On to Year Three

Friday marked the end of the formal education we have come to know since day one, when we sat in classroom and were spoon fed doses of information for the purpose of tests that evaluated how well we could study. We go from being students and passive learners to starting our doctoring apprenticeship. We take on the role of the student doctor and become responsible for the care of our patients. We now must take charge of our own education.

We have been told that we start out as students, who closely identify with our patients. By the third year, we begin to see our patients as a list of symptoms. And by the end of our fourth year, we closely identify with the doctor.

The third year has been compared to a socialization process, during which we develop our identity as a physician. As part of process, we learn to function as part of a medical team. We may oftentimes feel outside our team, standing on the periphery, watching and not really understanding or associating with others, especially when begin to navigate the complexities of the wards and the details of our patients lives and diseases.

You are also charged with advocating for your patients. The major challenge for any student stems from the dichotomy that exists between fulfilling the goals of the team and serving the patients, especially when the goals do not align.

As students, we are naïve and unaware about the social norms of the medical culture. We maybe referred to as dead weights or speed bumps on teams. We ask lots of questions, slow down the team’s progress, seek endless guidance and affirmation that we are doing things right. We have not yet been completely exposed to the realities of medicine and we are on the bottom of the todem pole, which makes us powerless.

At the same time, we do offer a different perspective because we spend the most time with our patients. In this regard, we are the closest to our patients and places us in a position to speak for our patients.

As we move forward, I know my life will change drastically. I know I will have to make sacrifices to excel in the third year. Fourth years have told me that you can pick two: sleep, exercise or a social life. Not sure which two I would pick, but I know I would focus on maintaining some sort of balance in my life (if possible). Most importantly, I hope I can draw on my sources of strength (family, friends, mentors, exercise and inner peace) to help carry me through the most difficult times ahead.

As we descend into the wards, we are about to enter an entirely new culture and we will soon be learning a new language that changes every 6 to 8 weeks. We are like nomads, traveling into strange lands without a map. We will fixate on what to wear, what to carry in our pocket, what to present and how to write a note. We are undergoing a transformation from a lay person with two years of formal medical education, to becoming fully indoctrinated into this mysterious medical culture.

From other students and physicians, I have heard that each field has a personality. As impressionable students, we will be tempted to change ourselves to excel. I know a number of students will change to please the attending of the month, like a chameleon that learns to blend in. At the same time, I know I will have to resist such dangerous temptations and remain true to myself and accept my limitations.

On day one of clerkships, we will be given a lifelong responsibility- “here is your patient, take the very best care you can.” I hope I can fulfill this responsibility and look forward to the challenges and learning ahead.

Wish me luck!

Turning up the heat

April 20th record heat- 88 degrees in San Francisco. On such a day, residents of SF flock to Ocean Beach, savoring every moment of heat, since we can probably count the number of hot days we expect in the year on one hand. The sun was out, beating down on the city today. No fog in sight. A prelude to summer in most other places. A unique time in SF. The time to be outside.

Transitional Clerkship has a fair amount of work. We've been transplanted at different hospitals and paired with preceptors, who help us refine our case presentations and SOAP notes. I've spent my days in the General hospital learning about the stories of homeless individuals, HIV-positive patients and patients with heart disease.



The days have been spent working on becoming functional medical students. The nights and weekends have been spent enjoying our freedom. I finally made my way to the California Academy of Sciences located in Golden Gate Park, during Night Life, which transforms the academy into a hip hangout for the 21 and over crowd. During evening hours, my friends and I enjoyed the sights of a tropical rain forest, an aquarium and an albino alligator (among other things). And the best part of all- there was music and people dancing.

Imagine this- science set to the tunes of techno with a dance floor around the Galapagos Island display. Interesting...



I got a taste of what it feels like to be on-call, when we were playing The Game on Saturday- an all night scavenger hunt that involves solving puzzles and looking for clues that have been scattered all over the bay area, everywhere from Golden Gate Park to the Dutch Windmill to Lombard Street to Coit Tower to Stanford. The combination of the dark, adrenaline and intellectual curiosity got my team through the endless clues and long hours.



I am definitely savoring each moment of free time and catching up with friends. After studying for the boards non-stop, I remember how I used to feel guilty about doing anything that did not involve memorizing voluminous amounts of medical knowledge. Now, I can breathe and enjoy the sunny days (rather than curse them when I used to have to stare at the sunset and sunrise from my library window)and time spent with my friends. Long ocean runs in the heat have never felt so good. I welcome back tan lines with open arms.

