Making Round Chappitis

Thought I'd share two of my passions with you- Cooking + Photography.
Here's a glimpse into my foray into the kitchen as I attempt to master the fine art of making round chappitis (among other things...). Enjoy!


Naan.


Keema Naan.


Burfy


Milk and Cookies.


Shaami Kebabs.

Finding the Horse among the Zebras

"What do you do when an elephant sits on your refrigerator?" asked the five year old girl during clinic.

After she asked this question, I started thinking.
Well, I suppose there is a logical next step. But no matter how logical, I also know jokes coming from a five-year old usually have some punchline that becomes clear after it's mentioned.

"I really do not know," I said.

"Get a new fridge." she responded.

Of course, that makes sense now that she mentions it.

***
I completed my pediatrics rotation over one week ago, after which I rolled right into the winter vacation. And with vacation comes a completely altered state of mind-you get caught up in the simplicity of life-- eating three meals at home, spending time with family and friends, watching movies, running in the bitter cold, relaxing and getting away from anything medical. Hence, the hiatus from writing.

My last week in pediatrics was spent in the primary care clinic, a completely different world from the inpatient setting, where I had spent the three previous weeks among a team of providers handling the care of more "complicated" patients.

In the outpatient world, the clinic visits focus on well-child visits, anticipatory guidance, growth charts, and immunizations (among other things). It's an opportunity to verse parents about developmental milestones in motor, social, and language areas. You see mostly healthy patients of all ages, from newborns to teenagers.

***
Before starting my third year of medical school, I was told by a master diagnostician that there are two types of patients at extremes. There is the "horse," which represents the common conditions who follow the text books and can be diagnosed by relying on history, physical exam, and certain studies. And then at the other end of spectrum exists the "zebras," which are the diagnoses that are unusual and bizarre. They follow no text book description and often represent a diagnostic dilemma- the types of cases that have become glamorized by television shows, such as House.

When I spent time on the pediatric wards, I was surrounded by many zebra diagnoses with some interspersed horse diagnoses. Only at a tertiary care center...

The medical complexity of their conditions coupled with juggling multiple social factors and medical consult services, makes providing care challenging and rewarding. While on service, I took care of patients with a myriad of conditions, including Guillain-barre syndrome, asthma, whooping cough, inflammatory bowel disease, recurrent arteriovenous malformations, and encephalitis.

While some of my patients were acutely ill, others were recovering and undergoing intensive rehab after suffering neurological injuries. While admitted, these patients meet with the physical therapists, attend school, and participate in social events. In many ways, the hospital becomes a transient home. And it's remarkable to watch how these patients improve, slowly regaining the ability to stand, walk, swallow--exceeding our expectations.

Some of the patients were well-differentiated, having been diagnosed prior to transfer, while others came undifferentiated and were transferred from an outside hospital for further work-up (or because initial work-up did not point to any particular diagnosis).

As the hospitalist team on the wards, we certainly had our share of diagnostic puzzles, which become more complicated when you have to rely on other sources, namely the parents, for an accurate medical history. As the result, the eyeball tests becomes even more paramount in helping guide the diagnostic work-up. And when you add multiple consultants, who have very specialized expertise into the mix, you face an entirely different problem. It's just like having too many cooks in the kitchen. The primary team then becomes charged with coordinating care for the patient, managing the consultants requests and completing a barrage of blood tests and imaging studies.

In many ways, the "horses" (the more common diagnosis) become the "zebras."

Despite the complexity of diagnosing patients who present with an atypical presentation of a disease or patients with uncommon conditions, there is something rewarding about making the diagnosis and being able to make our patients feel better.

One of the most memorable parts of my rotation was the patients. I am simply amazed by children and their ability to cope and heal despite the challenges.

Crunching Leaves

Autumn is here. Getting away from San Francisco reminded me about the seasons and the leaves with all their color changes--yellow, red, orange, brown.

As I ran around my neighborhood, I crunched the leaves that had fallen and blanketed the side walk. It took me back to the days of childhood. When I was younger, I would help my dad rake the leaves into nice neat piles before jumping on the piles and recreating the mess we had just cleaned. The good old days.

I had my first extended vacation of third year over the last two weeks. During the first week, I made a trip to Chicago for my brother's wedding. After the wedding, I came back to Davis to spend a week with my family.

It was so refreshing to get away from the medical world with all its differentials and histories for a short time to spend time with family and friends.

It's very simple to get completely consumed and to forget your human world. I had an amazing time at the wedding; it was so nice to be leave the medical student role behind temporarily to live life as a daughter, sister, friend and photographer.

As the old saying goes, "all good things comes to an end." And so too, does my vacation.

Despite having to give up unstructured days and three square meals, I am ready to return after a short hiatus. Being away has made me realize how much purpose I have as a medical student. There certainly are days when you feel inadequate and wonder if you will ever move forward. There is so much learning to be done, but you realize that you have come so far and and are moving ahead, albeit with small steps.

And each day is a gift that gets you a little closer...

I return to San Francisco today and the world of pediatrics. I move from the world of urgent care to the pediatric wards. There are four more weeks left in the rotation.

Hopefully, there will be time to crunch leaves during the next couple of weeks.

Halloween & Hand, Foot Mouth Disease

I was reminded of how much fun Halloween can be last week during the costume contest on the wards. The day before, our chief resident made an announcement during noon conference to remind us to dress up for the kids. I was a gypsy, which was not nearly as creative as the Mickey Mouse, pirates, fairies, cowboys, Pippy Long stockings, and other characters. As we walked around the wards, it was uplifting to see some of the patients dressed up and getting to Trick-or-Treat at different places on the floor.

