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Medical Education, SMS Unplugged

“It’s tough feeling like you’re always in a position to be judged” and other thoughts on medical school

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

One of the hardest parts about medical school for me has been the constant pursuit of approval. Having a pass/fail system during pre-clinical years helped ease things some, but there remains a personal desire to prove myself. In front of attendings, all I can focus on is performing my physical exam just right, presenting in the perfect manner, and nailing the assessment and plan. Unfortunately, my strong desire to look good in my evaluators’ eyes has led to missing learning opportunities at times. For example, I often passed up offers to do a procedure I really wanted to do, for fear that I would look bad if I messed up.

It’s tough feeling like you’re always in a position to be judged.

As I find myself in the middle of residency applications, I realize that this feeling of scrutiny has been elevated to a whole new level. And from this point, I’ll be judged on what is already done and how I’ve been evaluated on my rotations over the last few years. I can’t do anything more to change the “me” that those who review my application see. Part of the process is an interview, but it seems as if the interview has been taking place since I began medical school.

I’m extremely grateful for the training and preparation that Stanford has provided me, and I’m confident in my application – but the uncertainty is real. And the way I see it, my success with residency applications isn’t just reflective of me: I want to make my family and the Stanford faculty and mentors who have supported me along the journey proud.

As stressful as this process and the worry about judgment are, though, I’ve been trying to re-focus myself and “check my privilege.” To even be in the position of applying and interviewing for residency is huge. I’m months away from being able to put MD behind my name. As much as I could complain about how hard medical school has been, I’ve been blessed with a wonderful opportunity to be in a position to care for people when they most need it. And, in fact, of all the evaluations that we’re required to seek during a rotation, the ones I value most are from patients and their families.

For me, medicine comes easiest when my patients and their health outcomes are front and center in my mind -  not whether I stand out to my team or answer a tough question correctly. And so with my future patients in mind, it’s time to suit up (tie-clip and all). The work’s been done.

Moises Gallegos is a fourth-year medical student. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Photo in featured-entry box by Yuya Tamai

Health Disparities, Medical Education, Patient Care, SMS Unplugged

In medicine, showing empathy isn’t enough

In medicine, showing empathy isn't enough

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

SMS_image_072214As a medical student, it’s difficult to face a situation where everything possible is done for a patient, yet due to circumstances (seemingly) beyond our control, the risk of future harm remains uncomfortably certain. The majority of our medical school learning focuses on how to cure illness; unfortunately we’re not always taught how to deal with the real-world issues that face our patients and that threaten the medicine we practice.

This month I’ve been on my neurology rotation at Santa Clara Valley Medical Center, a county hospital with patient demographics quite different from those seen at Stanford Hospital. As I serve a more diverse and disadvantaged socio-economic population, it’s often the case that the information in the patient’s “Social History” section, which I usually quickly pass over, becomes a defining piece in deciding next steps. The 20-something-year-old with daily seizures because he’s so high on methamphetamine that he forgets to take his pills, the 40-year-old with left-sided paralysis who keeps checking in to the emergency department because she feels unsafe living alone in a trailer park, the 60-year-old who didn’t present to the hospital until days after suffering a stroke because he couldn’t physically get to the door to call for help: These patients demonstrate how social situations can make efforts to provide medical care at times seem futile.

In medical school, we’re taught the pathophysiology of disease and systematic approaches to medical management, but not how to deal with social contributors to health. (The latter is a not-so-glamorous aspect of medicine relegated to the hidden curriculum of clerkships.) During pre-clinical years we spend a lot of time discussing how to make empathy a part of our clinical skill-set, but a pitfall to practicing medicine in a way that is sensitive to a patient’s social context is the belief that showing empathy is enough. To express concern for a patient is different from really understanding a patient’s challenges. Things like the fear that drives a patient to repeatedly present to the emergency room for “inappropriate” reasons and the thought process behind not getting an MRI done since it would mean missing work may not fit traditional logic, but they represent an important piece in delivering care.

What can’t be taught in school is an inherent understanding of the difficulties that some patients face, which is why the push for future physicians to be individuals representative of the various backgrounds that patients come from is so important. (It can be surmised that students who have endured these difficulties, themselves or through family, socio-economic or health related, could better relate to patients they come in contact with.) While socio-economic demographics are easily seen on paper, though, what is harder to select for and recruit is the student who has lived the real-world environment characterized by social issues like multiplicity of chronic illness, housing insecurity, and financial hardship. And, of course, many students in this very position never make it to the point of training for a health profession as a result of the very hardships that make them more attune to the social issues that may contribute to poor health.

