Medicine From The Trenches

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

You Have Matched!

A hearty “Congratulations” to all who matched! This is the next step in your medical career no matter where you matched. On Friday, you will find out where you matched; some taking the news with tears and fears. Make no mistake, if you didn’t match, the future becomes more uncertain but certainly not bleak. As I have stated in other posts, those who didn’t match should be aware of the current S.O.A.P process and should be working on getting a training position for next year.

If you have matched, some things to work on as soon as you can:

  • As soon as you know where you will be training, get in contact with one or two of the senior residents to find out which textbook(s) is (are) the major reading material for your program. Purchase the book(s)(electronic or paper) and start reading.
  • Make a list of the sentinel journals for your specialty and start reviewing articles. You need to practice evidence-based medicine. Getting a head start on your journal reading helps to make journal reading a habit.
  • Start a physical conditioning program if you have been relatively sedentary during medical school. Aerobic exercise (30 minutes per day) can help reduce stress, help with stress and keep you healthy. Make physical exercise a habit along with journal reading. Even on your on-call days, you can walk/run the steps for a quick work out which will keep you more efficient in the long run. You will also sleep better if you are in good condition. Add some strength training too.
  • Find a place to live if you are moving. Don’t put this off because you need to be comfortably in your residence before orientation week in your new hospital. Your home should be simple, convenient for commuting to the hospital, restful and useful for your lifestyle. Though you won’t be spending tons of time at home, you need for your home to be your haven in your off hours. Make sure you have a washer and drying in your residence. You don’t want to be heading to a laundry room when you need to be sleeping.
  • Get your paperwork done for your training license as soon as you get information from your program. Some states have many tasks for you to complete before you can be licensed for training purposes. The sooner you get this done, the better.
  • Take a week or so off but do this long before you start your program. You need to have a bit of fun but using too much time in vacation before you start your PGY-1 year can be a problem too. Complete off time is great but not an escape.
  • When you get your residence, scout out several routes to the hospital so that you know how to get in even if there is a problem with weather, roads and other mishaps. Make sure your car or bicycle is in good repair with a good back-up plan.
  • Learn how to cook and take your meals into the hospital. Trust me, hospital food in most cases, is not great for keeping you healthy. I cooked on my days off, put a week’s worth of meals in the freezer and carried them in for my call days and nights. Good nutrition is key to good learning and training.
  • Learn a good organizational system for your ward work. I used an Excel program complete with dropdown menus for my sign-outs; still use this system. Learn to make check-off sheets to stay on top of your patients and their needs (lab tests, radiographic studies).
  • If you can, arrive a couple of days early to get familiar with your hospital’s physical layout, systems for dictation and record-keeping. Do a recon mission that will save you time in the long run.

Finally, this is a great time of learning and professional development. Having some organization is key to keeping your head in the right place. Enjoy the experience so that you can take advantage of every minute of residency with a positive attitude. Don’t underestimate the value of a smile on your face because you are learning the tools that will make you a good physician.

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14 March, 2017 Posted by | medical school, organization, residency | | 5 Comments

Achieving a balance

Introduction

As I write this, my career has been shifted into a higher level of comfort. I have spent the years since graduation from medical school and residency honing my surgical skills and the craft of taking care of patients. If anything has suffered in the task to become the best physician that I can possibly be, it has been my personal life. In short, it became easy to head off to the hospital or university rather than deal with things in my life that just were not working. Well, working in medicine has a way of making one reflect on what is truly important and making one move past things that are not a good fit for life.  I had decided after ending a relationship that had somewhat sustained me through medical school and residency, that I would throw myself into my work with vigor and a quest for self-discovery.

Make a definition of your “complete” life

I always knew that I was a person who saw the miraculous in all of medicine and humankind. I am just an instrument for our creator does the actual healing. You can call the creator anything that you like, God, Mohammed, the Great Spirit but positivity and balance have a way of forcing one to move along on a plane that is stable. One gets used to “death” as part of “life” and one can sometimes feel how to be aligned with the universe in one aspect of life but “going through the motions” in another aspect of life. So it was with me and I attempted to fill in my “gaps” and “blanks” with interests, flying, sailing and so forth. Being above the earth or on the ocean/lake can allow one to exhale and just marvel at how wonderful the world is at times. I also knew that I wanted to share the miracles of my life with another soul; as a human we all reach out for intimacy in some form. We can have a close friend or we can have a significant relationship (marriage) that allows us to find that person who can help us complete our mission in life. At times, I believed that I needed to work on myself and put all parts of my life in compartments so that I could achieve a close bond with another human that doesn’t mind that I sleep on my abdomen hugging a pillow and look like a “street urchin” in the morning after my nightly pillow fight; that my phone frequently rings all night if I am on home call; or that I might be away for 30 hours straight taking in house call. These are the realities of being in a relationship with most physicians and certainly with a surgeon. I can also add the time that I must spend in reading and study to keep up with my craft. In short, any person who is involved with a physician needs to see that they won’t have 100% of our attention all the time but when we are “with” you, we are 100% committed and need you like we need oxygen, food and water to live. My definition of my complete life was to meet and find a person who could be my friend first and perhaps more later. The inhumanity that is sometimes represented in my trauma bay can color how I look at relationships between humans. Domestic violence is very difficult to deal with but deal with it, I must and I must have a place in my mind that allows me to give my best treatment to the victims and sometimes to the perpetrator too. I am not the judge but only an instrument to an end point – getting that person back to health and solving health problems. My complete life has to allow me to find that person who can allow me to complete my “mission” on Earth and I complete them.