Post-Halloween, I spent my day in the ED during a day shift.

When I spoke with a kid with a possible wrist fracture, I asked him why he waited to come to the ED (he had sustained the injury the day before) and he had the most adorable response.

"I would have come on Saturday, but I wanted to go Trick-or-Treating."

Now, there is a kid with his priorities straight.

***

For the first time, there is something in medicine that is appropriately named- hand, foot and mouth disease.

During urgent care clinic today, I met a very cute four year old boy, who was been feeling awful over the last weeks with fevers, diarrhea, mouth ulcers, and diarrhea. He also had some interesting rashes on his palms and soles. As I listened to the story from his grandma, I started to put two and two together; he has problems with his hands and feet (rashes) and mouth (ulcers) in the setting of an infectious process (fever and diarrhea).

Like a simple math equation, it all added up to one thing- hand, foot and mouth disease, which is a coxsackie virus infection. Treatment is mostly supportive (fluids, rest, and Motrin) and the symptoms will likely resolve with time. Poor kid.

***

My days in urgent care have been a mix of evaluating upper respiratory infections (mostly coughs, runny noses and fevers) and some other interesting things, including jaundiced newborns, kids who have been vomiting, kids with diarrhea and strep throat.

On my call days in the Emergency department, I took care of a six year old boy, who sustained a wrist injury while dribbling a ball in a soccer match. I was the first to sign his cast with my signature sparkly Sponge Bob stickers. I also saw a toddler with gastroenteritis and a 16 y/o with vomiting.

In my one week of experience, I am really enjoying working with the kiddos and am beginning to see the "bread and butter" of pediatrics, which is still very novel to me during my second week of pediatrics.

The Eyeball Test

These days, I walk around with pockets that are less bulging.

I traded the gauze, suture removal kits and medical tape for stickers and a doggie pen. I am proud to say that I walk around with stickers in my pockets, including Sponge Bob and an assortment of dog stickers. My favorite part of my job involves giving stickers to my younger patients.

I have moved from the world of surgery to pediatrics, two completely different worlds. I went from waking up before the sun had risen to waking up to the sun shining (I am currently working in the Urgent Care Clinic). I move away from focused abdominal exams to full head to toe exams, including looking into patient's ears and noses. It's a constant battle to get the otoscope into my younger kids, who cry and squirm. Even getting kids to open their mouth can sometimes feel like moving mountains. And yet, despite the challenges- it's such a pleasure to work with kids and families. When they smile, you feel a little less guilty about having to probe their ears.

In many ways, it's a stark contrast. I'm well-rested these days, catching up with friends and starting up my half-marathon training. The chief complaints have primarily been lots of upper respiratory symptoms and ruling out swine flu in kids having flu-like symptoms. In summary, lots of runny noses and coughing. Surprise surprise.

I do miss the intensity of surgery, the operating room and the complexity of the pre-operative and post-operative management. There is something remarkable about cutting someone open, visualizing the anatomy and defect, and fixing the problem with your hands (or instruments). I will miss the suturing for sure. There is no experience quite like it. A part of me will always be in love with surgery.

***
I do look forward to working with younger patients and developing an understanding of how to best approach common and not so common pediatric problems in the outpatient, urgent care and inpatient settings.

Although pediatrics and surgery are so different, there is one thing very similar to both fields--the eyeball test.

In pediatrics, you are oftentimes working with patients, who can not speak for themselves or give accurate histories. So, you rely on the caregiver to convey the history.

One pediatrician jokingly compared pediatrics to "veterinary medicine," since the patient is a poor historian for obvious reasons and you have to consult the owners (or the parents) for information.

As a result, you rely on your ability to "eyeball" the patient, which involves observing the patient and taking note of how they look, how they interact with others, and if they look sick. In doing so, you can answer some really important questions- "is this patient sick or not sick? Does this patient need immediate medical intervention?"

In surgery, you apply the same approach when evaluating a patient. You "eyeball" a patient to get a general sense of their disposition and health, which enables you (as a surgeon) to quickly decide if the patient is sick and if they need immediate surgery.

The eyeball test can also replace lack of knowledge; it's almost an instict or gut feeling. It got me through my surgery rotation and has been useful for me in my first days of pediatrics.

Excellent, the New Average

Sometimes we all need to remind ourselves about the light at the end of the dark cavernous tunnel that is the third year of medical student. It can get murky when you are constantly being watched and evaluated and when you learn about what to expect in the near future.

The fourth year has become uncovered and now we are learning about the residency applications and the MATCH.

The cycle starts all over again.

Our third year creeped up on us not so long ago, and now it's starting to feel like it is slowly coming to an end. We are over half-way through and the fourth year discussion has already begun. Over fifty per cent of our class will choose to extend their education by at least one year, during which time they may travel, perform research or work. I am still on the fence about whether I want to take an extra year to sort things out. Medical training already seems so long. And having gone straight to medical school from college, I am accustomed to moving forward non-stop. At the same time, I want to certainly keep my options open and am considering research fellowships or an advanced degree in either public health or education.

Amidst all the lectures about fourth year planning, the Step 2 exam, clinical performance standards and extending medical school by taking a year off- we are learning more about the process involved in applying for residency and the match. The process and timeline remains very unclear and represent a source of anxiety for many third years.

