Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Is medicine the “holy grail”(finding satisfaction in practice)?

Introduction

Every day I read  many letters and posts from undergraduate students who view a career in medicine as the ultimate prize for academic achievement. While this view may keep many pre-med students on the road to high academic achievement, a more realistic view of this profession and it’s practice is a better choice for keeping a strong perspective. It’s very admirable to wish to enter medicine to “help people”. In truth it is also admirable to enter medicine because you want to be well-compensated for the work that you perform but monetary compensation will not keep you bounding out of your front door every morning as you begin a 16-hour day with many challenges. Medicine is very much like the publishing of a daily newspaper in that you have to work through the hundreds of daily challenges and get them right while loving what you do. When I say loving, I can also add that along with that love there needs to be a bit of compulsion albeit healthy that has to be in your personality. In short to be an excellent physician, it’s about always being, to quote Larry King, “100 per cent when the light goes on” with the  light on practically every minute of the day.

Why good medicine may be difficult for even the most dedicated

It’s not just the surgical specialties where one has to “get it right” or life-changing consequences can happen for both the surgeon and the patient. Non-surgical specialties are far more difficult to practice at the highest level than most surgical specialties with the greatest hurdle for  the primary care physician, being the time constraints, though operating room time has always been expensive too and the knowledge acquisition challenges that would frighten many other professionals. A physician simply has to be adept at the mastery of many hundreds of pages of information that will prove crucial to practice on a daily basis, like no other profession. It’s the time between seeing patients that becomes a snippet of both “down time” and “breathing” time which keeps everything moving. Additionally, a good physician has to become adept in communicating with patients and staff in order to achieve the best outcome for their patients. It’s a narrow fence to walk on a daily basis with the unknown which eventually becomes a constant companion.

If the pursuit of a career in medicine is causing an applicant to attempt to significantly change their personality or ethical system, then medicine becomes a symptom of a problem that will make the practice of medicine very difficult. Medicine is not for every person either from an academic/scholarship standpoint or from a personality standpoint. With the length of the day and the complexity of excellent job performance, a candidate doesn’t have the time or the energy to keep up and “act” in order to fulfill some perceived “fitness” for medicine. My medical practice is as much an extension of who I am as a person rather than the product of any training that I received in medical school or residency. It didn’t make a difference that I entered surgery as my personality doesn’t allow me to act like an “entitled jerk”. There are too many moments when I find myself thanking my maker for getting through the day and not losing my perspective or awe of the majesty of every human being from that elderly veteran to a newborn with multiple congenital anomalies. In short, your patient’s and your community will demand that you keep a solid balance between humility and hubris.

When one starts to complain about “lack of a life” or having other “passions” outside of medicine before one enters the field, one should probably question whether medicine is the sound or compatible career path. If you find that you just love doing procedures and duties of the physician but you are constantly worried about your life outside of the practice (“I want to be home at 5pm every night”), you may want to consider pursuing the profession of physician assistant (less training time and less responsibility) rather than making a minimum 7-year commitment to medical training in addition to the life-long learning at a high level. If you can’t learn to find balance between medicine and your outside life within the boundaries of training, you won’t find that balance once your training is completed. By selecting the profession of physician assistant, the shorter training period coupled with a bit less responsibility might be an ideal fit for someone who has multiple interests outside of medicine.

I found quite rapidly that I needed to set more of a standard for study and scholarship outside of residency than inside. For me, combining teaching with practice was an ideal situation as my teaching forces me to keep up with my literature reading and the latest clinical practices for my specialty. For some of my colleagues, the work of practicing evidence-based medicine is a chore that they seem to avoid at all costs which can be to their detriment. There is a compulsion that tends to keep me focused on getting my work and reading accomplished each week. I generally find that I have plenty of time to pursue other interests outside of medicine within reason. As the daughter of a physician and coming from a family that boasts 10 physicians between aunts and cousins in every specialty, I can say that none of us suffered because our parents didn’t make every recital, soccer game or play. We learned to be self-sufficient, almost to an extreme point and we learned that the love and support of our parents was always present even if they couldn’t be at an event physically.

