception rather than the rule. Approximately 7 hours after being admitted, once I had a break from all the excitement of call day, I sat down to check labs that I had ordered for Mr. S. on admittance. They had not been drawn. I then checked his vitals, which were scheduled q4h; not a single measurement. I suddenly got a sick feeling in my stomach and immediately went to check on my patient. Thoughts of him lying there dead passed through my mind, though I never thought I would be so right. Although he wasn’t yet dead, his heart had only a few beats left before stopping the first time. I immediately called a code blue after realizing he was not arousable to a firm sternal rub. The code team arrived quickly just as the patient’s O2 sats began to drop and he went into A fib. The anesthesiologist knew he had to intubate now. He began calling for anesthetic. There was none; not in the crash cart, not in the pyxis, not even in the pharmacy cart. Although Mr. S. was unconscious, it was difficult to watch him intubated with no sedation. After bagging him for several minutes and giving IV boluses of epinephrine, his heart regained rhythm and he again had a palpable pulse. He was wheeled to the ICU where he would stay for the next 5 days.

My roommate on the VA general surgery service inherited Mr. S. in the ICU. 5 days after dying, Mr. S. seemed well. After being extubated and deemed stable, he returned to our medicine service. That afternoon, I was rounding on Mr. S. who, besides small right lower lobe consolidation, seemed in great shape (not bad after 96 hours on the ventilator). As I went through my basic daily physical exam, for the first time Mr. S. admitted to pain. The same man who was in no apparent distress after close to 30 days without urination was saying he had some “discomfort” on palpation of the abdomen. We obtained an X-Ray which yielded an image of 2cm of free air under the diaphragm- he had perforated. Surgery was consulted; Mr. S. was either going to die of septic shock or risk his life on the operating table with about a 50/50 chance of making it through the procedure. He opted for surgery, and made it. He again found himself in the ICU, this time for 7 days. But he never made it back to our medicine service. He died on day 12 of his hospital stay.As I reflect back on the first day of Mr. S.’s hospital course, I can’t help but remember the massive finger-pointing that went on. Everyone was blaming everyone else for not checking vitals, not having the crash cart adequately loaded, not having the pharm cart properly equipped and not having a drop of appropriate sedating narcotic for intubation anywhere on the 6th floor medicine ward. It made me angry; we are supposed to act as a team yet all I saw that night was lack of accountability and passing of blame. You will experience more in the upcoming year than you thought possible. It will be tough more times than not, but know that you are a vital part of the team (as contrary as that may seem at times) and you owe it to your patients to act like it. Take charge of your work and have pride in it, never go through the motions and always keep teamwork in the forefront of your mind. It takes many people working well together to adequately care for any single patient, and disintegration of that key concept inevitably trickles down to those that we vowed to “do no harm.”

Sam Overley


69


After raking my mind to come up with just one very special, heartwarming, goose bump- instigating, or eye-opening story that would add exponential meaning to your and my third year experience, I concluded that every single patient I remember was just as important as the next. They all had left such a unique and valuable impact on my education: the 92-year-old WWII POW with two purple hearts who was my first patient to pass away; Jessica, an 8-year-old Down Syndrome child, who told me she loved me as she gave me the biggest hug possible; Mr. M., who thought I was way too young to be a doctor, yet predicted a great future for me; Mrs. F., who asked if I could be her doctor when I graduate medical school; Mrs. G., who taught me how to valiantly face death as she suffered from end-stage ovarian cancer; 5-year-old Nick, who was convinced I was his third girlfriend; etc. Instead of picking one or a few stories to tell you, I would rather impart a few rules I learned during my surgery rotation that may guide you through some of the most trying yet exciting times of third year:

1. Have confidence in yourself and your decisions. Though you may not have the exact answer, you can probably think it through and come up with something probable. Your attempt to come up with an assessment/diagnosis or your input on patient care will show your interest in your patient and your ability to think critically. If you make a mistake, someone will be there to guide you and re-direct you. Take their help and learn from your mistakes and work on your weaknesses.

2. Work hard and stay focused no matter what the situation. Your future patients need you to be the best that you can be, and you can’t predict when you will need a particular small-print detail from a textbook, lecture, grand rounds, or article to solve a complex case.

3. Keep a positive attitude AT ALL TIMES! There is no room for self-pity. At the end of the day, reflect on what you did right and the ways that you can improve instead of focusing on the things that went wrong. As Marcus Aurelius eloquently said, “The happiness of your life depends upon the quality of your thoughts: therefore, guard accordingly, and take care that you entertain no notions unsuitable to virtue and reasonable nature.”

I am sure you have figured out that medicine is a complex yet delicate balance of external and internal factors. In order to understand that balance and to come up with efficacious interventions to restore it, motivation and self-study are invaluably important. However, if you get too caught up on knowing everything, studying only for the shelf exams, or focusing only on the numbers, you may miss out on the best part of third year: patient care. Without compassion for their patients, physicians would be no different from a computer program spitting out diagnoses and prescriptions. Therefore, don’t forget to love what you do, make friends with your patients, have a ton of fun at work, and take breaks when you can. Third year is the most amazing part of medical school if you let it be.

Now, go show them what you’re made of! Good luck!

Sincerely,

Toral Parikh

70


Dearest Class of 2013,

Congratulations, you are halfway there! Step 1 is done and it’s time to focus on healing after the four to five weeks of cortisol creating havoc through your body. To be honest, when I was in your shoes this time last year, as much as I was excited to finally see REAL patients with REAL problems, I was equally terrified. What scared me more than anything was the whole idea of “playing the game.” How do you put on a smile and say “thank you” to someone that has spent half an hour chewing you out for not being able to read his mind? I am sure you have had numerous talks about this, but after finishing the better part of the year, what I would tell my naive-self then is to not get too bogged down focusing on it. I know it’s easier said than done, but once you let go of the idea that you can be prepared for everything that gets thrown at you, life will be much easier, and HAPPIER. However much you think that there must be something you could have done to avoid certain situations, you have to remember that you have absolutely no control over some things. The attending is going to come in a bad mood, and it has nothing to do with you, but it will be taken out on you. There’s nothing you can do to prevent it; it’s inevitable- so just keep doing what you’re doing, and be you, because that’s all you can do and, in the end, you will be surprised with what you are capable of and how well you can perform in light of situations that seem impossible at the time.

Another scary thing about third year is that there is no syllabus, which may seem like a relief, but it means that there is no set way to guarantee yourself success on the shelf at the end of each rotation. Talk to your friends that have already gone through the rotation; find out how they studied and whether they thought it was sufficient, and then pick a review book, whatever it may be and stick to it. Don’t try to read every book, it’s just not feasible. Most days you will come home too tired to think about doing anything, much less picking up a book to read, which brings me to my next point... make sure you take care of yourself. Make sure you are getting enough sleep (if you aren’t on call, that is), eating, and working out like you used to when you had the flexibility of a second year schedule. I know it sounds obvious, but these are things that are easy to forget when you are just trying to survive the long days of a rotation like surgery. You will be able to learn more, help more, and make a better impression if you just remember to take care of yourself.

The coming year is going to be a long journey, one that initiates you into a sort of brotherhood of people that can all relate to what you have been through. It is filled with many incredible experiences, opportunities to get to know classmates that you might not have before, and maybe even some surprises. What you thought you were interested in might not be so interesting anymore, and what you were absolutely sure you’d never go into might turn into something that you can see yourself being passionate about. And in the process, you will learn more about yourself than you could have ever imagined; it is definitely one of the ‘growing’ years in life. It can be emotionally trying and physically taxing, but what growing-year isn’t? It’s part of what makes it such an important year, and what you have to keep reminding yourself of is that at the end of it, you will be one GIANT step closer to doing what you set out to do.

Best of luck!

Ami Patel


71

Dear Third-Year Medical Students,

This is it. You are about to embark on a journey from the safety and comfort of the lecture hall into a world that you could never prepare for. A world with a set of rules and protocol that you wouldn’t understand even if you were previously “warned.” I consider third year the most character-defining year of my life, thus far. It wasn’t about the books anymore; it is all about your interactions with others, the good and the bad. You are going to be placed in stressful environments, you are as vulnerable as the patients you seek to treat, armed with next to no knowledge compared to the residents and attendings around you. My advice to you is stay true to yourself. It is easy to lose yourself in all the commotion and uncertainties of this year. Remember who you are and why you so strongly desire to practice the art of medicine.

There is a reason that you have made it this far in your educational career. When things have gotten hard, you have pushed back even harder; you decided to wake up early and study that extra hour instead of sleeping in. It is this personal motivation that has gotten where you are today. Remember this. It will get you through the tough hours and the times when you think your presence on the team is not being acknowledged.

Hold your head up high and know that you are a strong person that has the ambition to get as far as you have. Dig deep and rise above the difficult times, know that you have value. Use the experiences of this year to inspire you to become the best, most empathetic physician you can.

With my deepest regards, Annaceci Peacher-Seaney

72


Dearest Fledgling Third-Year,

You are about to embark on a one-of-a-kind journey. A journey where you will enter one end as a cocky youngster with a head full of book knowledge and a skill set void of practicality, and come out the other bearing a small resemblance to the type of humble physician you might actually feel comfortable sending your mother to see. Take a moment and congratulate yourself on making it this far. You’ve done well. Now, if my fellow classmates have been selling third year to you anything like the class of 2011 sold it to my class, you are no doubt looking forward to this journey as the close equivalent to a year spent in paradise. A time when you’ll laugh and feel good about yourself and find your way in life, and, who knows, maybe help save a life or two. For a proud few of you, your third year may actually live up to these expectations. However, in the interest of more thorough disclosure, I’d like to share with you several reasons why your third year may not be all it has been cracked up to be. In no particular order:

1. Remember how hard it was to wake up for 8 a.m. lecture every day during first and second year? Well…imagine how hard it would’ve been. I hate to tell you, but most days of third year start 6 a.m. or earlier. And if that’s not bad enough, you have to be there with a smile on your face.

2. You will probably never in your life feel more useless than you do towards the beginning of your first rotation of third year. That is, of course, until second rotation starts…

3. When you’re inexperienced in the OR you’ll find that you have only your wits keeping you from accidentally sticking your attending with a sharp instrument. I can personally vouch for the fact that sometimes your wits aren’t enough.

4. There will be times when you’ll think you’re not getting paid enough to do what you’re doing. Then you’ll remember that not only are you not getting paid, you’re paying. Then you’ll get really ticked off. Then you’ll hear your resident shouting at you to get your head out of your arse and finish your darn H&P!

With that said, I would be remiss in failing to acknowledge the redeeming aspects of third year. First, it really will be like no other year in your life. In a year’s time frame you will likely be exposed to a wider range of medicine than you will in your entire career. You will work under many good people who you will come to look up to and respect. In many of them you will see the ideals that drove you to pursue this path, and it will hopefully help confirm this path for you. You will also have the opportunity to work with people in your class who you otherwise never would have gotten to know, and you will make new friendships. All of this and I haven’t mentioned the patients. One of the things that struck me most about third year is the amount of respect patients will give you even though you are just a student. This will be a steady reminder of both the responsibility you’re taking on and the position of privilege that you’re in. Whenever you get down on third year, think about some of the patients you have met and it will quickly bring you back to reality. Sure, you’ll be getting up at 5 a.m. every morning to work your butt off and repeatedly be reminded of how little you know, but the guy on the 9th floor of the hospital is on dialysis waiting for a kidney transplant that he may never get, has already been woken up three times during the night, and is about to be woken up again at 6 a.m. by a bumbling medical student trying to perform a physical exam. As hard as third year may get at times, always remember that in the big scheme of things you really don’t have it that bad.

And finally, any good letter to a third year would not be complete without some advice. During the year it is easy to get caught up in worrying about how smart you look and whether your attendings and residents are going to give you a good evaluation. My advice is to focus on the things you can control and let everything else fall where it may. Work hard and enjoy the experience. Be happy and healthy. Care about your patients and the people you work with, and be a good team member. In the end, the knowledge and skills that you gain and the memories you make will be what you take with you down the road.

With that I wish you best of luck, and may all your third year dreams come true.

Yours sincerely,

Ted Perry


73

Dear New MS3,

First, I must congratulate you on completing your years of basic sciences. Welcome to the world of clinical medicine! In pondering what advice I might have for you as you enter your clinical clerkships, I cannot help but reflect on the best and worst aspects of this past year. It is critically important in third year to quickly learn from not only your own mistakes, but also the mistakes of those around you as well. By sharing some our class’ collective experiences, I hope you will have better insight so as to avoid repeating our mistakes. So without further ado, here is a short and sweet (and brutally honest) list of advice for third year:

One - Don’t believe anybody when they say the Pestana Packet is all you need to study for the surgery midterm! It’s not! Not even close. Freshen up on you medicine before the test, particularly acid-base disorders. NMS Casebook is a pretty good resource, as is Case Files Surgery.

Two – When working in the ER, don’t talk to the lady doing the CT scans. Just put the order sheet in the inbox and leave. She is too busy to answer your questions. Trust me; you don’t want to upset her.

Three – Never refer to your resident or attending as “Bro.” They will lose respect for you, and you will just look ridiculous.

Four – Always be the first one to get to the hospital. Be there before your classmates. Be there before your residents. Be happy about getting there early. If necessary, learn to love coffee. However you manage it, just be there early every day.

Five – You will never figure out how to do the OB/GYN list correctly. A satisfactory list is an enigma. There are very specific expectations, but nobody will tell you what they are. No matter how hard you work on it, it will always be sub-par. It’s okay though. They won’t really hold it against you.

Six – Always be on time to the OR. In fact, be there early. Help anesthesia intubate and place lines. Help the scrub tech get set up. Put in the foley. Be actively participating in the pre-op routine when your resident and attending arrive. You will look like a rock star.

Seven – Remember to deflate the balloon on the foley before attempting to remove it. Should be obvious, but you would be surprised how often it happens.

Eight – Bring a snack with you. You never know when a “short day” will turn into a marathon day. It is very hard to be on top of your game when your blood glucose is 35.

Nine – Always ask for feedback. You don’t want to be surprised by a bad evaluation. Every couple days ask how you are doing and what you can do to improve.

Ten – If you are done with a computer, for the love of god, sign off! Nothing is worse than not having a computer to use because somebody forgot to log out two hours ago.

Eleven – If you have downtime, you have study time. Always have a book on at the hospital, because when you get home you will be too tired to read.

Last (and most importantly) - Have fun this year. Work hard. Learn much. Most of all, try to remember why you chose to enter the field of medicine. You study every day in order to provide superb care to your patients, not to do well on tests. Don’t ever lose focus on the big picture, and you will be a great clinician!

Best of luck!

Bill Pientka

74



I am not very good at giving advice, so let me preface this by saying that you probably have already heard or know most of what I know about how to succeed as a third-year. There are lots of little tips people can give you to make things easier, but you don’t really need them because you will be able to figure everything you need to know while you are on the wards.

Probably the best thing I can say to help relieve any anxiety you might have is to tell you that you will not be alone during your third year. You will usually always have other medical students with you during this time. There are tons of really cool people in your class that you will get to know more, and this will become a powerful support group for you because these people are just like you and they are going through the same things as you. There will be times when other people are sick of hearing about medical school and this is all you can think of talking about, but you will always have your medical student friends who will be there to listen to you. In addition to this, you will still have your other close relationships that will help you through this time. I also want to say that God will always be there too. He has been a comfort for me, and thinking about Him helps me to realize how any anxiety for third year or mistakes I have made are ultimately very insignificant. Evaluations and grades are not the most important things during third year and should not dictate your actions.

I just want to end by saying that third year is for mistakes, and you will not be faulted for looking dumb sometimes. Third year is for preparing for your internship year, so it is better to mess up now and learn about how to deal with a situation than to face it cold as an intern. I know this sounds good on paper and often even I don’t follow my own advice, but I think that this is a good way to think about third year.

Cameron Poage


75

Rather than sharing a “lifetime” moment or give you “pearls,” I suppose it would help you to know certain things a third-year medical student should NOT do. I’d like to call this list the “Third Year 10 Commandments.” This will hopefully make you a better person, and your friends will probably better enjoy working with you.

1. Don’t ask too many questions. Yes, I am talking to you (the one who always raised your hand during first /second year). Please, if you really have a question about something, look it up. Otherwise, you look lazy, stupid, and waste people’s time.

2. Do not linger around when interns/residents/attending tell you to leave. Go home and study! If you have a genuine interest in a specific surgery or procedure, then make sure that’s really the case. Otherwise, just go.

3. Do not answer questions you are not asked. Give the medical student who was asked the question a chance to answer. It’s very disrespectful to your teammates. If they obviously do not know the answer, then don’t embarrass them even more by showing off. Tell them the answer later instead.

4. Do not say you want to do a certain specialty just because you want a good evaluation. People know what’s up. They can smell a suck up from miles ahead. If you have a genuine interest in the field, then it’s OK but just don’t lie about it.

5. Do not give 30 minute presentations. That is annoying. Learning when to shut up is crucial. Unless the attending wants a lot of details, then go ahead and talk away. Otherwise, be considerate of others. Nobody likes to listen to long-winded explanations about anemia.

