Category Archives: clerkships

Post-Medicine Rotation Update: On Studying and the Shelf

The internal medicine shelf exam was a rough one. Thankfully, I expected as much. Several upperclassmen and classmates who had taken this test before me warned me that it would feel less like “an internal medicine shelf” and more like a hodgepodge of questions from all subspecialties. They weren’t kidding. I was really glad I had taken 5 other shelf exams before this one. My main (read: only) goal last Friday was to finish all 100 questions on the test and not run out of time like I did on surgery. I met that goal with a few minutes to spare–in fact, after I made sure I had bubbled in all the intended spaces on the scantron, I watched the remaining 2 minutes tick away on the online clock being displayed on the projector screen. Even though I was still sitting in that chilly classroom, surrounded by the sound of papers rustling and pencils tapping, counting down those seconds was like counting down the time on New Years Eve.

Because of the expectations of the clerkship, there wasn’t as much time to study compared to other rotations. Like many students before me, I focused on the 1300+ internal medicine questions in UWorld instead of trying to read through a review book or two as I’d tried to do on previous rotations. Aside from the time I spent flipping through the Pocket Medicine “purple book” (so helpful I’d call it the must-read of 2014) and scrolling through UpToDate when I had a question, UWorld was just about all I used to study for this shelf. I won’t see my score for another 6 weeks, but I feel like this strategy helped me to retain a bit more than if I had tried to keep with my more ambitious approach from other rotations–less is more, if you will.

You’re all caught up on my life now. Immediately after the exam on Friday, we third years gathered in the student lounge for an “end of clerkships” party with catered hot chicken (a Nashville favorite) and ugly Christmas sweaters galore. I went out for Indian food with a few friends that night and headed home the next day. I’ll be with my family from now until the first week in January, and I plan to catch up on books, family time, music projects, and sleep while I’m off campus.

After we went our separate ways that Friday afternoon, some of us realized that that would really be the last time all of us would be together as a class until we graduate in 2016. The next stage of our medical education allows us to take more ownership of our schedules and meet requirements at different times and at various places across the country and world if we so choose. For example, when I return to Nashville after my break, I will be starting my 3 month research rotation, but others will be staying home to take Step 2 or to just relax for a month before starting again. I think I’ll have a lot more free time during January, February, and March than I’ve had over the past 9 months, and I plan to take advantage of that for sure. But I’ll miss the moments of class solidarity that having a more structured course schedule afforded us. Perhaps we’ll find creative ways to keep in touch while we’re all out carving our own paths over the next year.

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Post-Medicine Rotation Update: Weeks 7-8

We finished up Internal Medicine by spending several half-days in clinic over the course of about 2 weeks. The clerkship director described this as the “diastolic phase” of the rotation to complement the pressure of the “systolic phase” of the inpatient services.

Each student was assigned to work with a few attendings in several subspecialties. We weren’t evaluated for these two weeks, so it really gave us a chance to learn about common reasons for outpatient visits and see examples of ways that a clinic could be run. The attendings had differing expectations for us medical students; some wanted us to see patients independently, others wanted us to simply shadow them.

I was assigned to work with two attendings: one in primary care and one in endocrinology. They had completely different approaches to my role in clinic; the former suggested that I see particular patients independently (for new visits, hypertension followups, acute complaints of cough, etc) while she saw others and had me write one brief note each day that I worked with her, while the latter had me simply observe him in each patient room while we saw patients coming for workup of potential thyroid dysfunction, maintenance of poorly controlled diabetes, and other chief complaints.

I kept fairly busy outside of clinic as well. Throughout the week before the shelf exam, third years were required to take part in a 6- or 7-hour in-person and online assessment of our progress with topics from various specialties. We saw a total of 6 standardized patients, with chief complaints dealing with each specialty, received feedback for our encounters, and took a basic science test online afterward. It was an exhausting experience, but it was really cool to see how our 9 months on the wards had allowed us to perform better in these sessions than we had in the much less thorough ones we were required to do during our first year.

