Monthly Archives: October 2015

Immersion Phase Update: Obesity Integrated Science Course (9/28 – 10/23)

During Immersion Phase, we’re required to take at least one Integrated Science Course (ISC), which combines clinical work with aspects of our preclinical years.  The ISC I chose focused on obesity and its impact on adults, children, healthcare, and society.  We rotated through several clinical sites throughout the month and also had lectures and completed assignments on the pathophysiology of obesity, medical and surgical management, public health and cultural considerations, and other aspects of the topic.

This course was probably the most important one that I could have taken this year.  Given the fact that over a third of adults in the U.S. are classified as obese (by BMI), any medical professional will encounter patients who are dealing with obesity or some of the medical conditions related to it–diabetes, heart disease, sleep apnea, and arthritis, to name a few.  However, as I learned over the past month, many healthcare providers are more comfortable with treating the effects of the underlying problem than they are with approaching the problem itself.  To many, counseling a patient about weight loss consists of reciting some form of the “eat less, exercise more” mantra at the end of the clinic visit, or running through a list of reasons why being obese is bad for the health.  However, these tactics are rarely effective, as they largely don’t consider the patient’s opinions and goals.  A patient may know all of the oft-quoted facts but not be motivated to lose weight for any number of other reasons; by contrast, he or she may have tried and failed to lose weight alone countless times and need some guidance or accountability.  It is important for physicians to talk with patients instead of at them in order to get a better idea of their thoughts and their needs where their weight (really, any number of issues involving behavior change) is concerned; these are the underlying goals of a technique called motivational interviewing.

The Obesity ISC was also one of the most rewarding courses I’ve taken in a while, for a number of reasons.  For one, I appreciated the breadth of the experience.  I worked with internal medicine physicians, pediatricians, surgeons, nurse practitioners, dietitians, psychologists, and exercise physiologists at clinic sites specializing in bariatric surgery, hypertension, sleep, and more; I was also able to see how patients are served by the interdisciplinary teams at certain locations.  Another rewarding aspect of the  rotation was the level of continuity that I witnessed over several mornings at the adult weight loss clinic.  By being present several types of patient visit–initial consultation, nutrition and exercise evaluation, follow ups for medical weight management, education sessions and required psychological evaluations before bariatric surgery, post-operative visits–I got a good understanding of the longitudinal care that a patient might receive.  And, of course, it was a treat to meet patients for whom bariatric surgery had been a life-changing success.  I talked with a man who had lost almost 200 pounds over the year following his surgery–he legitimately did not look like the same person compared to “before” pictures in his chart; he also reported more energy and no need to use his CPAP machine at night.

For this rotation, we also worked on several projects in order to synthesize what we’d been learning over the month.  One project that someone chose to do required him to modify a recipe to make it healthier; he brought in a version of chicken Parmesan that he made in a slow cooker, which was very tasty.  We also created individual concept maps to capture the complexity of obesity and its various causes and effects.  Another project that we all had to do involved choosing a question that interested us regarding management of obesity and creating a presentation, handout, or other modality to educate our chosen audience.  For mine, I chose to look at mindfulness apps that physicians might recommend to patients who struggle with emotional eating.

Of course, that’s only a snapshot of what I experienced this past month.  Despite the relative ease of fourth year compared to everything before it, medical school has been keeping me on my toes.

Now I’m out of class for roughly two months in order to travel for residency interviews.  The process and progress of the interview season can be a bit of a sensitive topic, so I won’t openly talk about it here.  But if anyone has questions, I’m open to answering them!


Post USMLE Step 2 CS Recap

This post is long overdue.

I took the Clinical Skills portion of Step 2 of the United States Medical Licensing Exam (USMLE Step 2 CS) at the end of September; I meant to write about the experience soon afterward, but life got in the way.

In its current state, Step 2 CS is an exam unlike any of the other “steps” that medical students take.  Instead of spending countless, wordless hours in front of a computer screen at a local testing center, groups of students conduct mock clinic visits with standardized patients at one of five testing sites across the country (including Atlanta, where mine was held).  Depending on the case, students may be expected to take a brief history, perform a focused physical exam, relay a brief assessment and diagnostic plan based on the patient’s presenting complaint and physical findings, and write up a patient note.  Repeat this 12 times and add a few breaks (one of which includes lunch).  It’s a long day, but somehow it actually goes by quickly; probably because you get to talk and walk around.

Another difference between this test and preceeding parts of the USMLE is the scoring.  There is a scoring system, which is divided into Communication and Interpersonal Skills, Spoken English Proficiency, and Integrated Clinical Encounter (read: the part where you’re graded on your actual ability to function as a doctor). However, the test is reported as pass or fail.  I feel like one of the pieces of reassurance that’s offfered to U.S. medical students who are nervous about this test is that you’re evaluated in part on how well you speak English.  I liked another point that was made by one of the Vanderbilt faculty earlier this year: “It’s not about being perfect, it’s about being barely competent.”  I can certainly relate to that…

Scheduling the test is almost as nerve-wracking as taking it.  Spots fill up quite quickly on the registration site; in fact, we were advised to schedule the test 6 months in advance just in case.  And of course there’s the issue of where to take it.  With it only being available in 5 cities (Atlanta, Chicago, Houston, Philadelphia, and Los Angeles), it may take some extra planning even after the test date is secured.  Plus, it’s expensive.  Like, over $1000 expensive.  One of my classmates was convinced that she’d accidentally paid for the test three times.  But the amount makes sense once you consider that you’re paying for the facilities, standardized patients, and enough lunch for all of the examinees.