6. Do not show up to work late. Yes, emergencies do happen; make sure you call everybody (especially the resident) on the team if your car breaks or you have explosive diarrhea. Get the other medical students’ numbers so they can help you out if you’re going to be late.

7. Do not impolitely correct attending/residents/interns. Seriously, you are learning third year. They have more experience than you do, especially the attending. And if you are wrong, that just makes you feel stupid. If they obviously made a mistake, then just politely correct them. Don’t ever act cocky because that’s just plain rude and it will show on your evaluations.

8. Do not lie about lab values or anything about a patient. That just makes you look evil. Rather look stupid and not know the potassium level than to jeopardize another person’s life because you want to get a good evaluation.

9. Do not throw your friends under the bus. Even if the person is lazy, smells bad or is tardy all the time. Don’t comment about it. They know what’s up. It looks bad when you say “John is always late and takes 2 hour lunch breaks.” Do that in a private place outside of the hospital or amongst your trustworthy friends if you must vent.

10. Do not sit around and do nothing after you are done with your “work.” Read or do questions. Seriously, time is valuable during third year. Also, you don’t look so lazy.

This may all seem like common sense to most of you, but I saw these types of situations happening a lot. You’ll make new friends during 3rd year and hopefully, they’ll refer you patients in the future. I joke. Enjoy third year because it goes by way too quickly.

All the best – Nayeli Rodulfo

76



I wish you well as you make the transition out of the classroom and into the hospital. I want to share one of my stories with you from my very first rotation of third year because it has served as a precedent for my entire year. I was on my internal medicine rotation at the VA and I remember feeling like I did not know what I was doing – which was true. I met my new patient in the emergency room and although we suspected merely constipation, our team had to rule out a bowel obstruction. As my intern and I were leaving his bed in the emergency room, he mentioned that he had a “bad tooth.” As you will soon discover, most people in the hospital have poor dentition and getting any kind of dental care as an inpatient is virtually impossible. I asked my intern if we could remove it but he shrugged his shoulders and didn’t appear very enthusiastic about my request. When my patient was transferred to his bed on the 5th floor, I went to check on him. He mentioned his tooth pain again, prompting me to take a closer look in his mouth. On inspection he had multiple missing teeth and one remaining incisor was teetering back forth, just barely hanging on. He noted that it was hard for him to eat with the pain. I told my intern and resident about my findings and asked for a consult but, for the second time, my requests fell on deaf ears. They simply did not want to address that issue and wanted him to visit a dentist after discharge.

I relayed this message to my patient only to find out that he had no dental coverage or sufficient money to pay his own dental bill. As I was on my way back to the team room, I decided that I would continue to bring the subject up or simply pull the tooth out myself. So I kept bringing it up. Finally, I convinced my intern to place a consult to oral surgery. After proving to the consult team that his teetering tooth was directly related to his admission, they agreed to come take a look. The next morning, I read a surgical consult note stating that his tooth had been pulled. I went to visit him and he had a smile on his face, happy that the tooth and his pain were gone. I left his room knowing that our actions would make his life a little easier to live. He was discharged within the next 24 hours with a diagnosis of constipation and dehydration.

The experience above should convey two messages. First, never underestimate the effect that one small act can have on your patient’s life. Simply pulling a tooth can mean pain-free meals, improved diet, and fewer emergency room visits for dehydration or constipation. Secondly, you should be ready to face some challenges in your quest to make a change. There will be times when you have been in the hospital all day and you will have to resist your own desire to just go home. Or there could be times when your team seems disinterested in treating something other than the primary problem, forcing you to lobby for a change. In the far majority of cases, you will see each of your patients only one time this year. Therefore, seize that one opportunity and make some kind of a difference. As a student you will have limited power in the hospital hierarchy and many of your patients will not need you to go that extra step for them. However, an opportunity like mine will eventually present itself to you. My wish is that you stay ready and willing to help.

-TJ Sanders


77

Dear 3rd-Year,

I want to congratulate you on completing your first two years of medical school. Hopefully by now, you have taken Step I. This by itself is a great achievement. I have almost completed my third year of medical school and I can guarantee you a few things. I have worked very hard, experienced a side of humanity unknown to me, and I’ve made a difference in someone’s life and death.

You will do a lot of rotations. Some of them you will love, some hate, and some will be a love/hate relationship. I’ve gone to the hospital before many of my old friends go to bed and stayed till the next morning. I have felt unintelligent on many occasions. I have missed simple and important medical facts that I will never miss again. You can learn more about yourself in these times of trial than most people ever get the opportunity to. I have learned more in the past 9 months than the previous 2 years combined. I’ve learned more about what I want to do with my life and more about myself. My wife had her favorites, and there were ones she didn’t like. I remember on Surgery, for the first three weeks, I was working over 100 hours/week. It was hard on my wife, and it was hard to operate with that amount of sleep. Through it all, I learned to appreciate those days off with my wife. In the end, it’s good to have rotations you truly disliked because it can give you something concrete to compare to rotations you like. You’re a better person for it. Keep a good attitude. It makes everything easier.

You will get to experience many of your patients going through hard times. There are many patients I’ve had that were dying within a matter of months. There are a lot of people that are not financially stable. Severe physical problems exacerbate marital issues and personality dysfunction in people. I’ve helped a patient with metastatic renal cell carcinoma who was found to have disease in his brain. He was a very active 65 year-old-man. I remember he really wasn’t having any symptoms of disease except for some confusion that cleared after a few days. One morning, he stopped me for a litany of questions. He looked at me in the eye and asked me, why him? I had no good answers for him, but I gave him the best one I had at the time. He went home on hospice care. I feel I made a difference in his life. It may have been small, but I hope it was positive. Dying patients need a lot of help, and you can do a lot, though it feels like so little.

Medicine is a life and death struggle. It always will be. All the TV shows and movies have clichés that sound ridiculous, but death is as much a part of many doctors’ work as is life. One of my patients died right in front of me. I went to see him late at night just to check on him. He was working hard to breath. I went through a quick overview, spent a few minutes dealing with the pulse ox to figure out that his oxygen saturation really was 60%. I called the nurse, who took one quick look at him and asked if he was DNR. A couple minutes later my resident pronounced him dead. He was a sweet guy with a family who loved him. It never occurred to me he was going to die until the nurse asked for his code status. I’d spent almost a week with him, getting to know his family. He was fairly complicated, and I learned a lot from him. I remember the sinking feeling of realizing something was wrong. I took a long time to figure out what I could have done differently. I’m not sure there was much I could have done, but he will be with me for a long time.

I’ve got good news and bad. Third year is going to be so different from the first two years of medical school. It’s new and scary, with real patients. It’s awesome; it’s terrible; it’s work; it’s fun. It’s all these things. You’ll be far away from the friends that helped you through those tests. You’ll make new friends with the people that you haven’t met before. You’ll learn much more than you thought you could and still feel inadequate. I love being in medicine. I hope you love it too. Good luck. Enjoy this, it passes quickly.

Christopher Sartin

78


Every morning when going to see Mr. Fine, I knew that my day was about to be a little bit brighter. Mr. Fine was my first patient on Internal Medicine; he was an 87-year-old man with a long history of health hardships from three different types of cancer, renal failure, and atrial fibrillation who came to me with an exacerbation of congestive heart failure. However, every morning when I walked into his room to ask how he was, he would say, “Oh, I’m Fine.” Those three little words were repeated to me every morning for two weeks, and neither he nor I ever ceased to be amused by the play on his name. When talking with Mr. Fine, I was constantly reminded that someone can survive amazing hardships and still maintain a beautiful outlook on life. This gentleman was in a precarious situation; we were trying to treat his CHF while not worsening his kidney function. On top of that, he had just begun to have chemotherapy prior to his hospitalization for a relapse of cancer. While in the hospital, he slowly improved but also began to have symptoms of delirium and disorientation. Despite facing these adversities, Mr. Fine always focused on the positive aspects of life. The day Mr. Fine went home, he came up to me with a smile on his face and a big hug to say goodbye.

As third-year medical students, we have the opportunity to be involved in someone’s life at a period when they are vulnerable and scared. Although we may also be a bit scared too (after all, he was my first patient!), it is amazing the impact just coming to speak with our patients and listen to their concerns can make. Being that smiling face they see every morning makes a lot of difference. Every day, Mr. Fine taught me that no matter what hardships one faces, it is the outlook we have that truly determines our well-being. By following the example of Mr. Fine and keeping a positive outlook, despite the trials of third year from trying to learn vast amounts of information to struggling against fatigue, everything will be fine.

Kathryn Schmidt


79

June 2011

Dear Rising MSIIIs,

The moment I had been waiting for finally arrived on July 5, 2010 – I was finally a third-year medical student on the wards! I was wide-eyed, eager, and extremely excited to escape the library and the lecture halls and learn directly from patients. I was ready for the “real world.” Little did I know what the real world was about… (don’t worry, its actually really cool once you adjust to it).

After orientation for the general surgery clerkship, I headed over to University Hospital to meet the very first group of residents I would work with as a third-year – the Transplant service interns. I had been in the hospital many times before as a second-year medical student, as a patient, as a volunteer and as a visitor but never as the member of a treatment team so I had no idea what to expect and what was expected of me. Excitement soon turned to fear as I entered the resident room and met the team. I think that was the moment that I first learned to hide utter fear with a smile (don’t worry, if you haven’t already, you’ll become a pro at it). We had a brief introduction and orientation to the service. I tried to take in as much as I could as we walked through transplant telemetry and the TICU but all the abbreviations, all the names, all protocols, and all the patients proved to be too overwhelming to process in the 20 minutes that we spent orienting ourselves to service.

By the end of the tour/orientation I felt like a freight train just ran over me but nonetheless I was excited because I found out that we had a couple liver transplants on tap later that week. We finished our tour and went to the residents’ room to meet the chief resident. The chief sat us down and gave a spiel about the expectations of a medical student and what to expect on the service – what caught my attention was the schedule. We were to start rounds at 530 (though this changed as the weeks went on and often started later) which meant pre-rounding on our own beforehand which meant waking up between 0400 and 0430 every morning. Furthermore, our post-call mornings were spent rounding on patients instead of going home like the rest of the trauma team students (I later found out that this was not a requirement for all students but a recommendation in order to keep up with patients).

I gotta admit, my heart sank a bit but nevertheless I was ready and excited for what was to come…until Day 3 when I had, for the first time in my life, been awake for 30 straight hours and been semi-productive nonetheless. I could never have imagined what it felt like to be so utterly exhausted…and still have 5 more weeks to go…and have 12 quizzes to study for…and have two exams to study for. I went home and slept through the afternoon, woke up at 7 to have dinner, then went back to the hospital to see what was going on since I got a text telling me that a procurement was taking place. I went to the OR to get an update and see if I could get involved. What happened next was the thing of dreams…

I found one of the transplant surgeons who just so happened to be one our administrators chillin’ all alone in the OR waiting for help since the chief resident was gone for the procurement. He looked up at me, and said “you’re scrubbin in.” I didn’t show it but I was going crazy – I was going to first-assist…in a liver transplant! (which was soon followed by, “Oh crap I have no idea what I am about to do”). I quickly scrubbed in and immediately was handed the Bovie and given a 3 second crash course on how to use it. For 45 minutes, with a grand total of 3 days of experience as a 3rd-year medical student, I got to first assist on one of the sickest surgeries with one of the best surgeons in the hospital. The best part of the experience wasn’t even the surgery – it ended up being the great relationship I developed with crazy old Ms. Stripes during her recovery. I would see her bright and early every morning which would p*ss her off because I was waking her up at 5am every day. She soon got used to that and my jokes finally got to her and she warmed up. She would have her husband bring me shakes from Whataburger, would get upset with me if I had a day off and didn’t see her, and she even offered to make me a steak dinner since I talked about it so much (food and bowel movements are a common topic of conversation on General surgery services…). Fortunately I learned my lesson really early on - all the long days, the limited sleep, the stress from studying was worth it because I had the wonderful opportunity to be training to be a physician that could make such a long-lasting, positive impact on an individual, a family, and a community.

Being a medical student on the wards taught me some really valuable lessons which I think would be worthwhile to at least pass on (these are more general thoughts about 3rd year).

1. There will be days where you will learn more about yourself than your patients. – The hardest thing about third year for me was adjusting to hospital life (= being lowww on the totem pole), learning to work on a team and being a good team player (that means not cutting people off when they are talking, NOT THROWING TEAMMATES UNDER THE BUS, helping each other

80


out, being fair when it comes to scrubbing in, seeing patients, and sacrificing a little more for the betterment of the team and the patients), and adjusting to the schedule – I was never really a class-goer my first two years so getting up on a Saturday when people would be getting home from a night of partying was realllllyyyy difficult at first but, as the year went on, I got excited when my days started at 7am or 8am (something I never would’ve expected).

2. Respect your superiors

3. In the same token, respect your classmates and teammates. < ----- THIS IS A BIG ONE!

4. GET SLEEPPPPPPPP!!! < ------- I cannot stress this enough!!!

5. DO NOT PROCRASTINATE when it comes to studying. There was a lot more “book studying” that I had to do during third year than I anticipated and that took a bit of time to adjust…

6. Do the extra credit assignments – I can’t tell you how many people have made an A instead of a B because of the extra credit assignments…a few points on your grade can make the difference between an 87 and a 91.

7. Make time for yourself and decompress as needed! As a third-year medical student (this is also dependent on your residents) there will be times where you have to please lots of people, smile through the pain, and do scut work…it will wear you down so make sure you make time to decompress and relax (in a healthy way…) to escape the stresses of the hospital.

8. Some days are really fantastic…you may get to deliver a baby, first-assist on a surgery, make a depressed patient smile and laugh, get an unexpected compliment from an attending that just made your week…and some days just suck…scut work up the wazoo, having people get upset with you for reasons out of your control, etc. Just roll with the punches and…

9. DO NOT alienate yourself or your friends and spend time with them when you can!

10. Be nice to the nurses! They can be a huugggeee help.

Third year is a really challenging year which can be fun and is a time in which you learn a lotttt about medicine and sometimes even more about social/interpersonal skills. Be patient, make time for yourself, and work hard (go early, stay late, offer to help, etc). GOOD LUCK!!!!

Best,

Rehman Sheikh


81

Dear Third-Year Students,

“It’s all going to be ok.” This is the phrase that a fourth-year told me at some point during the middle of my third year as I was starting to panic about my life. And I thought about these words, and then I remembered to breathe. And it made me feel immensely better. But more importantly, I really believe that this phrase is true.

After I did my physical exam on a woman and noted, “Your nose is crooked—did you break it?” To which she replied with a blank look and a simple, “no.”

After I interviewed a patient with hyperthyroidism and a giant goiter on her neck, did the most complete, unnecessary, head to toe physical exam that there has ever been, except that I forgot to palpate the freaking thyroid.

After I scrubbed in on my first surgery, was completely clean, and then the first thing I did was adjust my mask and hat thus contaminating myself, and had to go start the whole scrub process over.

After I accidentally broke into the clinic on my first day of Family Medicine, set off the alarm, and then had to explain to the police that, yes I was supposed to be there, and no, I wasn’t trying to steal medical equipment to sell it later, and yes, that was my real name badge, and yes, it matches my driver’s license.

After I didn’t finish all the questions on my first shelf exam and I was completely convinced I had failed the rotation and spent the rest of the weekend coming to terms with the fact that I might have to repeat the clerkship.

After having April upon me, starting my last rotation, and all I know about my future is that I don’t want to be a psychiatrist.

After I felt so tired that I couldn’t think straight.

After I went for days of not seeing the sun, except, perhaps, through a passing window.

After I cried in front of my resident because I was so sleep deprived and emotional and embarrassed for not knowing all the answers.

After cutting off the leg of a man whose foot was rotting off from diabetes.

After I held the hand of my patient and let her cry when the doctor left the room having told her she had cancer. After I saw my first still-born.

After gingerly holding a 1-month-old baby boy to make sure he got human contact because he’d been taken away from his family after every major bone in his body had been broken.

After watching that boy go home a few weeks later because they’d found a new home for him.

After I stood by a doctor as he broke the news to the family that their loved one had days, maybe hours to live.

After witnessing their grief and tears and love.

After telling a 10-year-old boy that his cancer was in complete remission.

After walking into the room of a 9-year-old girl who was recovering from a pneumonia that had required a chest tube and seeing her smile for the first time in days and ask me for a breakfast taco.

After delivering my first baby.

After being part of the team that helped a wife bring her husband home, even after she thought she’d never get him out of the hospital again.

82


After helping an old vet learn to use an ostomy bag (ew).

After explaining to a 16-year-old girl that “just lying there” still counts as sexually active.

After all of this. And so much more. Because thousands of men and women have done all of this, made those mistakes, done that stupid thing, didn’t know that answer, said that poorly thought out comment, fallen asleep during that lecture, experienced this joy, this grief, these trials, and this life. We all know. We all have been there. And I still firmly believe: it’s all going to be ok. Have faith in that. You’ll figure out the rest.