What I tell myself…

I had told myself that my life could be complete and satisfying with a job well-done. I would enjoy “discovering new truths” in my research and writings. I would enjoy hearing the successes of my students and colleagues. I would have a rich and satisfying career giving back with my skills and teaching. Yes, my life was indeed full but not complete. I didn’t have that intimate relationship that adds the depth and richness that just needs to be there. And so I was going through my career, happily enjoying my friends, colleagues and adventures in surgery, medicine, flying and sailing.

No, one can’t plan everything…

I was happily moving along with the things that occupy my time. I decided to do some exploration in trying to reach out and expand my circle of friends. It’s good to be a trailblazer in some aspects of one’s life. I have always challenged myself to take some risk with something at various times. I took a risk and was happily enjoying the experience when a man reached out to me in a most unexpected manner. There was something in the things that he shared so readily with me. He knew that I was a physician/surgeon yet he said that he saw something that drew him to me. At first, my scientific training kicked in and I attempted to define what was going on here; I ran in the opposite direction. Well, there is no definition but only that one has to have the courage and sometimes the faith to know that your instincts are correct (much the same as how I treat a critical patient). In short, life does not always come with clear directions. I have been in uncharted “exploration” the past few weeks and it’s been both exhilarating and unnerving at the same time.  Here I am in a relationship that I can’t plan or define and suddenly my life that I thought was so full, seems empty before I was able to get to this point.

Why this is so vitally important…

In order to give our best to our patients and colleagues, we have to give our best to ourselves. My best now includes a very brilliant environmental engineer (he can’t stand the sight of blood) who inspires me to reach higher and further in all aspects of life. Suddenly the things that gave me immense satisfaction go beyond that and give me immense joy at the same time. I smile and laugh with my patients, my students and my colleagues. In short, he has made me a better and more fulfilled person. The only downside has been that my favorite OR music has moved from my signature “thrash metal” to a bit more “smooth jazz”. For those who work with me, that’s a huge change but they secretly like the music change. I am not playing as much Pantera or Goatwhore in the background. As you move through your university work and your preparation for medical practice, one has to have the best of humanity brought out from within themselves. To be able to give my heart, a myocyte at a time to this environmental engineer who can’t even see my lectures without getting sick, has made me a better surgeon, physician and human being. One simply has to find balance in all things in life and not shut off any part of life to focus on other parts of life.

10 October, 2014 Posted by | organization, relaxation, stress reduction | , , | 5 Comments

” Not because they are easy, but because they are hard..”

“We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.”  John F. Kennedy at Rice University on Sept 12, 1962.

Introduction

Why choose medicine (or any profession in health care) if the work and preparation for that work is so hard? I asked myself why I spent hours in chemistry, physics and biology lab when my friends who were business and marketing majors were spending their weekends enjoying the club scene and knew the latest shows on the telly? Why was I putting in the hours making sure that my organic chemistry lab reports were accurate and complete? Why did I choose to study advanced applied differential equations, multivariate calculus and higher algebra (math minor) when I could have stopped with integral calculus? In short, why did I deliberately choose a rigorous college education in math and science where I demanded only the highest performance from myself when I could have taken a far easier route? The answer for me was pretty simple, “I had to know how things worked” and setting a hard goal energizes me and my skills.

Yes, my majors in undergraduate were considered difficult by some people but they were sheer heaven for me. Every minute that I spent in lab and applying math theories was not a chore but a pleasure. I had always loved to “figure things out” and I had parents who challenged me (and my siblings) to always do our best work no matter how many hours the job would take. From undergraduate to graduate school (I was a research scientist before medical school), I could focus in on a problem and see many alternative methods to solve that problem. I wanted to explain mathematically, how energy from a laser was transmitted via a heavy mineral acid matrix to a delicate protein in order for that protein to become ionized. I wanted to understand the mathematical model for that phenomenon and others. Fortunately for me, science allowed me to go where my mind could take me and then some.

So what does that mean in terms of medicine? This means that all of my previous studies from primary school to secondary school to undergraduate university to graduate university and medical school are all aimed at understanding why and figuring out how things work especially the human disease phenomenon. One simply has to have a grasp of the whole picture and the whole person in order to have a strong perspective as to how to best help that patient. Medicine is not like business in that one can take a “shortcut” and still get to goal. Medicine is like preparing for a marathon or to lose 100 pounds in that one has to see the long-term goal, work constantly and consistently at a high level and one has to remain vigilant or the goal slips away. This doesn’t mean that the path toward the goal isn’t pleasant because the journey is great fun but the most enjoyment comes when one sees how building upon a knowledge base and application of that knowledge base actually solves a problem for a patient.

I remember spending hours as a third-year medical student in the anatomy lab as I was perfecting my suture techniques. I sutured the skin of cadavers much to the chagrin of the first-year medical students who had spent hours removing or dissecting that skin. I would come into the lab before my surgical rotation started (I was there at 3AM); practiced my suturing and tying techniques and was off (smelling of formaldehyde) to write my morning notes before rounds. Yes, it was “hard” to get up on a cold and snowy morning when it was dark outside and head to a cold anatomy lab with cold steel tanks all around. No, I didn’t “have to” get up early and practice my suturing and tying but after I knew that I wanted to be a surgeon, I knew that I had to put in the time and hone my skills.