Medical school recruitment has changed in ways that will hopefully improve diversity of recruited students and contribute to a greater understanding of the background of all sorts of patients among health-care providers. However, more still needs to be done to support students from less-traditional and under-represented backgrounds so they reach the point of applying in the first place. Instead of being discouraged by their less-than-ideal journeys to medical school, students who have endured educational, financial, and social hurdles should be encouraged to use their learned experiences as a frame of reference to positively impact the delivery of health care.

Moises Gallegos is a medical student in between his third and fourth year. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Drawing by Moises Gallegos

Medical Education, SMS Unplugged

Student transitions in medicine: putting blinders on

Student transitions in medicine: putting blinders on

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category

MCAT2MCAT, AMCAS, NBME, USMLE, NRMP, ERAS. These abbreviations are a bane for many students of medicine, pre-meds to fourth-years, during the summer months. Nervous excitement tingles in the fingertips of undergraduates and post-bacs as they complete their personal statements and prepare to submit MCAT scores and AMCAS applications to medical schools. Pre-clinical students straddle the fence between longing for more time and desiring to hit the fast-forward button as their Step 1 date nears. Clinical students revel in leaving behind the classroom, only to realize there’s a mountain of medicine before that they’ve yet to learn. And final-year students like myself are beginning to suit up, prepping once again to tackle the adventure that is application season.

This past month I’ve been e-mailing with several undergrads whom I’ve had the privilege to meet: bright future physicians who are taking the plunge and applying to medical school this cycle. Reading their personal stories, seeing their ambition and hearing their excitement brings me back to when I was in their shoes. I remember the insecurities of the time, feeling as if my story wasn’t good enough and that I hadn’t done enough for my résumé to reflect my professional desires. Sadly, my excitement was overpowered with fear. I couldn’t turn to my family as I was the first to even attempt such a thing, and I was too embarrassed to seek out professors.  Ultimately it was the support and guidance from peers who had been through the unknown that helped me the most to persevere. It’s because of this that I contribute to efforts providing support along the path to medical school through mentorship, especially for students from socioeconomic groups traditionally underrepresented in medicine.

As I head into residency applications, I’m finding myself reliving the same  insecurities that I’ve been telling my former mentees to ignore. What I realize is that I’m making the same mistake I try to help them avoid: I’m drawing comparisons. I see the people who I’ll be “competing” with for residency spots, and I begin to weigh the differences between my application and theirs (as if I know everything about them). Mentorship is easy when it’s between people who are on opposite sides of the transition in question, but not so much when you’re going through it simultaneously.

This is where Stanford’s shift away from the traditional grading paradigm has helped me. What refocuses me when I find myself getting caught up in comparing myself to other students is telling myself they’re not just “other students” and we’re not “competing.” With no grades, rankings or honor societies that commonly create competition and division, I was allowed from the beginning to focus on making friends, colleagues and support systems. Yes, we may be applying into the same fields at the same time, but we never contended before, and it won’t happen now.

It can be easy to get overwhelmed during the seemingly never-ending application steps of a medical career, but I think it’s important to remember what this first-world problem represents. The medical education-training pipeline may be marked with hurdles and stressors, but reaching the finish line is a blessed opportunity; we’ve been given the chance to be part of a profession that will allow us to interact with people in beautiful, challenging and often life-changing ways. We just have to “focus-up,” “put blinders on,” and “do work.” ERAS, here I come.

Moises Gallegos is a medical student in between his third and fourth year. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health. 

Drawing by Moises Gallegos

Medical Education, Medicine and Society, Patient Care, SMS Unplugged

Bridging the disconnect in health care

Bridging the disconnect in health care

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Moises connection sketchMy family has always expressed that they’re proud of what I’m doing – the funny thing is, they go on to say that they’re unsure of exactly what I do.

My parents know I’m studying medicine and that this means I’ll be a doctor. What they don’t get is where in the process I am, what specializing means or what I’m talking about most of the time when I share stories from school. Perhaps the unfamiliarity results from them not being exposed to the general structure of professional training, or it could be that the U.S. health-care system is simply a bit confusing. I’ve tried explaining to my aunts and uncles the process of going from college to medical school to residency. “Okay,” they respond, “but when can we call you Dr. Gallegos?” Adding one more ingredient to the mix, I took a year away from medical school to get a second degree.

Even though I’m not “Dr. G” yet, four years of medical and public-health training are worth something. I know enough to be helpful on a medical team, in patient encounters and to my family. Having family members approach me with medically related questions is both empowering and humbling. My family has played a large role in the support system that has helped me get to where I am today; to pay back by sharing some of the knowledge and skill I’ve gained along the way feels great. I have to remind them constantly that I’m not in a position to offer definitive advice, but they still appreciate the context-framing guidance from my simplified explanations. A doctor yet or not, I’m a resource for them to better understand their health and how to maintain it.