The nature of Step 2 CS makes it somewhat difficult to study for, at least when compared to the other Steps.  There is a First Aid for Step 2 CS which, although somewhat dated, is good to read through once or twice.  This book allows one to get an idea of the types of chief complaints that a standardized patient may present with, in addition to tips about passing in Communication and Interpersonal Skills (e.g. offering water to a patient who starts coughing in the room, or responding empathically to a patient’s distress).  There’s also a section with longer cases, including “scripts” that a standardized patient might use based on what questions s/he is asked; these can be useful to go over with a buddy to simulate the experience somewhat and help with thinking through the situations.  Working in a clinic site–especially on a primary care rotation–can also be useful preparation.

Hope this helps demystify the test a bit!  Good luck!

Immersion Phase Update: Primary Care (8/31 – 9/25)

This post is coming a lot later than I intended it to.  If the month of August was a whirlwind, the month of September certainly was too.  I really can’t believe it’s October now; this year has gone by entirely too quickly.

For most of the month, I was on the primary care rotation.  At Vanderbilt, each student is assigned to one clinic, which can be pediatric or adult and on-campus or off-campus.  I was placed in the Pediatric Acute Care Clinic (affectionately known as PAC), which I was familiar with from having spent two weeks there during my outpatient time on the Pediatrics core clerkship last June.  This time, I expected to have a bit more responsibility as far as which patients I could see and how I was expected to assess them, and that was certainly the case.

For this rotation, we had to make personal learning goals; one of mine was to become more comfortable with using interpreter services.  As a late second year student in PAC, I had not independently seen many (if any) patients and families who did not speak English, although several such families come through each day (I’ve heard PAC referred to as “United Nations Clinic” for this reason).  This time, when a patient whose caregivers spoke Spanish, Burmese, or Arabic presented to PAC, I signed up to see them myself first.  For Spanish and Arabic, there were sometimes in-person interpreters who would meet providers at the exam room, but for all other languages I had to learn to use Language Line, a phone service that is extremely helpful in clinic but that also comes with its own challenges.  Imagine trying to converse with a parent and an interpreter via speakerphone while the young patient and her siblings are crying or running around the room.  Or having the automated phone system misunderstand the lannguage you were trying to request.  One memorable moment using Language Line came when I tried to request an Uzbek interpreter for the mother of a patient.  I couldn’t get the system to understand what I wanted, so I took a nurse’s advice and asked for an Arabic interpreter, whom I then asked to transfer me to an Uzbek interpreter.  After several minutes, I was told that there was no one available who spoke Uzbek; I ended up going back into the room and asking the mother if she spoke any other languages.  We ended up conducting the visit primarily in Russian via phone interpreter.  Needless to say, I met my original goal and am now much more comfortable with requesting and working with an interpreter; now I want to learn a ton of languages (although I will say that using the Duolingo app on my phone has enhanced my ability to understand–but not speak–Spanish).

The variety of cases that I saw in PAC once again caught me by surprise.  I certainly diagnosed a number of “viral URIs,” but I also saw a few healthy children coming for annual checkups or ED followup visits, common childhood diseases, some rarities and a few cases where even the attending physician was unsure of what was causing the patient’s illness.  I kept a list within the electronic medical record of every patient I saw last month, and I plan to check on some of them every now and then to see what’s happened since I saw them.

For the primary care rotation, I also had to choose a patient that I saw in clinic, conduct a home visit, and write a reflection about it.  Despite some scheduling troubles initially, I found the experience quite rewarding.  We as physicians and trainees tend to forget that outside of the hospital, patients and families have their own lives, schedules, and priorities; it’s important for us to partner with the patients we see in order to deliver the care that they need, and not to simply make assumptions about their motivations or their concerns.

In addition to the busyness of the rotation itself, the 4th year class submitted their residency applications during this month!  At about 8am CST, countless medical students were refreshing the page of the application website, waiting to upload the information that would help launch them on the pathway to life after medical school.  As usually happens, the website crashed almost immediately and stayed down or “slow due to high traffic” for quite some time.  I’m sure many people across the nation panicked when they couldn’t submit their applications, but somehow I felt oddly joyful as I sat and waited for the chance to try uploading again.  I could physically feel a weight lift off my shoulders as I finally clicked submit, after the months of work and emails and meetings to get the separate pieces of the application together.  Now it’s on to interview season!

The week after I submitted my application, I took the USMLE Step 2 Clinical Skills exam (Step 2 CS) in Atlanta.  I’ll probably talk about that experience in another post, so stay tuned!

Another important event: College Cup 2015, potentially my last College Cup.  Last weekend, the four colleges of Vanderbilt Medical School competed for glory in basketball, water polo, Iron Chef, Twister, and more.  My beloved Chapman College won the tournament again this year, by only 10 points.  It was such a fun time, and I’m really going to miss this iconic part of my medical school experience.

Phew!  As you can see, a lot happened in September.  But no matter how challenging my schedule gets sometimes, I wouldn’t trade this for anything.