Med School Confidential

by Robert H Miller

  “Great,” you say, “that sounds like a solid plan. But is it realistic? How much time should I allot for studying?”

  This is a fairly individual thing, but as a rule you should allow for at least one full month of solid, 100 percent committed study time. That means studying every day, for ten to twelve hours a day, for the entire month. That means being dedicated to and focused on the undertaking, and removing as many distractions as possible. This will be a hard and painful push, but it is an important one. The USMLE Step 1 Exam is a critical checkpoint along the road of your medical education, and many of the more competitive residency programs use the score you earn on this exam as an important component of their match decisions. There is no way around it—the only way onward is through it, so resolve to use it as an opportunity to organize, synthesize, and work with the body of preclinical knowledge you’ve learned in the past two years. Approaching the challenge with that mindset will make the process much more pleasant for you.

  “My medical school allotted five weeks to study for Step 1,” Adam recalls. “I spent six days a week in the library, about twelve hours a day or so. I also scheduled time to go to the gym to get my mind off of things.”

  If you’re a D.O. student, you will be on the same path, but instead of the USMLE Step 1, 2, and 3, you will take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX), which is also broken into three Step-like exams given in the same sequence. Some D.O. students ultimately elect to take both the USMLE and the COMLEX in order to keep their residency options open. See the AACOM Web site (www.aacom.org), the COMLEX Web site (www.nbome.org), or the appendix on page 271 for links to more information.

  CONFRONTING FAILURE AT CHECKPOINT 1

  We all have bad days, bad months, and extraneous circumstances that prevent us from performing to our highest potential. The Step 1 Exam, though, is a bad time to underperform. These scores do matter, and they do impact your ability to get the residency of your choice. So what do you do if things go wrong?

  The first step in addressing a poor performance on the USMLE Step 1 Exam will be meeting with your dean to discuss a plan for how to proceed. If you failed the exam or have scores you deem to be unworkable, you should immediately start rescheduling another administration of the exam. Many schools require that you pass Step 1 before you can proceed to the third year of school, so you certainly don’t want to be waiting to finish up your boards while your classmates are already in the wards. Meet with your dean, find out what your school’s policy is, and be prepared to present to him/her with a plan of how and when you intend to remedy the situation. People do fail Step 1 and still go on to have productive careers in medicine. The test now is how you confront and remedy your failure.

  The next critical step is figuring out what exactly happened. You need to be brutally honest with yourself here. Review your score report from the National Board of Medical Examiners (NBME) and look at the distribution of your individual subject scores. Were you exceedingly weak in certain areas but strong in most others, or were you somewhat weak across the board? Look back over your practice tests and review the progression of scores. Look for areas you didn’t review or for evidence you weren’t really honest with yourself when you thought you had mastered a subject area.

  Finally, start the process all over again, but watch yourself closely. Don’t allow yourself to blithely pass over wrong answers or pass off mistakes due to carelessness. Be disciplined! Dig deep, and muster the resolve and stamina to review carefully. Enlist the help of your friends or support network to help you restore your confidence and keep you on track. It will be critical with this second set of scores to prove to your future residency that you had a bad day but redoubled your efforts and came back from defeat to triumph.

  The road to physicianhood goes through this checkpoint. You cannot get there without passing it, and you’ve come too far to turn back now.

  Resolve to win!

  PART FOUR

  The Clinical Years

  CHAPTER 16

  Life on the Wards

  Medicine is learned by the bedside and not in the classroom.

  Let not your conceptions of disease come from words heard in the lecture room or

  read from the book. See, and then reason and compare and control.

  But see first.

  —SIR WILLIAM OSLER

  AT LAST, YOU’VE left the breakwater of second year behind and find yourself rolling in the open seas of the real world of medicine. Already, the endless hours in the library and looming exams seem a blur, shadows of another life best left behind. Ahead lies the consummate adventure—and challenge—of actual patients in the wards and clinics. You’re about to discover what you’ve been waiting for.

  Welcome to the wards!

  Your schedule and your life will change dramatically as you enter the clinical phase of your training. The traditional September-toMay academic year will fall away, as will the arbitrary time constraints of quarters and semesters. Instead, your life on the wards will be governed by the sequence of your rotations and the service you’re on.

  At times, it will seem like you’re forced to reinvent yourself every six weeks as you assume a new persona, a new knowledge base, and a new set of responsibilities. But at the end of it all you will have had an experience virtually unparalleled in education—the opportunity to try on literally every facet of your profession and reach an informed decision about which clinical field interests you the most—and will become your chosen specialty.

  “I think the hardest part was often not knowing exactly what one’s role should be,” Carolyn notes. “In the preclinical classes, one is generally told what the student needs to do/read/study to prepare for the test and do well. On the wards, oftentimes no one tells the student what to do. I think that can be very unsettling.”