These family experiences remind me of one of the reasons I felt an urge to enter medicine: the disconnect. My parents, aunts, uncles and majority of cousins are first generation in the United States. They come from meager means and little exposure to medical care and health education. As such, they haven’t had the most positive experiences in pursuit of health care. Growing up, I witnessed plenty of challenging encounters between my family and health-care providers. Without the need to assign blame, I think several negative experiences were reflective of a mutual misunderstanding. My family being unsure about the functionality of the health-care system and the meaning of illness likely didn’t help the provider, who was unaware of my family’s need for extra guidance, education and reassurance. A patient labeled non-compliant may better be characterized as non-adherent – the difference is understood when the disconnect is acknowledged.

This last point is ever so important regarding the Affordable Care Act. Many people in the U.S. haven’t had the chance to develop an understanding of the health-care system or grasp what constitutes good or bad health. New access to health-care coverage doesn’t mean that people will magically be able to navigate the system. In my career I hope to carry the lesson my family has helped me learn: As a health-care provider, I must consider the level of understanding of my patients so that I don’t exacerbate, but rather bridge, the disconnect on matters of health.

Moises Gallegos is a medical student in between his third and fourth year. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Medical Education, SMS Unplugged

My fifth-year comeback

My fifth-year comeback

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

gallegos_blog3In a little over a month I’ll be finishing my master’s program; 10 days later I start the first rotation of my fourth year. I’ve begun to feel a mix of emotions. Anxiety as I review medical topics, trying to bring them out of distant corners in my memory where (I hope) they still exist. Excitement at the idea of getting back to patient contact, which even through the stress of being a medical student I have never doubted is where I want to be. To psych myself up, I’ve reflected on the clerkships that I’ve completed (read: survived); below are lessons, encounters and unforgettable moments that I’m blessed to have experienced.

Pediatrics: Yes, it was difficult to see kids when they were sick. It was also hard to complete a physical exam on fussy children. The laughter and high-fives made up for both, though. Even patients with chronic illness were inspirational, resilient and great to sit and talk with. What made my peds rotation even better: the wooden heart that a patient decorated for me, thinking that I was her “real doctor.” Win.

Psychiatry: While I completed my rotation in a locked ward, I never felt threatened around the patients. On the contrary, I was surprised by the connections that I formed with them. My takeaway memory:
Me to my wandering schizophrenia patient: “Mr. H, do you know where you are? What day it is?”
Mr. H: “Yes, I do… Why? Are you not oriented yourself, Sir?”
Given how tired I was at the time… likely not. Touché.

Ob/GYN: At the risk of sounding pretentious, I’m proud I can say that I’ve helped bring life into this world. Childbearing and childbirth, in its complexity, is beyond beautiful. Overwhelming? Yes. Amazing? Definitely. I wasn’t able to convince any new mothers to name their children after me, but I was offered a job as a birthing nurse given my awesome coaching skills. We’ll see how med school works out.

Family Medicine: The level of connection  between the doctors I worked with and their patients was incredible. Working to address all the patients’ issues in short appointments was trying, and often impossible, but the gratitude of patients was humbling. It was interesting, too, to see the incorporation of complementary medicine – and try it out. Acupuncture? Check.

Surgery: The smell of post-op infections is something I’ll never forget. So is the time a grateful patient stopped me in a hospital corridor to remind me that I placed an NG tube for him (with success). Beyond unforgettable: massaging a patient’s heart through their chest after a thoracotomy. I don’t see myself as a future surgeon, but I respect the skill. Also hard to forget: tying many, many, knots (mostly on strings attached to nothing).

Medicine/Sub-I: The hardest yet most instructive month of my life. The level of responsibility for patients was overwhelming and empowering. I oversaw patients from tears on admission to smiles on discharge. I experienced for the first time the death of a patient along with a deeper connection with his family than I would have thought possible as a student. I don’t miss my pager going off many times, but I do miss that patients asked for me.

Going into clerkships I felt uneasy about being in a position to care for people given that I was still in the process of learning medicine. What I’ve come to realize is that often the medicine I learn in books is best utilized alongside other care we can offer: a conversation, an inviting smile, a genuine concern. I can’t wait to wear my Medical Student badge and white coat again.

Moises Gallegos is a medical student in between his third and fourth year. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Photo box courtesy of Moises Gallegos

Medical Education, SMS Unplugged

Defining my own academic and community medicine

Defining my own academic and community medicine

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Gallegos sketchWhen I picture my future career, I see myself more as a community physician with a foot in academia than as an academic physician with a habit of finding himself in the community. Working in a county hospital and being involved in community-health programs have always been desired and natural end goals for me.