The “sacrifice”

Well, medical practice and medicine isn’t a sacrifice for me. It’s always a wonderful opportunity to test myself both mentally and physically. I have found that I have some innate qualities that allow me more ease with practice, such as not needing more than 4 hours of sleep, sleeping lightly – never missed a page, and having a generally upbeat disposition with an ease of communication. I simply adapt as best as possible to the situation at hand without much angst and worry. If I don’t believe I will enjoy working on a project, I don’t agree to do the project in the first place. I also have adapted to the thousands of changes that have become a part medical practice since I entered the profession nearly 10 years ago. For folks who have a difficult time adapting to change, medicine will be an extreme challenge. One cannot expect that medical school will teach everything needed for a modern practice nor does the medical school attended (as long as it is accredited and in the USA for practice in this country) matter much once you are done with that portion of your training. The habits learned long before medical school, such as, consistent and strong scholarship/study skills will make more of a difference in your practice as opposed to the school that you attended.

23 June, 2011 Posted by | academics, medical school | 7 Comments

It’s medical school (or any other school) orientation day (week)!

Well, you made it into medical school! Congratulations on that accomplishment but resist the urge to look around and size up what you believe is the “competition”. Your fellow classmates are far from your competition. They are a bit like your family in the sense that they are going to annoy you in the years to come. Additionally, you have no control over their identities or actions (waste of time to be annoyed with them) and you will come to appreciate them when they bail you out of a struggle or provide “comic relief” when the stress is causing you to lose part of your soul. In short, you inherit a bunch of brothers and sisters who will travel the experience of learning with you. Take a minute to take in the atmosphere, test out the “vibe” that you get from your class and enjoy orientation because it’s one of two periods of time that medical school will be totally enjoyable. Once the classes start, the work begins.

Many orientation sessions will have loads of information for you. Just like your coursework, get this stuff mastered! The check in and schedule is most important so that you know where you want to be and when you need to be there. This is also a time when you realize that you need to spring for a 140 db alarm clock without a snooze button for those days that you just can’t hear the one with the buzzer. My “super alarm” was my best friend on many a Monday morning when I was in medical school. By general surgery residency time, I found that I didn’t need it as I woke up when the curtains rustled; surgery makes one a light sleeper by necessity. You also do not want to get into the habit of hitting the snooze because you can’t hit that beeper once you get into practice. In short, you have to get up and get rolling on the first alarm. You will also need comfortable walking shoes and a car with a trunk so that you can carry home all of those books that you will buy, or in my case inherit, from your upper-class advisers. I watched in amazement as a few of my classmates carried what looked like a “house” on their backs as they marched to the underground or bus stop to go home. I drove during orientation week so that I could get my “loot” home comfortably.

If you haven’t done so, get all of the stuff that you need for your apartment (crib/loft) arranged and unboxed. I can’t emphasize more, how little time you are going to be spending there during first year but you don’t want to waste any time trying to arrange things when you need to be studying. Orientation week for medical school is also orientation week for getting your housing together too. Make your place as efficient as possible. Stock up on “the noble necessity – bathroom tissue” , soap, deodorant, ramen noodles- can be enjoyed in 2 minutes 1,000 ways, laundry detergent and most important for me, coffee. If you don’t purchase at least a semester’s supply of the necessities, it will be during exam week when you have no time that you discover you have no TP! Don’t let this happen. (If you have a roommate, put a couple of extra rolls under the foot of your bed so that you always have a stash in emergencies).

I will also recommend finding a 24-hour gym that is close-by because you never know when you are going to get an hour for a workout. My biggest mistake in medical school was not keeping in good physical condition.  Regular aerobic exercise diminishes stress and just makes you a more efficient student.  It also helps to keep your immune system polished (drinking tap water helps too) and ready to fend off your classmates’ viruses and bacteria that they will try to share with you. In short, driving yourself to burnout is less likely if you have a means of working out. You don’t have to have an elaborate routine just 30 minutes or so of walking on the treadmill plus 30 or so minutes of weights. I can’t tell you how much weight work helps to keep you focused on your studies. I have learned that fact after many years of teaching and practice. Take the time to pump some iron for your sanity and your health!

