What third year is all about.

During the third year of medical school, the med student is a rare form of human being.

"You are here to learn" they tell you. What they don't tell you is that you are here to help out, but don't get in the way and don't be too overzealous. You are here to report your findings but no one will actually listen to you, they will only wonder why your presentation isn't exactly how they like it (and everyone likes it differently). They will quiz you on the stuff you learned in the first two years, and when this happens, a couple of things become clear: 1- you know more than the residents, 2- you are being judged for every stupid answer you give. They ask you questions, but you're not supposed to always answer them, because then you're a know it all. But if you don't answer the questions, you are not a competent medical student. You have to be professional, be on time, and be okay with standing around with no clear directions on what you're supposed to be doing. You have to meet the expectations of all of the different attendings in each of the different specialties- some will let you do everything and others make you follow them around and never leave you alone with the patient. Some want you to present the patient to them as a whole, and others just want to know about the patient's particular disease, right now, today, and everything else is extra information that the idiotic med student is giving and wasting everyone's time with. Some of them want you to go and do all sorts of irrelevant physical exams "just for pratice," regardless of the degree of distress the patient is in. Some patients know this, and they've already had 2 other people come in and do their physical exam, so they refuse to let you touch them. And then when you go back and say what happened, it's your ass. Why? Because "this is a teaching hospital and patients know that." It doesn't matter that the woman in room 4 is depressed and alone and scared. Go make her touch her nose and your finger and ask her to repeat 3 words back to you and make her walk on her tip toes and listen to her bowel sounds and poke her all over.

On the other hand and on a brighter note, the third year med student gets to sit in the room with a patient for an hour or more. No one is relying on the third year med student to write any orders or actually take care of anyone. It is a chance to connect in a way that no one else on the team can. The third year medical student is learning every day. Learning and integrating the past two years of hard work. Seeing why we needed to learn every cross section of the brainstem and the names of all of the major drugs and drug classes and the reasons why certain diseases do what they do.

The learning goes beyong academics, though. You also learn, through first-hand observation, what kind of physician you want to be, and what you don't want to be. I have seen some truly insensitive, awful physicians and residents. The things that scares me the most is those physicians who have forgotten to look at people in the eyes. Or maybe they never did. The ones who have forgotten that each patient is a person, not a disease. The ones break awful news, such as "you tested positive for HIV" without asking the patient if it's okay to say that in front of a family member who is in the room. Without asking the patient if it's okay that 2 med students and 3 residents are also in the room. Without any concern for the fact that on the other side of a thin curtain, there is another patient in the room. Without going through anything that looks remotely similar the breaking bad news protocol, SPIKES, that we learned in our second year of med school. I can't remember what SPIKES stands for (ok, shame on me), but essentially, you prepare the patient to hear the bad news, you ask them what they know about the disease, you ask if they're ready to hear it. You show a shred of human emotion and look them in the eyes when you tell them.

I understand that for the sake of efficiency and in order to be fair to other patients, physicians can seem a bit cold and impersonal. But just because I understand it doesn't mean I will accept it.

I look forward to meeting more and more physicians who are not monsters, who are not jaded, who are not cold and impersonal. I have already met a few role models, and I am excited to meet a few more. Even the non-role models are good to have. They serve as reminders of what NOT to become.

Geri geri bo berry banana fana fo ferry me my mo merry... geri

-atrics... is over!

My four day rendezvous with this specialty is over (for now). I love the patients, but the doctor I was with the most didn't let me do ANYTHING. NOTHING! Poo! I think I listened to a couple of hearts but that's about it. Either way, I still learned a lot from him.

Old people are pretty cool to work with. So sweet and old and tired and wrinkly, some so close to death, they're all so full of... LIFE. They've been around for a while, they've reproduced and their progeny has reproduced and, in some cases, that spawn of their spawn has reproduced. It's crazy. I love listening to their crazy stories. Especially the old guys at the VA hospital.

As I leave this rotation, I think about the possibility of being a Geriatrician. The problems are complex, and some patients are so difficult to deal with, particularly any patients with dementia or Alzheimer's disease. The career involves dealing with death and dying, as well as working with the patient's family members- which can be quite challenging. It seems like a career with a lot of sad cases, and I do cry a lot, but... I kind of like that intensity. I imagine I might stop being a big baby if I dealt with the stuff on a daily basis.