Sarah Stayer


83

Letters to a Third Year Medical Student

The patient was well known to the emergency department – a 54-year-old homeless male with over fifty visits to the ER over the past few months. He mostly came in with complaints of difficulty breathing and pain in his right flank. On his initial presentation he had received an extensive workup; thousands of dollars in faculty time, diagnostic tests and hospital resources had been spent to ascertain a diagnosis. A lung mass and some old rib fractures were eventually discovered by CT, but the patient left AMA before any definitive diagnostic testing could be performed. This was followed by a series of casual visits to the ER with the same aforementioned complaints or to “sober up,” which was another characteristic pretext. It became standard operating procedure to triage him, perform a predictable assessment, and send him away without admitting him. I learned all of this from the extensive chart check I performed after I picked him up as an inpatient on my ward service.

My initial interaction with him established what would become a recurrent theme during my tenure with him on the service. I introduced myself, offered a summary of what I learned from his chart check, and afforded him the opportunity to explain why he was in the hospital, in order to achieve a better understanding of his perception of his illness. He briefly remarked about the pain in his side and, seamlessly, asked if he was going to get a meal tray soon – “with coffee,” he added.

The patient’s history and a new chest CT were highly suspicious for lung cancer. My attending at the time broke this news to the patient. I was surprised at how well he took it. “Well I’ve been smoking since I was 15,” he replied. My attending offered counseling and suggested that he undergo a bronchoscopy and biopsy to get a definitive diagnosis, to which the patient agreed. We set up a date for the bronchoscopy that day.

The following morning I went to see the patient, who was just finishing his breakfast. I gave a short recap of our current plan, to which he replied - “I have cancer? Well I’ve been smoking since I was 15.” This became a recurrent charade. Every morning he was told the plan, and he would respond with the same surprise. In fact, his primary concern most mornings was when the breakfast tray would come.

Eventually this man underwent the bronchoscopy and was found to have squamous cell carcinoma of the lung. This diagnosis meant little to him. I am not sure how long he stayed in the hospital, as I moved to a different rotation before he was discharged. I frequently reflected on my encounters with this man, and the workup we performed on him. I felt sorry for him, but struggled with the idea that so many resources were being expended to give this man a diagnosis that 1) he did not particularly care about and 2) was highly unlikely to undergo any long-term therapy. Moreover, he had no insurance, so all of his bills were being picked up by the tax payers. It became difficult for me to justify indulging this man, simply because he has a disease – especially a disease that is secondary to his own decision to smoke his entire life.

I would like to say that I came to terms with our treatment of this man, but I must admit that I still struggle with it. I believe that every person is born with the right to a long, healthy life. The vast majority of patients I have worked with are grateful, hard-working members of society who either seek out health care to prevent illness, or benefit from the miraculous power of medicine in times of need. There are others, however, that have led me – painfully – to wonder: how can we help someone who clearly will not help themselves? This country is in a severe economic crisis, can we afford to treat people like this? It is a fundamental tenet of the medical profession to treat all patients in need. The great respect I have for the medical professional ethos commands that I do the same. Nevertheless, I have to say that this patient challenged my concept of humanism and ethics. Perhaps with more experience, I will gain better insight into this complicated and nebulous concept.

I chose to write about my experience with this patient to illustrate an entity that every third-year medical student inevitably encounters: frustration. Like a sulfa-drug induced rash, this undesirable force has many forms. (Having recently completed Step 1, I hope you all can appreciate this terrible joke.) You will find yourself aggravated by uncooperative patients, annoyed by unintuitive computer systems, exasperated by cryptic grading systems, defeated by unending shifts. However, just as we all did, you will overcome these relatively menial frustrations in your medical career. You will find yourself encouraged by the strength of your classmates, and inspired by the ability of our residents and faculty – our program has some of the best in the nation. At the end of the year, you will sit back, perhaps with a beer in hand, and remark on how much you have progressed over such a short period of time.

Matthew C. SwannUTHSCSA Class of 2012

84


Dear MSIIIs,

Congratulations on completing 2 years of your medical education. As you step into the sphere of clinical medicine there are going to be a number of things that are going to be different from your first two years and slowly you will adapt to them. There will be a sense of responsibility and pride in your work that will be demanded of you that perhaps was the reason that drove you to medicine to begin with. However, it is tough being a third year medical student. You begin to realize the vastness of knowledge in the territory of medicine and how much about not only medicine but also the inner workings of hospitals, clinics, insurance, and social programs that there is to learn. Moreover, in order to be a great physician, you will need mastery of them altogether.

In the muddle of the long hours, there will be moments that you will look at, reflect on, and rely on to propel you further. As I wind out the remainder of my third year, one of the nights I can’t seem to forget was a night I had spent at the VBMC ER on call with one of my surgery attendings. The night started with a stab wound to the abdomen that required an exploratory laparotomy and ended at 10 a.m. the following morning with the completion of a surgery for a gunshot wound to the carotid that required an open thoracotomy and replacement of the original carotid artery with a carotid graft. In between these cases was a rare opportunity I had a as an MSIII. At around 2 a.m., a stab wound to the chest of a young male from a street fight had come in and the patient was in restraints, agitated, and writhing in severe pain. After my attending evaluated him, he indicated to the general surgery resident and me to insert a chest tube in him for his pneumothorax. While the resident went to gather materials and the kit required, I stood alone next to the patient in the ER room and he grabbed my hand and asked me, “Don’t lie to me, Doc. Am I gonna die?” I looked at him and reassured him that everything would be fine just as soon as we could re-expand his lung. As we prepared the materials of the kit, my resident graciously indicated to me that he would let me perform the whole procedure and he would guide me through it. I felt the excitement in my body as I had seen multiple videos of chest tubes, read about it, and understood the physiology behind it but never had done it in real life. As we went through the motions, the patient, overhearing us through his pain, called out to the resident, “Man, I’d just be a whole lot more comfortable if you just did it.” The resident kindly reassured him and I began systematically, indicating for assurance to my resident each one of my calculated and strategic moves until the chest tube was in and secured and the patient began to show signs of relief. Thank God, it was a success. The following day we made our rounds on the patients and I stepped into this particular patient’s room. He sleepily looked up at me and my resident then quickly became alert as he looked at me and hollered, “Hey, it was you that put this tube in me that night, right?” I replied to him, “Sure was.” He looked at me, grinned, and said, “Thanks, man.”

This is the year where you begin to put your knowledge to the implementation phase. The more you know and the more you understand a certain procedure, a certain aspect of physiology, a certain part of anatomy, the sweeter each one of your clinical or surgical experiences will be. Only another artist can truly appreciate another piece of art work. This is the year where you feel the emotions of a doctor: joy of a patient happy to see you at the crack of dawn, the agony on finding out your patient has metastatic carcinoma now that the biopsy results are in, the confusion you feel when they ask you a question you don’t know the answer to, frustration of having a patient not understand you or just plain refusing health instructions. All of which are realities of medicine that we were somewhat shielded from and have now come to experience. The advantage that you have over the seasoned doctor is that each one of these experiences will be native, sincere, and pure for you. As you progress further in this game you will look back at each of these experiences and, at times, wish that your future ones will still hold the same wholesome and heartened impact that the original had. Accordingly, enjoy each of these moments that will build your third year, as they will be your first and last—as a re-experience will never be the same.

Almas Syed


85

“Fifteen hundred years ago everybody knew the Earth was the center of the universe. Five hundred years ago, everybody knew the Earth was flat, and fifteen minutes ago, you knew that third year was about SCUT and shelf exams. Imagine what you’ll know tomorrow. “

Maybe you spent a whole bunch of time in the hospital before coming to medical school in a prior career as a ______; maybe you come from a lineage of doctors so long it predates the founding of this territory called Texas; maybe you have absorbed half of Harrison’s in the two weeks of Clinical Foundations you’ve just completed. To this I reply, courtesy of Dr. Tommy Lee Jones: “Cool, whatever you say, slick, but I need to tell you something about all your skills. As of right now, they mean precisely...”

Ok not exactly (if that Men in Black reference was lost on you, you should revisit your Will Smith movie collection)… Third year is a shove into the pool at the least, but you’ll likely find you are actually better equipped than you thought, and if you pause and reflect, you’ll be amazed at how much you grow. You are about to embark on a truly amazing and unique year to which few others in this life are privy. You will no doubt receive advice from countless people; allow me to relate a few pearls I came away with:

1. Learn how you learn (if you haven’t already!) and read, nightly. Louis Pasteur famously said, “Fortune favors the prepared mind.” This rings especially true on rounds. Despite those feelings that you always get pimped on the one thing you didn’t read, you might just get the opportunity to explain why your patient doesn’t have HIV-associated dementia, even though they have HIV and dementia, or you might know that Fenoldopam is another option for the treatment of malignant hypertension and can cite the NEJM article because you read it on a prior rotation.

2. Be interestedRumors aside, most of the professors and residents at this academic institution LOVE imparting wisdom. Your enthusiasm will pay dividends, and you may just get extra opportunities thrown your way for it… Like, clipping toenails with those crazy podiatry scissors (seriously, only doctors can do that), stopping a patient from bleeding out in the trauma bay or placing that chest tube (with supervision!), receiving a personal tutorial and system for how to interpret CTs, EKGs, or CXRs. You might even find yourself holding a beating human heart in your hand, “HOLD IT LIKE A CHEESEBURGER,” or having your intern ask for your feedback after he just broke bad news to a patient.

3. Reflect oftenSometimes you won’t fully understand what you’ve learned until later. On an inpatient medicine rotation post-call, my attending would, without fail, bring in a box of Shipley donuts and a bag of Taco Cabana breakfast tacos. It was only several months later on my psychiatry rotation that I understood the deeper wisdom in this maneuver. To paraphrase Dr. Schillerstrom: “It’s hard to be angry with someone if they just gave you a sandwich.” Note: this applies to both irritable residents and the “aggressive” patient.

4. Spend time with your patients and their familiesThere are mighty forces that will attempt to stand in the way of this: progress notes, discharge summaries, outside hospital patient record scavenger hunts, those pesky phone calls to the ultrasound tech, and numerous trips to the nurse’s station, but important things will come of your time. You might be the first to discover your patient is non-responsive to sternal rub and requires a code. You might be the one to alleviate the anxiety of Mr. Vilas’ family by explaining what an empyema is and how your team is going to treat it. You might redirect your patient with brain mets in status epilepticus to keep him from trying to leave AMA, while your intern consults neurology.

5. Be a team player

Really try hard to make your teammates look like all-stars, and help the team perform. The slack you pick up will be returned to you 10-fold, and besides, even if the attending doesn’t remember your name, he or she will surely remember that stellar group of med students during period 5 who were always prepared and knew their stuff.

Above all, don’t ever feel like you’re in the way, or are not supposed to be here. You’re an amazing person and you’ve worked hard to get to this point! You’re going to make a great physician. Relish the journey!

86


Best wishes,

Brent Thiel

REFERENCES:

http://www.imdb.com/title/tt0119654/quotes

http://en.wikiquote.org/wiki/Louis_Pasteur


87

Dear Third-Year,

Yes, you! The time has come to step out of your comfortable lecture hall seat and into the wards.

Perhaps you are like I was, feeling anxious, intimidated, and annoyed about the mere idea of staying awake for 24-hour trauma call. Perhaps you are also, like me, excited and thankful for the chance to finally put all of your book learning into practice.

There are a lot of clichés that I could embellish on here: “Keep a positive attitude, look out for your fellow classmates, enjoy the time you get to spend with patients, soak up as much information as you can, don’t be too hard on yourself, remember that even on your worst day you still have an enviable job.” All of these statements are true, and themes that you will hear again and again.

But the truth is, you don’t need any of this advice. All of you are going to survive third year. In fact, you are going to enjoy it, even the hard parts. And all of you are going to create your own unique experience along the way.

You will interact with people from all walks of life- moody teenagers, adorable premature infants, friendly nursing home residents, soldiers, prisoners, and everyone in between. You will see amazing recoveries, and heart-breaking losses. You will smell some terrible smells. You will get lost, a lot at first. You will occasionally be sleep deprived. You will learn to truly value your weekends off. And through it all, you will have the opportunity to provide hope and empathy to strangers. You will feel unqualified to do this a lot of the time, but your presence means more than you know. Your life will become richer as their life stories are woven into yours.

Then, magically, one day next spring, you will realize that you finally know your way around, you’ve learned the names of half of the staff you see in the hospital hallways, and you can’t walk down the wards at UH, the VA, or Santa Rosa without thinking about your patient who used to be roomed there, wondering how they’re doing now.

Third year is about a lot of things; developing your sense of compassion, learning to trust your instincts, and most of all- becoming the doctor that you were meant to be.

Be sure to enjoy the journey; it will pass by quicker than you think.

Kate Todd-Thompson

88


Hey Guys!

Congrats on finishing by far the dreariest part of medical school, and hopefully your entire lives. I don’t know about you, but I really despised first and second year. I would daydream in class (when I went) about dropping out to manage a McDonald’s or teach underwater basket-weaving or be a crazed homeless person, because anything had to be better than looking at one more PowerPoint slide about the oxygen dissociation curve. Third year, you’re going to be working harder than you have before, but, trust me, it’s going to be infinitely more fun. You actually get to talk to people instead of just reading about them in books (crazy concept, I know).

You’ve all heard the general advice about third year: work hard, don’t whine, know your patients, study, don’t be late, etc, etc, etc. It’s all good advice, and following it will help you out in a big way, but I think you get the picture. So I’m going to leave that stuff alone.You know that quote by Nietzsche, “If you gaze into the abyss, the abyss also gazes into you?” That’s kind of how I think about third year. There’s just no way you’re coming out with exactly the same mindset and opinions you came in with. Even the rotations you really have no interest in doing as a career can hold experiences that will affect you in a big way. For me, that rotation was psych.

Honestly, I was having a hard time relating to, or sympathizing much with, the psych patients. And then I met Sara. She was admitted to 4D (the psych ward at Wilford Hall) with a bang. Literally. She announced her arrival by dropping to the floor and banging her head on it as many times as she could before someone could put her in one of the padded rooms and restrain her to the bed (really, that happens). Her first twelve hours she plowed through Haldol and Ativan like it was her job, alternating between religious rants and offers of sexual favors to the residents. Clearly, the woman was off her rocker. In a quiet spell, the attending took the other third-year and me into the room to try and get a history.

Sara’s eyes darted everywhere as the attending talked. She was beyond nervous, but, seeing as she was the devil and the attending was Jesus, I guess that’s understandable. It was a little scary, honestly, because even though she was obviously not with it, Sara retained all her humanity. All the truly “crazy” people I’d seen up to this point had been in the movies, and were easy to laugh at. Sara was a real person, not much older than myself, and she was absolutely terrified. Whenever her eyes landed on my face, I would try to figure out what facial expression would best convey that I was there to help. I was pretty uncomfortable though, so an awkward half-smile ended up being all I could come up with. For an hour, the interview sputtered on, our tour through Sara’s jumbled psyche often interrupted by long periods of silence. Eventually, the interview ended, and we peeled our backs away from the padded walls, and left the room.

When the door shut, the attending turned to us and asked if we knew what Sara did for a living. My compatriot and I looked at each other and shrugged. Obviously, Sara was in the military, you have to be to be admitted to 4D. She looked to be about in her late 20’s, and she was in shape, but other than that we didn’t know much. Attendings are generally good at spotting cluelessness, and this one was no different, so he answered his own question. “Sara’s our best fourth-year surgical resident here at SAMMC. She just won an award in Washington, D.C. for the research she’s doing on saving limb vasculature damaged by trauma.”

As Sara came back to reality, it became more apparent that she was not the nutcase she seemed to be when she first arrived. Conversing with her was at first a delicate affair but, as the days passed, became like talking to a colleague. On the day she left she had fallen back into her role as a resident, at one point even complimenting me on my bedside manner. Watching her transformation forced me to acknowledge that, while I was more comfortable thinking of psych patients as alien entities, my comfort should absolutely not be my number one priority.

Third year is hectic and it’s easy to get caught up just focusing on getting your “chores” done: see all the patients before rounds, present, write your notes, call consults. If you are able to make time to talk to your patients and treat them as people instead of problems, you’ll get more out of this year. If nothing else, do it because you may just have more in common with them than you might think.

Erin Tracy


89

Hey there, Third-Year! Congratulations on all you have accomplished to get to this point! You have a new, exciting year ahead of you- so get pumped. The days can be long and the nights far too short, but overall, I think you’ll come to find that you enjoy being a third-year. It is a glorious transition from classroom to clinical years. Here are a few pieces of advice that I hope will help you have a positive experience this year!

Have low expectations I don’t mean this to sound cynical, rather, I think it helps you have a positive attitude. If you go to a rotation expecting the hours to be grueling, to not have a resident or attending say one kind word to you, expect the shelf to be impossible and your evals to be so-so, you will never be disappointed. If you can come to terms with all of those things, you will be surprised by how 95% of your rotation actually turns out. You’ll find that you get off really early a few days here and there, that your residents are super thankful for all your help and that your attending thinks that one presentation you gave on a difficult patient was really great. You’ll over-prepare for the shelf and do surprisingly well even though you feel like you bombed it, and though some evals will be so-so (like in surgery) you’ll get those one or two that say “performed at an intern level” or “contributed such and such idea to the team that improved our patient care.” You will always be pleasantly surprised.