On the same day as my scheduled assessment event, we got a small group together to participate in the National White Coat Die-In, a “black lives matter” demonstration organized and supported by medical students across the nation in light of the events surrounding the deaths of Michael Brown in Missouri and Eric Garner in New York, as well as other unarmed black men who have been killed by police in the recent past. We had a small turnout due to our decision to participate at the last minute, but we were all proud to be a part of a movement like this.

A few days later, I joined a few classmates for a free aerial silks class at a local fitness venue. I was pretty horrible at it due to fear of flipping upside down and/or falling and hurting myself, but I was able to strike a few poses. My entire upper body was sore for days afterward–in fact, I still can’t lift my arms all the way above my head a full week later! I’m on the fence about whether I’ll take more silks classes and work on overcoming my fears, but a classmate and I are considering showing up for a few pole dancing classes at the same facility, just for kicks.

Post-Medicine Rotation Update: Weeks 5-6

My last inpatient rotation was Oncology, back in VUH. Even though many of our patients were quite sick or had very poor expected outcomes, I really enjoyed this part of the rotation; in fact, it might have been my favorite part. For one, I felt like my team was fabulous. For the first part of this two weeks, I worked with the intern who’d been on my team for the first week at the VA and the 2nd year resident who’d been with us briefly on Morgan. I felt like I worked very well with and learned so much from both of these residents, so I was quite excited to come to a team of familiar faces. In some ways, I was able to better adapt to this service because I did not also have to figure out how to interact with a group of new people on my first day. In addition, the attending I worked with was one of the most compassionate physicians I’d ever worked with. Even when we were running late on rounds, she treated each patient as if we had all the time in the world to listen to them. She wasn’t afraid to speak honestly about her interests and dislikes in the field of oncology as well as her feelings about what the patients and families really needed from our team.

The oncology service itself is highly specialized, which was more than a bit overwhelming. While rounding with the team on the first day, I heard so many acronyms and names for cancer treatment regimens that my head started to spin. In addition to studying for the shelf when I could, I also spent time trying to at least know the mechanism of action of some of these drugs so I wouldn’t be completely clueless on rounds. I’m glad I did this, because my attending usually expected us to include some of this information when presenting new patients each morning.

These two weeks didn’t feel terribly hectic to me, partially because my residents were fairly laid-back and partially because I got 4 days off for Thanksgiving in the middle of the rotation. Our patient list stayed a manageable size. I picked up one new patient just about every day, but I spent less time on the notes than I had before. Because the daytime admissions were somewhat more predictable (patients were often admitted from clinic or expected to come in specifically for chemotherapy), I didn’t stay on campus as long as I did on Morgan.

As expected, this was one of the more emotionally taxing services I rotated through. Each day, our team interacted with 30 year olds with stage IV cancer and families who were faced with the realization that their loved one’s prognosis was poor. I was surprised that these cases didn’t seem to consciously affect me. In fact, although my time on the wards has involved some somber environments (the NICU, the Palliative Care Unit, the neurology stroke service, etc), I feel like I haven’t “dealt with” what I’ve experienced in a tangible way. I’ve recently been spending some time thinking about what that says about me as a person and how that will lend itself to my role as a physician. I haven’t figured that out yet. But I’ve got some time, I think.

Post-Medicine Rotation Update: Weeks 3-4

After finishing up on Morgan, I did two weeks on one of the six general medicine teams at the VA. I was the only medical student on this team. At first, I missed having a classmate to work beside, but I soon realized that being alone compelled me to answer more questions and interact more with the team; in addition, I was no longer as tempted to compare myself to others. I was also thankful for the slower pace of this service, as it allowed me to spend more time with patients and actually focus on learning instead of trying to get a set amount of work done.

