Thursday, December 27, 2018

The mentality of an ex-grad school third-year medical student

I’m now more than halfway through the fourth and last year of medical school, done with most of my residency interviews.  I’m starting to feel close to the end of this eight-year MD-PhD process, and simultaneously the end of the beginning.  Last spring, I started writing about my clinical experience as a third-year medical student, and the remainder of this post reflects on how my mental experience on the wards differed from my experience during grad school.  I also started writing about some of the coping techniques I developed during MS3, which became improved habits I have subsequently tried to maintain; this will be a topic of a subsequent post.

As a primer for anyone unfamiliar with med school structure, the first two years are largely classroom-based; at UCLA we refer to both the years and their students as MS1 and MS2.  The third and fourth years (MS3-4) are hospital- and clinic-based.  After MS1-2, I took a four-year pause for grad school, then started MS3 in May 2017.  MS3 is the year when students start learning how to take care of patients in a practical sense. Over the course of 12 months, students rotate through a variety of hospitals and outpatient settings across LA county, completing clinical courses known as “clerkships” in the core medical specialties: internal medicine (both inpatient and outpatient, a.k.a. “ambulatory”), family medicine, pediatrics, obstetrics & gynecology, neurology, psychiatry, and surgery.  Each clerkship varies in length from four to twelve weeks, and at the end of each clerkship, students must pass a national standardized exam called a “shelf exam.”  Within each clerkship, students often switch between multiple teams of residents and supervising physicians (called “attendings”), and may have different sub-rotations.  For example, my twelve-week surgery clerkship included sub-rotations on vascular surgery, general surgery, ophthalmology, neurosurgery, and urology, each at a different hospital.  All of this makes for an exhausting and demanding year, but it can also be a remarkable catalyst for personal growth.

When I finished grad school and started MS3 I knew I was an older and somehow different person than I had been at the start of grad school in 2013, but I wondered how it would feel to be back on the wards.  Over the course of the year I had amazing opportunities to learn from so many patients, families, fellow students, residents, nurses, social workers, and attendings, experiences for which I am so grateful.  By the end of the year, I had unexpectedly developed a new career dream for myself (psychiatry!), and with a clear understanding of why I was choosing this path.

In comparing my MS3 headspace to my headspace during graduate school, I found myself enjoying my time off much more during the MS3 year.  This is probably because graduate work, being composed of multi-year projects, is both self-directed and changeably structured, without clear demarcations of time “on” and “off.”  Theoretically I could take time off whenever I wanted, but that would just mean that as long as I was not working, my project would not progress.  From day 1, grad students feel the clock ticking, as they themselves are the biggest factor in how quickly and well they finish their program.  I have always found comfort in a structured routine, so despite the exquisite thrill of discovery that original science offers, the persistent unpredictability of grad school was extremely stressful for me.  I could create highly organized schedules for any given day or week, but those schedules were likely to get upended at any point by an unforeseen experimental roadblock, a piece of malfunctioning equipment in need of troubleshooting, or any number of other logistical challenges—indeed, learning to deal with this unpredictability is a significant part of graduate training in experimental science.

At the same time, this unpredictability and my swinging between enthusiasm and frustration meant that even during my “free time,” I felt near-constant guilt at not being more productive, thinking that I could and therefore should always be working longer and more productive hours.  This feeling is common among graduate students, and I think the associated distress is something of a rite of passage.  As my advisor once reassured me, it’s quite typical to question (even multiple times) whether one is on the right path, especially in the latter years of the graduate program, when one gets inevitably stuck in a disillusioning rut of repeatedly failing experiments, before everything somehow falls into place just in time for one’s dissertation defense.  On the plus side, graduate school is a rare time when one has the freedom to explore scientific ideas of one’s own choosing, to think deeply and critically about those ideas, and to benefit from that same schedule flexibility.  I certainly can’t complain about how much easier it was, when I was running my own schedule, to attend a doctor’s appointment or make a phone call to a relative in a different time zone.