When I was in the hospital on overnight call, I went to the library and read about my patients’ problems. I refreshed my knowledge of pathology, I reviewed every medication that they were on and I made notes of how the disease process should progress. Was this easy? No, it was far easier to grab a nap because the Trauma pager would be going off practically continuously after 9 PM and I would be in the emergency department almost constantly until 5AM when it was time for pre-rounding. I learned to cat nap on call (sleep no more than 20 minutes), read when I was exhausted (putting my feet up was better than sleeping for hours and hone in on a surgical procedure while the rest of the world slept. Was it easy? No but I had set a long-term goal for myself and I was determined to get the job done with the same work ethic that my parents instilled from day one.

Conquering Hard Goals

Excellence becomes a habit if it is practiced on a hourly basis. This was the first thing that my parents instilled in me. When self-doubt creeps in and procrastination begins, remember that you can turn around your thinking in the next instant. Why is it so easy to NOT do something well when it is just as easy to DO that something well? There is always more than one way to do anything and any method that one chooses that brings about excellent results that are safe and ethical  is the method to accomplish something. In one’s academics, there is little time to spend on “thinking” about how inferior/superior you are in relation to one’s peers if one is constantly striving toward a long term goal of consistent excellent performance. This doesn’t mean that one wastes time on being “anal” or a “perfectionist” because these two traits carried to an extreme waste too much energy. Consistent excellence means building upon a foundation and linking prior knowledge to present knowledge to setting the foundation for future knowledge.

Sometimes one needs to get a different perspective. If you are finding that you are “spinning your wheels” on a task that seems insurmountable, break that task into more manageable pieces and tackle each one in turn until the whole task is done. Again, if you have 100 pounds to lose, you have to lose that weight one pound at a time. You can’t spend time hating the process (takes away from time that could be better spent working toward the goal) and you can’t afford to indulge in self-pity “Why is it so hard for me and so easy for everyone else?”. In short, your goals and challenges are unique to you and trust me on this one, everyone has goals and challeges that you may or may not be able to see or appreciate. You are no lesser or no greater than any person around you but you can make better or worse decisions as to how you will handle your challenges and goals.

Look from a different perspective

I have been fortunate enough to have spent some quality time looking at the world from the cockpit of my small plane. When I need to put a problem or goal into perspective, I head “up top” and look at the wonders of the world below. When I fly in a commercial airliner, the world below is much smaller at 37,000 feet (on a clear day), than at 3,000 to 6,000  feet where I can mentally interact with things below. The people below are not insignificant at that altitude and the world below becomes more than just the day in and day out tasks of getting things done. In short, find something (for me, it’s flying) that can take you out of your world for a short period of time and help you refocus. For me, flying takes focus and concentration but the pay off is worth the effort. It’s a challenge for a person who thrives on challenge.

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You can see the goal (the runway) down there and you can take the steps to line up and get down there to that runway. Flying for me, is a metaphor for meeting the challenges that I encounter on a daily basis. Again, I learned to fly not because it was easy but because it was a hard challenge” that it “serves to organize and measure the best of (my )energies and skills ” and it allows me to accept, willingly, other challenges (not postpone them) that I meet in life.

14 December, 2013 Posted by | organization, relaxation | 8 Comments

Everybody is doing better than I am doing…

Well, for most people, it’s nearing the end of the first semester of school for this particular year.  It’s a time to complete the projects, papers and assignments that are needed to complete the year strong and it’s a time to start getting organized for those final exams that are looming in the future. This is not the time for berating yourself for not performing up to the standards that you created when you began the semester. For all students, there is quite a bit of “life” in between the start and end of any semester (or any period of time) in the educational process. Over any period of time, distractions and immediate needs/problems will get in the way of your learning. How you manage those distractions/problems is something that you can change to help you in the next semester. In short, as soon as you are done with your work for this semester, take an honest appraisal of what you would like to change and keep the things that worked for you.

Every person has a tendency to compare their lives with what they perceive as the life of another person. That other person might have been your sibling as you were growing up. ( I thought my sister was smarter, more beautiful and more talented that I could ever imagine).  That other person might be someone in your class (I see that X or Y is at the top of the class and he/she doesn’t even have to study) or that other person might be someone you see on the telly or in the movies that you perceive would have a better life or greater abilities than yourself. This practice of comparison is a huge time waster because the only person that you can compare yourself to (in any way) is your previous self. Only you know how to live your life and only you know what you need to succeed in getting what you need to live your life. It’s always easy to believe that others are somehow innately “better” that you are but in reality, they can’t live your life as well as you can live your life and you can’t know what challenges them.

The stress of school, especially medical school or any professional school, can send many students into behaviors that they would not even consider if academic stressors were not present. Assignments, tests and projects seem to be endless. The time that you thought you would have at the beginning of the semester, at this point, seems to have evaporated faster than dry ice. You find that you feel overwhelmed and rushed to complete things often feeling less satisfied that you have been able to give your work your best efforts. When this happens, stop and take a minute to prioritize the upcoming tasks. This is a good time to make a very simple list of the things that have to been done immediately and the things that can wait until you have a bit more time. This is also a good time to pencil in at least 30 minutes of time daily to just reward yourself for keeping up with your semester/academic tests as best you can. That daily 30-minute reward should be something affirming (not self-destructive) that you can keep coming back to when you need to take a short retreat.

Why is it so easy to believe that everyone else is doing better that you are doing at this minute? This happens because you project your feelings of inadequacy into your thoughts about others as you compare yourself to them. You are no more inadequate than the next person in your class but you may be making decisions that are not productive in terms of getting your academic work under control. Just allowing distractions to eat up your preparation time for study and completion of projects can be counter-productive to doing  your best work. If something is so distracting that you can’t concentrate on things that you need to be working on, then take that daily 30-minute reward time and use it to indulge in your favorite distraction (social media for example) as a reward instead of “beating up” on yourself for procrastinating on Facebook.  This means that you use your Facebook time as a reward for getting your other work accomplished rather than something that takes you away from what you need to do. In short, make a better decision not to deprive yourself of indulgences but to limit the amount of time that you participate in them.