Speaking of sad, today I watched a woman score a 3 or 4 (out of 30) on the MMSE- Mini Mental Status Exam. A score below 20 means severe impairment. The test includes all kinds of simple questions that assess attention span, thinking, memory, language, and something else that I can't remember right now (maybe I need to take an MMSE). She didn't know the day of the week or where she was, she could only repeat 2 of 3 words, then she could only recall 1 of those words when prompted later. It was remarkable. She seemed like a regular sweet old lady when we walked in the room, but her brother told us about her memory issues and with a simple test that we learned in our first year of medical school, it became painfully clear that this woman was suffering from Alzheimer's diseae and that that she was on her way to progressive decline. It was so sad. It was also quite touching to see that her brother was with her, taking care of her, making sure she ate properly and didn't hurt herself.

This rotation has, above everything, shown me the value of family and the harsh reality that is lonliness in old age. I think for good measure, I'll make sure to have at least 5 or 6 children, in the hopes that one of them will take care of me when I'm old and gray (just in case my siblings fall through).

Next up, 3 weeks of Neurology in beautiful Jacksonville. And by "beautiful" I mean "potentially beautiful but I don't actually know because I hide at the dorms for fear of my life." No, seriously, you hear gunshots right next to the hospital. Miami feels like a warm safe nest compared to this place!

Career assessment, Part 4,567

Today I got to do wound care at the VA hospital. Man oh man!

The first case was a nasty leg wound... and the guy was in excruciating pain. I had to leave the room for fear of falling on my face. My face was hot and I was dizzy as all hell. The smell... the oozing pus... blegh. About 5 minutes after I was brave enough to come back, the nurse made me use a culture swab... right on there. On that oozing nastiness. But somehow I made it through that time. I think seeing him suffer was what did me in the first time, and by the time I had returned he had calmed down a bit. Perhaps I was able to do it without feeling queasy because I was focusing on the fact that this nurse was undeniably terrible person for making me do this knowing that I had left earlier because I was not feeling well. I'm glad I did it, because I had felt bad for the patient after I left. I mean, imagine, you go to the clinic to have your awful, debilitating wounds cleaned out and you're in terrible pain, and the girly med student has to excuse herself because she is so disgusted, meanwhile YOU are the one who's suffering! Poor guy!

So, of course, like clockwork, what happened??? That huge, neon, flashing sign showed up in the back of my mind:

wrong career - wrong career - wrong career

I hate that sign. It seems to shine brighter at times like these, when I feel like a total whimp-o.

But hey, at least I'm a student and on loans and no one's expecting me to get a job right now. I'm unemployed and that's okay! Plus when I do finish, I'll have job security. Soooo... even if it's the wrong career, at least it's not one that was a total waste of time to pursue (I hope).

Regardless, this woozy whimpy girl shit has got to stop! *snaps fingers and swivels neck*

I'm supposed to be this strong, intelligent woman who will take care of people one day. Instead, I'm like "eeeewwww pus! OMG It smellllls." I swaer, by the beard of Zeus, next time I'm staying in the room. And if I faint, I faint. But I'll make sure to stand next to someone who looks soft to fall on, like a chubby person. Or maybe I'll sit down or something and allow myself to just pass out in the chair, then maybe no one will notice. And I'll be cured!

Geriatrics?

I was toying with the idea of Geriatrics as a career (it's on a long list)... but today might really affect that decision.

Today I went to a nursing home/geriatrics medical center. The lobby was tastefully decorated in warm colors and mahogany. It looked like it belonged to a cozy bed and breakfast. There was even a nice small fountain, and I said to myself "that's a nice fountain" and proceeded cluelessly...

I kept walking and the warm cozy happy lobby turns into a strange, sad, place that engages all five senses and then some. The sight of flaccid withering people, the smell of urine, the sounds of suffering and nurse call bells, and the feeling of wrinkly, pasty skin as I examined people who have lived more than 3 times as long as I have. There was an eerie sensation that death was lurking nearby, and it was impossible to ignore the overwhelming feeling of sadness for those suffering patients and fear of the future of my own family and friends at this stage of their lives.

The nursing home had a neat physical therapy room and I checked out the calendar and spotted some cool activities for the residents to enjoy. I had noticed that all of the patients had nice maniures, and discovered later that it was on the calendar as well. That was cute. All in all, I'm sure it's a great place for the elderly compared to some other nursing homes, but in the end, it's still a nursing home.

The patients that made me the most sad were the ones with cognitive decline/dementia. They seem lost and empty, just waiting for their bodies to catch up with their brains and expire.

Death itself is not so bad. It means peace for so many of these people. The physician I am following told me that for many patients, he will not treat an infection or he might withdraw all medications if it means that their suffering will end. Essentially, it is much better to let an elderly suffering person pass away than to keep them alive and pump them full of meds. Keeping someone alive if they're in agony is barbaric, but sadly sometimes mistaken for true medical care. A good physician will do his or her best to reduce suffering, not just prolong life.