My primary research paper from my graduate work was accepted for publication on the very first morning of my first clerkship in MS3.  After all the revisions and resubmissions, I felt relief even more than accomplishment.  One of my biggest anxieties about this paper was whether I would still need to work on revisions once I was an MS3 and had clinical work that would require my complete attention, so it felt like such a stroke of fortune that my research paper made it through its hoops just in time.  Ironically, ten months later I found myself preparing and submitting another paper during my general surgery rotation, when I in fact had the least free time of my entire MS3 year.  This was something I had expressly told myself I would not try to do, and yet, when the time came, I found myself sitting with my laptop in a surgery workroom, waiting for the trauma pager to go off, and actually finding it mentally refreshing to spend a couple hours placidly editing a manuscript.  We rise to meet our own expectations in ways we can’t foresee!  This paper-editing episode also made me realize how much I value having a certain amount of variety in the type of work I do over the course of a week (or a day), including being able to sit with and develop scientific ideas.

Speaking of expectations, another aspect of the MS3 year that is somewhat unique within the medical training pathway is the frequency of evaluation.  Med students are evaluated by attendings and residents multiple times on each rotation.  These evaluations, in combination with the shelf exam scores, result in our clinical grades.  We students do our best to focus on learning as much as we can, integrating into each of our teams, and taking care of our patients, but it can sometimes be hard to forget that we are constantly being graded.  During the first couple weeks of my pediatrics rotation I was particularly anxious about performing well, because I thought this specialty was going to be my career.  However, constantly thinking about how I was being perceived quickly became counterproductive in that it felt acutely uncomfortable, and may even have appeared that way to others.  After I actively tried to shift my perspective for the rest of the rotation, I was actually able to enjoy the experience.

Part of this perspective included returning to the truism that in my career, I will never again have as much time to spend with individual patients or their families as I did during MS3.  From the patient or family member’s point of view, the medical team generally disappears after the brief interaction of morning rounds, only reappearing if something urgent arises or there is a prearranged family meeting.  From the team’s point of view, the vast majority of the day is in fact spent frantically doing work behind the scenes: checking lab results, discussing the patient’s progress with nurses / fellow residents / the attending, adjusting medications, calling consults, coordinating discharge plans with the social workers, and writing notes.  Between these two worlds of the patient rooms and the provider workrooms, MS3 students are able to be a bridge because they may only have 1-3 patients on their “list,” while an entire inpatient medicine team list frequently comprises 15-20 patients.  Unlike the interns or residents, MS3s, while slower to get their work done, have the time to return to the bedside multiple times over the day.

On most inpatient rotations, I liked to see my patients again at the end of the day.  Sometimes the team would do afternoon rounds, but often I would do my own mini-rounds after I was dismissed to go home.  I got to hear how the patients’ afternoons went, say good night, tell them that I’d be back in the morning or the following day, and sometimes answer another question or review the treatment plan one more time.  It was during these informal check-ins, when I wasn’t trying to perform a physical exam or ask “review of systems” questions like whether the patient was having constipation or diarrhea, and when no one was evaluating me and my “clinical skills,” that I got to know my patients and their family members as individuals, far more than people dealing with a certain disease.  I felt like these moments helped me to maintain their humanity and my own, and kept me centered on why I had chosen to pursue medical training.

Simply because of the demanding schedule, MS3 is ostensibly not the best time to prioritize one’s own emotional or physical wellness, but as the year progressed I found myself actively thinking about wellness and trying to incorporate it as a regular part of my life.  This will be the topic of my next post, written as some sort of retrospective survival guide for my pre-MS3 self.

Saturday, March 31, 2018

Scrubbing in and suiting up

Early morning from a hospital hallway

I am currently just over halfway through my 12-week surgery clerkship, just five weeks away from the end of the third year of medical school.  It has been an amazing year of learning medicine and learning about myself, and as I have been reflecting on this year and making plans for the next steps, I have begun putting those thoughts in writing.  Below is part of my "brain-dump," which I thought I would share even though it is relatively unpolished.