Another thing that you can do in this minute, is to replace your belief that you are somehow inferior to others with the affirmation that they would have no idea of how to live your life. Only you can live the life that you are living. You were born with all of the tools that you need to make a success of what you would like to be successful in. All skills can be mastered if you put yourself in a position to master them and take each step needed toward a goal on a daily basis. Success is more of a habit rather than something that is “conferred” on a few “lucky souls”. Success in little daily tasks always adds up to overall success in the “big” items. If you attempt to “rush” or “short-cut” your way through your academics/projects, then you WILL run out of time to do your best work. Objective and thoughtful planning, with daily adjustments, works better than waiting until the last minute because you have the idea that “working under pressure” will spur you to work better. Adding pressure to an already stressful situation adds more stress and does little to get your tasks accomplished. Remember, people who are stressed tend to exhibit behaviors that add to stress rather than relieve it.

The other problem with constantly comparing yourself to others is that under stress, you always believe the negative thoughts first. In stressful situations, it’s aways easy to believe that you will “never” understand all of this or that you will NEVER get everything done that you need to get completed. In reality, if any student in the past was able to get the work completed, you will be able to get the work completed. You have all of the tools do your best under any circumstances. There is no other human out there that can life your life better than you can live your life.  You make a list of what needs to be done and you plan how you will do it. This doesn’t apply to anyone except you because only you can figure out what you need (and how much time you need) to complete your list. Yes, it’s true that there are only 24 hours in each day (and you have to sleep) but look objectively at your priority items on your list and do the most important items first. This is how we triage patients (we treat the sickest patients first and take care of the less acute patients in turn). If you don’t get everything completed, then you examine how you would change things and take action so that you get the most out of your academics.

Finally, telling yourself that you have “passion” for something is not the same as putting yourself in a position for being successful with something. Passion does not overcome or offset daily work toward a long-term goal. If you seek a long-term goal, realize that these long-term goals are reached by taking regular/daily small steps toward them. There is a path toward a goal and the steps along that path are the challenges that you have to meet. Meet and greet each challenge with the idea that you will figure out what each challenge requires and get the job done in your unique manner.

Put comparison terms out of your mind and replace them with action terms such as ” I can” and ” I will” do what I need to do along with asking for assistance at the first sign of trouble. Asking for guidance or assistance is not a sign of weakness but a sign of logical and careful evaluation of that you need for success. If you needed to lift a car, would you keep struggling alone or would you enlist the assistance of 10 others to help you lift that car? Anyone can lend you a hand along the way because most people are willing to help others if asked. You just need to be able to swallow your ego, ask for assistance if you need it and affirm that you will live your life, taking care of your needs without comparison to others and what they are or are not doing. In reality, those people that you believe are so much better than yourself are more like you than you would believe and have the same challenges that you have. In the end, you are equal to them and better in living your life.

7 November, 2013 Posted by | academics, organization | | 2 Comments

Taking Stock of the First Semester

For most people in school, it’s the end of your first semester of something. That “something” might be your first year semester of medical school, college, clinicals or even the first half of your first year of residency. With the end- of -year holidays brings a time of reflection and adjustments for most people. My first thoughts are to tell anyone who is doing a first semester “post-mortem” to make sure that you don’t forget that you actually were able to survive your “first”. The next thing to do is to figure out what might need to be tweaked, removed or started. For most folks, no major changes are needed but don’t be surprised at how a small adjustment in one area can reap huge benefits in others. It turns out that life just works in that way.

There are some things that I have been telling my patients to institute for the last two weeks of 2011. I don’t call these “New Year’s Resolutions” because they can become habits for the new year rather that something that will be forgotten by the second week of January. These are:

  • Perform at least 10-minutes of exercise of some type per day.
  • Give up meat for three dinner meals each week
  • Don’t patronize any restaurant with a “drive thru” window (Sorry Dunkin Donuts!).
  • Don’t add salt (NaCl) to any food before tasting it
  • Try a new vegetable each week (most stores have a great selection).

Taking each one of my goals

I know that every study out in the news media states that one needs at least 30-minutes of exercise 5 to 6 times each week but I know that if one strives for 10-minutes, they will increase to 20 minutes and get to 30 pretty quickly. I am a person of small increments of change working better than one large increment that does not work. Like your studies, exercise can be divided into small manageable bits that can be checked off and mastered. A 40-page paper is written one letter and one page at a time. Daily systemic practice of one small change can lead to larger and better results as that practice becomes a welcome habit.

I also encourage my patients to allow their 10-minute exercise break to be a time when they don’t multi-task. This means that this break should be a true break from cell phones, tablet computers (well maybe the I-pod/MP-3 player) were the mind can be refreshed and renewed. Couple that with getting one’s heart rate up and you have a true “mini-vacation” that decreases stress and makes the rest of your day more efficient. If you want more of a challenge, go up flights of stairs on your 10-minute break. Your brain and joints will be grateful for the movement.

In getting to know vegetables/fruits again, one can develop a relationship with color, texture and anti-oxidants. While I know that fast-foods are wonderful time savers, those heavy fat meals are terrible for keeping alert later in the day. If one does the burger/fries routine for lunch, the rest of the afternoon is spent trying to overcome “food-coma” so that you can get through the day. If you do the burger/fries routine for dinner, one finds that “food coma” can make your studying particularly inefficient. Try making a nice light dinner/lunch of rice noodles and grape tomatoes which can be appealing for the eye and add some “zip” to your taste sensations. One can also have a bag of cut and uncut vegetables, carrots, bell peppers (red and green), carrots and those lovely grape tomatoes in your backpack so that you can snack on something that won’t put you into nap time during your study time. One can also invest in great spice mixtures, curry powders and chilis for waking up taste buds and mental clarity.