I'm taking it all in- the sunshine, the realization that we will soon be treating patients, the spare time we get in between learning to be doctors- it's exactly what we need before being thrown into the next phase of our training. In less than one week, we start on the wards; I start with medicine at the General hospital and will be working 6 days a week and will be on call every sixth night, leaving me with 4 days off per month. By the looks of it, rotations will surely turn up the heat too.

Stepping Ahead- Transitional Clerkship

There is some comfort in knowing that we are not quite starting just yet. Two weeks of transitional clerkship is exactly what we need to ease back into the whirlwind of the clinical core post-boards.

It's a step by step. Ok, more like- baby step process.

On the first day back, our professor compared medical school to skiing down a steep hill. In the first two years of medical school, we have climbed the mountain. Now, we've made up to the top and are looking down.

The view can either be extremely scary or spectacular. I can appreciate both views.
Regardless of how we see the challenges ahead, our goal is to simply learn how to ski down that hill without falling. In transitional clerkship, we will learn how to put on our equipment to prepare us for the next two years.

We spent the first day learning about the patient interview (again) and presentations. This time, I think we all paid closer attention, since in less than two weeks, we'll be delivering patient presentations to groups of superiors in white coats. Like anything else in life, we need to "practice, practice, practice."

I spent this afternoon drawing blood, performing a blood ABG, inserting peripheral lines, learning basic life support and suturing. All procedures were performed on mannequins and the suturing was done using pig's feets. Our blood sample was red Koolaid. Somewhat realistic.

We also celebrated the essential core by acknowledging the lecturers, small group instructors and clinicians that have made an impact on our education. In doing so, we close the chapter of classroom learning as we move to learning on our feet in the wards. I had the privilege of introducing the award for outstanding lecture series to a physician that taught us everything we need to know about parasites. We may never look at pork, beef or sushi the same way- but we did learn a great deal about these interesting creatures that have complex life cycles and cause so much harm globally.

As we go through the next two weeks, we are constantly reminded that third year requires a serious paradigm shift. During the first two years, we showed up with a "backpack, ipod and whenever in a controlled environment." And now, things change, we become professional and show up for a job. The student goes from being the center of the academic universe to becoming the bottom of the totem pole. Third year is a time of learning, but it may also be a "spectacular opportunity for failure."

We were told that it's normal to be anxious. In fact, you're probably abnormal if you're lack nerves. I'm definitely nervous (an understatement). Yet, I'm curious about the unknown.

We'll see how this transition goes. I'm slowing making those steps forward.

We're only Human

A week has passed since I took my board exams. Although it has only been one week, it feels like I took the exam months ago. As expected, I have already forgotten all those facts that were crammed into every nook and cranny of my brain. I've done everything I can to suppress the memory of the exam, including forgetting all those questions that came out of left field. Oh well- it is what it is.

Older classmates and physicians have told me that completing the exam is an accomplishment in itself. This is true. We always seem to forget that point.

Generations of physicians have taken this exam before clerkships. In a way, the Step 1 represents a rite of passage for medical students transitiontioning from the lecture hall to the wards. But at the same time, taking the exam left me feeling numb and inadequate. After answering my last question (question 336), I realized that no matter how much you study, there will always be things (mostly trivial details) you'll never know on an exam.

We're only human.

As I continue to distance my mind from the post-boards anxiety, I'm enjoying the oblivious bliss that comes with finishing the exam and not knowing that three digit score that has been rumored to play some role in determining the course our future. I spent the last week doing nothing but relaxing, sitting in the sun, running, biking, kickboxing, exercising, and catching up with friends and family. I tucked away all the board review books and flashcards (out of sight and now out of mind) and finally caught up on some of my favorite tv shows, including Ugly Betty.

This unenventful and unproductive week was exactly what I needed to culminate the end of my second year and the monthes of endless studying that go into preparing for the Step 1 boards exams. Now, I feel refreshed and mentally prepared to embark on the next phase of medical school- third year, which reminds me- I need to update my email signatures.

Before being thrown into the wards, we have transitional clerkship (TC)- a two week buffer. TC represents the perfect time to be reminded of how to present patient findings and perform focused physical exams, learn necessary skills (suturing, blood draws, ABG, etc.) and be reminded that we will survive what may feel like one of the scariest moments in our medical school lives.

I'm not sure what to expect from the third year. I start off with medicine at the general hospital. I've heard so many different stories (some uplifting and some not so promising). I'm not sure how I will cope with working 6 days a week and losing sleep on my call nights. I'm not sure how to maintain my life outside medical school, when I'll be spending most of my time in the hospital. I'm really just not sure about anything...

