Emergency Medicine: In the heat of the moment

In August of 2016, I rotated through the emergency department at what I consider my home institution. I think a combination of factors played into my overall takeaway from the month – I enjoyed the whole clerkship immensely. I was fresh off of my Step 2 CS and CK exams, and therefore clinical workup and management was fresh in my mind. There was a large amount of autonomy given to students and residents by the physicians and staff, and, having rotated through a fair number of other services, my time in the ED felt like it was the last missing piece in the patient hospitalization process.

Easily the best part of the rotation was being able to see the patient firsthand and make clinical judgements and assessments without other physician input. The wide gamut of pathology and diverse population allowed for a very broad experience. There was also plenty of suturing to be done, and I was able to sew up three facial lacs, a hand, and two knees.

Overall, I found my EM month an imperative part of my education, and though I will not pursue emergency medicine professionally, I can better appreciate the lifestyle and pressures of such a career.

A guide to M3: The clerkships and SHELF exams

I made this post to help guide study efforts (for NBME Shelf exams) during M3 year. I found that there was a mix of information as to which sources were the best sources to use during core rotations, and given that you have limited time to dedicate to studying, it is imperative to use it well. That being said, everyone, including myself, has their own sets of resources they used that they will claim is the best. It should be stated that the best prep for any rotation is working up patients and looking up their best treatment and management regimen on UpToDate while on the wards. Here’s my additional study plan:

  • Internal medicine
    • UWorld is the staple for prep – about 1400 q’s. This will take a considerable amount of time but is worth it in the end if you can finish it during your rotation.
    • MKSAP for students (aka IM essentials) – another key learning tool. The explanations are better than UW in my opinion. It takes a lot of effort and doesn’t simulate your exam, but it’s great for building a foundation of clinical IM knowledge.
    • Pre-test IM – a few wonky questions and many are too short or easy, but this book gives you some random factoids that might help in tricky stems (e.g. CHF is more likely to cause R-sided pleural effusion). I did about 10-20 q’s every morning to get through the book.
    • MKSAP audio – probably a bit overkill, but I like listening to audio lectures rather than reading, so I went through the sections on cardiology and GI. I love this series, and listened to the bulk of it throughout M3. Great for the gym and commuting. Not great when you’re driving with people though, haha.
  • Obstetrics and Gynecology
    • APGO uWISE – plenty of short quizzes on high yield topics. The problem is that you’re going to miss a lot of questions if you don’t already have a solid foundation of knowledge. This is the best source hands down.
    • Case Files Ob/Gyn – I used this to sort of learn the basics of Ob/Gyn and get a foundation. It’s a good text without too much filler or fluff. Even some of the more esoteric topics in the book came up on the shelf. To note, I never used Blueprints.
    • UWorld – a staple, but not enough. I think it is better to save these q’s for 2-3 weeks before your shelf to use as a gauge.
    • Dr.Chapa’sObGynPearls: Texas A&M College of Medicine – this is the best audio source for this rotation. Go to you podcast app and subscribe. Usually about 7-12 minutes a piece on high yield topics (e.g. endometriosis), covering every salient point (e.g. MCC, presenting symptom). If you learn the material for each topic, you’ll be able to present with some competence and actually have a discussion about stuff.
  • Surgery
    • Pestana – a great ‘cover your bases’ review of many topics. The staple for this rotation. Has some questions in the back.
    • Case Files Surgery – I used this extensively, but be warned that some things might be outdated if you don’t have the latest version (I was burned on thyroid nodules). Overall this was my second staple.
    • UWorld – not many q’s, but you should supplement by re-doing some of IM. Many IM topics are bound to show up. Spleen and GI questions come up a lot.
    • Pestana audio – this was my favorite resource. He reminded me of one of my pathology professors from Basic Science years.
  • Psychiatry
    • UWorld – this covers most bases. There will be a few esoteric topics on the shelf exam that you won’t find anywhere.
    • First Aid Psychiatry – A good thing to review if you have nothing else to do and want to read something.
    • Lange Q and A – I wish I had known about this beforehand – i did some of these and they were good quality questions
  • Pediatrics
    • Honestly, I had little time or patience at this point in my M4 year for this exam – I was more focused on interviews. There are likely better places for advice on this topic
    • UWorld – solid “cover your bases” approach with a decent amount of questions
    • Pretest – more filler questions if you have time
    • UT HSC video review – this was the majority of my studying

Family Medicine: The nucleus

During April I rotated through my mandatory family medicine ‘elective.’ About a year prior, I began my first rotation ever, and, of course, I had formed many opinions of rotations and specialties before I even had them scheduled. Rotating through M3, you hear the stories of other students and their trials and tribulations, misfortunes and misgivings. Everyone’s a pariah. Somewhere along the line, I had formed the opinion that FM was among the more banal rotations, and, naturally, this was supported by mountains of anecdotal evidence.