If I have one vice, it’s a hot, fresh cup of Dunkin Donuts  (DD )coffee. I just have to stop by the shop, get out of the car and walk in to get my steaming cup. I can drink this coffee black and enjoy its rich aroma and flavor. For me, DD coffee is less harsh than Starbucks (though I will drink Starbucks when I can’t get DD) and is a nice break during my day. In the late afternoon, I often reward myself with a nice hot cup of coffee or tea (Twinings Earl Grey) rather than something fatty or sweet. I try not to drink anything with caffeine after 5pm if I anticipate getting into bed at my usual time. Since I get up around 3AM most days, I find that I need to be in bed before 11PM most night for sleeping. If I am on call, all bets are off and I enjoy my coffee/tea at any hour. When my favorite Dunkin Donuts shop put in a drive thru window, I had to change shops because I don’t want to break the drive-thru habit.

Finally, the NaCl habit is one that most of my patients need to skip. The American diet has increased the love of that salt taste in most people in this country. Since most of my patients have more than a passing experience with hypertension and diabetes, I do encourage them (and my students) to tread lightly where sodium is concerned. This is why most “fast foods” are not good diet choices. Couple the high sodium content with the high fat content and one has a potentially troublesome combination. Do keep in mind that it takes some time to get used to eating foods without salt and to lose that love of salt. For me, it was difficult to get used to eating baked potatoes with no added salt but now I use pepper and happily enjoy munching on the potato (with skin) with nothing other than pepper added to this vegetable.

Taking Stock

Be willing to forgive yourself for doing things that were counterproductive to a strong performance in your academics or in any area of your life. Everyone, even the person who has the highest grades in class, would like to perform better and more efficiently. Efficiency comes with experience and with adaptability. If you can make some shifts and learn from things that didn’t work well for you, then your efficiency and performance will increase. Remember that every day is another chance to do better than the day before. One test, one semester or even one year do not define a lifetime. One can just decide to change your thinking about any subject or taking one step ahead rather than remaining stagnant. No one’s past defines them but the past does allow one to have thousands of experiences to draw from and to learn from.  As you move into the new year, look at one or two small things that you might like to try to do differently and try a to change them one day and one small experience at a time.

16 December, 2011 Posted by | academics, first-year, organization, study skills, success in medical school | , , | 7 Comments

My First Week of Medical School

Many people have asked me, “What was medical school actually like?” “What was you day-to-day schedule?”. I will attempt to describe my first day in medical school from the time I woke up to the time I fell asleep in this essay.

I woke up at my usual time of 4:30AM. I was raised on a farm and getting up early is as much a part of my life as brushing my teeth every morning and evening. I am fortunate that I actually have always had less of a sleep schedule than most of my buddies and thus, I generally awaken around 4:30AM without the need of an alarm clock. I also roll out of bed and hit the shower while my single cup of “Joe” is brewing.

Over coffee, I usually catch up with the newspaper (online) and then I headed out the door for my walk to the subway station. This walk generally took about 20-minutes and was a built-in source of exercise for me for the first couple of weeks of medical school. My coursework on the first day consisted of Introduction to the Practice of Medicine Class at 8:AM- 10AM, Psychiatry at 10AM to noon. Lunch was from 12 noon to 1PM. Afternoon was Gross Anatomy Lecture from 1PM-3PM and Gross Anatomy Lab from 3PM to 5pm.

All of our lectures were in 50-minute blocks with 10 minutes of break in between each lecture. This allowed us to get a drink, walk around and prepare for the incoming lecturer. It also allowed the media person to set up in between the lectures as our lectures were available for download and all PowerPoints were down-loadable from out seats. Most of us took notes on the Powerpoint slide sheets or just listened in class.

Our syllabi had been handed out during orientation so that we knew the objectives and content with each lecturer. We also knew which textbook readings were to be covered. My Introduction to the Practice of Medicine course had a syllabus that contained an outline of the lecture. There was no text reading for this opening lecture that included the duties of a physician, how to fill out a death certificate and how to gather and interpret vital statistics for a locale such as birth rates, death rates and rates of disease.

With all of my syllabi and text books, I would remove the covers, take the books to Kinko’s and have the bindings removed. I would then have three-holes punched and I would place these sheets in large 3-ring binders. I had a binder for each course. In the evening before each course, I would remove the syllabus sheets for that course, remove any textbook pages that I thought I might need and place them in a small 3-ring notebook along with sheets of lined notebook paper (for taking notes). This was the notebook that I brought with me to school. I would have the subject matter divided by separators so that I had all of my information with me for the day.

I would download my PowerPoint slides and place copies of these in my subject notebook when I got back home for the day. My lecture notes (or copies of note service) would also go into each subject note book. My textbook pages would go back into that textbook three-ring binder.

On my first day, I took notes and placed them in my Introduction to the Practice of Medicine binder when I arrived home at the end of the day. For psychiatry, again, the lecturer had no slides but discussed Erickson’s stages of development and Piaget. I took notes but knew that detailed explanations of these subjects were in my textbook.