But one thing is for sure, the third year is all about labeling. Our clinical performance is packaged into a one word adjective. You can be any of the following- "Superior, outstanding, excellent, very good, or good." With over 53% of the UCSF class labeled as "excellent," excellent has become the new average. Seriously.

This culture of labels makes me wonder about the utility of such characterizations. First, the entire process is subjective and determined purely based on other's opinions of you. Second, medical students are unique individuals with very diverse backgrounds, opinions and perspectives, who really can't be characterized by a single number or adjective. But despite such issues, we continue to label each other.

To standardize the process, we are evaluated and given a numerical value that reflects a number of fabricated categories that are intended to measure our fund of knowledge, clinical reasoning and patient relationships. In many ways, the numbers marginalize us, and we may even see ourselves in light of the label we are given. The feedback that accompanies the number oftentimes does not always correlate and we wonder what we could have done differently, or if we should do anything differently. There is only so much any individual can change.

The system exhausts me. It's tiring to always think about what others think about you. A number of us (myself included) have decided to make the most of our third year by focusing on learning and taking care of our patients. And in the process, we hope the evaluation will reflect that. But as much we tiptoe around the inevitable evaluation conversations, there really is no way to avoid the unavoidable. It's on all our minds akin to the white elephant in the room. We all think about it and wonder about it. Some of us complain or try to rationalize the process. No matter what, we work hard and hope it all works out.

And last time I checked, there is nothing wrong with being excellent.

The End of Surgery

Friday was the last day of surgery. We ended on a somewhat anti-climactic note with the surgery shelf exam, a somewhat arbitrary measure of knowledge and clinical reasoning. I was experiencing flashbacks (nightmares) to preparing for the Step 1 exam, as I hopelessly reviewed esoteric details of diseases I had never encountered. It was certainly one of the least pleasant testing experiences I've had with 100 long questions in 2 hours- marathon test taking at it's worst. Sigh.

"If you finish you are ahead." I was told by another medical student.

As I studied for my shelf, the fellow on my service was preparing for his oral boards. Sadly, the tests just never end.

I left the exam feeling numb and bit flustered. Before I could start thinking about the test, I plugged myself into my headphones, tied my running shoes and set out for a long run. Actually, a really really long run- the longest run I've had thus far (14miles).

With the sun beating down on me, I just had the urge to keep going as I took in the sights of a city I had become estranged from while being on my surgery rotation. Moving one step forward, not looking back at all. This is definitely the year to run a half marathon.

Despite the challenges of surgery, I will definitely miss the rotation.

***

My last two weeks of surgery were spent on the kidney transplant unit. The best night of my rotation was on Monday, when I joined our team during an organ procurement. At 10:30 PM, we set out from San Francisco in a black van and made our way to a local bay area hospital, where we procured the liver and kidneys from a donor. The experience was surreal.

I felt disconnected at times-- not quite fully thinking about exactly what we were doing. But I also kept reminding myself how the organs we harvested could potentially save lives. No matter how I justified it, I could not forget the reality of what we were doing. We were removing organs out of a patient, who had been proclaimed brain dead. I got my best anatomy lesson that night. The heart continued to beat and the organs remained perfused, as we dissected away one organ at a time.

***

After my shelf and long run, I spent my golden weekend in the company of family and friends. My weekend was filled with quality time and food. I was able to recharge and refocus my energy.

I move now to Pediatrics, which starts next week.

Before moving ahead, all third year medical students will congregate in the classroom for a week of intersession, a series of lectures and small groups dedicated to ethics and clinical reasoning. Even after being lectured about how to resolve ethical dilemmas today, I feel more confused and uncertain about how to grapple key ethical topics, including allocation of scarce resources, end-of-life care decisions, euthanasia and patient autonomy. I hope this week will shed some light on these topics.

It's hard to believe that we are over 50% of the way through our third year of medical school. We reminded of this during one of our lectures, which focused on planning our fourth year of medical school. Already? I'm still just getting the gist of third year.

Shelf

About to take the surgery shelf exam.
And will then be done with the rotation.
Stay tuned...

Empty Crib

I will remember the empty crib. On my last day of my pediatric surgery rotation, we returned to round in the intensive care nursery. As we made our way to the west side, we walked to the crib and the baby was not present. Right away, we all knew what had happened-- the baby had died.

My fellow medical student and I had been following this infant's course during his hopsital day. Each day we reviewed his numbers, noting little signs of improvement. We would come by and examine him and speak with the mother. At one point, he was being maximally sustained on pressors and the maximum ventilation support. Despite all the interventions, the infant failed to improve, something we had expected from the start.
***

In the neonatal intensive care nursery, each infant receives the most specialized attention from a large team of healthcare providers, including physicians, nurses, social workers and students. Every conceivable piece of information is recorded on large elaborate flow sheets, everything from vital signs to infusions to amount of urine and stool to when the baby moves or sleeps. The life of an infant is chronicled by the hour. The fluids and output are meticulously measured. Medications and drips titrated exactly to the infant's weight. The amount of detail is nothing short of perfect.

And when the decision to withdraw all forms of life sustaining treatment is made- the flowsheet detail decreases, eventually disappearing. The infant is whisked away to a seperate room, where he can be with his family for the last few moments of his young life.

***


During my last week of pediatric surgery, I observed the spectrum of interventions to sustain life, from basic to complex procedures.

I watched as we sewed the ends of an esophagus for a baby that was born with esophageal atresia, where the esophagus ends in a blind pouch. The physician meticulously laid each suture to create an anastomosis between the blind bouch and the remaining esophagus, which was located more distally.