In college, while fellow pre-meds sought out laboratory research and publication opportunities, I was most content teaching health-education workshops in public high schools. In medical school, while others worked in clinical science labs, I chose to work as a health navigator in a clinic. I value the concept of biomedical research and its contribution to medicine as we understand it, but I feel more at home in community outreach than I do in lab research.

Academic medicine has traditionally been centered on advancing clinical and physical sciences, and knowing this wasn’t an interest of mine, I began to see it as something  perhaps I shouldn’t be a part of. I worried that academic medicine might draw me away from community involvement and, worse yet, I met professionals who felt I should focus on academic medicine or community medicine, unconvinced that I can do both.

But yet, I also enjoyed the innovation, the cutting-edge practices, and the game-changing discoveries that come from academic medical centers. And I came to realize that academic and community medicine actually aren’t mutually exclusive – it’s just that the traditional definitions I have of them imply they are. Unfortunately these were the definitions I brought with me into medicine, a consequence of the misrepresentations that exist at the pre-med level.

It was the advisors, professors, and students who make up the Community Health scholarly concentration at Stanford, through their approach to medicine, that showed me a redefined possibility for academia in community health. Currently, as I work on my Masters of Public Health I’m also looking to redefine the potential roles I can take as a physician. And as medicine and public health continue to embrace a synergistic approach to caring for people, I’ve tried to adapt my view of what being an academic physician can mean. While I may not be meant for research dealing with pathogenesis of disease, biophysical properties of medications, or stem cell innovation, I envision my role in understanding and developing the practical delivery of medicine, studying health-care use patterns, impact of health education, and health-needs assessments on a community level.

Lloyd Minor, MD, recently wrote in his “Letter from the Dean” that, “On an institutional level, we are striving toward excellence in patient care by building a network of care that gets our specialists out into the community and brings high quality physicians from the community into Stanford Medicine.”

Validating my career goals, Dean Minor recognizes that community experience is as essential to complete health-care delivery as academic experience, and that we need to strive to create an exchange of skills and service between the two. Academic inquiry in the community setting is necessary to inform best practices and better serve the target population of health interventions. In turn, community experience is important in the academic setting to better inform policy and directionality of health-care changes to ensure the most vulnerable populations are not forgotten.

I don’t see myself in the traditional academic role, marked by research, publications, and tenure tracks, but more as a physician learning skills in the academic setting to use more directly in the community, serving groups that might otherwise not be exposed to health professionals with such training.

Moises Gallegos is a medical student in between his third and fourth year. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Sketch by Moises Gallegos

Health Disparities, Medical Education, Public Health, SMS Unplugged

In between: Learning medicine beyond the hospital

In between: Learning medicine beyond the hospital

Gallegos image - smallSMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

My upbringing and career goals can be summarized as a collection of “in betweens.” I was middle child in a family that was first generation in the United States, and I grew up bridging my parents’ history in Mexico and the American Dream they hoped for. I was raised in Pasadena, Calif., enjoying the perks of an affluent suburbia but witnessing the challenges my parents faced as low-to-middle-income laborers. I had little dental or medical care as a child, as health insurance was inaccessible and my parents were unable to pay out of pocket. I grew up in between socioeconomic lines, blessed by my parents’ sacrifices to support me as the first person in my family to pursue higher education, but aware of the struggles that poverty creates.

One of the reasons I decided to pursue medicine is a desire to serve as a connection between the underserved poor and health care. I wanted to translate my experiences growing up in a Hispanic household without health insurance and with little knowledge of the health-care system into a career meant to empower underserved populations and improve their overall health. However, the image of the health provider I desired to be was at one time very narrow.

Initially, I was focused on making my way into the hospital, unaware of the health impacts that come from other fields. But through a series of undergraduate courses and extracurricular programs, I discovered the impact that public-health interventions, policy and ideology can make. I came to realize that in order to address health-care needs, it’s important to understand the circumstances creating them. It’s not just about dealing with high blood pressure, obesity and mental health – it’s about drawing awareness to their causes and coming up with ways to prevent them. My career goal became to position myself between providing direct patient care and defining health prevention and maintenance practices.

When I was deciding where to go to medical school, I initially dismissed Stanford. I felt its lack of a public health school would hinder my goal of becoming both a health-care provider and a health-care promoter. Second Look Weekend not only dispelled this false vision of Stanford, but also introduced me to the Stanford that I’ve come to value highly: a center of excellence that positions itself between academic medicine and community outreach, and between scientific advancement and public health empowerment. From learning about social determinants of health in the Community Health scholarly concentration, to providing services such as health education through free clinics, Stanford creates an environment to learn about and participate in numerous public-health approaches. In doing so, it exemplifies what I believe is important in defining what the future of medicine is: caring for people and communities before and beyond the hospital.

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