For Gross Anatomy, I had the text pages with me and made notes in the margins of the material presented by the lecturer. I also made a few notes on photocopies of my Netter plates for use in our lab. During Gross Anatomy lab, I had my list of structures that I had made from scanning the dissector. I had also reviewed the relevant plates in my Netter atlas and had made photocopies of these plates. My photocopies were stapled to my list of structures.

In our first Gross anatomy lab, we studied the bones of the vertebral system and skeletal structures. We were also given instruction in how to work with the diener to keep our cadavers in good condition for the entire semester. We were also introduced to our cadavers and our tank groups (each was six people).

After lab was over, I took the subway back home (45-minutes) and walked from the subway station to my house. I then took an hour, made dinner, ate and begin to study and review the material from the first day’s lecturers. As I studied, I made notes an questions in the margins of my books, syllabi and note sheets. Since most of my notes were typed, I printed these out and placed them in my subject binders. I also studied and memorized the relevant bone structures using my bone box that was issued to me during the first day of Gross Anatomy laboratory.

My next task was to preview the notes for the next day’s subjects and do any readings/problems that had been assigned. After my previewing, my textbook pages, relevant notes and syllabi pages were placed in my daily notebook which went into my backpack. My next days courses were Biochemistry, Microbiology and Microbiology lab.

My day ended about 11 PM and I hit the bed because I knew that my next day would be starting at 4:30 AM. Since Tuesdays and Thursdays were shorter days (class started at 8AM but ended at 4PM) I actually had an extra hour on these days. We also had a Microbiology Discussion session on Tuesdays and a Biochemistry Case Discussion session on Thursdays where we would discuss clinical cases from the standpoint of these subjects. Our instructors would bring a case, present it and then we would discuss these cases in detail from the standpoint of the basic science involved.

When we started to actually dissect the cadavers, my Mondays, Wednesdays and Fridays included 2-3 hours of dissection in the evening after class was done. I would get some dinner at school and then get into the dissection laboratory to study and complete dissections. The extra dissection/study moved my bedtime back to after midnight on these nights.

I also studied in the dissection laboratory and with my study group on Saturdays. We would have an early breakfast (at one of the nearby churches to help them raise funds) and then study and quiz each other until noon. We would then study and quiz each other in the Gross Anatomy lab after lunch and generally until 3 or 4pm. After that, we would do another group session in Biochemistry and Micro and then head home around 8pm.

Sunday’s were generally my day of rest. I would spend a couple hours in the evening putting together my materials for my Monday classes but most of my studies would be completed in the time that I had put in Monday through Saturday.

If this amount of study time seems extreme, it was extreme in some ways. I would not stop until I felt I had mastered the material. I also made the crucial mistake of neglecting my physical conditioning in favor of my studies when I should have incorporated my studies into my physical conditioning routine. I ended up gaining a considerable amount of weight but my grades were excellent. At this point in my life, I know that I have to strike a balance and now I am in excellent physical condition with no neglect to my academics/reading.

Medical school was all about balancing my studies with my life. I learned to multi-task and I learned how to focus on getting things mastered and completed. I also learned the value of discipline. My schedule didn’t allow much “downtime” but the “downtime” that I had was utilized to an ultimate degree.

It becomes easy to procrastinate in medical school because the days are long and the material seems voluminous. I fought procrastination by asking myself, “Why are you avoiding getting on with this task?”. Since I never had a good answer for this question, I just broke the task into smaller tasks and checked them off until they were done.

As I have said in other posts on this blog, the telly went by the wayside. I would spend a bit of time on Sunday scanning the log for shows that might be of interest. I would program my recorder for the shows of interest and watch them the next Sunday if I felt like a bit of relaxation. In most cases, my relaxation became hanging out with my classmates and the telly wasn’t much entertainment. I still tape shows that I love or documentaries that might be of interest to my students as I am teaching more these days.

Other things that tended to waste my time in medical school were phone conversations. I seldom use my telephone more than 5 minutes per week and tend to use e-mail communication more. I also pick and choose the meetings that I attend. Many times, academic committee meetings can be a total waste of time and energy and thus, I pick and choose whenever possible. If something is mandatory, the organizers generally will time the meetings around the schedules of those folks who are attending.

One of my medicine professors encouraged us to read the case reports in the New England Journal of Medicine every week from the first day of medical school. He said that we might not understand all of the aspects of each case but that this habit would prove invaluable as we moved through the curriculum. He was totally “on the money” with this one. I can’t tell you how studying and reading these cases helped me on all steps of USMLE and in residency too.

Medicine requires that you read and keep up with the journals of your discipline. I strive to read selected articles in New England Journal of Medicine, Journal of American Medical Association weekly. I also read American Surgeon and Archives of Surgery regularly along with Nature Medicine (excellent articles to be found in this journal). I keep a computer log of the articles that I have read and their sources. This keeps me current with the literature as much as possible.

16 June, 2007 Posted by | first-year, medical school, medical school coursework, organization, study skills | 9 Comments

It’s On to Medical School!

You have managed to go through the medical school admissions process and you have selected the school that you will attend. At this point, approximately two months out from actually starting classes at medical school, what are some of the things that you might want to place in order? Graduation from undergraduate is behind you and those wonderful celebrations are over. It is now a good time to look at some of the basic necessities that you are going to need in order to start your freshman year of medical school off on a solid foundation.