In this nursing home, I saw a lot of suffering. And it's not just patient who is suffering, but also their loved ones.

I am grateful for every single person who goes into Geriatrics and takes care of the old folk. It is challenging and delicate, and surely not the most fun job in the world.

Quotables....

"You're dating a Jew? I don't really like them Jews" - A patient, to me
"See, we doctors, we're not people people. We're science people." -A robot disguised as an attending physician.

Ok, yeah, the second quote was actually a physician that I worked with recently. Doctors ARE people people. Or they should be, at least.

He made that comment at the beginning of my 2 hours following him around. I tried to put it aside and just observe his style. Mechanical, efficient, quick. The patients love him. He is overly excited when they do stuff right and applauds them loudly, yelling things like "beautiful!" and "magnificent!" whenever blood glucose measurements are good and hypertension's under control. It's like he's the Emeril of medicine. "So, is this dude a good doctor"... I asked myself. Well, let's see here: patients like him, check. Patients are doing exceptionally well with him, check. He is thorough, check. He dictates his notes IN THE ROOM just after patient interview, which seems so weird to me, but actually probably reduces medical error. His awkwardness is trumped by all that other good stuff. Hooray! He's a good doctor. But he's not a people person.

That's so weird to me. Maybe he's learned to be a people person, and he doesn't realize it yet.

Third year funny moment of the day:

A patient started going off on how she can't stand this guy she dated because he's a democrat. She went on and on about how anyone who voted for Obama is a total idiot blah blah blah and she hoped that I didn't vote for Obama cause I'm gonna be sorry.

See, wuh had happuned wuz, I did vote for Obama.

Hooray for awkward moments.

Day 3 of third year:

New attending, longer day, very nice!

Saw less patients today but did more stuff. I'm getting less shaky when I do the physical exam, but I still have no clue what I'm looking at in the fundoscopic exam. Slowly, third year is growing on me.

Today we diagnosed a woman with depression and I watched as my attending convinced her to take medication. She was not pushy, but she was persistent and took the extra time to explain depression to the patient and the implications of taking medication. It was very inspiring to see the respect and admiration that the patients have for this particular physician. She is a mother of three, which gives me hope that I can be a good doctor, have a life, have a family, and still look like a woman after all that (she looks great!)

So today was a good day, and not once did I bemoan the idea of med school or dread the upcoming fiery hoops that I must jump through. I believe this is acceptance, and possibly even embracement (SO not a word) of the path ahead of me.

But, I've gotta wonder... is it too early to begin counting down till fourth year???

Third year commences...

"Well well well, missy, isn't this exactly why you came to med school? To work with patients? To talk to people? This is exactly why you abandoned the idea of a career in basic science research. You idealized it but never felt quite right sitting in the lab all day and entering intimate personal data about islet cell transplant patients, because you wanted to KNOW those patients, not just their data." That's what the person inside of me is saying. But I'm still not excited yet. And yes, the person inside of me calls me "missy." She's pretty condescending if you ask me.

To be fair, during my first two days of official real life third year rotations, I saw some really cool stuff, and got to do what I love in this whole realm of medicine- talk to patients about health. I saw mycosis fungoides, gout (and diagnosed it, too!), an incredible rash, a girl with extreme pelvic pain not yet diagnosed, and of course, the "bread and butter" of primary outpatient care: hypertension and diabetes. Ironic, bread and butter might not be the best diet for these patients. But I digress... I got to do a pelvic exam, my hands still not quite graceful with a speculum as I'd like them to be, but with the observation that with every patient I'm getting better. I got to sit with a patient diagnosed with "pre-diabetes" and explain to her the importance of weight reduction and the different diet alterations she could make. I told her to google information on diabetes and what kind of foods are right for her, because we all know that the human attention span is limited, and anything I told her then and there would likely not stick. That's what pamphlets are for. I'm particularly excited by this case, because I love the idea of patient empowerment and education. Physicians and we as future physicians cannot simply ask everyone to change and expect it to happen just because we wear white coats. They must *want* to change. And while I would love to function as a physician, nutritionist, life coach, and psychologist, I have learned the perils of spreading oneself too thin. So I hope to "teach a man to fish" and allow the patient to take control, because 20 minutes per patient is not enough.

While I have been enjoying myself in every single patient encounter since I started med school, a part of me feels hopelessly lost when it comes to actually choosing a career in medicine. Forget figuring out which specialty I like, I don't envision myself as a physician, period. It makes it harder to deal with the bullshit when you think you're not in the right career. However, I'm open to all possibilities. I may find a specialty that I fall in love with this year (dear God please). I am keeping an open mind and open heart.

