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Countdown to clinics: The 5 best things about jumping into third year

Countdown to clinics: The 5 best things about jumping into third year

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.  

cake2Here at SMS Unplugged, we’ve been counting down to July 1, when current second-year medical students make the leap from pre-clinical to clinical trainees – arguably the most formative transition in medical training. We started our countdown with the most challenging aspects of the third year transition, and continued with the most pleasant surprises. Now that the long-awaited day is finally here, we present the final installment in this series: the best parts about jumping into third year.

5. Reclaiming your mornings
The silver lining of early mornings on the wards is the moment around noon every day when you realize that you and your team have completed almost a full day’s work. Of course the day is only half over, but still: Third year will make you into an early-morning All-Star (whether you like it or not).

4. Medicine as a survey course
As difficult as it is to start an entirely new rotation every few weeks, there’s something to be said for being a ‘chameleon’: blending in wherever you go, sampling a little bit of everything and entering each rotation open-minded. Hate suturing wounds? Don’t worry, surgery rotation will be over soon. Had second thoughts and can’t wait to get back to the operating room? Good news – it’s only a matter of time until a surgery elective comes around.

3. Delivering babies
Each rotation has its own highlights, but obstetrics and gynecology takes the (birthday) cake. Even those of us who are headed toward a different specialty can always look back and say our hands helped to guide a new life into the world.

2. Everything is interesting
For all the agonizing about picking a specialty, there’s another side of the coin: When everything is interesting, it’s hard to go wrong by picking one over the others. And for those who truly can’t make up their minds, there are fields like Emergency Medicine that still see everything.

1. Finally doing what you signed up for
After two years of studying for and taking an endless array of multiple-choice tests, it’s time to start doing what you signed up for: seeing real patients with very real needs. One of our professors would start morning rounds every day by saying, “Let’s go save some lives!” He was only half joking.

To all the new third-year students out there: Congratulations and welcome to clinical rotations!

Mihir Gupta is a third-year medical student at Stanford. He grew up in Minnesota and attended Harvard College. Prior to writing for Scope, Mihir served as co-editor in chief of H&P, Stanford medical school’s student journal.

Previously: Countdown to clinics: 5 pleasant surprises of jumping into third year and Countdown to clinics: 7 challenges of jumping into third year
Photo by Kimberly Vardeman

Medical Education, SMS Unplugged

Countdown to clinics: 5 pleasant surprises of jumping into third year

Countdown to clinics: 5 pleasant surprises of jumping into third year

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.  

this wayHere at SMS Unplugged, we’re counting down to July 1, when current second-year medical students will make the leap from pre-clinical to clinical trainees – arguably the most formative transition in medical training. We began with the most challenging aspects of the third-year transition, involving early mornings and the emotional demands of confronting morbidity and mortality on a daily basis.

But for every new challenge, there comes at least one welcome surprise. Above all else, third year is a time of professional and deeply personal discovery. Systematically rotating through every major medical specialty is a tour of the health-care system that we may never experience again. And it’s during third year that we decide which specialty to pursue – a choice that will have an impact on the rest of our lives.

With that in mind, we continue our countdown with the most pleasant surprises of third year.

5. Productive confusion
There are two types of students entering third year: those with a short list of specialties they’re interested in, and others who are open to exploring the wide world of medicine. But even the most focused students can end up somewhere vastly different than they’d originally planned – much to the relief of those of us who hadn’t decided on a career path. Every rotation is truly fascinating, to the point where even the best laid plans suddenly come into question. Discovering that you’re interested in (and maybe even good at) something completely new is a great feeling, even if it derails the career you mapped out at the start of medical school.

4. You know a lot more than you think
Third year is notorious for constantly pulling the rug out from under you: As soon as you start to feel competent on a rotation, it’s on to the next one, which reminds you just how little you know. But in spite of spending most days struggling to speak the language of a new field, students also have a wider knowledge base than they realize. A seasoned resident or faculty member will have command over the information specific to their field – but if a patient has an issue the expert doesn’t remember from their own medical school days, suddenly the student becomes the teacher.

3. Nurses are not doctors… or are they?
Although the role of mid-level providers has sparked significant controversy recently, one thing is clear: Nurse practitioners and physician assistants have a lot to teach us. One big lesson I learned during third year is that high-quality patient care takes a lot more than just a professional title or even a great medical or scientific knowledge base: diligence, leadership and a certain degree of savvy in navigating a complex health-care system are required. We don’t learn those qualities in medical school lectures; we’re expected to pick them up on the wards. And as any third-year can attest, nurses and physician assistants are often the best teachers in the clinical setting. It’s humbling to realize that MDs aren’t the only ones who can make decisions in patient care. But it’s also refreshing to realize that we’re not alone in that undertaking.