Comparison is the thief of joyNo two third-years will have a year that is the same. Everyone has such different teams, schedules, and rotations. Because of this disparity, don’t compare your experience to those of your classmates, or think that you’ll have a rotation go the same way theirs did. There is too much variability in residents, attendings, locations, and even the hours that a rotation will offer. This is a corollary to having low expectations- if you compare to your classmates, you will be let-down most likely. Similarly, don’t compare evaluations, shelf scores, or even career choices. Even comparing which books you’re using to study can make you worry! All we do when we constantly compare ourselves to one another is cause a lot of heartache and stress.

The residents always have it worse.Always. Always. Always. They have been awake longer, been on call more, had fewer meals that day, have been talked down to by a disgruntled attending more times and, on top of that, have ACTUAL RESPONSIBILITY for patients’ lives. So do not complain to them or around them. Complain to a fellow classmate in private or to your significant other via text if you absolutely have to, but do not complain to a resident. Nobody has good things to say about a whiny MS3.

Never forget how privileged we areThere will come a point during a rotation or at some point well into your third year that you will become desensitized to it all. Instead of being excited to see your patients, or learn something new from your resident, or see a new surgery, you’ll wake up and count down the hours till you can go back to bed. You can get lost in the hours, the numerous patients, the notes, and the hoops you have to jump through. You’ll feel like you’ve lost your desire for medicine. When you realize this, you must fight it! If you can’t find a good pep talk from a friend, go back and pull out your personal statement for medical school. Remember why you came here in the first place. Remember how you really do want to serve people and care for them in their most vulnerable times, how you want to be trained/educated in a way that few are. More importantly, remember that we are so privileged to be in medicine. Your patients are completely vulnerable with their lives and their bodies, trusting that you’ll care for them- what an amazing position! You must re-sensitize!

Watch for that look of confusionYou have the special position of being the one person on the team who hasn’t learned all of the lingo yet. When your team is explaining something to your patient, you are the only one who can come closest to remembering what it is like to NOT know what that means. Watch for the confused look on your patient’s face- and then take time to go back later and explain what the term, procedure or diagnosis means. Also, make yourself available for the patient to ask questions since you are far less intimidating than your attending and have a lot more time on your hands.

You will be amazed where a smile on your face can get youA better grade, a more glowing evaluation, rapport with your patient and kindness from the nurses. Priceless.

There are no angels singing or neon signsI always secretly hoped there would be some enormous, impossible-to-miss sign (or angels singing when I walked in the first day of whatever rotation that I was supposed to do) that would allow me to know for certain what specialty to choose. Like many of my

90


classmates, I thought I knew for a while- and then I was faced with the realities of that specialty: the hours, the bread-and-butter procedures/patients/problems that become routine, the fact that I really don’t love one organ as much as I thought I did, etc. I know this is advice that you won’t need for awhile, but I just wanted to make special effort to tell you that if you find yourself in March/April/May of your third year and you’re not 100% sure what you want to be when you grow up, you are PERFECTLY NORMAL. My advice is that you realize that as wonderful of a career as medicine is, it is not going to always be fulfilling, exciting, or perfect, and that for most people there are no supernatural signs telling them what to do. It is a decision. One that requires a lot of honest thought figuring out what priorities you have in your life- marriage, kids, mission work, hobbies or a decent amount of sleep. As well as a lot of honest research about whatever field you’re interested in. Then, once you’ve collected all the data and feel like you have taken an honest look at what you think you want your life to look like in the future – make a logical decision. It’s ok not to be head-over-heels in love. Though medicine is a wonderful and noble career, at the end of the day- it’s just a job.

Best wishes for an amazing year full of pleasant surprises!

Krista Vizuete


91

Letter to a Third-Year:

Put yourself in this scenario: you’ve been on your surgery rotation for 4 weeks and you’re preparing for your first case of the day, Monday morning in the OR around 7:00AM. You’re helping strap on SCDs, putting in the Foley, and pulling your gloves for the scrub tech (obviously, this isn’t your first rodeo)…and then, the OR nurse screams at you for being within 5 ft of the sterile instrument table. And, as if sensing his cue to ‘teach’ another dumb third-year med student, an anesthesia faculty doc comes running over to show you how to tie the gown for the resident scrubbing in. All you want to do is scream at these people “I’m not stupid! I know my way around the OR! Just because my name tag says ‘med student’ doesn’t mean that I’m incompetent!” Or even if you have the self-control to hold all of it in, you’re still seething underneath your mask and your body language is giving away every thought you’re fighting to keep from coming out of your mouth.

Or how bout this scenario: you’re in the trauma pit, and you’ve been up for about 20 hours straight now. A trauma rolls in and, being the proactive, one-step-ahead third-year that you are, you grab blankets without being asked, get an arterial blood gas on the first stick, and run the CT scan request over to the scanner room. As you walk through the door, the CT scanner technician screams at you for leaving the door open, rips the request out of your hand, and throws it in the HIPAA box. All you want to do is either slap her in the face or burst into tears.

Here’s the point of my letter---you can’t react negatively in either of these situations. Both scenarios I encountered during my third year (if you couldn’t tell by the wonderful attention to detail). I’m sure that any person who has gone through third year has had similar experiences and will probably give you the same advice: BE NICE. I could tell you about books to buy that will help you pass the shelf exams, I could tell you about what to expect on certain rotations, but after polling several of the residents and faculty that I have worked with this year as to what is the one thing they could impart to up-and-coming third-year medical students, they all say the same thing, more or less: “Be nice to the nurses and technicians,” “treat everyone with respect,” “have a good poker face,” “don’t show it if you’re pissed off,” etc.

Even though it sounds so simple, the truth is that most students will fail at being nice. Your fatigue will get the better of you or your frustration at being treated poorly will explode. And all your hard work will be for nothing if you react because the nurses and technicians have a lot more pull with the attendings and staff than you think they do.

Just remember when those moments happen (and they most definitely will) to take a deep breath, bite your tongue, and make up your mind to move past the moment. Because if you can, and if you humor those who will treat you like a stupid medical student, they might be the same OR nurse that will give you a valentine for Valentine’s Day and sing your praises to the neurosurgery staff, or the same CT tech that will appreciate your help when another trauma rolls in while screaming at your fellow classmates J.

It’s the little things in life J

Sincerely,

Erin Wait

92


“You are one of the ducklings. You know . . . the three of you that always follow the long white coats.” I laughed and then nodded my head, “Yes, then I guess I am a duckling.” Mrs. Street was the wife of my first patient. She was an attentive, devoted, kind woman who was always at her husband’s side. Mr. Street was a 65-year-old veteran whose diabetes had ravaged his body despite being his endocrinologist’s poster child for compliance. His kidneys had failed long ago, he was blind, and both legs required above the knee amputations. He had been hospitalized because his peritoneal catheter had broken and he was in need of a new one. The day I met Mr. Street, the only catheter I had every heard of was a Foley.

In fact, my entire initial encounter with the couple was somewhat disastrous. I came into third year feeling pretty confident. I had near perfect performances on my OSCEs, felt at ease with the four patients I saw during my ACES preceptorship, and had been eagerly awaiting the start of third year. When I walked into his room on the 5th floor of the VA, my first two years of medical school failed me—miserably. I stumbled through the entire history of present illness, my review of systems made chaos seem organized, and my physical exam maybe lasted a whole minute. I finally said, “I’m really sorry but this is my first day. I still don’t really know how to do this.” Through it all they waited patiently, answering my questions repeatedly, showing no frustration or annoyance. I remember walking out of the hospital on my first day feeling so unbelievably dumb and incompetent.

Fortunately, it got better. With each day, I became more capable and confident. It quickly became clear to me that the attributes that will make you a good doctor are not taught in the classroom or even with your standardized patients. You will realize that scoring a 250 on Step I will not give you the hands of a neurosurgeon, that the vast majority of your patients will not be impressed that you were a member of AOA honor society, and a 4.0 from your first two years of medical school won’t keep you cool under pressure.

The important things, the things that matter to your patients, you probably already know: Be respectful. Don’t just act like you care; actually care. Get to know your patients and their families as people, not just as patients. Let them know—and show them—that even though you may not know everything, you’re learning. What matters is how you make people feel when you walk into the room and introduce yourself for the first time. When you’re working with a non-compliant patient who cannot afford her medication. When you’re holding the hand of a grown man dying of AIDS. When you’re cleaning blood off the face of a young Jane Doe in the emergency room who may not live through the night.

On my last day on the wards, I ran into Mrs. Street in the hallway. She greeted me with a big hug. Unfortunately, Mr. Street had been readmitted into the hospital because of a catheter-related infection. She encouraged me to stop by his room to say hello, that he’d really appreciate it. So I stopped by to talk to him. He told me about his niece who was interested in going into a healthcare profession, and asked about how my month had been. I told them about some of the things I’d seen, and that I’d learned a lot since my first day. As I got up to say goodbye, Mrs. Street stopped me: She said, “You’re going to be a great doctor because you really cared about us. You never looked up at the ceiling trying to find the air vent. I know that whatever happens, you’ll be great.”

Not every patient will be like the Streets, but learn from the ones that are. They will teach you more about the art of medicine than any attending or resident. Work as hard as you can for them. You will learn things from them that you’ll never forget, and often, your patients will be touched that they get to teach you. As you progress in your medical career, your coat will get longer. You’ll know so much more than you ever thought you would. But remember the part of you that was a duckling. Each patient and each rotation has something to teach you, so pay attention and learn.

Rorey Walsh


93

Dear Third-Year:

Third year is a bit like a hard run. The true, hard-core runners among us will not really follow my analogy, but for me, I find running most enjoyable after I have finished. Although somewhat painful at the time, there follows every good run some sort of chemical high composed of all sorts of good feelings of accomplishment, self-discipline, and motivation. Although parts of each rotation may seem painful at the time, I promise you will look back and say, “I am really glad I did that, I don’t know how else I could have learned so much.” Third year is a challenge in several ways: just when you are starting to feel comfortable, you will switch rotations and feel woefully awkward and unknowledgeable again. Also, being evaluated is a new concept for most of us, who have finished about 18 years of school where we alone are responsible for our grades. It is difficult to be continually aware that someone is watching you and determining what grade you deserve. The other factor which makes the year difficult is fatigue. Despite the challenges, however, third year is an amazing opportunity because of the unique role a third-year medical student plays.

Although you will undoubtedly feel busy and stressed, you will realize that unlike everyone else on the medical team, you carry many fewer patients, and have much more free time to get to know your patients. Third year offers a great opportunity to get to know your patients like the back of your hand. Some of the best memories that I have from third year were the times I went back to a patient’s room after my work was done to just see how they were doing. When your patient has questions about his diagnosis and treatment, you are the one with enough time to sit and answer all of his questions. I often learned the most by trying to teach patients, in normal terms, what we were trying to accomplish and what we had found. You may feel like you have forgotten a lot of your anatomy, etc., but when you sit with a patient and draw them a picture of a liver or a pancreas on a napkin from dinner, and explain exactly why they are feeling so sick, I think you will be surprised at how much you do know!

Now, just a few specific dos and don’ts: in the operating room you will discover that it is very difficult to understand what anyone is trying to say to you behind that surgical mask. If you don’t understand, don’t guess! I completely turned off all the lights in the middle of an operation because when the surgeon stopped and looked at me and said “turn up the spot lights” I heard: “turn off all the lights.” Learn to laugh when you make mistakes...I am just now starting to be able to laugh about that embarrassing moment. Second: open your mouth if you have something to offer! Your patients will often tell you things that nobody else knows because you have the time to sit and talk with them. Remember all that good stuff about CYP450 inhibition? It turns out that my patient on statins, with near-fatal rhadomyolysis told me (and only me) about his latest grapefruit diet. Even though you may not always feel like your role as a med student is clearly defined, you are in a great position to be of great help to your patients. Take your role seriously, and there is nothing better than knowing that you influenced the care your patients received for the better. Enjoy third year. You will never learn so much. Work hard and I promise that you will look back and be feel good about what you have accomplished.

Sincerely,

Michael Ward

94


“Third year is so much better than the first two years!” “Third year is so awesome!” “I LOVE third year!” All quotes that I heard coming into third year. All statements are very positive and uplifting, yet a little misleading. Third year, like many other things in life and particularly in medicine, are subjective and very simply luck of the draw. There are parts of third year that rock and you exude every one of those statements. However, just as quickly as you felt joyous, you can swing to the dark side.

Third year is awesome for a number of reasons:

1) I loved the times that I got to go, one on one, see my patient and do a full H&P, practice a head to toe assessment, and chat with them about their life (now that I knew every detail). Some of the most encouraging feedback that I received this year is from the patients that I worked with. I remember one time that my team rounded on my patient (me humbly in the back of the crowd, arms crossed, head down), and my patient interrupted my surgery attending and asked for me by name. “Well, where’s Cassie? What does she think about this plan?” I popped my head up just in time to squeak out that I agreed. I got teased a little after that, but it was so rewarding to know that she valued my opinion and trusted me enough to weigh in on what was happening with her medical care.

2) I have had the opportunity to get to know so many of my classmates that I never really knew before. You almost always work in teams, and you end up spending a lot of time with them. I have valued my experience getting to know my colleagues. It is good to know that so many honorable, solid people are going into medicine.

3) Third year is the buffet line of medicine, you get to sample everything. I can now say that I have observed surgeries, sutured wounds, delivered babies, and come up with differential diagnoses for complicated diseases. I think it is important to have been exposed to all of the fields both for making a career choice and for developing a respect for everyone’s place in medicine. Each specialty plays an important role and the interplay between them is what ultimately gets your patient well.

On the other hand, third year is tough for a number of reasons:

1) You are low man on the totem pole and you wonder if anyone would notice if you weren’t there. You feel insignificant at times and isolated from your friends. During the first two years you get used to spending time with your classmates and doing things on the weekends, but during third year you do not always have the time or the energy to spend time with your friends.

2) You are stressed out most of the time. Trying to impress your attending and residents plus studying for the shelf plus trying to figure out what you want to do with your life can be overwhelming.

3) Your time is not your own. You get there when your resident tells you and you leave when your resident tells you. Often times, you will finish your work by 1 or 2 and will not leave until 5, so you sit and wait for what seems like the rest of your life.

Somehow, every year, we all get through it. We grunt and bear it together. My recommendations on how to tackle third year include:

1) Enjoy your patients. You will not always have the luxury of chatting for hours. Sometimes this is what I would do when my resident hadn’t released me yet. I learned about bullet wounds to the heart and gangs and drugs and families and life stories and goals. Many times, remembering the clinical picture of a disease on the exam was simply a recollection of the face of my patient.

2) Enjoy your classmates. We all got to medical school for a reason and it is amazing to me how many people I missed out on knowing for the first two years of school.

3) Gain a healthy respect for all of the medical specialties. You may never do some of it ever again. Learn from it. One of my patients had a rare form of pancreatitis that all her doctors repeatedly overlooked. One night, a different doctor from her usual was on call when she came into the ER. He remembered her condition from a brief rotation he had done in medical school with a GI specialist that had taken a special interest in pancreatitis. His brief experience on a rotation in third year is what got her diagnosis and saved her much pain and suffering.

4) Humble yourself. You won’t always be the lowest on the totem pole. Remember how it feels.


95

5) Spend as much time with your friends as you can, even when you are tired. Go. You will miss out on too much and will feel drained, isolated, and burned out if you don’t go and spend time with your friends. They are going through the same thing as you, encourage one another. A doctor once told me that the closest friends he has ever had were the ones he made in medical school. He said it was because they all felt like they were in battle against med school and were forced to rally together. “It’s like we were all hiding out in fox holes, bullets whizzing by our heads, just trying to survive the war.” It really does feel that way sometimes, and it bonds you together.

6) Take things one step at a time. With time, presentations get easier. Always ask your resident or attending what they expect from you or what kind of presentation they would like. Bring articles about your patients if you can, but don’t stress about it if you don’t. You will, eventually, figure out what you want to do. Let the uncertainty fuel an open mind to every rotation.

7) Embrace the fact that you may be sitting on the floor in a call room for hours on end with no real job to do. Always bring a book to study for your shelf. Appreciate that you are getting study time done and do not have to do it when you get home. Stop looking out the windows and begrudging the resident… it won’t get you out any sooner.

At the end of the year, it is a remarkable difference how much you have learned and how comfortable you are walking into yet another 1st day. Lean on your friends and family: they want you to succeed as much as you do. Take things one day at a time, one shelf at a time, one rotation at time. You will survive, and after the dust settles, it’s time for 4th year where you are master of your schedule once again and have 10 weeks of vacation built in. Don’t stress, enjoy your time in the fox holes. Good luck!

Cassie White

96


Letter to a Third-Year.

My white coat no longer looks perpetually starched. It took about three years, but it finally looks like someone has worn it. It didn’t happen all at once, but eventually it happened.