I watched how we managed acute renal failure in a baby with an obstrution secondary to a large cyst. I saw numerous inguinal hernia repairs and catheter placements.
I saw how we fix congenital diaphragmatic hernias, a defect in the diaphragm that develops when the diaphragmatic folds fail to fuse during development, which results in abdominal contents herniating into the thorax and preventing proper lung growth. Infants with this defect are born in respiratory distress and typically require ventilatory support prior to surgery.

We performed two repairs this week, on infants who had severely defected diaphragms. With the thorax open, the abdominal contents were carefully redirected into the abdomen and the diaphragm defect was patched and sutured close.

When I asked the neonatologist about the prognosis for infants with severe hernias, he told me the following-

"Fifty per cent of such infants will make it out of the hospital alive."

He was right. Only one of our infants survived.

Venturing into Pediatric Surgery

The sun was shinning today, beckoning me to come outside. Despite the impending surgery shelf exam and a pile of incomplete reports, I made a decision to go running. A run to the ocean and some sunshine was exactly what I needed to recharge before another week of surgery. I have come to realize that it's better to live life when you have a chance rather than put things off for a more convenient time.

It's evident the list of things to do just gets longer.

***

"Medicine is like music. You have to listen for notes before you can appreciate the melody."

A truly insightful comment from the pediatric surgeon I worked with last week.

I am still struggling to put the notes together.

My first week on pediatric surgery was interesting. Just when I started adjusting to the world of general surgery, I was transplanted to an entirely different place, where the patients are smaller, have rare congenital anomalies and typically can't communicate directly with me.

You see the entire spectrum, everything from neonatal in the intensive care unit on bypass for respiratory failure to toddlers undergoing hernia repairs that require no hospitalizations to children with appendicitis to teenagers with midgut malrotation.

I spend my mornings in the neonatal intensive care nursery, collecting the numbers that reflect the respiratory, cardiovascular, fluid, electrolyte and hematologic status of the critically ill infants. I feel more like a recorder, writing and reciting the numbers without fully understanding the meaning. I was only beginning to understand adult ICU values. Neonatal intensive care is far more complicated and requires more than one week to grapple the ins and outs of management.

I have come to really appreciate the complexity of pediatric surgery. The operative approach is unique in pediatric surgery. The instruments are so much smaller and special attention must be paid to every little motion. When I watch the surgeons, I am amazed at how they navigate through such small holes to identify vital anatomical structures.

I have three more weeks of surgery left. We'll see what my last week of pediatric surgery brings...

Golden Weekend

"No one ever tells you that you are doing a good job. But everyone yells the moment you mess up. It's a thankless job. Welcome to surgery."

While we were operating on Friday, the surgeon made this statement as I drove the camera during a laparoscopic hernia repair. His statement is true on many levels.

In the OR, you move when told to move, or you stand and watch. It's almost paralyzing when you are called on to do something. Time stops, as everyone waits for you to complete your task. You pay close attention to detail to make sure you do your task right- be it cutting suture (no matter what you do it's either too short or too long), suturing (it's always a struggle to approximate everything properly and you move too slow), driving the camera during laparscopic cases (following and keeping the horizon straight takes some experience), or retracting tissues (you never quite know how much tension to apply).

Whatever the task maybe, you always find yourself fixated on the smallest details. It's perhaps this close attention to detail, which makes surgeries successful and makes surgeons perfectionists.
***
Friday was my last day on the general surgery service. I move from the world of hernias, appendectomies, cholecystectomies, fistula repairs and gastric bypass procedures to an entirely different world- pediatric surgery.

I've had my first preview of pediatric surgery over these last two weeks, while I took care of a patient with midgut malrotation. I was the first to meet this family in surgery clinic and review here films. While in the hospital, I have been their point person. In working with the family and patient through her admission and surgery, I was felt lucky to work directly with my her and her family. In getting to know her story and in interacting with the family, I was able to learn far more than any pediatric surgery book could teach about such anomalies. It's such longitudinal experiences which make this rotation so memorable.

Before venturing forth to my next surgical rotation, my chief resident graciously gave me this weekend off. I have to stay this is true golden weekend. I am lucky to be spending time with my family and friends during the last day of Ramadan (the month of fasting) and Eid (the holiday marking the end of Ramadan). I am looking forward to eating my mother's home-cooked meals (actually anything other than crackers), catching up with my friends, having normal people conversations that do not conist of asking about bowel habits, sleeping, studying and exercising.

A perfect balance. I am now officially half-way through my general surgery rotation.

Surviving on Crackers

I was once told by an anesthesiologist that he made his way through residency by surviving on saltines and water. When I heard this, I did not entirely believe him. But the more I think I about it and having spent 3 weeks on surgery, I can see the truth in his statement.

My daily diet (when I'm in the hospital) has been mostly consisting of two things- saltine crackers or graham crackers (and if I'm lucky- a whole wheat bagel with peanut butter). With ice water. Very appetizing.

While in the hospital, you sometimes go hours without really eating or thinking about stopping to eat. Between pre-rounding and rounding early in the morning, meeting patients before the case, prepping the patient for surgery, scrubbing in on the case and accompanying patients back to the PACU to write orders- you are left to scavenge for bites of food in the few minutes you have before the next case starts. And your body gets used to it. This is why dinner has become my favorite meal. I can actually sit and chew my food.

There a few things I have come to appreciate while being on surgery.