However, regardless of my preformed inclinations, I always try go into a rotation with an open mind and an eager spirit because there are great teachers everywhere, and prejudgment leads more often to disappointment than substance. I was taken aback by the versatility and welcome of the program I rotated through. It was ideal for a student, and the residents were excited and genuinely caring and kind. The attending physicians were surprisingly well-attuned to listening, and were receptive to our presentations. The structure of the rotation was also well-designed; two weeks of clinic, one week of inpatient nights, and one week of inpatient days.

The population served had abundant pathology and disease, and I was thrown into the thick of it during my first overnight shift when a patient coded and I performed compressions. That memory will stay with me for some time – the code itself was successful, but, I had asked myself that night, at what cost? After the fact, I learned that the patient was on her way to hospice care and her daughter had wavered that day on a Do Not Resuscitate (DNR) order. The code was grisly. Throughout the whole ordeal there was brown seemingly feculent material streaming out of the patient’s mouth. I performed compressions as the resident valiantly attempted intubation, intermittently suctioning. The large laparotomy wound on her abdomen that was leaking serosanguinous fluid was held together tenuously by staples; these began to tease apart during only the second round of compressions – by the fourth or fifth the thing had come undone. The anesthesiologist intubated, and I was rotated out of the compressions, and that pause let me absorb the scene. Somehow we attained return of spontaneous circulation (ROSC), though the patient was unresponsive.

Other memorable events included management of post-surgical hemorrhagic shock overnight, textbook rheumatoid arthritis, and of course, clinic. The abundant clinic time gave me comfort in that setting and I was able to see the wide swathe of patients that FM encompasses; from routine pediatric visits and obstetric patients to idiopathic pulmonary hypertension and sepsis, FM is the first line for many encounters. I remember suturing supervised with a resident’s and attending’s guidance in one clinic encounter – never during surgery had that ever happened.

In short, I had a great time on FM. I learned much, was actually able to get up close and involved with some of the management aspects of ward medicine, and worked with extremely kind and caring physicians in a clinical setting.

Surgery: A sense of duty

Last week I finished my surgery rotation; two months of general surgery followed by a specialty elective. I, of course, have my thoughts.

“Love is a better teacher than a sense of duty.”

– A. Einstein

Surgery is, in many ways, the quintessential human realm. At its most basic level, it is straightforward: there are problems that can be dealt with surgically, and there are those with the surgical acumen to help. This sentiment is lost in the reality of the upkeep of a surgical service. The truth is that surgery is the intersection of many interests, with divergent and convergent goals. There is the attending, the resident, the student, the scrub tech, the circulator, the anesthesia team, the company representative, and, of course, the patient.

From this blog, there is the vantage point of the student: my perspective. The surgery clerkship is, in the words of one resident I worked with, “a rite of passage” for all budding doctors. That being said, many who graduate with an MD after four years of studies do not pursue further surgical training. While I will not seek a career in surgery, I can appreciate the rigors of what such a path would entail. Being a student on the service gave me insight into the daily schedules and demands of life as a surgery resident, from PGY1 to 5. Life seemed to drain out of some of the residents. Many were abrasive. The gentility I had encountered during my medicine clerkship was largely absent. Stern looks and long silences were not uncommon.

The operating room, however, was its own beast. I was introduced to the O.R. in my Ob/Gyn rotation, and the romanticized ideas I had of it were quickly dissuaded and replaced with an understanding of my role in the surgical hierarchy and my total lack of surgical skills. My initial reticence waned as the months passed, and by my fourth month of surgery on orthopedics (after urogynecology, general surgery team 1, and general surgery team 2) I was competent with a needle driver and suturing. Moreover, I was not afraid to ask to be more involved with cases even if I would likely be turned down.

There is a certain thrill one receives in the O.R. when properly executing a technique under guidance from a mentor that is almost unparalleled. For me, that thrill alone is not enough to push me to pursue a lifetime of surgery. One wise surgeon I spoke with described surgery in two ways; one as an addiction and one as a duty. He said to truly embrace being a surgeon “you have to be addicted to it – you have to want to be there at all times.” The other side of the coin (and this is where that quote at the beginning of this post comes in) is that surgery (for the surgeon) should feel like (and is) an obligation. Per that surgeon, there should be a strong sense of duty involved in surgical training and practice – “it’s like the military, really,” with its structure and commitments. I think that duty, while a strong motivator by any means, is far surpassed by love; by that I mean that passion should be the prime motivator for action. For some, it may be enough, and I’ll leave the operative interventions to them.