The only things I don’t like about the VA are the lack of WiFi in the hospital and the medical record, CPRS. Because it’s only accessible at the VA, students have to stay at the hospital to finish the bulk of their notes, which typically makes for some late hours. Obtaining the proper access codes for the computers often takes weeks and can be a frustrating process as well. In an unexpected turn of events, I never got full access to CPRS, so I wrote very few notes while I was there (I promise I actually tried to get this fixed)! This added to the less hectic pace of the service.

The cases at the VA made up for the “zebras” I encountered on Morgan. During my time there, our team took care of several heart failure patients with symptoms of “volume overload” (leg swelling, rapid weight gain, shortness of breath), patients with liver disease who came in with jaundice, and patients with chest pain who required care under the Acute Coronary Syndrome protocol, which includes steps to manage heart attacks.

All told, I enjoyed the VA. While there, I began to realize that although I surely have much to learn, I know more than I think I do. Thanks to the encouragement of my patients and the residents I worked with, I started to feel confident about my ability to become a good doctor.

Post-Medicine Rotation Update: Weeks 1-2

A classmate and I started out on one of the “Morgan” general medicine teams at VUH with a resident, an intern, and a 4th year doing a sub-internship. We each carried 2 or 3 patients at a time, often following them from admission to discharge. When we weren’t in class or talking to our patients, we spent our time writing notes, observing bedside procedures, helping put in orders, making phone calls, obtaining outside records, and learning about topics that the residents chose to teach us in their free time.

Although I expected to encounter “bread and butter” cases that would teach me about management of congestive heart failure or proper workup for chest pain, I didn’t see many in my first two weeks. There’s a quote often used in medicine that reminds us to consider common diagnoses before those that are more interesting but less likely: “when you hear hoofbeats, think horses, not zebras.” However, I encountered a handful of “zebras” myself. One of the more memorable cases involved a woman with a recent history of adverse reactions to multiple antibiotics who had come in with a fever and subsequently was found to have a very low white blood cell count. When it was determined that her symptoms were likely a reaction to yet another antibiotic, our attending wondered if there might be an overarching disease that might explain her numerous illnesses. I’ll have to visit her electronic medical record to see if there are any new developments.

Unlike several inpatient teams that admit every day, the 4 Morgan teams have their own unique call schedule. Each team cycles through an “accept” day (hearing about overnight admissions that morning), a “short call” day (admitting a set number of patients before 2pm), a “long call” day (admitting patients from the time the short call team is capped to 5:30pm), and a “pre-accept” day (no admissions). My classmate and I were often with the team until 7pm–sometimes even later. Writing notes on admission days was tiring–for internal medicine, medical students are typically expected to not only write a thorough history and physical but to also include an in-depth discussion of a particular topic related to the patient’s case, complete with references. I stayed up late many nights to finish notes before bed and found myself fairly drowsy during the day. I’m honestly surprised I didn’t acquire a taste for coffee.

Despite this, I tried to make time for self-care any way I could. Even though Morgan was a very time-intensive service, I still managed to DJ (read: provide a spotify playlist) for the school-wide Halloween party (I went as a mouse this year) and share a reflection I wrote at church one Sunday.

Post-Medicine Rotation Update: Intro

Great news! I am unofficially a 4th year med student. I took my last shelf exam a few days ago and joined my classmates in celebration of the close of our time on 3rd year clerkships and the beginning of new chapters for all of us.

Internal medicine was a tough rotation to finish with. With its long hours, high expectations, and expansive breadth (and depth) of information, it was a tough rotation, period. I’ll be honest–I wasn’t quite looking forward to it when I started, but I enjoyed it a LOT more than I thought I would. 6 of the 8 weeks were spent on various inpatient services. While on inpatient, students were expected to perform the usual tasks–seeing patients before rounds, presenting to the attendings, and helping out wherever we could. In addition, we also saw new patients with our teams, wrote admission and progress notes, and sometimes put in orders for labs and medications with supervision. Our time on inpatient also involved attending “morning report,” at which interesting recent cases were presented and discussed among the housestaff, and several lunch lectures on numerous educational topics. The constant provision of free food was pretty good on my wallet (although I probably spent enough on chai lattes to balance things out), but my waistline took a bit of a hit for sure.