In psychiatry, terrified of what my first third year rotation might bring, I proudly debuted my short white coat. Even with two years of occasional wear, there was not a wrinkle in sight as I walked in the room to meet my first patient. He was withdrawing from heroin, and he looked just like what Dr. Talley had described in second year—runny nose, tear-filled eyes, and sweating profusely—all of it getting on my white coat. And that was just the beginning. My attending in psychiatry was a big believer in squatting on the floor so that we could be at eye level with our patients while we interviewed them. Needless to say, psychiatry interviews can last a while, and soon my coat and I found ourselves leaning on just about anything to maintain our balance during rounds. Unfortunately, this was around the same time as the VA cricket infestation during which every surface was covered in crickets that had been stomped on by the psych patients. Gross, I know, but somehow after throwing my white coat in the wash at the end of my rotation, it returned to its original bright white color and the slight wrinkle in the back was hardly noticeable.

The last week of my ob-gyn rotation was my night float week. I never could get used to going to bed at 7 a.m. and getting ready for work at 5 p.m. I’m not a coffee person, but I drank more than my share that week. Between seeing patients in gyn triage, rushing to finish “the list” for the residents, and the jitteriness of being a novice coffee drinker, I must have spilled coffee on myself at least once a day (or rather night).

But getting the coffee stains off my white coat was nothing compared to my fear of surgery. It was the rotation that I had been dreading since day one. As I walked into the trauma ER for the very first time, somebody yelled “Med student, this is a code! Go get the platelets!” Not knowing what to do, I stashed my white coat in a bin filled with other white coats, and ran around yelling “where are the platelets?!” until a kindly nurse helped me out.

Wrinkled from being thrown in odd corners during my surgery rotation, my white coat resurfaced in my family medicine and pediatric rotations. No longer pristine and starched, I soon came to view it as a safe haven for germs that I collected throughout the day as patient after patient came in with a sore throat and cough.

Today, despite—or perhaps because of—all that my white coat and I have been through this year, I feel like I can wear it with a little more confidence as I finish up my third year with my internal medicine rotation.

This year has gone by faster than any year before it. I almost can’t remember everything that’s happened. Thankfully, I have a few wrinkles and stains on my coat to remind me of all of the crazy things that I have seen this year. In one year I have seen babies born, people die, illnesses that I didn’t even know existed, and I have met and spoken with people whose lives would have never collided with mine otherwise. Despite the stress and uncertainty of it all, looking back it really is amazing what a year can bring. It’s not to say that I’m not looking forward to eventually putting on a fashionably longer white coat, but rather that wearing this short one has actually been pretty neat.

Matan White


97

Dear Student:

The third year experience will be different for everyone, no doubt. Some will love it, others may not. But, there are a few things that you can do to ensure that nothing too terrible happens to you most days, and this will help you enjoy your time on the wards. If you approach third year the right way, you will have a great time.

1. Keep your initial expectations low. This sounds counterintuitive, but as long as you stay interested, work hard, and ask to be in-volved, you will end up being pleasantly surprised by the things you get to do.

2. Be early. There is nothing worse than hurrying in from the parking lot and being frazzled while you’re trying to present your patients because you barely had time to look up the daily labs. This is especially true on inpatient and at the beginning of the year.

3. Always have a pen and something to write on.

4. Keep snacks in your pockets. The white coat is full of pockets for a reason. Also one book, always. If you have too many, your neck will start to hurt from the weight of the coat.

5. Study for shelf exams because they will tend to make or break your grade. Do all extra credit assignments.

6. Pay attention to things that your attendings do that you do and don’t agree with. Try to incorporate these things into your interac-tions with patients for practice. One day you’ll have to have to come up with your own style and now is as good a time as any to get it going.

7. Take time to educate your patients - higher ups don’t have the time. It is astonishing how little people know about good, healthy habits. A good example is the idea of eating half of a meal when you eat out – many patients have never considered this but are trying to lose weight. Or, they say they eat a low salt diet, which to them means they do not add more salt when they eat at Luby’s. One conversation can help a lot, and they will thank you repeatedly and then tell you what a great doctor you’re going to be.

8. Don’t complain. Everyone is working hard.

9. Have good daily habits. That way when you are feeling hopeless because you have no control over your life, you can go do some-thing really fun and not feel bad about it.

10. Be yourself. As long as you are sincere, most people will like you.

Sincerely,

Margaret WhitneyClass of 2012

98


How to Survive Third Year:

--DON’T BE SURPRISED IF YOU HATE YOUR FIRST ROTATION…IT GETS BETTER, I PROMISE.I went into third year with very high expectations. I kept hearing from everyone how it is so much better than first and second year and how fun and exciting it was going to be. Needless to say, I was a little surprised when I got into my first few weeks on my pediatrics rotation and was miserable. I was nervous all the time, I didn’t know where to go or what to do, I constantly felt like I was in the way, and honestly just didn’t know what was expected of me as a third-year medical student. Every criticism I took personally. To put it bluntly, I felt flat out incompetent and worthless…and for your typical “type A,” slightly high strung, always-eager-to-please medical student that is about the worst feeling you can have. To tell you the truth, it was like that for my entire peds rotation. It wasn’t until Family, my second rotation that I finally started to get an idea of what was expected of me and what I could do to do a good job of this whole third year thing. I learned to let things roll off my back a little easier, and once that happened, third year got better and better, and I actually began to enjoy it. It’s a steep learning curve, but once you get the hang of it, life improves. So if you find yourself hating life in the beginning, you are by no means the only one, and it doesn’t last forever, which brings me to my next point:

--THE FIRST DAY OF EVERY ROTATION SUCKS…JUST EXPECT IT.The first day of every rotation is like your first rotation of third year. You are usually at a new hospital, with new staff that does things differently, and that feeling of incompetence comes rushing back. The good news is, it usually only lasts about a day or two. Just know the first day is going to suck and be mentally prepared. Of course, once you figure things out and start to get comfortable, it is time to change to a different rotation and the process starts all over again.

--DON’T BE SHOCKED IF SOME OF THE NURSES ACT LIKE THEY HATE YOUR GUTS. THEY PROBABLY DO.Occasionally (or more often), you will come across a nurse that seems like she just can’t stand you. She acts generally annoyed when you are in her presence, yells at you for unknowingly using “her” computer, lectures you on your first day for twenty minutes in front of everyone about how this is a busy practice and your mere presence in the OR slows things down, gives you the stink eye from across the room, or completely ignores your presence altogether (yes, all of which happened). Just remember, these people have been doing their jobs for years and years and have their own system of doing things to make their worlds run smoothly. When we come in, we totally throw a wrench into that system. They have to take time out of their busy day to show us where things are and how to do things. It’s like training a new employee every three weeks or so. So don’t take it personally. And remember, we are on their turf, so act respectfully. With that said, some nurses are incredibly nice and helpful and are invaluable to our education. Hence topic number four:

--MAKE FRIENDS WITH THE NURSES, SURGICAL TECHS, ETC…THEY WILL TEACH YOU TRICKS OF THE TRADE THAT WILL MAKE YOUR LIFE IMMENSELY EASIER.No one knows the logistics of how things get done on the floor better than the staff that works there every day. If you are friendly with them and even help them out with their work, they will reward you by letting you place a foley or getting you new gloves when you inevitably contaminate yourself in the OR. That goes for everyone you work with, including anesthesiologists and nurse anesthetists. Go into surgeries as soon as they bring the patient in and ask questions. More than likely someone will recognize your interest and let you do a spinal or intubation. Plus, they are not evaluating you, so you don’t look like an idiot by asking a stupid question. Just remember, you can learn from everyone…not just doctors.

--IF YOU WANT GOOD EVALS, BE A GOOD EMPLOYEE.You will hear over and over to “be a good team player,” and it’s because that is what gets you good evals. Those of you who have worked in the “real world” before going into med school will be a step ahead of the game on this one. You know that if you want to get a raise in a job, you do whatever it takes to help out your boss and make things run smoother for her. We are not fancy-schmancy doctors yet, so don’t let your self-importance become inflated. Third year is less about being a doctor and more about being a hard worker and pleasant person. Do what it takes to help those around you, whether it is writing an extra note for your intern, helping a nurse clean up urine, getting a patient’s family member a chair, or letting a classmate see a procedure or delivery that you’ve already had experience with. Also, never sit on the job. Don’t let your resident catch you on Facebook or texting on your phone 24/7. Nothing annoys an employer/resident more than a student being lazy while they are working their butts off. If you have free time and there is nothing you can do to help out the team, read. Finally, whatever you do, do it with a smile. Follow that advice, and half your grade will be an A. To get an A on the other half, proceed to next bullet:


99

--IF YOU WANT TO GET GOOD GRADES ON YOUR SHELF EXAMS, DON’T BE A PROCRASTINATOR LIKE ME…START READING FROM DAY ONE.Even if it’s just five pages, read on your first day. On many rotations, especially medicine, surgery and OB/GYN, you will be so tired when you get home, you won’t want to study. As the rotation goes on, this doesn’t get better, so it is important to read a little bit each day so that when it gets close to test time, you don’t have to cram. In fact, cramming is really not possible anymore, because there is simply no time. Generally, if you read one or two books per rotation and do as many practice questions as you can, you will perform well on the shelf exams. The only way to do that is to start from the beginning of the rotation. So please, learn from my mistake and read early!

--MOST RESIDENTS AND ATTENDINGS ARE SUPER NICE AND REALIZE YOU HAVE NO CLUE WHAT YOU ARE DOING.Most attendings and residents aren’t expecting you to know everything. That’s what we are there for, to learn everything. What they do expect, however, is for you to have enthusiasm and show interest. If you don’t know an answer to a question, just say you don’t know and look it up later. Most of the time, they will not chastise you for not knowing the answer. --WHEN YOUR RESIDENT TELLS YOU TO GO HOME…GO HOME.I had heard a rumor that residents would try to trick you and tell you to go home, and give you a bad eval if you did. From my experience, this is just not true. The residents are not out to get you. Honestly, they could probably care less. They were students not long ago and remember how important study time is. As long as all the work for the team is done and there is nothing left for you to do, it’s safe to leave when they tell you.

--TAKE TIME TO TALK TO YOUR PATIENTS. YOU MAY NEVER HAVE AS MUCH TIME WITH THEM AGAIN, AND YOU WILL LEARN A LOT FROM THEM.As a physician, you will have fifteen, twenty, thirty patients at a time, but as a student, you have usually only two to four. Take advantage of that. I would guess that most physicians spend about five to ten minutes talking with each of their patients. Third year, you could spend all day talking to yours! Remember why you came to medical school: to help people. We may not be able to prescribe medications yet, but you would be surprised at how much just talking to the patients helps them. It allows them to feel heard and well cared for. This is a good place to start learning to build those relationships. In addition, often you will catch things that others have missed that could be integral to the patient’s care. Not only will that obviously help the patient, but also it will look really good to your resident and attending too. So don’t be in a rush. Get to know all of your patients.

--WATCH AND LISTEN WHEN YOUR ATTENDINGS AND RESIDENTS INTERACT WITH PATIENTS. IT WILL GIVE YOU INSIGHT INTO HOW YOU, AS A FUTURE PHYSICIAN, DO AND DO NOT WANT TO INTERACT WITH YOUR PATIENTS.Throughout third year, you will work with many physicians, each with very different styles of caring for people. Some, obviously, have very opposing views of the way things should be done, but you can learn something from each and every one of them. When I think about all the attendings I have worked with, there is one in particular who really stood out to me: Dr. T. She had such a great, warm personality, and seemed to really care about the well-being of her patients. She took time to talk to each of them, often sitting down on their bed, even during busy rounds. She touched each patient, not only to perform a thorough physical exam, but also to hold his/her hand during a procedure. This may not seem like much, but to me, and I’m sure even more to the patient, it had enormous significance. It is important to remember that as physicians, we are not treating diseases, we are treating people.As an example, there was one patient, Mr. G, who was on our service for weeks. He came in with alcohol withdrawal, delirious and agitated. He was a lovely patient. He spit on the nurses, threw punches, urinated in his bed, and cursed at anyone who came near him. To make matters worse, he was hard of hearing and the only way he could hear you was if you put your face right next to his ear and yelled. This is the kind of guy who if you saw walking down the street, you would walk on the other side to avoid getting too close, much less getting close enough to see his ear wax. And despite this, Dr. T never lost her cool. In fact, she seemed to show him even more care and compassion. After he was moved to a solitary room for keeping other patients awake all night screaming curse words, we visited him one morning. He had been uncommunicative since his admission, but this day, he was trying to talk. Without hesitation, Dr. T leaned up onto his bed and put her head right next to his face to speak with him. I noticed how she held his hand and patted him occasionally, which I knew was comforting to him. Again, it may not seem like a big deal to many, but it just struck me as incredibly kind and altruistic to treat someone who seemed so difficult with such tenderness. You will come across many people like Dr. T who will impact you in your third year.

That’s my advice on how to survive and succeed in third year. I wish you all the best of luck and have fun!

Lindsey Williams MS3

100


Congratulations, future Doc!

You have made it through all of the long, grueling lectures of medical school, studied your tush off, and have essentially become a seasoned test-taker, full to the brim with medical knowledge. Gone are the days of sitting in a classroom for 8 hours. Soon you will be taking care of patients, draining abscesses, stapling wounds, waking patients up early in the morning and staying with them on late night calls. You will be the first face that they see on most days and most likely you will be the only one with time to come back after the hurricane of morning rounds and talk with them, understand their concerns and teach them more about their diagnosis and treatment. You will essentially convert all of those study hours spent staring at a book into hours spent with your patients. This is time well spent, because your patients will teach you more than you could possibly ever learn from a book. Tests and books aren’t eliminated from 3rd year, but books will be smaller and meant to be read as you go. Every rotation will be an adjustment. The first week is always the hardest- you WILL find your stride. Write down all of the bathroom/locker/door codes and keep them in your phone/pocket. A good attitude and a pocketful of snacks will serve you well. No one likes a grumpy student, or one that has passed out on the floor during a ______________________ (enter stomach-churning procedure here).

The Specifics: Work up every patient like you are the intern. It will happen soon enough, and you’ll have a little more practice if you have worked out those brain muscles. When you present a patient to an attending, don’t forget the easy part of the assessment/plan. Most hospitalized patients need some sort of DVT prophylaxis (Lovenox or SCDs) For the ICU, the best advice is to get to know the nurses- they are used to caring for complicated patients and they know all of the little details. Look at all chest tubes (outputs, whether there are bubbles (air leak), if it is attached to the wall suction) For the OR: The scrub tech is always right. If they say you have contaminated yourself, you probably have. Be the first to scrub in before the surgery, get there early to pull your gloves and offer to pull extra gowns. Stay with the patient after the surgery and help wheel them to the PACU. ASK to do procedures on your patients. If you are excited and motivated to do the little things (put in foleys, change wound dressings) then the residents will think of you the next time they need a hand doing something more interesting. Be a good teammate, if you’ve put in 1 billion arterial lines, ask the other students if they have ever tried one and let them try their hand at it. Always wear eye protection when draining abscesses/delivering babies/washing out wounds. You may be knee-deep in learning but you don’t want to be knee deep in bodily fluids. Residents love baked goods. If you have any talent in the kitchen at all, bake something to show you appreciate them for putting up with you. If you are on surgery or medicine during period 6 you will struggle to apply to VSAS on time. If you think you may want to do an away rotation, start working on your CV & personal statement EARLY to lower your anxiety level! Spend every moment you can with your loved ones and pets. Try not to bring the hospital home with you- in your conversation (or on your clothes).

Best of luck,

Lauren Wood


101

Dear Incoming MS3s,

Congrats on making it past your first two years of medical school and Step 1! You are halfway through medical school and another step closer to achieving your goal of being a doctor.

Most everyone is probably telling you what to do as an MS3: take this rotation, use this book, cozy up to the second-year residents and not the interns because they don’t grade you…instead of me telling you what you should do, I think it is better to tell you what NOT to do. STOP LISTENING to what everyone is saying! No one is going to magically make any decisions for you. In the end YOU are the one in charge of what you do. You need to realize that EVERYONE has their own advice to give. However, just because it worked for them does not mean it is going to work for you. Stick with what you know and do best and don’t freak out if other people around you are doing something different.

Please don’t be a suck-up. It is obnoxious to everyone around you. In fact, you might even be annoying yourself if you listen to yourself speak. If you are not interested in pediatrics, do not pretend to be. People can see right through you and you will be exhausted trying to play charades for 6 weeks.

Don’t kid yourself – if you thought you wanted to do surgery and then you did it and hated it, it’s OK to admit that you didn’t like it! Don’t just go into something because you like the idea of it. You will hate yourself later if you do. When you make your decision of what you want to do for your career, you have to think long-term in medicine: when I am old and tired, will I still love what I am doing? Don’t be afraid to vent to your friends, but please, do it in private. Not everyone wants to read about how crappy every 5 minutes of your day was on Facebook. We all have crappy days, but the whole world doesn’t need to know. Vent to your friends on the phone, via text, or via email: if they really are your friends, they won’t mind listening to how your day sucked. They will probably even vent back!

Don’t complain about the long hours. Everyone goes through them. In fact, as an MS3, you work the fewest number of hours compared to everyone around you. Just be happy that you have the opportunity to learn something new. Finally, don’t be afraid to be “pimped” by your attending or your residents. You probably will hate it now, but you’ll appreciate it later when you hear the attending’s voice in your head telling you the right answer on the test.