1. There is nothing like breathing air. By that I mean, being able to take a deep breath in and out without a mask on your face. It never felt so good.
2. Sitting- it's a wonderful thing. Wow, what a different it makes for your back, legs and achy feet.
3. Medical students do have a useful job on surgery. We are glorified supply cabinets. Need four by fours, gauze, tape, saline, suture removal kits? Don't worry- we got it on our person, or know how to get some.
4. I think my patients think I am preoccupied with bowel habits. Because every morning I ask the same questions- "have you passed any gas? Had any bowel movements yet?"

With three weeks down, I can truthfully say that surgery has consumed my life, taking up most hours of my days. There has very little time to see friends, sleep, study and exercise (although I think standing all day and running around rounds qualifies as exercise). I leave my apartment when it's dark and return home when it's dark. The only glimpse of sunlight I get is when we round on our patients, I can sometimes catch a view of the sun setting on the city. Even when I'm not in the OR or hospital, I am thinking about my patients and their diseases, the surgeries of the day, the suturing techniques I have learned, and the hospital course of my new patients.

The hours are long. And you work hard. Despite the challenges (namely lack of hours in the day to sleep and study), I feel lucky to be actively involved in my patient's care. There is something very special about taking care of the patients you have operated on. By performing surgery, you not only become acquainted with your patient's anatomy, but you are also able to use your hands to fix a problem, whether it is a hernia or enterocutaneous fistula or excision of a mass or a bowel resection. Postoperatively, you see how your patient regains bowel function, has improved pain, and starts eating food. The transition can be rewarding, when you see your patient discharged in good condition. It can also be frustrating, when your patient does not improve and remains hospitalized and you are left to wonder what went wrong.

I spent Friday night taking trauma call at SF General Hospital. The motto for SFGH is "It's as real as it gets." The SFGH Emergency Department serves as the only Level-One Trauma Center for the City and County of San Francisco and northern San Mateo. With over 58,000 visits annually, the Emergency Department serves both critically injured patients, as well as a large underserved and urban population.

The night was fairly mellow. We had a couple of 900 emergent pages (a gunshot victim and motor vehicle accident), which upon further evaluation did not require surgical intervention. We also had some patients with acute appendicitis, a patient with pneumothorax requiring chest tube placement, and a patient with an abscess. I performed my first incision and drainage on this woman's abscess. In doing so, her pain was improved and she was able to go home.

My first overnight call (with 2 hours of sleep) done. I left at 10 AM the next morning, completely exhausted and hungry- looking for some crackers.

Completing an Important Job

Week 1 of surgery is done. 7 more weeks to go.

Within the first few days of this surgery rotation, I realized I had entered an entirely different medical culture. The structure of the day, the language, the clinic and the operations all represent eleements of a completely new experience.

One thing is for sure, I'm getting used to going through the entire day without seeing the sun shine. I wake up at 4:30 AM to make it to the hospital by 5 AM. I pre-round on my patients and help prepare for rounds, which start promptly at 6 AM. We round as a team on over 20 patients from 6 AM to 7:30 AM to make it in time for the first OR cases, which start around 7:30 AM. At this time, most other teams are just beginning to arrive at the hospital. We move fast and quick.

Then we spend the day in the OR, operating. As a medical student, you scrub in and wait for instruction.

"You have the most important job. We rely on your precision," said the attending surgeon during a laparoscopic gastric bypass surgery. Surprisingly, he was addressing me- the camera driver during a laparoscopic case.

I was able to admit my first patient from the ED. A 60-something year-old gentleman, who presented with diffuse abdominal pain localizing to the right lower quadrant. He had the classic presentation of acute appendicitis. Once he was admitted to our service, I stayed and scrubbed in on his case--a laparoscopic appendectomy. Within his abdominal cavity, we found the worm-shaped structure, inflammed and engorged, covered with white pus.

Friday was a special day. The third year surgery students from all the different sites congregated in the skills lab and learned the basics of knot tying and suturing. With the guidance of a plastic and reconstructive surgeon, our group learned how to close skin and layers of deeper tissues. We made incisions on pig's feet and sutured the wounds closing, using a diverse set of suturing techniques. Hopefully, these skills will be put to good use during the rest of the rotation.

The week has been busy. The hours have been long (the longest of any rotation so far). Time to study has been scarce. The pace has been rapid. And the learning enviroment has completely transformed.

Learning the steps

"It's like dancing. You got to know the right moves," said our surgery block director during orientation. He was referring to scrubbing in on cases in the OR and navigating around the carefully orchestrated flow of nurses, physicians and OR staff. The movement of instruments, the position of drapes, the placement of surgeons--all part of this dance. The medical student has to learn his or her place.

I attempted to better learn these steps when I ventured into the OR today on my first case as a third year medical student. The case was a laparoscopic cholecystectomy, gallbladder removal to treat gallstones that were causing agonizing pain in our patient. Through small incisions on the abdomen, we placed ports that held different instruments and a camera that gave us a view of the abdominal cavity. I scrubbed in, held instruments, drove the camera and watched the monitors as the the instruments navigated through the biliary geography.

Once the gallbladder was removed, I made a longitudinal incision to slice open the gallbladder, which contained multiple green pigmented stones. It was impressive to see how the entire pouch was brimming with stones; each stone has the potential to block the ducts that carry bile to the colon and cause excruciating pain.
***


Hard to believe that I have officially begun my eight week surgery rotation. During orientation, I also found out that one of my photographs from Med Link, a mentoring program that pairs medical students with underrepresented high school students, was selected as honorable mention for the 2009 School of Medicine Summer Photo Contest: "Learning Moments." Thought I'd share the photograph.