Anyway, I digress. During this rotation, I spent 2 weeks on a general medicine team at VUH, 2 weeks on a general team at the VA, 2 weeks on Oncology, and a portion of the last 2 weeks in clinic. Keep reading for more details.

Post-OBGYN Rotation Update: On Studying and the Shelf

Because it’s late I’ll keep this part of the update short.  I will say that the shelf exam was pretty hard for me; there is a heavy focus on screening guidelines which are difficult to keep up with sometimes.  And there are a number of diagnoses that sound similar but have subtle differences in presentation, which makes choosing the right answer difficult sometimes.  I survived though–had enough time to get through everything.

Here are the resources I used.  I’m (finally) learning that a heavier focus on questions is more helpful for grasping concepts than passively reading.

  • Casefiles: I like this series a bunch, but using it first before going through a more comprehensive reference was probably not the best idea
  • First Aid: I can get through FA more quickly than Blueprints (prose = snooze fest), but I’m not sure if one was more thorough than another for this rotation
  • UWorld: Hands down, necessary for every rotation.  Not more I can say here, because I’ve already said it in other posts
  • UWise: Through the school, we got free access to this expansive set of questions provided by the Association of Professors of Gynecology and Obstetrics.  Absolutely useful
  • I wanted to be super ambitious and finish Blueprints, Kaplan, and Pretest, but I didn’t get to any of these.  I used BP as a reference book sometimes when working on assignments for clinic, but that was about all I got to do.

Well, that’s about it!  Other updates: we had College Cup this weekend!  My College came in 2nd place this year, but we put in a ton of effort despite half of the med school having taken a shelf exam the morning that the Cup started.  This year, I competed in the Hula Hoop Relay, Spirit Showdown (dancing), Board Games (specifically Twister), and Trivia, in addition to doing vocals for the Chapman College’s opening song and screaming my head off for my College whenever I possibly could.  I’m exhausted beyond belief, but it was so worth it.  And now it’s back to real life…my last clerkship is internal medicine, which I start Monday.

Post-OBGYN Rotation Update: Clinic

For my last two weeks, I spent several half days at Vanderbilt’s One Hundred Oaks outpatient facility.  During OBGYN orientation, we were given tips for how to prepare for clinic; we were told that an “honors” amount of work involved printing patient summaries from the medical record, determining why they were being seen that day, and coming up with a plan for their visit.  So even though clinic visits didn’t start until 8am, I often got to campus at 6am to look up patients (10-12 per half day usually) before catching the shuttle to OHO.

Clinics were usually extremely busy, even when only a fraction of patients showed up; this happened more frequently than I expected it to.  Over the course of the two weeks, I worked with a number of providers–nurse practitioners, attending physicians, residents, midwives–for various types of clinic visits, such as urogynecology, genetic counseling, colposcopy, routine prenatal care (with individual patients and groups of patients and their partners as part of a program called Expect with Me), and annual well-woman checkups.  During these visits, I had varying amounts of responsibility depending on whom I was working with and how busy their clinic was.  For some visits, I simply shadowed the provider.  During others, I gave patients printed information about contraception options, performed supervised pelvic exams, estimated fetal growth by measuring fundal height (how high the uterus has gotten), or listened to fetal heart tones using a doppler ultrasound device.

The attending that I worked the most with gave me lots of responsibility in clinic.  I just shadowed her on the first half day.  The next day, she allowed me to start placing the speculum for pelvic exams and trying to find fundal heights and babies’ heartbeats.  Eventually, she allowed me to take histories on new gynecology patients while she saw others, in an effort to not get too behind on a busy clinic day.  Once, she let me take a history and do a physical exam on a return obstetrics patient–completely unsupervised–and present the patient to her before we both went back into the exam room.  She even let me remove an IUD (intrauterine device, a form of contraception) from another patient; afterward, she told me that she’d never let a medical student do this before.  In addition to all of this, she still found time to teach me on various topics that would likely show up on the shelf exam.