Time and experience will tell how I will adapt to the third year. I'm keeping an open mind to the possibilities.

I am looking forward to being reunited with all my friends and classmates. It will be nice to touch bases and form support groups as we venture into uncharted waters. Hopefully, transitional clerkship will teach us the basic strokes we need so that we coast through our first clerkship rather than drown.

The Homestretch!

I'm 5 days away from regaining my life and getting out of the library.

5 days from an extremely long run.
5 days from watching countless movies from my list of "movies to watch."
5 days from spending time doing nothing.
5 days from relaxing and lounging around in the sun.
5 days from freedom.

Short-term memory utilization has begun. It's time now to memorize all those rare lysosomal storage diseases, biochemical defects (that have extremely long names and look the same) and the complement cascade. Plus- all those drugs with their rare toxicities. The next 5 days are going to be splendid fun, full of forceful memorization.

I just hope there is space in my brain, which is overflowing with medical facts that keeping spilling out.

Until test day, I'm staying calm and thinking of this time next week, when I'll be done!!!!!

Counting Days

I'm still here, counting days to freedom.

Nothing too interesting going on. Just the usual studying marathon. Enough said. Watching spring time emerge from my window, yearning to be outside.

This shall pass...

Almost 50% MD

We bid farewell to the Essential Core today. The Essential Core represents the pre-clinical years, where we are learn the basics of medicine.

We completed our clinical final over this past weekend, with a series of patient interviews and physical exams. We officially ended our second year with a small group about common ethical dilemmas in older adults followed by an interview with an elder, who spoke about her life and the challenges she confronts as she gets older.

After the interview, we were joined by our deans and administrators, who congratulated us on making it to the half-way mark of our medical education. It was more of an early congratulations, since we still have to take our life cycle final and that other big test (the boards). In what has been described as a "milestone," we will now see a shift, where the center of education shifts from the medical student to the patient, as we move to wards.

With some games, a raffle and a burrito, we walked out of the lecture hall- to the library to study for the upcoming exams (it's like a marathon). As I walked away, I realized that were all about to go our seperate aways; this was the last time we would officially assemble as a class of preclinical students. Hard to believe.

We move from lectures and small groups, where information has been spoon fed to us, to the real clinical world, where we learn from our patients. The third year became more real after we received our rotation schedules on Friday.

We will face an entirely new learning curve ahead. I am excited and apprehensive. I'm just pacing myself through the next weeks to get through the boards.

After we complete our life cycle final on Thursday, we become third years with half of an MD.

The Countdown Begins

"It is what it is." This has become my new motto, whenever I am asked about how board prep is going. Quite frankly, it's almost like pushing a heavy boulder up a mountain that keeps getting steeper with no end in sight.

At the same time, I realize this time shall pass and we'll move forward. It's just a temporary inconvenience.

The countdown to test day has begin, as I reach the one month mark.

A typical day for me consists of the following:
1. Study
2. School (usually just small group sessions)
3. Study some more
4. Exercise
5. Eat
6. Study
7. Sleep

And then repeat.
It's very regimented and monotonous. Not too exciting. Just got get through the next month.

We'll find out our third year schedules on Friday, which will give me a sense of what to expect for the next year. Once I know where I will be, I'll be able to finally RSVP to all the weddings and graduations I'm supposed to attend.

Aside from ongoing boards prep, we enter our last week of life cycle next week with our final on Thursday. According to some of my classmates, attendance to lectures has dropped off (~20-30 students). So sad. It's that time of the year, when all the second years disappear to study. Sigh.

We now enter full test training. Let the endurance training and countdown begin...

Farewell to MSP

I taught my last MSP session tonight. Potassium balance. It's hard to believe how fast the monthes have gone by. I've grown with my students, walking them through the first week of anatomy through the cardiovascular block through pulmonary block through the last renal MSP lesson. Tonight I bid farewell to MSP.

Teaching has always been a fresh breath of air in my learning and an opportunity to tell really unfunny jokes. Thanks to teaching MSP session, the first years actually know my name and invite me to their parties (I even received an invitation to an upcoming End of the Organs party on Saturday). It's like being a popular nerd. In a way, I have been reliving the first year vicariously through teaching and interacting with my students, as I address their questions and concerns about exams and life as medical student. The first year has become something of a blur, but becomes more clear when I interact with my students, who take me back to the first year.