The other part of me that's not excited is the part of me that is jumping through hoops. There are grades and there are requirements and most other rotations leave you with little energy and time, as evidenced by the misery of my classmates. There is Match day, where you make a list and schools make a list and a computer program makes ONE decision and that's where you're going for the next 3-5 years no questions asked. Then residency where your first year HAS to be hell for most specialties because that's how it is. And while the past is behind us, I will never forget second year and studying for the Step 1 exam. I have an aversion to this system of education for future physicians. Why must it be this way? "This is the way it's been for years now" is not a sufficient explanation, in my humble opinion, because communication and access to information has NOT been this way for years. Changes in these realms should allow for a different style of curriculum, a more practical way of delivering the knowledge and skills needed to become a competent physician. But what do I know? This might be necessary. I just don't like it. Blah.

I suppose the hoops and loops and bullshit is also bothering me of late because I have been subjected to being separated from my dear boyfriend. Call me weak, but it SUCKS to do long distance. Period. Web cam helps. I would easily fly up there as much as possible, but hey, guess who's on a student salary of NEGATIVE forty thousand bucks a year? I am! And if I were a rich girl, then the next barrier to boyfriendland is schedule. His first year intern schedule SUCKS and my third year med school student SUCKS. So yeah, I should just SUCK it up. I'm working on that.

My complain-o-meter has now overheated. I should end with some positives: I have met some amazing friends in med school. I have learned so much and continue to learn every day. I am fortunate enough to be pursuing a career whose main goal is to take care of people. I am surrounded by love and have wonderful people in my life. And, even though he's far, I'm lucky to be in a good relationship with solid communication and a wonderful, mutual sense of adventure. I will graduate with job security (hey, in this economy, ya gotta think about that). And, even if I went through all of this, and decided it was the wrong career, I can still pursue my other goals in health care (that's a whole other blog entry, honey!)

During my re-entry into the blog world, I realize I wrote a LOT about med school during the first year, and never wrote one thing second year. That's *good* because it sucked.

So here's second year in a nutshell:

You're in class from 8-5 pm on many days.
You are supposed to study every single day (which, of course, I didn't do)
Your extra-curricular activities begin to feel like chores instead of fun stuff.
You being to rot from the inside and out.
You begin to question your decision about med school more frequently and with more "umph"
You tell first year med students that they shouldn't complain, because second year is 4 billion times worse.... (then you go back and read your old blog entries from first year and realize that you complained like crazy).

All joking aside, the second year was pretty awful. I have never seen so many people become depressed, struggle with anxiety and sleep, etc. I mean, we're not at WAR here, we're supposed to be learning. Why should it be torture?

And the crazy thing is, I was one of the people who was able to maintain *some* balance. I didn't care about grades enough to study all the time. I worked out regularly, cooked regularly, spent quality time with those I care about, and traveled (California, scattered locations throughout Florida, Morocco, Dominican Republic). And despite all that wonderfulness in my life, I was still absolutely miserable at times.

Seeing the toll that med school took on my classmates and myself makes me wonder what they're doing wrong. I am not just a negative bitch. There is something inherently wrong with this system.

Daily reflection... an attempt at a concise blog entry.

A toast:
To great communication between two people who have decided to spend a lot of time together.

A grievance:
About people who go to the library and are obnoxiously loud while you're trying to study for the most important exam of your life.

Some gratitude:
For my attitude, which allows me to convey a million words with just one stare... directed at those loud assholes at aforementioned library.

Honorable mention:
To those friends who let you know it's about time to take a shower.

When one of my classmates posted a link to his blog on facebook... it brought me back to the good old days of blogging it up. Oh the catharsis.

Perhaps I'll start up again once third year rotations begin (for those non-medically immersed, that means I'll be out of the classroom and in the CLINIC and HOSPITAL and interacting with REAL PATIENTS!)

But, since the last time I blogged until now, the only thoughts I care to write down is HOLY SHIT SECOND YEAR OF MED SCHOOL SUCKS.

And, as I prepare for the USMLE Step 1 exam, I'm realizing what I have (and have not) learned in the past two years. Preparing for this exam is a daily adventure, wherein I spend 8-12 hours a day studying, with some breaks to use the restroom, waste time on facebook, nap, and acknowledge that nagging voice asking me why the hell I came to med school when I damn well know how much I dislike the following: studying, blood & guts, annoying people, and being trapped in a bullshit system where you really have very little control over the next 7-15 years of your life. I do love people, and helping people, and science is kinda neat. And I've met some amazing people in the last 2 years.

Ok back to the grind. *Yay* med school...

*sobs*