  ROTATIONS

  Your third year starts in June or July of the summer after your second year, so say good-bye to summers off. But by now, Step 1 is a receding memory from the spring, and you will find yourself driven with anticipation. You will probably have a week to two weeks of transitional class work followed by your first rotation. The actual sequence of your third-year rotations (or “clerkships,” as they are sometimes called) is given to you in the spring of your second year. Typically, you will first pass through a set of core, or required, rotations. Since only a few students can do a rotation at any one time, everyone’s sequence of rotations will be somewhat different.

  The classic core rotations include internal medicine, surgery, pediatrics, obstetrics and gynecology, and psychiatry. Many med schools now also require a rotation in emergency medicine, and some also require one in family medicine. The typical third-year rotation lasts six weeks, though individual rotations may vary. Vacations will be spaced out between rotations. You will usually work throughout the summer, have a week off in the fall, work until Christmas, have a standard Christmas break, then resume rotations in January with another week off in the spring.

  WHAT YOU NEED TO LEARN FROM YOUR ROTATIONS

  You will have two primary goals for each of your rotations. First, you want to develop a working knowledge of the fundamentals of each specialty. This will include a review of the relevant anatomy, physiology, and pathophysiology, a sense of the most common diagnoses and differentials, and familiarity with essential workups and basic management of patients on that service. You will be expected to be an active member of a team of students, residents, and attending physicians (faculty) seeing patients in clinics or caring for them on the wards. Second, with each rotation you will be expected to continue to refine your history-taking, physical-exam, diagnostic, and documentation skills. These are broad and universal skills, and each rotation will challenge you to refine these fundamental clinical tools and understand how they are applied by physicians in each specialty. You will be surprised by how differently each specialty views the elements of these basic skills. Over time, you will adopt and adapt elements from many different experienc
es and gradually develop your own practice style.

  Many people feel frustrated in their first few rotations because the information they spent so many hours memorizing during the preclinical years doesn’t seem applicable to the cases they’re seeing in the wards. The truth is, what you need to know is all in your head, but it’s organized differently. In the preclinical years, you were given a disease and expected to memorize all the details about it. On the wards, you will be presented with a patient who has a relatively nonspecific constellation of symptoms and be expected to deduce the disease from these clues. This is a wholly opposite way of thinking that will feel foreign at first but will grow easier and more comfortable with time.

  Oh, and there’s one more important thing:

  While the ultimate goal is to craft you into a knowledgeable and effective clinician, people do realize that you’re just starting out. In the beginning, you won’t be expected to know everything about clinical medicine or about the field you are rotating through. You won’t be expected to make direct life-and-death decisions about patient care without assistance and oversight. As you progress in your rotations and gain experience, you will be trusted with greater degrees of responsibility and independence.

  Remember that these programs are closely supervised. You’re not going to kill any patients with your decisions during a rotation.

  A TYPICAL DAY ON THE WARDS

  The experience you have on individual rotations will vary widely, but there are some general commonalities, particularly for your core hospital rotations. In the hospital, you typically will be divided into teams. Your team will most likely be composed of a single senior resident who oversees the team, one or two interns (first-year residents) who are responsible for the majority of patients on the service, and you. Initially, your role will be to assist an intern with the patients that he or she is responsible for. In your first rotation, you’ll take one patient at a time. As you develop more experience and expertise, you will start carrying more and more patients, until ultimately you will start carrying patients on your own with oversight only from the senior resident or attending physician. This gradual ramping up of responsibility will be a common theme throughout the rest of your medical training.

  Prerounds

  Your day on the wards will usually start early—very early! With most inpatient (i.e., hospitalized) patients, you will be required to preround. This means that for all patients to whom you’ve been assigned, you will review their charts, note any events that occurred overnight or since you last saw them, gather any new laboratory information, and review any intervening test results or X-rays. You will interview and examine the patients daily. Finally, you will record your observations, findings, and an assessment and clinical plan in daily chart notes, and if you’re smart you’ll run your thoughts past your intern to ensure that you’re on the right track.

  Sound like a lot to accomplish? Wait until you have to do it on six to ten patients—you’ll be expected to do that as a resident!

  The good news is, as with most things, you’ll get more comfortable with the process and become much more efficient over time. In the meantime you’ll have to arrive early enough to get your notes written before your team rounds begin, sometime between 6:00 A.M. (on many surgery services) and 9:00 A.M. (on various other rotations). When you start out, you’ll probably need to get to the hospital at 4:00 or 5:00 A.M. to complete your prerounds. Eventually, though, you’ll figure out ways to optimize your data gathering and minimize these early hours.