Have you found a place to live? The ideal “home” for a freshman medical student should include, a bed (mattress on the floor doesn’t work well), a desk with good lighting (preferably in front of a window), a bathroom with both tub and shower, and some manner of kitchen facilities. If you are doing the “dorm” situation, a small-refrigerator and coffee/tea pot are bare essentials if you don’t have access to a kitchen or kitchenette. Other “niceties” are a sturdy bookshelf for organizing your textbooks, a filing cabinet for papers and notes (2-drawer is fine) and a comfy chair with reading lamp for change of position. A large-sized dry erase white board (60-incher) is good for concept mapping and writing down upcoming test dates etc. You can fall asleep while looking at one of your concept maps. Leave the telly at home but an MP-3 player and radio are good to keep on hand.

You won’t be spending loads of time in your “crib” so you don’t need to load up on creature comforts. You home should be something of a sanctuary but you don’t need to spend thousands of dollars on furniture for your apartment and an interior decorator. You will be basically doing the three “Ss” in your apartment(shower, study and s–t) and rushing out of the door on most days. Even on weekends, you life is going to center around your studies for the most part. If you have a family (or significant other person in your life), then you may need to make more sophisticated provisions but in essence, medical school is going to make your life pretty simple and fairly routine.

Your home should be an easy commute to your medical school. Hours of sitting in traffic or hours of driving to and from school are a very bad idea. There will be days when you are just exhausted and traffic/commuting will be the very last things that you will want to contend with; not to mention having enough energy to hit the books and notes after you have battled traffic. When I was a freshman medical student, I had a 45-minute subway ride into the city each day. I used that time to preview lecture material or just relax and listen to the sounds of my environment. I definitely would not have put that much time into driving. Before starting third year, I moved much closer to school and my clinical rotation sites.

Most of your time will be spent in and around school. You will attend classes and you will study your notes and books in the evening on a daily basis. The more information that you have to remember, the more organized you want to be in every aspect of your life. I planned as much of my day as possible around my classes and study schedule as I became the ultimate multitasker. It was always my goal to get ahead of my professors and stay ahead of them as much as possible. This task became the goal of my organization skills.

If you have an automobile, you need to scout out parking as soon as you hit town. It may work out that you end up parking your car further away from your school and getting a short but brisk walk to school and a secure parking spot that you can count on. At my school, parking was such a premium that taking the subway daily was a better option for me until third year. It just wasn’t worth the money to park or the worry that my car might be broken into as several of my classmates discovered. If you school has safe and secure parking, again, park far and walk more. Your nerves and stress level will appreciate the extra exercise.

On weekends, I would drive into school for sessions in the Gross Anatomy lab or study groups. Since I didn’t have to deal with traffic on the weekends, driving made more sense those days. Having the car also gave me an option of finding a great restaurant for a good meal as a reward for getting my studies done.

I also made sure that I had at least three months of expense money in my savings account for any emergency. Things that might come up would be your financial aid being delayed or an extra expense that you didn’t budget for. I kept a very strict budget and could account for every penny of my expense money. Again, not having to pay for parking saved loads of change for me. I also had the option of working on holidays which added to my stash of emergency cash. I would work any holiday as keeping up with my studies gave me holiday time as extra days. In addition, holiday pay was very very lucrative for me. (I was a registered respiratory therapist with a specialty in pediatric critical care). I did not work during the regular school session no matter how thin the budget was stretched. It was difficult but my studies came first.

During the summers between my first and second year and between my second and third year, I had either a paid position (in addition to my contract work) or a paid fellowship. I would leave a couple of days to do absolutely nothing but I could not afford to do too much vacation during these summers. The summer between my first and second year, I was a peer tutor for our pre-matriculation program. The other summer, I had a pathology fellowship. In both cases, I furthered my career and honed my knowledge which proved great for boards.

Food turns out to be a fair expense for most medical students. The worst thing that you can do is rely on fast food. It has too much fat and you end up paying with your health and energy level. I would limit my eating out to once per week and explored the ethnic restaurants of my city. I would eat Vietnamese, Ethiopian, Jamaican, Thai, Japanese and Cambodian food every Saturday evening. My study group loved to go for breakfast (or Sunday dinner) at a nearby church. We would get a good home style meal and support the community which, loved having a table of hungry medical students. We learned to be very careful because “food coma” could be a major problem after one of these great meals.

If we were studying at one of our houses, we would “pot luck”. Sometimes it would be a mixture of supermarket “take out” but we tried to keep our “study meals” nutritious and non-fattening. The worst thing would be those late night sessions before an exam when the Nacho Cheese Doritos would be out on the table. There is something about crunch snacks that fits well with study time.

Collect your favorite study supplies and stock your desk as soon as you can. I had colored pencils, different colored highlighters and my favorite four-color pen. I also had a large cork board above my desk for pinning notices and sticky notes. My other favorite technique was to cut the bindings off the back of my text books, punch three holes and carry only the pages that I needed to read instead of the entire book. To this day, my pathology text (Big Robbins) is divided into two notebooks. I did the same with my Gross Anatomy text, Pharmacology text and all of my syllabi too. Kinko’s can do this little task for you.

Another essential piece for my desk was a kitchen timer. I kept one in my backpack and one on my desk. I would set the timer for 50 minutes and study for those 50 minutes. I would then take a 10-minute break and back to another 50 minutes. This kept my mind refreshed and kept me more efficient. I would also check off each subject as I studied them. This check-off was more psychological so that my mind would see that I was making some progress. During my study breaks, I would walk around, get some water or just look out the window and let my mind rest. (See the purpose of having your desk in front of a window).

Purchase a good medical dictionary such as Stedman’s Medical Dictionary so that you can look up words and terms as you come across them. I made it a point to look up any words that I did not recognize and keep a running vocabulary list. I also obtained a subscription to the New England Journal of Medicine on-line. I would print out the Case Reports and read them on the subway. The medical dictionary came in handy for these articles. I also learned how to present patients and increased my general medical knowledge. I also read the review articles and any original research that was of interest to me. I would scan JAMA in the library but NEJM was my daily reading in some manner.