As days go by, I look forward to learning the steps to make it through the next eight weeks.

A year wiser

"One year older, one year wiser." The words of a family medicine doctor on our last day, which happens to be my birthday.

I found my first gray hair today. I'm not sure if it's a sign of aging, or a product of being a third year of medical student.

Whatever the case, it's a sign of more to come.

On our last day of family medicine, we took an exam (what a way to celebrate a birthday) and had a cultural competency lecture. Lunch was a celebration of my birthday and the end of family medicine rotation with the three other medical students over lunch, a slice of pie and singing waiters. Oh, how I love surprises.

I look forward to this weekend off. A time to relax with my family and friends, reflect and celebrate being one year wiser and 33.33% done with third year of medical school.

Breaking in the New Shoes

This weekend has been all about breaking in the new running shoes. As much as I love the feel of worn-out ripped running shoes that have faithfully served me over 100s of miles, I finally decided it was time to start the cycle again with a new pair. So, I laced up my new shiny, silver, white and turquoise shoes and broke them in this weekend with some long runs to the beach.

Yesterday, I made my way through Goldengate Park to Ocean Beach up to the Cliffhouse. Today, I followed the same path and went farther up to Land's End. With the sun shining over my shoulder, I took in the scenes and sites of a familiar running trial with all of it's climbing, descending and incredible views of nature and water. I have to say running (along with friends and family) has gotten me through my first two years (and now my third year) of medical school.

As I run, I always take time to reflect and think, mentally sorting the loose ends of my life- everything from pondering about existential thoughts (what is the meaning of life) to thinking about my personal life (how can I make time for my friends and family given such limited time with rotations) to thinking about my professional trajectory (I have so much distance to go before I feel like a real doctor).



It's interesting how we sometimes seek escape from thinking of anything medical the moment we leave the clinic or hospital. But our minds have a way of redirecting us back. As I ran, I started thinking more about my inpatient medicine rotation and my past patients and experiences-- the moments of triumph in taking care of patients and the many moments of defeat in coming to terms with the reality that we are students at the bottom of this immense hierarchy.

We are surrounded by other long white coats and members of large teams that march around the hospital, rounding on patients. Despite being part of this team, we can't help but feel alone in our lack of knowledge on many fronts. The culture of each field is initially foreign to the nomadic student, who has to quickly adapt to a new environment every eight weeks.

We never know what to say (everything sounds significant at first), or how be efficient with our words. We stumble through our long-winded presentations (we have yet to understand the "pertinents"), talk to fast, take up way too much precious time, ask too many questions and know nothing.

Third year is about learning. But how do you balance learning with the pressure of being evaluated based on your performance. It's almost like you're always on a stage, constantly being watched. And the feedback overflows. Constantly being told how you can improve definitely chips away at your sense of self-security, or makes you more insensitive to any type of feedback. I have interacted with classmates that have either valued or completely disregarded the feedback. I'm in the middle. At a certain point, you reach your threshold and decide how to process the critique; I run.

The process of becoming a doctor is truly a unique experience. Despite the inherent challenges, students are privileged to be working directly with patients in their times of need. In truth, memories of my patients stay with me; my patients have been the best teachers. In managing their diseases and learning about their lives, I have learned far more than any lecture, physician or textbook could teach. At times, you relate more to your patients (rather than the long white coat you are supposed to become), as your patient turns to you for guidance in medical decisions, addressing you as his or her "Doctor." The small moments of triumph carry you afloat during the tumultuous waves of third year (and probably beyond)...

You learn to pick your battles and decide how to focus your energy. From Day 1, I knew my focus will always be the patient. Third year is about learning. Sometimes, I have to repeat that to myself (a maantra to remind oneself to find a higher meaning in a somewhat unstructured and difficult year).

***


As I ran and watched the waves crash, I looked at the depht of the ocean and directed my focus to the life around me- surfers emerging from the ocean, runners, tourists. I quickly stopped and looked at the deep blue water. I could only think about one thing- what an incredible view. I took one more look, and with a deep breath in- I picked up my feet and start running again to fully break in my new shoes.

The Inner Child

As I walked out of a clinic today, I saw a familiar face. He instantly recognized me and smiled. "Do you remember me?" He said.

It took me a second, before I remembered. He was the dad. And sitting next to him was the mother and the baby. They were the family who I had just seen last week on Labor & Delivery (I delivered their placenta).

I was amazed they remembered me. As a student, you always wonder who remembers you (or if anyone will). And it was truly wonderful to see the whole family after the labor and to have them recognize me.

***
My whole day has been about infants. I performed a head-to-toe newborn exam on 16-day old infant, evaluated a two-year old with fever of unknown etiology, as well as examined a rash in a young girl.

Pediatric clinic is always enjoyable because of the patients; I can give high fives, make funny faces and play games (and it's completely ok). The inner child is welcomed and it's such a pleasure to learn from kids.

Slippery

With the umbilical cord clamped, I placed my left hand just below the abdomen as my right hand gripped the cord, tugging and pulling to slowly liberate the placenta from the uterus. As I held the cord, my glove turned red, covered with blood and other uterine contents from the delivery. With more pulling, the placenta moved closer to the opening the of canal. With a final push (from the exhausted mother), I could see the reddish blue disc-like mass advancing. I repositioned my hand, and pulled the cord.