I think when I came into surgery, I had grandiose notions of what I would encounter. There a sense of authority that comes with surgery; it is the final measure in the eyes of many, and the acuity of surgical problems is keener. That said, I would be remiss if I did not mention the sense of pride you carry when you say you were “in a case for __ hours” and were able to help or perform part of the operation, albeit minor.

A few good people is often all it takes, and I can say there were a few residents and attending surgeons I was lucky to work with that were very accommodating and eager to teach. There were a few days I was able to be first assistant to the attending surgeon while on general surgery, and these experiences were particularly fun.

By far the most experience I got with actual surgical tasks was during my month of orthopedic surgery; it was a pleasure to rotate on that service (despite the NBME surgery shelf exam looming over my head). The residents were very enjoyable company and generous teachers, patiently walking me through the fundamentals of some techniques and giving good feedback. Oh, also – the residents’ knowledge of orthopedic surgery really seemed inexhaustible. That month the variety of cases I saw was excellent. I’m sure if I had been there for another month some of the cases would have seemed repetitive, but some of the bigger cases like hip and knee arthroplasty were so involved and fascinating that I enjoyed the multiple exposures.

That’s my surgery experience in a nutshell. On to the next one.

Obstetrics and Gynecology: Of birthing, surgery, and nights

Whew, I just finished my OB/Gyn rotation. After those two months of medical exposure, I truly feel like I have only begun the marathon that is MS3/MS4. Both months were challenging in their own ways.

In November, I was introduced to the revered O.R. My inauguration was brief, and much of the mystique and wonder I had built up dissipated within the first week of my month of gynecological surgery. The surgeons and residents I was privileged to work with were focused and skilled, and I have the utmost respect for their craft. Surgery, I found, was demanding in ways I had not anticipated. The focus, diligence, and dynamic coordination required for the routine tasks of surgery was largely new to me in a medical setting. Internal medicine, to contrast, was steeped in speed, intellectual fastidiousness, and static coordination. The O.R. is the here and now; the floor is what was and what will be. The distinction is dramatic, and after experiencing both I can begin to understand the schism between the two disciplines. Moreover, I also can appreciate that while IM is more of a science (to some extent), surgery is an art. The control of every decision in IM guided by evidence cannot readily be replicated in the nuanced motions and subtleties of incisions, cautery, and knots.

“We are all fixing what is broken. It is the task of a lifetime. We’ll leave much unfinished for the next generation.”

Part of me finds dissatisfaction in this. There is an inner desire for certainty in the actions I take. The certainty in art of surgery stems from lifetimes of experience, against which my 25-year old self has comparatively paltry assuredness. And, really it’s a cop out. At its essence, I’m saying there are too many variables in surgery. That’s tantamount to saying there are too many variables in life. There are infinite aspects of in any situation, not simply surgery. I think it’s my engineering background that gives me this aspiration for an ideal action or solution at every turn.  Does medicine simplify many variables into digestible forms that are more interpretable? Blood pressure? Temperature? Possibly. I am not able to determine that. Maybe no one is.

In December, I was exposed to the practice of Obstetrics. In line with the discussion above, the field of OB has similarly a handful of cardinal variables that are critical to its practice – cervical thickness, dilation, contraction frequency, etc. Once mastered, the decision trees are fairly intuitive. Anyways, I was really tested on this rotation. Half of my month of OB was nights, one of the most demanding experiences I have had in medical school thus far. The nights were mixed – some were action packed, some were slow, some haphazard. The adjustment to a nocturnal lifestyle was not smooth, and I found myself craving sleep at times. The best part and the worst part of the rotation was its unabashed spontaneity – at moment’s notice, a C-section case could (and did, many times) step through the door. That readiness required was daunting, and often times, I found myself dreading action towards the end of my shift.

This dread stemmed from a very concrete (and mildly embarrassing) experience I had while on my first week of nights. A patient required a C-section at around 3AM and the team was notified. I had about an hour of sleep at that point, and also had not eaten dinner. I had a vasovagal episode and had to sit down on the floor of the OR in the middle of the case (in the middle of the night), later to be wheeled out against my requests. The ignominy of that event was replayed when the resident reenacted the scene in clinic.

As an aside: one particularly sad part of OB was being part of unsuccessful pregnancies. Intra-uterine fetal demise was unsettling and I cannot begin to fathom the feelings of the patients I saw that underwent such an ordeal.

This rotation was the one I learned the most from during the rotation. My basic science curriculum did not address the nuances of the management of pregnancy; I knew little of pregnancy and its clinical aspects. The hands-on experience I was afforded bridged much of that gap in my knowledge base, and I can say I appreciated it.

 

Oncos: My month on Heme/Onc

Last month I was on an elective month – hematology and oncology. Part of my inspiration for going into medicine was the book The Emperor of All Maladies, a poetic walkthrough of the history of cancer and medicine from ancient times to present day by SM. The writing in the book is superb, but not the topic of this post.