Other supplies for me were ringed binders, large coated paper clips, erasers, No. 2 pencils, an electric pencil sharpener (I love sharp pencils) and narrow ruled notebook paper for written notes. I usually took class notes on my laptop computer. I used a mini cassete recorder (I have now replaced this with a digital recorder) for those days when I found myself dozing in class. I would make study drill tapes and listen to them when I walked or exercised.

15 May, 2007 Posted by | first-year, medical school, organization, stress reduction, study skills | 2 Comments

Burnout

I was answering a question from a student on that dealt with “burnout”. It’s that sensation that you can’t see “the end in sight” and that dealing with your high stress is taking a major toll on both your mental and physical health. Many students find themselves in the middle of a depression that seems to add to the stress. Depression is one of the first ways the mind attempts to handle high stress. This cycle becomes a circle of perpetual positive gain unless you find a way to break the cycle.

I certainly remember days when I felt as if I had 36 hours of work to cram into 24 hours. When this happens, I remind myself that I need to stop, get some organization and eliminate some of the small “stuff”. By small stuff, I mean things that are “low yield” in terms of contribution to the major tasks at hand.

There are things and actions that MUST be done daily. Eating, sleeping, showering and taking care of other physical needs come to mind in terms of the “MUST BE DONE” category. If you are employed, you can add work/study and its necessary tasks. There are things that are optional but necessary like physical exercise that make the other tasks go well but if skipped, are not the end of the world. Then there are the “small stuff” like cleaning out your closet, sink, bedroom etc, that are great to do if you have time but can be postponed to vacation/downtime with few consequences.

One of the biggest problems with the “small stuff” is that it becomes the thing that you find yourself doing with the “major stuff” becomes overwhelming. This can greatly add to your stress level but you are looking for relief and anything that IS relief is a temporarly welcome.

Other actions that can greatly add to your stress is that little “inner voice” that keeps telling you that you “should be ” doing something or “should be better” at work/study. The problem with that little voice is that it gets louder and louder the more stress that you find yourself under. As that project/exam nears, that “little voice” becomes a “constant shout”. This is another sign that you need to change something and break the cycle.

The first thing to do is organize your tasks. What do you HAVE to get done? What is the time frame? How much have you actually accomplished towards your major task? You can list your tasks on a sheet of paper and rate them as A, B, C in terms of importance. Your A tasks HAVE to be done; B tasks are good to do and C tasks carry little penalty of not done.

Take each A task and figure out how long it will take you accomplish each one. Your study schedule can be arranged around your class schedule and thus you want to have time to preview, listen to lecture, quick review, study and preview… Get your A tasks taken care of first and be sure to put in some “break time”. It is not efficient to pencil-in “Study Biochemistry 5 hours” because you will be saturated with Biochemistry after 1 hour (for me it was 50 minutes and I AM a Biochemist!). After one hour, take a ten-minute break, get some water, stretch, walk around, get some fresh air and then come back to your desk refreshed.

Check off your subjects as you get them done. This psychologically gives you a boost because you have a sense of accomplishment. Don’t beat yourself because you can’t look out the window and recite every enzyme of the Citric Acid Cycle complete with affinity constants. Your goal is to understand your studies well enough to apply them. For example: Sorbitol is an alcohol sugar that is produed by enzymatic/chemical reduction of an aldehyde group on a monosaccharide. It provides sweetness but does not increse blood levels of glucose or insulin. This makes sorbital a good sweetner for diabetics. The concepts are alcohol sugar, elevation of insulin/glucose in a diabetic and reduction of an aldose. In addition, since it contains more -OH groups than other monosaccharides, too much sorbitol can produce diarrhea too. Stop, try to link your lectures and keep the concepts in mind as you study. How does this fit into the big picture? Instead of rote memorization that puts information into your short term memory, go for understanding of concepts that links your short term memory with your long term memory.

Finally, do at least 30 minutes of physical exercise. Do something that you like and vary your routine. Take a brisk walk or walk up two flights of stairs and come down one. Do three 10-minute intervals of physical exertion if you can’t find 30 minutes in one block. Lean against the wall and stretch/breathe and laugh. This gets rid of stress and helps to keep you calm and focused. Use your 30-minute exercise period to let your mind go anywhere. Don’t try to study during this time, let this be your cheap “play time”. Remember “recess” when you were a child in elementary school. You didn’t combine “recess” with study back then. Don’t combine your exercise with study either for at least 30 minutes. After that, you put on your earphones and listen to drill/study tapes but do at least 30 minutes free of school work.

Keep your life organized as much as possible. Know how much underwear you have and get your laundry done before you run out. Lay out tomorrow’s clothes the night before so you have them ready in case you get rushed or oversleep. Pack a light lunch the night before (you can make a PB & J on your study break) instead of loading up on heavy and high fat foods that drag you down and decrease your alertness in the afternoon. Fold your laundry and stretch at the same time.

Finally, get yourself a mantra that you can repeat to yourself over and over when you find that you are starting to hear that “should be ” inner voice. You know, the only thing that you “should be” is yourself. Forgive yourself (this means that you give yourself permission to move on) if you make (a mistake or mistakes) and keep moving forward. Just because you did something wrong yesterday is not a good reason to do the same wrong thing today. Change your behavior now and change your thinking now. By doing this, you world will change and you won’t know who “Burnout” is.

10 April, 2007 Posted by | organization, stress reduction | 2 Comments