Before I knew it, the placenta slid out and fell into the bucket that was precariously resting on my knees. As the placenta fell, so did the other bloody and gooey contents- some splashing on to my blue gown.

My first placental delivery. Two words- very slippery.
Mental note- do not wear porous shoes and eye protection is a must.

Just earlier, I watched how the 7-lb baby boy emerged with some assistance and careful maneuvering/pulling from the resident (first the head, then each shoulder and then the body). With the baby in the crib, I was summoned to take over. With the guidance of the resident and attending, I positioned my hands and soon caught the placenta.

Next step (logically at the next delivery) is to catch the baby.

My last trip to labor and delivery was during my first year of medical student. The view was quite different; I stood in the background, awkwardly positioning myself and acting as the mirror girl, holding up the mirror for the patient to see. Things have changed since then. Today, I had a closer view and was able to finally take an active role in the delivery.

The one draw-back to being closer- you will walk away covered in some sort of fluid. A small price to pay for what you see- the process of birth.

***
As week 4 nears an end- I'm really appreciating the scope of Family Medicine. In this last week, I've gained a spectrum of experiences. I spent some time in my continuity clinic, the ED, labor and delivery, gyn clinic and pediatric clinic.

We even found time to visit the Sonoma County Fair, where I got pet a llama (I think I was the oldest one in the petting zoo), taste my first funnel cake and people watch. The fair is an interesting cultural experience filled with bright flashy lights, intoxicating smells of fried food and lots of overpriced rides. It was a flashback to my last childhood fair visit in Fresno, CA...

The diversity of clinic is both rewarding and challenging. Every day is so different-you work with all sorts of patients. But at times, it feels like you are always switching mental gears. With different patient populations, there are different considerations, although the bottom line really remains the same- PREVENTION.

With kids, we immunize and educate about diet and exercise. With adults, we still educate about diet and exercise and try to reduce the risk of developing hypertension, diabetes, hyperlipidemia and other chronic diseases (or we just continue to treat the best we can, when prevention has limitations).

The experience so far has been interesting and look forward to the learning opportunities in the last two weeks.

From the inpatient wards of the SF General hospital and the fourth floor operating rooms in SF, I have migrated to an entirely different world-- the outpatient world of family medicine.

Two weeks ago, I packed up my car and traveled 55 miles North to Santa Rosa, a city that prides itself for it's proximity to a diverse array of natural attractions, including vineyards, redwood forests, rivers and lakes, as well as a unique downtown that features a year round Farmer's Market. I left the fog behind and discovered a real summer filled with sunshine and heat.

In my two weeks of family medicine, I have learned about the broad scope encompassed by family medicine. So far, I have counseled several patients with metabolic syndrome (the triad of diabetes, hypertension and hyperlipidemia), examined pregnant women during their prenatal visits, listened to fetal hearts, performed well child visits for babies, evaluated numerous pediatric rashes, performed a PAP smear, participated in a wellness group therapy session, attended homeless clinic and learned about mental health issues in the homeless, interviewed patients in a community clinic as well as in a Kaiser clinic, burned warts off, counseled almost every other patient about lifestyle changes, and so much more.

I am lucky to be taking a hiatus from my beloved SF and learning about family medicine in a community-based program in a city that has few specialists and a large underserved patient population (mostly Spanish-speaking). I am starting to see how medicine is practiced outside an large academic institution (its pretty similar) that is equipped with specialists for every possible disease.I've had to draw on four-years of high school Spanish to communicate and in the process I have probably sounded absolute ridiculous. Oh well.

In such a community, patients rely heavily on their family medicine doctors for most every aspect of healthcare maintenance.

"One of the best things of family medicine is really the longitudinal care. For example, we take care of a pregnant woman, provide prenatal care, deliver her baby and take care of the baby and mom afterwards," said one of the family residents.

Family medicine is truly unique because of the focus on taking care of a patient through their entire life, requiring a comprehensive medical knowledge and solid patient-doctor relationships. At the same time, healthcare providers are limited by 15-minute appointment visits, healthcare cuts, a growing patient population and lingual barriers.

Despite the challenges, the process of interviewing patients, learning about their lives and developing meaningful relationships represents a incredible learning opportunity. We'll see what the remaining four weeks bring.

Venturing into Urology

"We help our patients pee and have sex," said the urologist, who was giving us a talk about erectile dysfunction.

Since completing my medicine rotation, I started my two week urology subspecialty rotation. With one week down, I can definitely say there is some truth to the statement (although urologists definitely do so much more for their patient). I've had the opportunity to observe a wide array of cases, everything from prostate cancer to vesicovaginal fistulas to circumcisions to labial reductions.

In addition to spending hours in the operating hour observing surgeries that utilize advanced technologies, including lasers and a robot, I have been learning about the preoperative and postoperative management of patients with common urological conditions. I have worked with patients, greeting them early in the morning (before 6 AM) and assessing their health (asking about passing gas, walking, eating and pain) before presenting their cases to my team to determine the best plan.

Coming from a medicine rotation, it's interesting to be involved in the operative management of patients. Surgical morning rounds are also so much shorter and so much earlier. Observing the operations has also been interesting; sometimes it's simply amazing to watch the urologists use laproscopic devices to remove the prostate or use basic surgical tools to reconstruct labial folds.

I have thoroughly enjoyed my first week. And the urologists I have worked with have been friendly and welcoming. I look forward to the next week and hope to continue learning about what urologists do...

Block 1

I am still here. I still exist. I have just been caught in the whirlwind that is third year.