Enjoy your third year – and, PLEASE, don’t be annoying J

Ming Yang

102


Dear MS3,

Congrats on surviving the first 2 years! As exciting as it was to sit in class/Briscoe all day, 3rd year is when the real fun begins! Here’s a “preview of coming attractions:”

• The majority of your experience 3rd year will be team-dependent. You’ll be amazed at how one person can make or break your rotation, but don’t let it deter you from that specialty.

• Don’t throw your teammate under the bus. If you’re not the one being pimped, keep your mouth shut until the question gets thrown your way.

• Enjoy getting to know your patients well. You’re the only one on the team who has the time and luxury to chit-chat.• The shelf exams you take 3rd year are easier, especially when you can recall a patient you took care of. That being said, read

up on your patients!• Everyone warns you about the nurses, but really, it’s the scrub techs you have to watch out for. Be nice, smile, say thank you,

and move on.• Accept your position at the bottom of the hierarchy. It sucks, but it’s only temporary.• You find out 3rd year which friendships you value most. Even though your clique from the first 2 years may be scattered in

different cities or on different rotations, make time to reunite! Who else are you going to exchange awkward stories with?• At the same time, rotations provide a great opportunity to meet classmates who didn’t sit on your side of the lecture hall or just

never came to class.• Even if you get positive verbal feedback from an attending, don’t expect all 5’s. Remember that you still have some control over

_ of your grade, so study hard for the shelf!• Do as many physical exams as possible. That’s the only way you’ll ever be able to “appreciate” normal vs. abnormal.• Keep a sense of humor—it’ll get you through those long days.

Best of luck,

Leah Yieh


103

“Confidence breeds success. Success breeds confidence. Confidence applied properly will surpass a genius. There’s nothing like confidence. The whole name of the game is never getting scared.”

- Mike Tyson, motivational speaker, circa 2010

Take initiative and be ready to jump in feet first. It reflects a desire to learn as well as a mentality that’s unconcerned with looking stupid or making a mistake. This is especially true on trauma call where you won’t do any procedures if you’re not in the right place at the right time.

On the other hand, be humble and don’t act like your BMs don’t stink. If you were wrong about something, then acknowledge it and learn from it. Make peace with the fact that, sometimes, you’re going to be treated like you’re at the bottom of the totem pole. So just suck it up and build some character.

Be ready to adapt to a whole new routine for every rotation. Cater to the different preferences, nuances, and whims of each new attending or resident. If you’re not sure what they are, then ask and find out within the first day or week.

Talk to your patients and address their questions without relying on medical jargon. Recover those interpersonal communication skills that you may have neglected for the past few months while studying for STEP 1 in physical and social isolation.

Take time for yourself whenever you can. Definitely have that rash inspected at your next physical. The dentist probably needs to clean your teeth because you’re consuming caffeine by the liter. Hit the gym, do your laundry, and get your tan on if you happen to be in Corpus or Harlingen.

Zibin ZhaoMS-3

104


Dear future 3rd-Year All-Stars,

After a long day in the ER, I had one patient left to see. Bob had flu-like symptoms for 5 days. There were dark lesions on his arms and legs, which he said were old mosquito bites. They looked like legitimate bug bites to me, so I didn’t think twice about them.

I told my attending that Bob probably had the flu. “Did you look in the guy’s mouth?” #@$#, I thought to myself. “No.”

Bob had thick white deposits all over his tongue and oral mucosa. HIV popped into my head, and Bob was in fact quite promiscuous.

My attending then asked, “What do you think about the lesions on his arms and legs now?” “Kaposi’s sarcoma,” I said.

The big lesson to take home is to BE SYSTEMATIC and THOROUGH. Third year is challenging. You will be tired (I fell asleep a few times while standing in the OR, but that is another story), but treat your patients like they are your own family members.

As students, we can’t do much for people like Bob. What we can do is perform a thorough H&P, spend time with him, and help him feel as comfortable as possible.

Another take-home message, take your patients seriously but also with a grain of salt. Bob probably believed his lesions were from bug bites, but we have to think of other possibilities.

I hope you have a happy 3rd year, friends.

Nabid Ahmed


105

A word on advice

Medical Students LOVE to give advice. In fact, the relationship is direct and exponential; the more years you spend in med school, the more advice you have stored up and the more you enjoy doling it out freely and at length. If you’ve ever been to a peer group event, interest group meeting, or panel discussion, you know what I’m talking about: someone asks a simple question with more than one possible answer and suddenly the whole room is subject to 3 differing opinions stated 7 different ways each and no definitive answer to take home. In fact, if I had to rank this on a list of “favorite pasttimes of non-first-year medical students,” ‘giving advice to underclass-men’ would rank only after ‘talking about the latest class email listserv drama,’ ‘griping about mandatory attendance days,’ and, of course ‘discussing test questions.’

That being said, I am guilty of giving advice at times myself, and, even worse, of giving unsolicited advice, but do you really blame me? My guess is that you’ve already spent the past year handing out your very own pearls of wisdom to whoever is eager enough and nervous enough to hang on your every syllable.

Of course, it’s completely understandable; we’re all well-meaning advisors, and with experience comes knowledge, so why wouldn’t we want to spare our fellow students the anxiety we went through dealing with this great unknown? Unfortunately, we’ve all also been on the other end. But, like I mentioned, medical students do love giving advice.

Now that we’ve established that truth, I can already guarantee that you guys have gotten more than a digestible amount of advice about what lies ahead of you by this point in the game. So, that’s exactly what I’m NOT going to do. If it’s advice you’re longing for, I can assure you that between the covers of this book, you will find plenty more.

So, instead of giving you yet more advice to synthesize, I want to share with you some (mostly simple) lessons that I learned through-out the past year.

On day two of my first rotation in July, I learned that if you inhale – or for that matter breathe at all- while checking a patient’s volume status during your 6 a.m. pre-rounds, you will discover not only if in fact your patient’s “oral mucosa is pink and most” but also get a really good idea of what their morning breath might taste like.

The next month, the theme was “Pimping is caring.” I didn’t believe it when my attending said it for the first, second, and third time, but wait until you get a team where no one cares enough to check in to make sure you’re learning from even the most seemingly simple cases or cuts off that carefully thought-out assessment and plan on morning rounds. Then, tell someone.

In September, I noticed that in the oupatient setting, not unlike the DMV line or Starbuck’s counter, people universally expect to be greeted cheerfully, as if they are the only person you’ve seen all day, to validate their (always long) wait, and for you to give them the best effort you’ve done all day. Efficiency, organization, and prioritizing are key and a big smile will go a long way.

In October, I learned the wonders of distraction as well as the importance of practicing an exam order. For example, in kids, ears are always last, unless of course, you particularly enjoy irritated parents or straining to hear heart sounds between sobs.

November was the month I finally mastered the fine art of maintaining a smile in the face of odor and flying flakes of skin. Let’s just say there were a fair share of diabetic feet, ingrown toenails, and unfortunately located abscesses in the family medicine clinic, and leave it at that.

Then, in December, I realized that without my knowing it, somewhere along the way, I had gotten the hang of what this doctor stuff was about. This was apparent when over the holidays, I had (privately) diagnosed not only many of my family members with their milieu of symptoms and complaints, but also the passengers beside me on the flight home, and, more importantly, knew what kind of consults I would call if I were lucky enough to be their primary doctor.

My first lesson of the New Year was simple; surgeons live for one thing- cutting. They like to cut open patients, cut out the detailed pathophysiology-based differential diagnosis in the note, cut up in the hallway about the case you just saw/operated on, cut you off midsentence… it’s ok to feel offended, just don’t let them notice.

106


With regards to February, I (perhaps appropriately) discovered an important lesson about passion. I learned that there are only two types of physicians: those who will try to convince you to go into their specialty and those who will do everything in their power to try to talk you out of it. No matter what they say to you about any specialty, including their own, they still believe that theirs is the best, most interesting, most important, most relevant, and, probably, most difficult to truly master.

Then, the next month, I gained a new realization regarding my opinion about accepting advice, depending on its source, of course. When your vascular surgery attending recommends compression stockings, your general surgery chief tells you which staff to work with and which to avoid, and your facial plastics attending says your new glasses are “cute, but don’t fit your face,” you should prob-ably take note. This rare advice is coming from people who really know what they are talking about and no one else will probably ever bother to share these gems with you.

Early April taught me that if inpatient psychiatry makes you uncomfortable at first, it’s most likely not your patient’s fault. Dig a little deeper into why you feel that way. On second thought, now’s probably not the best time to uncover something like that. Practice patience and cling to those coping mechanisms!

May and June are months for organizing, planning, and keeping up the good work ethic, especially since they do not encompass the specialty I have fallen in love with this year. That being said, don’t forget how much they still matter.

So, now, as the year winds down and I reflect on the most important things I’ve learned over the past year, one thing remains constant. In third year, as in life, there are a very few [albeit essential] things that will get you a very long way. Every day, be sure to bring with you the following things: an open mind, willingness to participate, solid work ethic, effective communication skills, and a portable snack. You will surely figure out the rest for yourself as you go through the year, along, of course, with the help of some good advice from a few trusty sources.

Christine Burke


107

Dear Third Third-Years,

What are the patient’s ins/outs? How much did the patient weigh yesterday compared to today? What is the chem 7 today? These are all questions that can potentially be asked of you during a rotation. Each attending analyzes a patient in their his own way and it sometimes can be challenging to predict what the attending wants you to see that day; , but don’t let this frustrate you. It’s just an exercise to train you to think of the big picture and to keep looking at the patient in a complete manner, not just the individual ailments at hand. Always keep in mind that the hospital is a nidus for disease; on many occasions a patient comes in with one problem only (only to have?) for another, more emergent problem to develop.

During third year, always be cognizant of your patient as a whole and don’t become too focused on individual problems. It can become overwhelming at times when a patient presents with multiple problems, and, as young future physicians, it is in our nature to want to fix all their problems at once. However, this can’t always be achieved and one must learn to prioritize ailments in terms of most severe and work your way down the list.

Third year is a great change from the first two years of medical school. All the time you spent reading books and syllabi during the last two years, finally, manifest in real life; everything you’ve encrypted in your brain will finally be tangible. Spending the full year at the Harlingen campus has allowed me the opportunity to do a great deal of hands hands-on work that I wouldn’t have had in San Antonio.

During your third year, you will be thrust into the lime light with opportunities to perform procedures of all sorts. Always enthusiastically accept the opportunity to do any task, even if you don’t know what to do; , but, clarify to the attending or resident that this is your first time and that you need guidance from them. I have found this to be the best way to gain experience.

When you wear a white coat, the majority of people automatically assume that you are a doctor and know what you’re doing, even though, many times this is hardly the case; always portray confidence when dealing with patients. You have learned a lot over the past two years and that is your foundation. Build upon that foundation,, and trust yourself and your instincts. It will make the patient feel at ease and help with further interactions with the patient. At the same time, don’t be afraid to tell the patient that you don’t know but you’ll consult with someone that does.

At times you will feel like your role as a medical student is only slowing others down or that you aren’t having a great impact in terms of helping your patient get better. Always remember it is the small things that you do during the day that can help bring a smile to a patient or even help save their his life. Stopping by to say hello and asking if they he needs anything will go a long way in helping the patient feel that they he is are being cared for and help them him feel more comfortable in the hospital.

Best of Luck,

Tariq Dayah

108


Keep It Simple StudentsDay 1:“His palms are sweaty, knees weak, arms are heavy. There’s vomit on his sweater already, mom’s spaghetti. He’s nervous, but on the surface he looks calm and ready…” - Eminem

Day 2-5: Same as day 1, but with more enthusiasm.

Day 6: Wondering if your attending forgot it was the weekend.

Day 12: You have been re-acquainted with caffeinated beverages and it’s not even test week.

Day 100: You finally figured out what the “H” and the “P” really meant in “H&P” and you feel you have performed your first correct one. Last rotation: At this point you should be speaking in tongues, and as you talk to your attending the patients will think you are summoning all the angels from heaven to heal their disease.

In all honesty, 3rd year is a challenge that may seem overwhelming at first, but by the end of it you will feel like you can actually make it as a doctor. The way I see it, every month of third year shaves at least 10% off of your morbidity and mortality in the future. The only catch is that, as a medical student, you start off at 200%. Meaning that if you were actually allowed to reign free in the hospital, you would not only kill your patient but might possibly kill a completely healthy family member who just came to visit. That is exactly why you have mentors guide you through the process. Use them! Use third year as a way of refining your clinical skills. Don’t feel bad if you have to ask your attending or resident to explain certain clinical findings. Trust me, you weren’t the only one pretending you heard crackles during wards second year.

Finally, make sure you get to know the staff (Nurses, MAs, Techs, janitors, etc.). They can help you out and may even warn you when the doctor is in a grumpy mood. Overall, make sure you take care of your patients, learn from them as well as from your peers and teachers. And remember to play as hard as you study!

By: Carlos Gaona


109

“Tell me more about your vision problems,” I asked Mrs. R. “Well, you see, I’ve got this thing they call immaculate degeneration” she candidly responded in a Southern drawl. I fashioned a hearty smile and Mrs. R., my first hospice patient of my young career, sent me a warm smile in reply. Though unaware of her slight mistake in medical jargon, her unintended pun would forever frame my outlook towards patient care.

The third year of medical school is truly transformational. But, in order to grasp and appreciate such a transformation, you ought to approach this upcoming year with a varied perspective. By this, I mean that during each clinical scenario, each E.R. admission, or each morning’s bedside rounds, third year is about observing and absorbing the world around you. And the best way to accomplish this is to try and gain the perspective of those around you. To view health care through varied lenses is to appreciate the nuances of the clinical world. This is my best advice, and my challenge to you for the upcoming year.

Through the lens of the Attending Throughout this upcoming year, you will have the opportunity to work with a myriad of physicians with various personalities and teaching styles. In addition to keeping an open mind, I encourage you to adapt to these various teachers who will be so formative in your career as budding physicians. On pediatrics, for example, I had the pleasure of working with an attending physician who loved to teach ‘life lessons’ just as much as, if not more than, pediatrics. Over the course of the year, he and I became very good friends outside of the clinic. Of course, you’ll run across some attending physicians who you might clash with, as well. I’ll never forget one of my attendings on general surgery service who greeted me every morning with: “You’ve got a 32-year-old female, lower left quadrant abdominal pain, GO.” There was never time for jovial chatter, and only enough time for endless pimping. Regardless of the type of doctor you are working with, try and visualize their daily routine and take a glimpse of the clinical world through their eyes. You’ll gain a deeper understanding of what it’s like to be a physician, and you’ll do a better job of connecting with him or her.

Through the lens of the Nurses One of the biggest lessons you will learn early in third year is that doctors can’t do patient care on their own. Or, at least, they can’t do it successfully on their own. Regardless of the rotation that you are on, you’ll get a quick introduction to the importance of teamwork in the clinical setting. In my opinion, the most important members of the team are the nurses. These are the true workhorses of patient care; they have the most contact hours and are always down “in the trenches” day in and day out. Some of my fondest memories of inpatient Internal Medicine service include the nurses on the various floors of the hospital. These nurses, in a short amount of time, truly become your best ally in patient care. Whether you need a quick set of vitals, or you need to write down pertinent events from overnight, the nurses are there for you and have your back. It is important during third year to take a step back and put yourself in the nurse’s shoes. Spend an off afternoon with some nurses and you’ll see that these are the people who truly care for the patients. You’ll also notice some frustrations, some hilarious moments, and some gut-wrenching emotion when you see the clinical world through the nurse’s eyes. These are lessons that cannot ever be taught, only experienced.

Through the lens of the Patient’s Family Caring for patients as a third year medical student may sometimes seem trivial. Many times, you are near the bottom of the totem pole when it comes to the authority to diagnose or prescribe care. But don’t let this lack of power fool you; you actually have an array of talents and skills in your armament to bring you to the forefront of patient care. Sometimes sitting and chatting with family members and explaining their loved one’s condition is a powerful way for you to build your foundation as a young doctor. I distinctly remember the saddest case of my third year. A young 32-year-old female, who had recently had a C-section to deliver a premature baby, was being managed by our team for an Ulcerative Colitis flare-up. In a matter of days, her condition worsened dramatically, as her colon had perforated and she developed septic shock and D.I.C. The patient’s family, including her four other young children, were in a state of emotional overload. I tried my best to put myself in their position, to view the scenario through their eyes. In doing so, my own emotions were brought to the forefront. I joined our palliative care consult service as we thoroughly explained her condition to the family. Never had I experienced so much raw emotion, never had I seen so many tears. But it is in moments like these during third year that we, as young doctors, develop the strength and courage to handle such tough situations. By simply viewing a scenario from the perspective of the family, we allow ourselves a bit of vulnerability and a gentle reminder of what health care is like from across the bedside.