2. The prescience from standardized patients
Pre-clinical students work with ‘standardized’ patients – actors who simulate a variety of clinical encounters. It feels a bit odd to practice (and be graded on) seemingly obvious interaction skills like introducing oneself, listening carefully or letting the patient speak. I didn’t fully appreciate those lessons until I observed a senior physician bluster into a patient’s room without any introduction, deliver a 10-minute soliloquy on her prognosis and leave without asking if she had anything to say. As it turns out, she did: “You were talking to the wrong patient.”

1. The person waiting for you at the end of the year
You’ll meet hundreds of patients, physicians and nurses over the course of the year, but the person you’re looking for all along is the one in the mirror. The best surprise of third year is discovering not just your interests, but your talents, passions and even weaknesses. As one of my classmates said, “It’s like being in a movie, but you get to write the ending.” And no adviser, professor or countdown list can spoil it.

Stay tuned for the final installment in this series, when we’ll count down the most rewarding parts of third year. To all the second-year medical students out there: Good luck and keep your chin up!

Mihir Gupta is a third-year medical student at Stanford. He grew up in Minnesota and attended Harvard College. Prior to writing for Scope, Mihir served as co-editor in chief of H&P, Stanford medical school’s student journal.

Previously: Countdown to clinics: 7 challenges of jumping into third year
Photo by Dave Catchpole

Medical Education, SMS Unplugged

Countdown to clinics: 7 challenges of jumping into third year

Countdown to clinics: 7 challenges of jumping into third year

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

diving into waterRecently, on Match Day, medical students around the country learned where they would land for residency. But the fourth-years aren’t the only ones graduating; the current second-year medical students are leaping from pre-clinical to clinical trainees.

If you haven’t heard from your second-year friends recently, they’re probably studying for the Step 1 Board exam. Before starting clinics, students must pass the exam that tests two years’ worth of knowledge and generates a score that will stick with them until their own Match Day. Beginning clinical rotations is a step that feels as big as the one from medical school to residency, albeit with less fanfare.

Third year, like residency, traditionally starts on July 1. It marks the time when doctors-in-training finally start doing what we signed up for: actually doctoring. No more patients-on-paper; third year means real patients with real issues, many of which the pre-clinical curriculum doesn’t teach. No more spending all day in class and studying at home all night; third year means spending all day in the hospital, and then studying at home all night. And no more summer break; third-years transition to the year-round world of working adults.

Here at SMS Unplugged, we’ll be counting down to July 1st with a three-part series about the soon-to-be-clinical student experience. Below are seven challenges of starting third year.

7. The early mornings
Medical students usually arrive even earlier than residents, in order to “pre-round” on patients before making rounds with the full team. Be prepared for at least a few months of reaching the hospital at 5 AM – or earlier. If you’re not a morning person already, you will be soon.

6. Making decisions
Putting on the white coat is a privilege that comes with huge responsibilities. It’s jarring when someone calls you ‘doctor’ and asks you to make a clinical decision: Is it OK for the patient to eat? When can we turn off their IV fluids? What’s the plan for pain medications? It doesn’t matter that you’re still a student, or that you’re only on each rotation for a few weeks – just long enough to start feeling competent before starting over elsewhere. Third year students have to learn fast, or at least think of a few ways to say, “I don’t know. Let me ask the resident.”

5. Not making decisions
Thankfully, most clinical decisions aren’t in the hands of medical students; a resident or faculty member must approve every order. But that, too, poses a challenge for medical students. It’s easy to get complacent when someone else is calling the shots, and it’s frustrating to feel vestigial when it comes to most aspects of patient care. Much of third year is an exercise in finding a way to be useful, or playing catch-up to figure out why the team is doing things a certain way.

4. Being judged
Anyone in medical school is familiar with the rigors of earning strong grades. But third year grades, which feature prominently in residency applications, are not just objective performance measures. They also include a major subjective component, and so enter the gray area between being graded and being judged. While most medical schools carefully review subjective evaluations for fairness, it’s possible that rubbing one resident or faculty member the wrong way can submarine a student’s chances for a high grade on a rotation. This is compounded by the problem of small sample sizes: An evaluator may only interact with a student for half a day, and sometimes not in any meaningful capacity. Third year involves not only assimilating clinical knowledge, but also navigating personalities and being under a microscope constantly.

3. You’ll never get this training again
Unless you’re going into obstetrics, third year might be the only time you get to deliver a baby. And unless you’re heading toward surgery, you may never suture another wound. (Until years later when you’re in a parking lot and a woman suddenly goes into labor, or on a camping trip when a friend falls and needs stitches.) There’s a huge sense of accomplishment after each rotation, mixed with anxiety – even if you don’t plan to use it again, you have to remember this stuff for the rest of your life.