  “The hardest part about the transition to wards medicine was learning to multitask,” Kate notes. “Seeing multiple patients while trying to move efficiently through each patient exam and write a clear and concise note just took practice.”

  Rounds

  With your notes safely nestled into your patients’ charts, and with another cup of hot coffee in hand, you’re ready for the team rounds. This is the first and primary time during the day that you will meet with the entire team and review your service. Most services do walk rounds, also known’ as “bedside rounds,” during which you walk throughout the hospital visiting each patient on the service.

  When the team comes to your patient, you will be expected to give a brief presentation on that patient’s case. If it is a newly admitted patient, you will be required to present a complete history and physical exam, a diagnostic differential, and an assessment and plan. If it is a patient the team is already familiar with, you will just provide a review of the patient’s presentation of symptoms, an update on overnight events, and a review of the day’s labs and your physical findings. Finally, you will present an overall assessment of the patient’s condition and a plan for each item on the patient’s problem list.

  Your attending physician and senior resident will then ask you questions about the patient and the pathophysiology of the patient’s condition. This Socratic exchange between you and your superiors on the team is known as “pimping”—a daily cold-call on your medical knowledge base that is designed to expose and fill in any gaps in your understanding. Since you know this is coming, you should research each of your patients’ presentations to aid you in reaching an informed diagnosis.

  The best attendings will take these opportunities to teach and lead you to a better understanding of the diagnostic process and an effective treatment plan. Some attendings will, admittedly, be less forgiving and less gentle. Either way, you will learn immensely from the process.

  “Know your patients well—talk to them, learn about their symptoms and also about what they are like as people,” Carolyn advises. “Read about their diseases, understand what medicines they’re on and why. Practice your presentations so you learn how to present succinctly only the pertinent positives and negatives. Read about one topic (even if only a few pages) every day. Always be willing to help. Help your fellow classmates—being competitive with them is not pleasant and doesn’t look good.”

  At the end of your presentation you will make a list of the day’s action items for that patient. Your team rounds will typically take several hours, meaning your first respite won’t come until midmorning. This is when you will be expected to follow up on each of the action items on your patient, be it entering new orders for medications, following up on new tests, calling in consultations, or getting more history. You’ll then grab a quick lunch on the run and jump into the afternoon.

  Lectures

  As your afternoon begins, you will typically have a one-to-twohour lecture, usually given by the senior resident or the attending physician. These sessions will provide you with the bulk of the clinical teaching for the service you are on. During these lectures, you will review common complaints and disorders seen by that specialty and the most effective treatment programs for them.

  Clinics

  Later in the afternoon, depending on your rotation, you will also spend time in the outpatient clinics or in the operating room. If you’re in the clinics, you will be expected to go in and see scheduled patients in exam rooms on your own. You will complete your history and physical, then come out and present the patient to a senior resident or attending physician. That person will then pop in and see the patient, confirm your findings, and pursue the agreed-upon course of treatment. This will be excellent practice because it forces you to work through individual cases and try to reach your own conclusions before discussing the case with a superior. Furthermore, these are the long-dreamed-about moments when you’re alone in a room with a patient, and you are the physician.

  “At first I was quite anxious around patients, and I suspect they were also anxious with me,” Adam admits. “As I learned to project some confidence in my skills, I noticed my patients trusting me more. It is important to remember that patients are just people—they don’t always expect you to know everything. The most important skill to master is compassion.”

  Call

  You will also periodically take call with your team. If it’s a call day, that means your team is responsible for admi
tting patients to the hospital on your service for a twenty-four-hour period. You will spend the night in the hospital and assist with the initial evaluation and management of patients. You will be responsible to follow any patients you personally admit for your team. These are often long nights of little (or no) sleep. But these will be some of the most memorable experiences you will have in your entire medical-school career. Whisking the patient with the ruptured appendix off to the OR at 3 A.M., or helping a terminal cancer patient find relief and peace from his pain in his last moments of life are sobering, meaningful, and deeply gratifying experiences. True, you will also find yourself admitting patients with intractable back pain or patients who are angry at their illness and who want to take it out on you, and, yes, the sleep deprivation can be hard to adjust to. But it is precisely these long hours that will bring an appreciation for the broad spectrum of illness, the immense body of medical knowledge amassed to treat illness, and the subtleties and nuances of patient relations.

  This is what you went to med school for.

  The logistics of call are fairly straightforward. While on call, you will usually wear scrubs provided by the hospital. The pager that you imagined as a badge of distinction and used to dream of wearing will become an incessant, nagging voice on your hip. You will eat with your team between patients or whenever you get a chance. There will be a call room available with a simple desk and bed for you to use to complete paperwork or to catch a few precious minutes of sleep when you get the chance.