Through the lens of the Patient Perhaps one of the most important perspectives to acquire during third year is that of the patient. To reverse roles and approach health care through the lens of the patient is, arguably, the most difficult perspective to attain. Yet, it is easily the most

110


important. One of the most memorable experiences of my third year started at a general internal medicine outpatient clinic. My patient was complaining of lower back pain, near the area where he had a nephrectomy due to renal cell carcinoma. He also complained of some chest pain and dyspnea, as well. After a thorough work-up, we came to the conclusion that he likely had metastatic disease and referred him to an oncologist. Later the next week, I was able to see him at the oncologist’s clinic, as I was working with him on an ambulatory rotation. His pain was much more severe and his wife was in tears. He did, in fact, have metastatic disease to the bone and lungs. It was incurable. Although I could not literally feel this patient’s pain, my various encounters with him allowed me to get a glimpse of the difficult situation he was in. Viewing the situation from his perspective was a valuable lesson for me as a young doctor-to-be. It is crucial that, during your third year, you gain a certain appreciation for and understanding of the perspective of the patient. Only in doing so will you be able to craft and hone your skill as a future physician.

As you embark on third year and you begin to view health care from these various perspectives, it is important to keep in mind one final viewpoint: your own. It is all too easy to lose sight of your own vision, your own ideals and your own passions during third year. Long nights on call and endless hours in the operating room will do their best to jade you and strip you of your idealism. But stand strong and keep hold of your own perspective. If need be, dig out your personal statement from your medical school application to remind you of what brought you here today. Most importantly, use this upcoming year as an affirmation of your inherent passion for patient care. Just as I was blessed with Mrs. R. and her immaculate degeneration, you, too, will have similar patient encounters this year that will be formative and game-changing as you work towards becoming an excellent physician. Good luck to all of you and have a great year!

Martin Hechanova


111

Welcome to third year! The coming months are guaranteed to be incredibly busy and you’ll be wishing for more time to accomplish necessary tasks. You’ll find yourself squeezing the clock for more time to read about a case for the following day, to review material for the shelf, or to simply to sneak in a favorite TV show. Two simple ways to increase your productivity are to either pause time or stay awake. The former is pretty difficult, essentially impossible, but the latter can be manipulated. Initially, when the med student meter is on full charge, things are going well and fatigue isn’t a factor. But once the rotation is in full swing, things are slowly sacrificed to add more minutes to the day. One goes from a nicely cleaned and pressed white coat to a quick flick of the wrists to let out some wrinkles from the off-white, white coat, and from clean shaven to a permanent five o’clock shadow. Thus, two allies in your quest for alertness are caffeine and couches.

Caffeine, for being a psychoactive stimulant, is legal, widely available and easy to acquire. Coffee seems to be everywhere in the hospital. Hotspots for free coffee usually include the nurse’s lounges so make sure to be friendly and courteous to them. Unfortunately, the quality usually isn’t the greatest. Of course, there are plenty of places to buy coffee but free is a pretty good price.

Not a coffee drinker? No problem, there are plenty of other ways to jump start your neurons. There’re the ubiquitous energy drinks, from the well-known Red Bull and Monster to the less popular concoctions like Venom and Nos. If you need a larger jolt, head over to the local nutrition store where they pretty much sell arrhythmias in a can. There are also caffeinated flavored drink mixes to enhance your favorite bottled water. These fit conveniently in your white coat pockets next to other ward essentials. The most amusing product I’ve seen people use is caffeinated gum. Two pieces are apparently equivalent to a cup of coffee.

More importantly to the amount of energy ingested is the timing of use. My experience has been that in the mornings there is always a burst of adrenaline to get you going because of the constant fear of being late because, of course, you snoozed twice or thrice. Thus, if you save your caffeine intake for after lunch or early afternoon when you start to drag, the effect might be greater. Though, if you really need it, you can always drink something morning and afternoon. Just don’t overdo it on a day you need to have steady hands.

Power naps are another weapon in your arsenal for increased productivity, since you likely won’t be getting the recommended 8 hours of sleep. Seek out a comfortable couch, whether in the library or in a lounge somewhere, and relax. Hopefully you aren’t self-conscious about sleeping in public areas. Listed below are some highly recommended maneuvers for a quick snooze. Take off your white coat, kick your shoes off if you can and try these out. And, very importantly, if you plan to nap for more than a couple of minutes, be sure to set an alarm.

The slacker-this position involves using a single sofa chair. Sit in the sofa chair as you normally would then slide down until the back of your head rests on the top of the backrest. The downside is that this position leaves you susceptible to snoring because of the neck hyperextension and the possibility of your mouth coming open if you slide into a deep sleep. Other variations to this maneuver include the mirrored slacker, which involves using another chair facing you in which to prop your feet. The corner pocket-this move requires a loveseat type of furniture. Essentially, you place your back to the angle formed by the armrest and the backrest. Provides similar risks and benefits as the slacker, but less restrictive.

The couch surfer-this is the most natural position because you are lying completely flat, almost mimicking sleeping in your own comfortable bed. It is perhaps the most efficient and most refreshing minute for minute. The only logistical problem is finding a full-sized sofa in which to nap. You could always just lie on the floor, but I wouldn’t recommend that option in a health care setting.

Honestly, ladies and gentlemen, third year clerkships are not that bad. Sure, they’ll be times of fatigue and stress but you’ll also be learning incredible things along the way. At the end of the year you’ll reflect and be amazed how quickly time flew and how much you’ve learned. So, in preparation for the wards, remember that a good combination of caffeine and naps will keep you performing at your maximum potential. Guaranteed to work 100% of the time, all the time. Good luck!

Jesus Juarez

112


First and foremost, I can say with almost 100% certainty, my PPD this year will be positive. Why is this important? Well, TB sucks. If you ever see a disease and have no idea what it is and you’ve made it this far, guess either sarcoid or TB, I’m right about that one. There were 2 separate occasions I was “exposed” to TB, and I am still the running joke on the medicine service at VBMC. Just ask the residents, about ‘Maurice and TB’ and they will all laugh and joke… Funny now, har har… but not at the time.

So this is how it all went down. I got to work early-ish because I was taking on a new patient for Medicine inpatient. It was still early on in the rotation, week 3, and I was still getting the layout of the hospital. Ok, fine, I was trying to hurry because lecture was at 8 and I had 12 minutes to get a P/E from this patient. So I walk into the room like usual, half-asleep, hands full of papers and labs. Only one thing was different, this room had 2 doors to enter it, but I was too busy to think about it. It was an elderly woman lying in bed. I start asking her questions, listening to her lungs… and then my resident comes in, followed by the nurse, both of them wearing N95 masks. He looks up at me, chuckles, and says, “You didn’t want to wear a mask?” And that’s when it dawned on me. TEACHING POINT #1: double doors = isolation = find out the reason why. There were no signs on the doors (there usually are), and no cart with masks anywhere near the door. TEACHING POINT #2: talk to the nurses. If I had taken out a couple of minutes to talk to the nurse, they probably would have mentioned the suspected TB, more than likely…

Regardless, I was sure I had TB… and my resident did not hesitate to mention it at morning report, rounds, to other residents, and pretty much any nurse. (The patient came back negative for TB, by the way, so don’t everyone rush out now and get your masks, it’s too late anyways). TEACHING POINT #3: go with whatever the resident says. Anytime we had a patient with TB, I volunteered myself because everyone knew I had “experience” with TB, and it certainly didn’t hurt the grade.

Second time I thought I was infected with TB was on my General Surgery rotation. We had a gentleman who had n/v, signs of obstruction, and CT was suggestive of TB throughout the abdomen. TEACHING POINT #4: TB can be anywhere and do anything; mention it for your “zebra” and no one will look at you crazy. Needless to say, I walked into the OR as they were prepping to grab my gloves and did not notice the CRNA plugging in stuff and charting, all while wearing his N95 mask. It wasn’t until after I left the room did the head nurse mention to me the “possible TB” part… long story short, it wasn’t TB (it was mucinous adenocarcinoma that looked a lot like TB). TEACHING POINT #5: talk to the scrub techs, surgery techs, CRNA, and anesthesiologists, they probably will tell you if the patient has TB or not…

So what all should you take home from this? I am sure all my other colleagues are busy filling pages with pearls of wisdom and interesting quips about 3rd year, mine may save your life…literally… so be nice to everyone, you never know who might help prevent you from contracting TB.

Maurice Kimiagaree


113

My first rotation was internal medicine, and I was on a pretty large team with two medical students, a senior resident, intern, and some pharmacology students. Since this was my very first rotation, it was very hard to get a feel for what exactly my role was on such a large team, and where the balance was between not wanting to step on anyone’s toes and being a good team player, but also making sure I was taking initiative and being proactive. This was in July, when the brand-new interns are also just getting started and trying to feel their way along. I do still think it is a great idea to start off with medicine and set up that foundation for the rest of the year, but this is one negative point of starting off with internal medicine, you’re on a team where the senior resident’s priority is training the new intern. So for the first month or so you’re kind of on your own until the intern gets settled down and comfortable. This can be very frustrating, when you feel like you’re getting lost in the shuffle, or you’re not getting enough hands-on experiences, etc. But my advice would be to just keep in mind trying to keep that balance of being proactive and take advantage of opportunities to do or see things, but also accepting that your senior resident has a greater responsibility of training that new intern.

This really only applies to the internal medicine rotation. Spending my whole year in the Valley, there were very few times when I was on a large team. Other than medicine, it’s pretty much just you and the doctor. Nonetheless, every attending you work with is different, and it’s very important to get a feel as soon as possible for how that doctor likes to work with students. Be very flexible and adaptive to whatever role your attending wants you to fill. My best experience during my surgery rotation was with one of the supposedly hardest-to-work-with surgeons on faculty. I had heard rumors and horror stories from other students who had worked with him, so my very first day I sat down with him and had a very frank discussion of what he expected from me, and what I expected from the rotation. And every week we had the same discussion, during which we reevaluated how things were going, what to improve on, and set very clearly defined weekly goals for me to focus on. Having this open communication with my attending, and having such a clear idea of what I was to accomplish, made me feel like I got the most out of my time with this surgeon than with any other I worked with during that rotation.

Finally, the last little bit of advice is for those who feel like you’re coming into third year without any idea of what you really want to go into. Even those who do have one specialty picked out before starting medical school, I think it’s still important to keep an open mind. Go into every rotation with the mindset that this is what you’ve always wanted to do. You never really know how much you will or won’t like something until you spend some time doing it. I got really frustrated about half-way through the year because I still didn’t feel like any one specialty was just right for me. Then I heard some really good advice about not trying to pick out one specific specialty out of the dozens there are to choose from. Rather, after you’ve gone through several rotations, think in very broad terms of what you enjoy most: procedures vs. clinical patient encounters, inpatient vs. outpatient, working in a hospital vs. in a clinic, working with kids or adults. For me, I really didn’t get a feel for which settings I enjoyed most until my 4th or 5th rotation. And it was only then that I could really sit down and kind of mentally work through that little algorithm, again, not focusing on any specific specialties but just general work settings and patient populations I had enjoyed working with over the months. Thinking in these broad terms rather than “do I want to be a radiologist, or a dermatologist….” made me realize what I would ultimately be happy doing for the rest of my working life, which is all that really matters. Forget about everything else, monetary compensation, the implications of health care reform, overhead costs, your exam scores, etc. and just find something you can be content doing day in and day out. That’s what is really great about third year. You get to spend little chunks of time trying out all these different work environments so you can get a general idea of which one best matches you.

Derek Koller

114


Dear Class of 2013:

It’ll happen. No matter how hard you try, the night before your first day of your first rotation, you will have 1) no idea what you’re supposed to do ‘tomorrow’, and 2) once you get the hang of what you’re supposed to be ‘doing,’ you’ll realize you know nothing about medicine. And you’ll find yourself wondering, as you wake up your terminally ill patient at 5 a.m., “How on earth is what I’m doing beneficial for this patient?” At least, I found myself asking this very question each morning as I went to re-evaluate Mr. R.…

He was the first patient assigned to me in September, my second month of third year, on inpatient Internal Medicine. Mr. R. was a ripped, shaved-headed, tattooed Hispanic male in the jail wards, who had drunk so much alcohol in his life he was admitted to the hospital for complications due to liver failure in his 40s. He was so jaundiced he glowed (in the light, as I wasn’t allowed to turn off the light in the jail ward); he had esophageal varices, palmar erythema, and gross ascites; in fact, his fluid wave was the first I could actually feel, rather than just pretend to feel. Over a week and a half, his MELD score reached 29, with a direct bilirubin of 14. Most people die long before they get to this point. He was uninsured and convicted for two felonies, and was not a candidate for transplant. All that said, he had no signs or symptoms of encephalopathy and was completely oriented and able to communicate. When we discussed his prognosis with him, he was stoic, asked a few big questions, and then nodded. He had us speak with his sister as well, in his presence, and still maintained composure throughout.

My other patients at the time were an angry drug addict and a woman with thyroid cancer completely inhibiting her ability to talk, so I always gave extra time to spend with Mr. R., someone with whom I could actually converse. It didn’t take long before we considered each other friends. The Friday of my second week I waltzed on in to his room - only to find someone else in his bed. I went searching for the chief officer, frazzled by the idea that he might have suddenly passed away. Turns out, he had been granted parole, so he had been moved to the floor to be set up with home hospice. I went to his new room, and found him no longer in ankle chains and hand cuffs, watching a soap opera on television, and smiling from ear to ear, yellow as can be. “I’m going home tomorrow. I won’t have to die here.” A seemly morbid statement, but said with such joy. I put down the piece of paper I usually took notes on, and sat on the window bench across from him. We started talking about what he was looking forward to most during his last days – watching Cowboys football with his grandson. And then he said, “Thank you for everything. I’ll miss you.” I started to say the same back… and began to cry. I felt so embarrassed crying in front of my patient and, without making eye contact, started mumbling about how I’ve appreciated him as a patient, and hoped his family was doing well. I looked up to see that he, too, was crying. We hugged (after asking permission), and wished each other the best. I left, never to see Mr. R. again.

For twelve days straight, I don’t believe I did much in the way of medicine for Mr. R. Ordered some lactulose, arranged some GI consults, but to me it seemed that was it. However I’d like to believe I helped in another, less organic way. So what am I trying to get at with all of this, other than nostalgia? Even when you get every pimp question wrong, your plans are all rejected by your team, and you can’t decipher the results of a patient’s labs, you CAN make a difference in the lives in your patients. Don’t give up. And don’t worry, the clinical acuity will come with time.

All the best,

Jessica Koller


115

Letters to a Third-Year in Harlingen

(An adaptation of the song Everyone is free (to wear sunscreen) by Baz Luhrmann)

Friends from the class of 2013

If I could offer you only one tip for the upcoming year, sunscreen would be it. The long-term benefits of sunscreen have been proven by scientists whereas the rest of my advice has no basis more reliable than my own meandering experience...I will dispense this advice now.

The best “pearl” I was given before embarking on my 3rd year was, “Find the bathroom, if this is all you accomplish on day one, consider it successful.” He was right. Each first day at a new place I would get lost. It was inevitable. Locations constantly change...and a full bladder

is worse than you can imagine.

Don’t worry about having the perfect schedule. The schedule is always flexible; you can come to and from San Antonio as much as you’d like, and everything will work out as it should. At the end of the year it won’t matter if you did surgery first or last....the point is you did it and

you survived.

Do something nice for someone else each day.

Respect your attending.

Janie, Julie, and Angie are angels sent from heaven. They are there to help in all of your desperate times of need. Utilize them.

Eat whenever you can.

Harlingen is hot. Though there will be times where you won’t see much of it--the sun is always out. Wear sunscreen.

Don’t waste your time memorizing every text book. Pay attention during rounds, learn from your patients, and try to squeeze in some studying. In the end the grade evens out. Qbanks are gold.

Get a good pair of shoes, you’ll be standing a lot.

Eat at Magnolia.

Don’t feel guilty for failing the pimp question. Sometimes the doctor himself doesn’t know the metabolism of aspirin on the molecular level. It’s ok if you don’t either. Sorry Dr. Keeton.

Sleep. It’s a precious thing.

Be kind to your nurses, you’ll need them when you’re lost.

Some people you’ll get along with, some you won’t. Maybe you’ll love a rotation, maybe you won’t. Maybe you’ll know the hidden diagnosis, maybe you won’t --whatever you do, don’t congratulate yourself on winning a dispute or berate yourself on losing it. Some of

the people who taught me the most about myself weren’t necessarily the people I got along with. Put away the frustration and embrace the chance to learn something more about yourself.

Smile....even if you feel like crying, save the meltdown for after work.

Getting sick is going to happen; it’s ok to call in.

Do NOT be a solo artist, when on a team, be a team-player.

116


Don’t lock your knees. Passing out during surgery is frowned upon.

Be nice to your classmates; they are the ones who will call to remind you that you’re late for a meeting or slept in past morning rounds. Remember there is more to life than school. Find something else to be involved in. It helps keep perspective on the world outside of

medicine. The time is limited but it will help your sanity and social skills.

Enjoy the doctor’s lounge, but not too much. Remember you’re still a student and the last dessert should go to the doctor in line behind you.

Be humble.

Accept certain intangible truths: you’ll get the question wrong, you’ll forget to get the labs, you’ll get cranky and over-worked, and when you do you’ll fantasize about when life in second year was predictable, when there was a right and wrong answer to a question, and when

alarm clocks worked dependably. In the end, it’s how you handle these situations that makes you great.