Since last reflecting before beginning third year, I wonder why it has taken so long to write. In fact, the only thing I can really say is- where do I begin? So much has happened. I have been sleep-deprived, a bit overworked, and completely immersed in this new culture, learning the reality of being the student on the bottom, always on the spot and unsure.

I meet my patients when their lives intersect with diseases. When my patients are the most vulnerable, I am at their bedside- learning about complications of their disease and lives, in an attempt to make sense of it all.

Tomorrow will be the last official day of inpatient medicine; after which I will reflect on block 1 and write my thoughts.

Stay tuned...

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.

It's almost a month into the New Year. Glancing back at my previous entry, I realize I've already broke one of my resolutions (write more). I've been making tons of mental notes about interesting topics to write about in my blog, but have been struggling to find the time to transform all my mental post-its into actual entries.

Since the start of Life Cycle, we have learned about the complexities of development and embryology, taking a whirlwind tour of development from fertilization to the development of the fetus. We attended our last anatomy lab (forever) and histology lab (no more of those microscope slides). I presented my research poster at the UCSF Research Symposium and taught the mechanics of breathing during the pulmonary MSP session. I've also been busy getting the Surgical Skills elective rolling. I am preparing to teach my last MSP lesson in February and will be teaching suturing at the next surgical skills session.

It's been a busy. Time has become a scant commodity. I always find myself thinking- there are just not enough hours in a day. Right now, the time pinch is even more palpable. The second years have starting to slowly go into hibernation. By that, I mean they are becoming preoccupied with preparing for the boards and revisiting all those topics of medicine, we have since forgotten.

The exam looms on the horizon, an unwelcome presence all the time- in the library (in the form of First Aid books and other prep books), in our day-to-day conversations, in the lectures (with lecturers dropping the "B" word so much more), and in our tired faces. It's boards fever! And it's spreading, sucking the life and energy out of MS2's. I can feel it.

I've been trying to maintain balance. But balance has become more of predictable routine- school, study, exercise, eat, study, sleep and repeat all over again. Sounds fun, doesn't it? I have found time for friends and running, which has made all the difference.

I am trying to live by my motto: there will always be things that have to be done, but there is also a life to be lived.

As they say, every cloud has a silver lining. In our case, that sliver lining is in the form of thinking of the road ahead- clerkships. We are in the process of planning our third year rotation schedules, including making decisions about enrolling in either a structured or traditional program. And we also must start thinking about how to order our core rotations, which inclide family community medicine, internal medicine, surgery, pediatrics, neurology & psychiatry and OB/Gyn.

It's a matter of getting through the next months and then moving on to an even more exciting chapter of our medical training. When I start thinking about actually seeing patients, I am reminded of the reasons why I came to medical school.

The test shall pass. Life will go on.

New Year's Resolution

I have had some time to think. The last three weeks of vacation were a welcome hiatus. I thoroughly enjoyed spending time with my family, running in the bitter cold, resting and eating three meals a day. It was such a blessing to catch up with my family and pet cats.

As far as a New Year's Resolution, I'm old enough to know the cardinal rule of making resolutions: it's probably better not to make resolutions, since you are likely to set yourself up for failure. OK, I admit it is a defeatist attitude- but it is true.

In actuality, I can think of a couple things (in no particular order):
1. Stay in good health (physical and mental)- train for a half-marathon
2. Try to use the phone more often when communicating with friends
3. Broaden my experiences outside the medical bubble
4. Find time for family and friends
5. Write and reflect more
6. Photograph more
7. Explore SF and beyond (which means actually going to museums and restaurants outside the sunset)
8. Study hard for the Boards and do well (without going crazy)
9. Avoid making endless lists of things "to do" (I'm already breaking this resolution with this list)

Break was a welcome change. I felt recharged when I arrived in SF on Sunday. Three days into the first week of life cycle, I'm settling back into the groove of school and my lists of things "to do."

It's hard to believe Life Cycle/Epilogue brings us to our last pre-clinical block. The boards exams are sandwiched between Lifecycle and our clinical clerkships.
"You're in your homestretch," said our course director on the first day of course.
It's so bittersweet. On one hand, we are culminating our preclinical years, attending our last lectures and labs and gearing for the transition to clerkships. We had our last official anatomy lab on Tuesday- male and female pelvic anatomy (what a way to end). On the other hand, we are also facing the biggest barrier to moving forward- the BOARDS exam (believe me, you'll hear more about this with subsequent essays). And the realization that we don't know anything. OK, a little bit of an overstatement.

"So have you hit the board books?" (A question I have been asked a couple of times already). Answer- No, but I probably should. Thanks.

We are realizing the testing has only began. Step 1 is numbered one, because it is the first of a series of tests we'll take. Hooray.

$495.00 equals the amount to take the Step 1 exam. I submitted my application for this 336-question, 8 hour test a couple of days. I guess the time has come to develop a study game plan.

Other than the looming boards, I have returned to my MSP obligations, which involve teaching sessions in the Pulmonary and Renal blocks. I also have been tying some last odds and ends as one of the coordinators of the Surgical Skills elective, which provides students with an opportunity to learn basic surgical techniques (knot tying and suturing). I am also organizing a poster to highlight my summer research that examined in-utero stem cell transplantation for an upcoming research symposium next week.

It's a busy week and a busier quarter. I'm calm. I wish I could say I'm ready, but I figure I'll take it one day at a time, one step at a time (no pun intended).

Stay tuned for the adventures.