The month gave me a first-hand look into the face of malignancy. The recurring theme of the month, it seemed, was mortality. Patients and I alike were fascinated by the prognosis of the grim diagnoses and outcomes of disease. There was a definite gravity in the specialty rotation because it seemed (in contrast to my IM rotation) that there was a serious finality or consequence in everything we did. The staging, the cycles of chemotherapy, the radiation treatment. Everything was momentous for me, and moreover, the patients. I, a student with some inkling of education, could barely grasp the totality of the underpinnings of what was partaking in front of me when the oncologist would outline a regimen and discuss the rationale behind it. The historicity of the evidence, the experience of the attending and the fellow, and the confidence of the rest of the team all reassured me that there would be some positive outcome for the patients we treated. However, in my readings, I often encountered scarce data and evidence behind certain therapies.

Part of the reason I was originally drawn to medicine by oncology was the fact that there is something so primal and visceral about cancer that it poses as a problem that must have a primal and visceral solution. Another thing that drew me to it was the fact that it is so prevalent, and can happen to anyone (beyond the obvious associations, many of the patients I saw seemed to have the worst luck if nothing else). And of course, there must have been some macabre fascination I had in my imagination years ago of what being an oncologist would be like, fighting death with science and commiserating with my dying patients if there was no remedy to their fate.

As naïve as those reasons might have been, they now have the weight of some real experience behind them. Now that I have seen the groundwork of oncology in an inpatient setting and in the clinic, I have a more real sense of what that lifestyle and goals might be like, were I to pursue that path. At this time, I still know there is much for me to do and see, including obstetrics, gynecology, surgery, and pediatrics.

Lastly, I will say that the elective did have a few brushes with death. A patient on our service coded and failed to be revived; another passed away after a chronic battle with cancer. These were routine in the hospital setting, but that did not lessen their impact on me. When confronted with such a grim truth, it is hard not to consider my own life and think of other outcomes. One thing my mother told me a not too long ago still resonates with me – she said that if she were diagnosed with cancer and only had a few months to live, she would not waste a single day with chemo or in the hospital. I cannot say I disagree – while there are certainly appropriate times for therapy, I think, there are also times that are not. Seeing the hardship of surgery, the stress of chemo, it is too much for a hypothetical question.

Internal Medicine: Intro to clerkships

I’m deep into my internal medicine rotation – exactly halfway through the 3 month clerkship. The journey from Louisiana to Maryland to Louisiana to Missouri was mechanically necessary, but uneventful. I have transitioned from the ‘being’ portion of my medical career to the ‘doing’ part of it. The hospital through which I am rotating is a hive of activity, and the days I spend toiling as a medical student in the wards are markedly different from those I spent guzzling information and regurgitating it for exams during basic sciences.

As it is with everything in life, the attitude you take with your endeavor determines its outcome. I have been blessed to have great attending physicians and residents thus far so as to nudge me along, and I know that there is always something to be learned from every patient I manage. Even if it is something I have managed just the day prior, even if it is only a comparison of outcomes to a treatment used in another patient with the same condition, the observation is made. With this attitude, I have taken the first few footsteps in the seemingly never-ending career of observation and solution that is medicine.

The hospital setting is ironically the exact opposite of the training environment I underwent to prepare for it. It is a bustle of activity and noise, with teams comprised of attending, resident, and students prowling the floors and corridors. The dynamics of walking as a group and presenting to the team is new to me, and occasionally I feel like a duckling in my short white coat walking behind the rest of the team with their flowing knee-length garb. Gone are the days of pure multiple choice questions, pure lectures, and pure solitude. Interpersonal interaction is constant, so much so as to make me lose myself in the present moment, rounding from one patient to the next, with any momentary lull filled by updates and notes. Being part of the the hospital feels like being part of a living, breathing organism, with a number of functioning systems and hierarchies that crosstalk to a common end. It is engrossing and enveloping, and I have found myself feeling idle on my days off.

I cannot say every experience is gratifying, as with internal medicine many patients are eventually discharged and followed up as outpatients, but when the interventions I suggest are appreciated and contribute to patient care, there is certainly a thrill and rush of easing another human of some suffering. My one dissatisfaction with the particular rotation – internal medicine – is the pace at which diagnoses and care take place. Many conditions are severe and inherently slow to recover from, and despite the fact that recovery is likely and prognosis guarded, the previous instant gratification awarded my multiple choice questions is long gone. My attendings have told me that internal medicine is a field wherein the big picture is important, with the little details falling into place. I look forward to my next few rotations, recognizing that while I have read about many things, I have seen few, so as I broaden my experience, I broaden my insight.