It has been a privilege to work with such talented and bright students. They have taught me so much of myself and my capabilities; I can be funny (usually this in unintentionally and still deliver an education message). I will truly miss MSP and my students. Teaching has definitely been one of the most rewarding experiences of medical school thus far. I walk away with some new friends and a unique set of experiences that will ground me through my future educational endeavors.

On Tuesday, while I was teaching about potassium disorders, such as hyperkalemia and hypokalemia, I was thinking about the stages of development through pregnancy, infant and childhood. The reason being, I was in the process of studying for our second Lifecycle midterm that was on Wednesday. So, Tuesday was one long night, as I bounched from teaching renal physiology of potassium balance to studying the physiology of labor and congenital heart defects.

My mind is still racing. The exam is over. MSP is over. Surgical Skills, the elective I am coordinating, will wind down next week with the final lecture and scrubbing and gowning session. As I relinquish all my responsibilites, I still feel as though there is always something that needs to be done. Perhaps, I was just born this way-- born to be persistently active.

I am also in the process of inventing the perfect third year schedule, which involves ranking my preferences for the order of rotations and site. In the end, the schedule will be generated by a computer through this elaborate "lottery" system.

There is this one other thing that requires my complete attention-- studying for the boards. This has been a challenge, like no other, more a test of mental endurance. My strategy has become to minimize memorization and maximize understanding through integration, which is almost impossible with lots of memorization. It's a Catch-22. I knew that.

My mind is always trying to make sense of all these floating facts and trying to find the logic behind the complex disease processes; some have clear pathways, while other explanations make little or no sense. And sometimes, what we learn boils down to these bizarre mnemonics that are just memory tools to remember all those details we will inevitably forget. Sigh.

Studying continues. At least I will remember somethings from teaching MSP.

Don't Break my Hearts

"Don't break my hearts." These were the closing words of our pathology lecturer.

We made our way to the pathology lab to examine a number of delicate hearts. It's ironic, we were instructed not to "break" these already broken hearts. Some hearts were the size of walnuts, while others barely fit in my palm. Each heart had some sort of congenital heart defect. Everything from holes in the walls of the chambers (atrial septal defects and ventral septal defects) to hearts that were missing an entire ventricle (hypoplastic left heart syndrome) to hearts that had the incorrect vessels paired with ventricles (transposition of the great vessels). These hearts had once beated inside the chest wall of developing fetuses and infants and eventually could no longer perform the job of a heart.

I was lucky to have met a five year-old child, who had a hypoplastic left heart on my pediatric preceptorship. When I had met him, there would be no way to know that this child, who loved Sponge Bob Square pants, had undergone numerous surgeries to repair his little heart. Today, I got to see what his heart looked like at one point in his life.

Using our examination skills, we attempted to identify each pathology. I have to say that this was my favorite pathology lab. I am simply fascinated by the heart. And seeing hearts with congenital heart defects reminds me about the complexities involved in developing the pump of our body.

This week has taken through pregnancy to birth to development. Earlier this week, I held a placenta in my hands. The flat structure, which looks like a really flattened cake, serves as a fetus' life line, providing nutrients and oxygen.

In lecture, we had the opportunity to meet families with young children. We were given the task of guessing the age of an infant and a child. It was hard to pay attention to the lecturer with kids in the room.

Today in small group, I played the role of pediatric resident as we ran a mock code that involved resuscitating an infant in respiratory distress. Although our infant was a stuffed gold and yellow tiger, we walked through the crucial steps required in managing the ABC's- airway, breathing and circulation, a task that awaits us in the wards.

Tomorrow, my doctoring group and I will be presenting an autopsy case about a 63 y/o female who suffered a myocardial infarct with a mysterious liver problem. We examined her gross specimens that had been stuffed in a white plastic bucket, including her heart, liver, spleen, lungs and GI tract, along with histology slides. As we pieced the organs together, we worked through a long differential to put together her medical story. I'll be sharing the liver part of her story.

On Monday, I helped teach instrument ties and suturing to first year medical student during the surgical skills elective. I also learned the horizontal mattress and this new suturing technique. It was so nice to finally work with my hands for a change.

The week has been extremely busy. My mind is definitely on overdrive (in a good way). I've squeezed in some board studying when I can, but I must admit there has really been no time. We all feel overextended. As we think about the boards, we simultaneously studying for lecture and ranking our program choices for our clerkships.

All in all, I look forward to the weekend. Although, I already know what I'll be doing...

There a break for some in site. Prom 2.0 will be held tomorrow night at the Academy of Sciences with an open bar. The oversold event promises to be even better than Prom 1.0. I have opted out of attending the festivities. Guess, I won't be breaking any hearts tomorrow.