Work hard.

Don’t expect others to get the job done for you. You may have to wake up earlier to see all your patients and you may have to skip lunch occasionally. But if what you lack in knowledge is made up for with hard work...you’ll still be a studly third-year.

Take responsibility. There will be times that you’re late or you’ll fail to do the reading. It’ll be ok. Just own up and learn from it. Be careful whose advice you buy, but be patient with those who supply it. Everyone has an opinion and wants to share it with you. Take it

for what it’s worth. Use what you like. You’ll figure out the rest.

But trust me on the sunscreen.

Bryt Marshall


117

Letter to a third Third-Year:

Congrats on finishing the basic sciences portions of medical school and moving into the clinical stage! I am sure that many of you are brimming with excitement about what the future holds for you. Some of you may be like me and still feel curious about what a year in Harlingen, TX, really entails. As I look back on my third year experience thus far, I think I can sum it up into one word: privileged. We are truly privileged to be able to go into the hospitals and clinics and work with the patients that are there. We are truly privileged to work so closely with each and every one of our very busy attendings. And, as odd as it sounds, we are privileged to have the close proximity to the border.

Right before Christmas, I had the opportunity to spend two days working with a Pediatric Heme/Onc physician. In comes a little girl with an advanced leukemia, necessitating treatment that was not available in McAllen. Dr. Bernini explained to me that he and his staff had worked to get this little girl and her parents 6 weeks of treatment at MD Anderson. The only problem is that this little girl was not born in the U.S. When local authorities discovered that her family was here illegally, she and her parents were allowed to stay in our country solely for the reason that she was receiving treatment for such a deadly disease. As you know, there are border check-points checkpoints along the highways out of the Valley. Just because she was given permission to stay in McAllen for treatment did not guarantee that she would be able to go to Houston for treatment. Dr. Bernini’s staff wrote a letter entailing the situation and the need for further evaluation in Houston. They also worked with local politicians to write letters of support on behalf of this family. Armed with these resources, the family boarded a bus for Houston. Somewhere along the way, the border patrol did a random check of the bus, found this family, disregarded their letters, stating “Why would a politician care about you,?” forced them off of the bus, and left them at a random bus station, nowhere near McAllen and certainly nowhere near Houston. The family spent the night in this bus station trying to find anyone who would take them the rest of the way. Unfortunately, no one volunteered and they were forced to return to McAllen. I was there when the mother and daughter arrived after this ordeal. Dr. Bernini and his staff had spent countless hours and resources to enable this child to be able to get to Houston for her 6 weeks of treatment, and yet because of her legal immigration status, she was denied access to this care. Rather than become discouraged, they joyfully reassessed the situation to determine a plan B for how she could be treated.

I mention this story because I think it illustrates several of the gifts associated with working in the Valley. Our border with Mexico is incredibly fluid, and you will undoubtedly face the benefits and challenges associated with this fact. Despite the inclination to define this girl on her immigration status, Dr. Bernini looked past those political pitfalls and identified that all that really mattered was that his patient was sick, and he needed to find a way to help her. We can easily become robotic in our day-to-day activities as medical students—go to clinic, see patients, make an assessment and plan, talk with attendings, wave the patient out of the room and never think about them him again. In the Valley, prescribing medication to heal diseases is simply not enough. We are constantly forced to think about the entire patient—socioeconomic status, home life, ability to get access to and pay for medications, legal immigration status, etc. I feel privileged to work here because I get to work every day with physicians who challenge me to see that simply practicing medicine is not enough. For the benefit of our patients, we cannot only think only about their diseases.

Just today, I was again challenged again to take off my medical student hat, and put -on my humanitarian hat. After a long day of surgery and follow-ups, my attending surgeon and I were rounding on a patient who was readmitted last night in septic shock. Mr. B., a 57 57-yo male, has a history of pancreatic cancer that has since spread throughout his abdomen. His white count was 34, albumin 1.4, and just about every index of his prognosis was looking poor. My attending, Dr. Salcedo, had performed a fistula repair on Mr. B.’s torn bowel. He continued to develop more fistulas and because of his overall health status, it was determined that palliative care would likely be the best we could offer. As we sat in the critical care unit with Mr. B. and his wife, it was evident that this couple was struggling with the reality that he will likely pass away in the near future. His wife, exhausted, commented that all she wanted was answers. “All they do is take X-rays, draw blood, do CT scans, and no one can give me any answers.” We sat and did our best to answer her questions, but it quickly became clear that she did not want answers as much as she wanted support. She has been taking care of her ailing husband for the past year, and she was tired. We left the room and looked at his chart. Dr. Salcedo noticed that today was Mr. B.’s birthday. We walked back into his room to wish him a happy birthday, and Mr. B. said he was so caught up with everything that he had forgotten it was today. A solemn air filled the room as we all realized that this was likely going to be his last birthday. Because of his NG tube, he would not be having cake on his last birthday. How sad would it be to know this is the end and not be allowed to have even one bite of cake? Mr. B. sat in his bed entangled in the lines and machines meant to keep him alive, yet they were preventing him from living.

118


In an act of kindness, Dr. Salcedo asked this couple what type of coffee they prefer. He then went to Starbucks, bought two mochas, brought them back to the CCU and handed them to this couple. The nursing staff looked on confused—outside food was not allowed, especially for someone in such grave conditions as Mr. B. The expressions on their faces asked, “But what if he has a complication?” It is in moments such as these that I am forced to re-evaluate the practice of medicine. It would have been easy to peak our heads in, say hello to the family and leave without hearing their concerns. Upon learning it was his birthday, it would have been easy to never say a simple “happy birthday.” When asked if he could have a treat, it would have been easy to blame it on the rules of the hospital and deny this dying man some simple pleasures in life. Dr. Salcedo, however, did not do what was easy. Instead he did what was human. It was amazing to see Dr. Salcedo completely disregard hospital protocol in order to give this man some dignity in his final days of life.

I am so incredibly excited for each and every one of you as you begin the journey through your clinical rotations. At times when your routine seems monotonous, or the amount of work becomes too great, I challenge you to take a breath and think about the big picture. You are about to be given tremendous opportunity to heal others, but will you use that opportunity to heal just their diseases or will you challenge yourself to work to heal the whole person—whether it be working extra hours to help a little girl get past border patrol or chucking protocol to the wind to give a dying man one last happy birthday?

Beth Melia


119

Dear Third-Year Colleagues,

I was the first person on our team at the ER to see the patient that Saturday. She came in complaining of weakness, nausea, sore throat, vomiting, and dizziness. However, what I found astounding was, at 62, this woman had no conditions to speak of: no hypertension, no diabetes, no dyslipidemia, and she even walked to two jobs everyday. Her emotional affect was decreased, but her mental state was intact, as she revealed no cognitive impairment on the mini-cognitive exam, with 3 out of 3 recall and a normal performance on the clock drawing test.

Given all the symptoms she presented us with that afternoon, the one the rest of the team latched onto was the patient’s bradycardia of 45 bpm. My attending thought the bradycardia must be the single cause producing all her symptoms. I needed more evidence.

I looked at her history. My review of her previous medical records revealed that she had come to the same ER two-years earlier with a complaint of sore throat and a cough, but yet again that team also had focused upon the fact that she had bradycardia. Ultimately, they stressed her with a pharmacologic stress test, gave her an echo, and found that she was fine, leading to her discharge. Even further back in her history, another team had consulted psychiatry for possible depression as manifested in her decreased affect. The psychiatry consult came back with the finding that if anything, it could only be attributed to menopause.

I questioned her adult daughter who accompanied her to the ER. Her daughter reported that she had always been like this as long as she could remember, and that she had always had a slow heart beat. I tried to draw my team’s attention to the account given me by the patient and her daughter, which described that the symptoms had been progressive over a three day period, starting with weakness, then dizziness, a sore throat, and finally the vomiting that morning. I commented that we were rushing to conclusions as I explained that her symptoms are just as easily explained by an infection and working outside in 100+ degree weather here in the Valley. She was admitted that evening with the diagnosis of sick sinus syndrome.

When I returned that Monday morning, I went to do my pre-rounds. I was eager to see how she was doing and what was to be done. As I looked through the notes, the direction of care was becoming clear. A consult to a cardiologist had been made and that cardiologist was scheduled to put in a pacemaker. Since I last saw the patient, what new evidence or compelling reasons had been produced to justify the pacemaker? Her records disclosed that the patient’s twenty-four-hour Holter monitor had been cancelled, she had an unremarkable EKG, except for the continuing bradycardia, her TSH level was normal, and the treadmill stress test that I suggested had not been ordered. The cardiologist had decided since her TSH was normal, the symptoms and bradycardia were indications enough that she needed a pacemaker.

I pleaded with my resident and attending to slow down, there was no rush to do the procedure this soon. I freely admitted it could be sick sinus syndrome, but why not work it up first? She was stable and had been improving since entering the hospital. We needed to work her up, stress her heart on a treadmill, do something to see if there was objective evidence before we did an invasive, life altering, and expensive procedure.

By the time we rounded the patient that morning the pacemaker had been put in and any work up was pointless. I continued to follow the patient before her discharge and she had another episode of vomiting after the procedure. Why had the pacemaker not stopped her symptoms I asked? I was never answered and the patient was soon discharged.

I decided to write about this experience because once a patient enters the hospital, it is easy for us as medical students to go with the flow and not make waves with our colleagues. We can just do what the specialist says, do what the attending says, do what the resident says, and never raise our concerns. It is probably the smart thing to do as a student receiving a subjective evaluation. But, the reality is we are no longer students sitting in a lecture hall. We are now members of a team. Each of us is making life or death decisions that potentially affect our patients for the rest of their lives. We can’t stop advocating for our patients because of a grade. When we take patients under our care, we must be willing to advocate on their behalf to get the work-up they deserve. We must possess the strength of character to challenge simply taking the path of least resistance.

All the best,

Michael Millstone

120


Just Be

As your second year of medical school winds down, you may recall that after the pathology final exam and Step 1, your academic gears need to switch completely to prepare for third year. No, it is no longer appropriate to wear sweatshirts, jammies or slippers to school. You dress as if you’re going to ACES every day, except it’s your third year of medical school and you get to talk to real patients! All day. Every day. Dream come true finally, right?

As you prepare for this wonderful year that is sure to be full of first day jitters, P.I.M.P.ing, wonderful experiences and non-stop learning, you will find that, as always, your fellow medical students will have lots of unsolicited advice for you—as I am sure you are already well aware, medical students love few things more than giving other medical students advice. So, who am I to grind against the grain?

Many of you have probably heard tips including, but not limited to the following: never ever be late, remember to smile even when you don’t feel like it, be a team player, read about your patients each night, do NOT PIMP fellow students, pack a granola bar in your white coat pocket next to your stethoscope, and be a “Yes Man.” The things you need to know for third year are truly endless. The best thing you can do is jump right in…while smiling, of course!

There are days, especially in the first weeks of third year, when you will not know the answer to a single question the residents or your attending ask, or when you will forget to report the large, infected wound on your ER patient’s left lower extremity. There may be days when you wonder if you remember anything at all from your first two years of medical school. When this happens, try to relax. Know that this happens to everyone—even to that guy you see in the library all the time that must be in the top of your class. These are the days when you will need a “pick me up.” Calling home reliably offered you this comfort during your first two years of medical school, but your attending may knock you in your evaluation if she finds you in the team room calling home at 2 in the afternoon to complain about how Gunner Johnny totally stole that fact about liver failure you had just shared with him right before you both got PIMPed on it. I would like to recommend that on these kinds of days, you find your security and boost in spending time with your patients. When morning rounds on Medicine did not go so well, spend 20 minutes in the afternoon with Mrs. Dawson to see how her HIDA scan went. Ask her about her children and her favorite foods, and let her ask you about where you are from and what kind of doctor you want to be. These are the moments when you will remember why you are in medical school. It will also help you build stronger relationships with your patients. Heck, you may even get a better history from her the following day and be able to provide an important fact to your resident of which he was unaware. The patient may comment to the whole team about how awesome you are during rounds (psst! This kind of thing is really good, come evaluation time). All of this will make you look smarter, especially on days when you are not.

As students we do have one thing that residents and attendings do not have: extra time. You have the opportunity to just be with patients at times when you may not be able to do much else. I suggest you use this time to take more thorough histories from your patients, personally retrieve the ice chips they request instead of passing the message to a nurse and take time to massage their feet. I am just kidding about that last one. I repeat: do not massage your patient’s feet. That may earn you the stink eye from the nurses as well as a bad nickname for the next two years while on the floor. There are two kinds of patients where my strategy of “just being” led to my most fond memories and experiences—patients on labor and delivery, and all senior citizens.

Based on my experience, senior citizens—especially Winter Texans you will encounter while doing rotations at the RAHC—love talking to young students. If you are thorough in your history and physical exam, they also seem to be the most appreciative patients. They are the ones who are the most likely to give great feedback about you to your attending, which, again, looks great for your evaluations. Putting in a little extra time and a big smile can really take you a long way during third year. This was definitely true during my OB/GYN rotation.

During my time at the RAHC, I was able to deliver nine babies, myself, and watch many other deliveries even though I had only three days when I was technically on L & D. Some expectant mothers were rushed to the hospital and delivered quickly after having gone through much of their labor before making it to our department, while others would be in labor all day or all night in the hospital. After my H&Ps were written, I would spend time getting to know the patients by sitting bedside to keep them company or team up with the father-to-be to form a dynamic duo of cheerleaders. I found that the mothers had lots of questions about all the monitors and equipment in the room, the process of labor or wanted to discuss of what their celebratory meal/post-child-expulsion binge should consist.


121

After spending extra time with my first patients, Mrs. Garza and her husband, who were expecting a baby boy, they were very comfortable with me delivering their son under the close supervision of my attending. When my attending told the happy parents that this was my first delivery, they appeared to be just as excited for me as they were to see the newest member of their family. After a couple of rounds of high-fives and hugs, I helped the nurses transfer Mrs. Garza’s bed to the post-partum side. After delivering three more babies that day, I checked up on each of my patients before leaving for home.

The following day consisted of pre-rounding and then rounding with my attending. The nurses let my attending know that Mrs. Garza wanted to see us soon, and we decided to check in on her first. She and her baby were doing beautifully. “Zach, we just wanted some help completing the birth certificate,” stated Mr. Garza. “Sure thing, how can we do that,” I responded. “I wanted to double check the spelling of your first name so we have it right on the birth certificate. Is that okay?” the father asked.

“Is that OKAY?!” I thought to myself. “Of course, that would be amazing. You just made my entire year,” I finally blurted out. After sharing some laughs and having a few photos of the happy parents and both Zacharys, I walked out of the room feeling incredible and as if I had made a difference.

Each week of third year presented its own challenges and wonderful experiences. I encourage you to work hard, study hard and enjoy being present with your patients. If you do these things, you will have an incredible, memorable third year. Who knows, you may even end up with one or two children running around Harlingen answering to your first name!

Zack Taylor

122


Hey 2013!

I know finishing the first two years of medical school feels great and that finishing STEP1 feels even greater… but you’re not out of the woods yet. A critical component of your medical training lies before you – the one in which you begin interacting with patients and believe it or not - impacting their lives. You are going to learn lessons, good and bad, that will help shape the physician you will become. There will probably be parts of third year that will make you question why you chose medicine for your career, but there will also be moments that hit you so deeply, you will carry them with you for the rest of your life. This year will be challenging and hopefully very, very fulfilling.

Unlike our typical days of first and second year, getting to your clinical site on time and dressing appropriately aren’t going to get you very far during third year. You won’t have the luxury of spacing out or texting at the back of the lecture hall after a night of ‘not much sleep,’ knowing that you can always listen to the lecture on Blackboard later. Third year entails being attentive all day long, learning as you go, and fitting in time to study at night.

I must warn you that if you thought the days of people telling you that you don’t have what it takes to be a good physician were over, think again. Undoubtedly, there will come an attending that either through their words or actions will make you feel like whatever you do isn’t enough. If this is something you encounter, just do your best, ask them what you can do to improve, and push through. Don’t let anyone change your mind or make you question your abilities. You may inevitably need to harden your shell, but you can do it, and you’ll come out stronger in the end. We are not perfect, we all have flaws, and that is what makes us human. On that note, I implore that you all respect your fellow classmates and help them out when they need it. In the eyes of an attending, arrogance is often despised just as much as ignorance. This is not a race, it’s a marathon, and chances are you’re going to need a helpful nudge at some point, too.

This is a wonderful blessing each of us has been given – the power to walk through the halls of hospitals and enter doors that the public isn’t allowed behind, the same doors that some people never come out through alive. Many, many others would love to be in our shoes, to have had the education we’ve been given, to get to see the things we see - this is something I personally had to remind myself of on many occasions (especially on nights when I was tired and felt like I’d never be able to learn everything). Please don’t abuse this power, but cherish it, and remember to hold your head high even if you’re not proud of how you performed on rounds that morning because chances are someone is looking up to you and might even be putting their faith in you at that very moment.

Now jump in!

Rachel Yurcheshen

from the class of 2012 - long school of medicine, ut...

Documents