2. The times nothing can be done
One eye-opening part of third year is seeing what modern medicine can’t do. Doctors can image the body with exquisite resolution and treat cancers using genetically tailored therapy. But even the greatest physician can only watch as an end-stage leukemia patient slowly passes away while on hospice care. Even idealistic students may question whether they can do this every day. And everyone will (hopefully) find a source of stress relief, a safety valve that keeps them going and prevents burnout.

1. The anticipation
You worked for years to get into medical school, memorized tomes for two long pre-clinical years, made it through Step 1, and now it’s the evening before your first rotation starts. If you get any sleep that night, you’re ahead of the curve. But if you can make it to it, you can make it through it.

Stay tuned for the next two installments in this series, when we’ll count down the most surprising and most rewarding parts of third year. To all the second-year medical students out there: good luck and keep your chin up!

Mihir Gupta is a third-year medical student at Stanford. He grew up in Minnesota and attended Harvard College. Prior to writing for Scope, Mihir served as co-editor in chief of H&P, Stanford medical school’s student journal. 

Photo by Mike Baird

Medical Education, SMS Unplugged

The OMG Factor: Curbing your enthusiasm during clinical rotations

The OMG Factor: Curbing your enthusiasm during clinical rotations

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.

stethoscope on shirt - medium I had never seen my young cousin sit so still. “What did you do?” my aunt wondered, amazed that her hyperactive twelve-year-old had been transfixed for nearly an hour. “Were you two playing video games?”

“Actually we were just talking about some of the things I learned in medical school. He’s really interested,” I told her. Indeed, he hadn’t even touched one of the delicious samosas we were eating. Every time he picked one up, he thought of another question or exclaimed, “OMG. The body can do that?”

He wasn’t the only one getting excited. I had barely been in medical school for a few months, and was being exposed to the wonders of human biology on a daily basis. Whether beautiful or frightening, it was all fascinating – and like my cousin, my classmates and I consumed it with the voracity otherwise reserved for a savory samosa.

At the same time, we learned to comport ourselves appropriately in the presence of patients, to contain our enthusiasm when faced with exotic diseases. First with patient-actors and then hospitalized patients, we learned to treat patients as people instead of diagnoses, and to be empathic even while being enthralled. Upon starting clinical rotations two years later, though, it became increasingly difficult to do so.

On one of my first evenings on call, I was sent to see a patient with appendicitis. “It should be straightforward, a really textbook case,” said the resident. The case was indeed straight out of a textbook, but not from the chapter about the appendix. I found myself staring at a man nearly seven feet tall, with the characteristic hollowed-out chest, spidery fingers and long limbs of – “Yeah, Marfan’s Syndrome runs in the family,” he said. “Every doctor stares when they first see me.”

I tried to never repeat my mistake, but sometimes it’s hard not to stare for at least a moment. In fact, students are often asked to do exactly that as part of the physical exam. Take the physical exam rounds, when a faculty member takes students to see patients with findings appreciable by careful examination. Even when those rounds are lead by the most empathic physicians, it’s hard to ignore the fact that we are not contributing to the patient’s care and do not even know much of their story. Rather, we walk into their room only to palpate a spleen or see a Babinski sign.

Not staring isn’t easier to do even on surgical rotations with less face-to-face patient interaction. During one operation, a neurosurgeon used an endoscope to navigate the deep recesses of the brain. While gazing at the anatomy that even the best textbooks don’t show in such rich detail, I forgot to breathe and nearly passed out.

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Sleep, SMS Unplugged

Sleep on it: The quest for rest in the modern hospital

Sleep on it: The quest for rest in the modern hospital

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.

hospital bed cornerI first saw it on the face of a resident at the end of a 24-hour shift. And then again on the weary visage of a nurse after a whirlwind shift in the emergency room. Soon it was written across my own brow: The expression that said, It’s time to take a break. But as I soon realized, it wasn’t just the students, doctors and nurses who were struggling to get enough rest.

“It’s impossible to get any sleep here,” remarked one patient whom we awoke on early morning rounds. “There’s just constant disruption. I don’t feel like I’m healing.”

“Is there anything we can offer him besides sleep medications?” I asked the supervising physician after we left the room.

“Everyone says they can’t sleep,” he replied. “Unfortunately it’s just part of being in the hospital.”

I often ask patients to suggest one thing we can improve in their medical care. An overwhelming majority of them comment on the lack of peace and quiet. Perhaps the most memorable example was an elderly gentleman hospitalized for tuberculosis. Even in an individual room with airtight separation from others (“respiratory isolation”), he couldn’t go more than a few minutes without being disrupted. Doctors and medical students started their morning rounds before sunrise, vital signs were measured every four hours (including at night), and nurses constantly came in and out with meals and medications. He lamented, “The only thing I want to do is sleep. But as soon as I do, someone else comes in.”