There is a unique desperation that arises during the medical student surgery clerkship, when the student is confronted with ostensibly simple tasks – such as finding a roll of paper tape, or opening the correct dimension of gauze, or holding a retractor with the right amount of tension – that have suddenly become staggeringly challenging.  Great attention must be paid to the placement of one’s hands when one is doing nothing but standing and observing.  The differentiation between what is light blue (the color of sterility and safety) and not light blue is now the most salient, if one wants to avoid the justified wrath of the scrub technician, to say nothing of keeping alive the chance that one will get asked to hold an instrument or possibly even, if lucky, help close an incision. 

It is safest to keep one’s arms crossed, or forearms folded over one’s stomach, or, ideally, resting on a draped area that is away from the operating field, if the surgeons or a particularly thoughtful scrub tech invite one to step closer.  It is definitely not safe to begin to doze off while sitting on a stool between a patient’s [draped] legs, while watching the surgical proceedings on the screens around the room, to then realize that one has just contaminated one’s gloves by touching the stool.  This may or may not have happened to me in my second week on the inpatient gynecology service, during a six-hour surgery, during part of which I had been told to push in various directions and then isometrically hold an instrument placed in the uterus, while the surgeons used the Da Vinci robot to manipulate parts of the pelvic organs through the abdominal wall.  One of the more surreal moments in my life: being told “Harder!  Push to the right!  No, the patient’s right!,” contorting my shoulder into increasingly uncomfortable angles, seeing on screen the uterus move with my clumsy adjustments, while the surgeons stared into their arcade-like consoles and used carefully calibrated movements of the control knobs to trigger precise adjustments of the articulated robot arms.  For obvious reasons I was extremely alert during that part of the surgery, but all bets were off once my physical and intellectual involvement was over and I was left to watch.

It took well over a week – and if I’m being honest, closer to two weeks – before I felt comfortable scrubbing in, and then just to be a minimally invasive component of the OR milieu.  By the fourth or fifth week, I started appreciating the rhythm and routine around me.  The structure-seeking part of me did find comfort in the repeated ritual of being gowned and gloved by the scrub technician:

After scrubbing for upwards of three minutes, walk into the OR with hands held up in front of you, elbows away from your chest, water dripping downward onto the floor.  Take a sterile towel and, still keeping your elbows up, dry the hands and forearms on one side, then use the other (clean) side to dry the other arm.  Place your arms into the gown which has been held open for you, extending your arms under the arms of the scrub tech with only a slight back bend, and immediately straighten with your hands once again held in front of you, fingers together, so that the arms of the gown can be pulled down just enough.  When the first glove is held open for you, slide one hand down into it, then use those now-sterile fingers to help hold open the second glove that is proffered.  The back of your gown has already been closed by the circulating nurse, but you now ask him or someone else to take the paper card tethering your waist ties, then spin counter-clockwise and pull the other waist tie off with a subtle flourish, so that you can fully close your gown.  You are now enclosed in cleanliness, and you have only to avoid messing it up.  

This sequence of actions, repeated at the start of every surgery, armors the surgeons – and wide-eyed medical students – in a papery, synthetic, fluid-proof, and anonymity-granting suit.  When everyone who has scrubbed is gathered around the draped patient, with only the operating field exposed, they coalesce into a nucleus around which the outside world, the non-sterile and chaotic and hazardous, recede.  Despite interruptions by pages or phone calls, or episodes of chatter regarding weekend plans or how the family is doing, there are always stretches of collective scrutiny on the task at hand.  Sometimes it seems to me that in the OR, the patient’s personhood and humanity are intentionally deemphasized, tucked into the background by the blue drapes.  And yet I also see that in the OR there is a unique dimension of respect for the human body and its natural variations in anatomy and [patho-]physiology, which create the potential for surgical challenges that are not always forseen by imaging studies.  I sensed that the haptic unpredictability of surgery, as well as the monastic focus that must result, is part of what surgeons love about their work.  As an observer and intermittent participant, scrubbing in provides a memorable glimpse into this unique cognitive realm.