Go to all of those social events during orientation. They may seem stupid but you want to get to know as many of your fellow students as possible. No, you are not running for office (don’t run for office unless you know you can get your class work mastered well- our class president didn’t do so well first year and being a class officer is pretty meaningless for residency so don’t take a chance on this) but you want to have a cordial/professional  relationship with everyone in your class. Resist the urge to form cliques (many students do this by ethnicity) because your future colleagues are going to be every ethnicity and color and you have to work with them. Get along with everyone and have a sunny relationship with everyone even if you have a family at home. You need to be able to work with your classmates on projects and in the future on the wards. It’s also your classmates that will cover for you when you need to take that sick kid to the doctor or leave early because there’s an emergency. Go to those social events and get to know everyone. I met my best friend from medical school while we were in a line to shake hands with the deans at the Deans Reception. We studied together, cried together and graduated together. Even today, I miss those great times that we had even though we thought we were suffering.  The greatest thing about my best friend is that she spoke to everyone in the class and worked easily with everyone. She is truly a gifted person.

Make sure that your study area at home and at school is well equipped (plenty of note paper, pens and highlighters) and easily accessible. Don’t seek out the darkest and most remote area of the library (too dangerous) and don’t seek out the most popular area ( you won’t get much accomplished). Find a place where you and a couple of like-minded individuals can study (watch each others stuff when you need to use the facilities) and get something accomplished. I found that I studied best at home (not an option if you have a family that will compete for your attention) with a couple of beagles at my feet. My “facilities” were next to my office and any telly, video games and other distractions were far away. Once a week or so, I would do a group study with my study partners but not until I had mastered my work (see my post about my study habits).

As I have said in other posts, the two times that you can truly enjoy medical school are during orientation week and during fourth year after you match, unless you haven’t taken Step II. Orientation week is a time to get to know as much as possible about your school, your classmates and how you can set a strategy to navigate the next year or two. I can’t encourage you more strongly to read all of the information in those handouts and student handbooks so that you know where things are  and know who to contact if you have trouble. If you are given course syllabi (we were), look though them and get an idea of how much work you are going to need to set aside for your courses. Planning and organization are two of the most important tasks for medical (or any other professional school) success. Have fun for this week because the classes are going live too soon!

4 June, 2011 Posted by | medical school, orientation to medical school, success in medical school | 1 Comment

Why students fail USMLE (any of the steps)…

False sense of security

Every year no matter what medical school a student attends, some people are going to fail one or more of the USMLE Steps. (This can apply to COMLEX as well.) I have heard students say that because they attend school X that has a 100% pass rate, they are assured of a pass. Well, that pass rate for School X is characteristic of the class that it applies to. If you are not a member of that class, you have no assurances. Your medical school attended is no assurance of anything other than they have met the standards set by the LCME (Liaison Committee for Medical Education) and that if you have passed your coursework, you will be eligible to sit for your USMLE/COMLEX exams.  With that being said, you have to understand and be proactive if you want to pass and score well on licensure exams regardless of school attended. In short, passage and performance of these very important exams is dependent on how well you prepare for these exams.

The big mistakes

Many students purchase tons of review books and start memorizing questions, outlines and isolated facts as soon as they have been accepted into medical school. You can’t MEMORIZE your way into a pass on licensure exams because these exam require you to master and understand concepts in basic science, clinical science and application of the concepts to patient care. Just memorizing board review books is not sufficient knowledge to do well. Daily and consistent mastery of your coursework with systematic review will enable you to pass and do well on these exams. Many students discount the importance of their coursework with the idea that they will cram in what they need for a course exam and spend the rest of the time memorizing a board review book for the licensure exam. This is the biggest and more common reason that students fail these licensure exams.

Coursework is too detailed for the boards!

While your coursework is very detailed, your mastery of those details (and I mean thorough mastery) is a very significant strategy for doing well on your licensure exams. It’s the details that enrich your understanding of the basic concepts that will be vital to your eventual practice of medicine. Rather than looking for shortcuts or complaining about the rigor of your curriculum, set a strategy for mastery of your materials and get the job done.  As a medical student, I complained about the level of detail in many of my basic science courses but was quite happy when Step I came around and I know those details. The more experience and exposure to the details of concepts, the greater your likelihood of being able to rule out incorrect answers and rule in the correct answer. In short, those coursework details are invaluable both for boards and for “pimp” sessions during clinicals.