Hospitals didn’t always used to be hectic. In fact, restful environments were long thought to have healing properties. Early in the 19th century, the French physician Laennec noticed lower rates of tuberculosis in seaside communities away from the hustle and bustle of the city. Wanting to bring a piece of that environment to his urban-dwelling patients, he began putting ocean seaweed under the beds of Parisians. More recently in the 1940s, a popular treatment for tuberculosis and other serious illnesses was the ‘sanatorium.’ Patients enjoyed the fresh air of the countryside, where it was thought they could rest and give their bodies a chance to build protective ‘walls’ around the infected nodules in their lungs.

The advent of antibiotics around the time of World War II brought a rapid end to seaweed, sanatoriums and other similar remedies. Nowadays, it’s easy to look back and chuckle at the idea of trying to cure tuberculosis by lying in a bed on the seashore. But it’s also increasingly difficult to justify the (somewhat) controlled chaos of today’s hospitals – an environment that is at best claustrophobic and at worst dangerous. After all, the benefits of a good night’s sleep have been proven beyond the shadow of a doubt. And numerous studies show that many people live longer and healthier if sent home instead of staying in the hospital with the exact same disease. Granted, much of the benefit of going home lies in avoiding exposure to others with contagious infections. But after seeing innumerable patients exhausted from being poked and prodded around the clock, it’s hard to shake the thought that the hospital environment itself may be more pathologic than we once believed.

Many of our clinical mentors came to this realization long ago, and teach us on a daily basis how mindful doctors can buffer patients from the stresses of a bustling hospital. Of course, helping someone to rest comfortably is more easily said than done. But as students, we can at least identify role models who are the kind of physicians we want to be – physicians who notice when a patient is sleeping and decide, “I’ll come back later.” Or those who notice when someone is exhausted and ask, “What can we do to help?” And if we can help patients sleep a little better, maybe – just maybe – their doctors will too.

Mihir Gupta is a third-year medical student at Stanford. He grew up in Minnesota and attended Harvard College. Prior to writing for Scope, Mihir served as co-editor in chief of H&P, Stanford medical school’s student journal.

Photo by oddmenout

Medical Education, SMS Unplugged, Stanford News

You are what you read: The academic diet of the 21st-century medical student

You are what you read: The academic diet of the 21st-century medical student

Gray's Anatomy - 260SMS (“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.

A recent survey published in H&P, the Stanford medical school magazine, asked twenty graduating students to recommend books to read during the clinical rotation in internal medicine. Surprisingly, the top vote-getters weren’t books at all. The two most popular resources were both banks of practice questions, while the next two included a review book and a pocket handbook. (The top four resources: MKSAP question book, USMLE World question bank, Step Up To Medicine review book, and Pocket Medicine.)

“Is this how our students learn the subtleties of sickness and health? What happened to textbooks? We had to read Harrison’s Principles of Internal Medicine cover to cover!” remarked one professor after reading the survey.

For what it’s worth, Harrison’s did receive one vote in the survey. But the results reveal a profound generational change in how medical students are learning the fundamentals of human health and disease. The recent explosion of printed and digital resources offers students alternatives to the classic texts that previous generations swore by. As a result, medical tomes are no longer the primary means by which students learn medicine, but just one piece of an increasingly complex puzzle.

Medical school is often compared to drinking from a fire hose; the student’s job is to imbibe as much knowledge as possible without getting bowled over. This is not a new phenomenon. Western physicians have been producing vast compendia of knowledge for millennia. The ancient Greek physician Galen published hundreds of treatises, aided by an army of scribes and students who recorded his every word while he saw patients.

The modern academic physician also leads an entourage of student doctors during daily rounds. But instead of scribing away on scrolls or stone tablets, today’s trainees scroll through their web browser on tablet devices. While one resident looks up drug dosing on UpToDate, her colleague consults Diagnosaurus to make sure he didn’t miss anything in the differential diagnosis. Meanwhile, the medical student quickly does a practice question on the USMLE World online question bank to test if he really understands the treatment algorithm.

The shift away from voluminous texts starts early in medical school, when the first exams come up before any of us has made it all the way through Gray’s Anatomy. Students opt for streamlined review books and digital resources in part because they are, well, streamlined and digital. Instead of reading about each step in the Krebs cycle, download an app with vivid pictures and animations. Instead of lugging a cardiology textbook to the library, go for a run while listening to a podcast about congestive heart failure. And if Google doesn’t have the answer, consult the online version of Robbins Pathology (soon to be powered by Google).

Students also point out that reading textbooks is “passive learning,” which many studies have shown to be less effective than “active learning” such as answering quiz questions. Others may want to tailor resources to their individual learning styles; visual learners frequent websites like SketchyMedicine and Picmonic, audiophiles stock up on lectures from iTunes U. Medical schools (including Stanford) even collaborate with web-based platforms like Khan Academy to digitize their curriculum.

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