Get out of the “I will just memorize this” mentality

You have to learn to evaluate and synthesize concepts in both basic science and in clinical medical science. For the rest of your career, you will largely be teaching yourself the things that you need to keep a mastery of for your practice. In short, keeping up with medical literature means that you master how to read what you need and how to incorporate what you need into your practice. Where do your learn these tasks? You learn these tasks in mastery of your coursework and in preparation for you licensure boards. Just taking a review course and memorizing everything in a review book will set you up for an unpleasant surprise when you open your score report because you must have a solid knowledge base in order to review for a board exam.

Every licensure exam will post a list of key topics to be mastered for the exam. These are never secret and are why books such as First Aid for Step I are so crucial for preparation for USMLE. First Aid contains all of the topics but none of the details. It’s up to you to provide the details and provide the thorough grounding and mastery that you need. This can’t be done in a month-long review course unless you have a solid knowledge base to begin with. The solid mastery that you need can’t be done by memorizing the answers to questions on a website either. While practice questions are good, they are not useful memorization and can give you a false sense of security in the long run. I can’t tell you how many times student Y had told me that they were scoring 70% on Q-Bank but they turn up with a failing score on Step I. Kaplan’s Q-Bank is great but it’s an adjunct to solid study and mastery of basic and clinical science materials (coursework).

Giving Step I more power than it deserves

In today’s world of residency application, residency directors know how much time you as a student have to master the knowledge needed for the USMLE/COMLEX steps. While there will be people who want to take a “year off” to study for Step I in order to insure a high score, this is not a sound practice. Residency directors do not want to see students taking “time off” from medical school unless you are pursuing a higher degree such as MPH or a Ph.D. Utilize the time that you are given wisely and efficiently and you will be able to review completely and comprehensively for this exam within that alloted study time.

Residency directors also realize that IMGs also often have years off to study for the USMLE Steps and take that into consideration when evaluating scores from these individuals. This is why IMGs are usually required to post higher scores on Step I than their AMG counterparts in order to be competitive for a residency program. Another caveat for IMGs is do not attempt any of the USMLE Steps if your language is not up to the standards of that exam. You can’t blame lack of language understanding as a reason for failure of Step I. Residency slots are more competitive (more AMGs now) and failure of any steps can be very problematic for an IMG. In short, if you are an IMG reading this, prepare well and be prepared to pass any of the USMLE Steps with at least a two digit score of 85 (even for medicine programs) on one try. Does this mean your are doomed if you are and IMG and you fail? No, but you have greatly decreased your chances of match in the USA and may have shut yourself out of many residency programs (other than prelim slots) because of the sheer numbers of US grads and the lack of  categorical slots.

Passing USMLE

  • Your first stop is the USMLE website. On that site, you will find the subject lists for what’s covered on the exam and the characteristics of that exam.
  • Your next step is to thoroughly master your coursework with regular and systematic study (if you haven’t done this in the past, start now).
  • Obtain the most recent copy of First Aid for USMLE (whatever step) and read it from cover to cover so that you know what tools are available for the particular exam you are taking.
  • Look into a commercial prep course only if you are certain that your knowledge base is poor or that you know you need plenty of feedback and practice with USMLE-type questions (most US grads don’t need this).
  • Don’t tell yourself that you can’t get into residency if you don’t get a two-digit score of 99. Chances are, you are not going to get that score even if you follow the exact study schedule of someone who did.
  • You have to figure out what works best for you, in terms of mastery and review so that you can prepare your best.
  • If the worst happens and you fail, look at my post “Failing USMLE and how to get beyond it” for strategies for passing on a retry.

Remember, USMLE is not the MCAT. You don’t get “do-overs” for this exam unless you fail. If you fail, you have significantly made yourself less competitive but you are not out of the residency game. You will need to make sure you don’t fail any other steps and you need to accentuate other things (excellent coursework for one thing) in your residency application. Plenty of US grads who have failed Step I but gone on to have a strong third year have managed to match into very strong university-based residency programs. In short pick up and keep moving forward.

Also keep in mind that wishing and hoping for a pass/high score isn’t going to make it so. Plot a strategy and get busy doing what you need to get the job done. Don’t discount the value of consistent strong coursework performance but realize that you have to have mastery of coursework before you can “review” for boards. Board review is not the same as study for your medical school courses. Good luck!

3 June, 2011 Posted by | academics, medical boards, study skills, USMLE Step 1 | 37 Comments