Usually I’m a bit nervous about having a lot of responsibility for patients.  I entered into this clinic setting in a similar fashion.  However, by the end of this two weeks, I realized I had gained a great deal of confidence in my ability to see patients effectively.  I hope that this confidence grows as I continue to treat patients in the future.

Post-OBGYN Rotation Update: Elective (Palliative Care)

My third two-week block was a bit different, as I transitioned from inpatient OBGYN to Palliative Care (PC).  I knew very little about PC before this elective; I knew that teams often consulted them to talk to patients with particularly difficult diagnoses, and that they were the people who managed getting some terminally ill patients into hospice.  I learned that the role of PC in the hospital is three-fold: symptom management, goals of care discussions of various caliber, and hospice referral.

I worked at Vanderbilt Hospital (VUH) and at the TN Valley VA hospital down the street.  At VUH, there is a PC consult service and an inpatient PC unit.  I got to spend time on both services, shadowing the providers and learning so much from them in the process.  They taught me about how to manage pain with various opioids, how to deliver bad news to patients and family, how to discuss goals of care and advance directives (not the same thing), and how to conduct family meetings.  The family meetings were especially interesting–we were present for a particularly difficult one that included members of the primary team as well as the ethics board, whom I’d never been able to work with before.  The VA’s PC service was a bit slower than VUH’s, but I still feel like I had a very robust experience and learned quite a bit about the important role of PC.  In addition, I got to know the team quite well; I helped them celebrate one of the attendings’ birthdays and found out that the PC social worker there had gone to my grandfather’s church while he was still pastoring in New York!

The attendings I spent time with at both hospitals were phenomenal.  Their bedside manner, their way of coping with difficult situations, even their sense of humor…all of it is something I want to emulate.  One of the attendings sat down with me and gave me some great encouragement, reminding me that I am meant to be here even when I feel like the opposite is true.  She also put me in touch with some child psychiatrists, so I can learn about what they do and why they do it in the near future.

On my last day of the elective, I shadowed a Child Life specialist.  Child Life finds creative ways to make being in the hospital or having a family member in the hospital easier for kids.  This can involve playing games with them, leaving them toys to entertain themselves, using puppets to teach them about aspects of their care…the possibilities are really endless.  I helped build a Lego tower for a boy who had been badly burned, talked to an adult patient followed by PC about meaningful gifts he could send to his grandchildren (such as “fingerprint jewelry” which is a fantastic idea), and “shopped” Child Life’s personal “toy store” (they probably had a different name for it, but I don’t remember what it was).  I didn’t know Child Life existed before spending time on PC, but if you ask me, these people work absolute magic.

PC has to be the most emotionally taxing service at the hospital.  I asked about the coping strategies of many of the people I worked with and was encouraged by their willingness to advocate for self-care.  I’m not absolutely certain about what I want to do with my life, but it has to be something that allows me to make myself more of a priority than it is right now.

 

Post-OBGYN Rotation Update: Labor and Delivery

Next was the infamous L&D service.  We each worked 4 12-hour day shifts and 3 12-hour night shifts, taking care of laboring patients on the floor, checking medication levels for the residents, and scrubbing in on vaginal deliveries and c-sections (both of which culminated in “catching a baby” if the med student was lucky).  On the day shift, students also rounded with the Maternal Fetal Medicine team which is responsible for managing the care of patients whose pregnancies were complicated by preterm labor, gestational diabetes, and other medical problems.

This was a tricky service in the sense that it was sometimes hard to be fully involved, especially during the daytime.  Some residents allowed med students to do periodic “mag checks” on patients being managed for high blood pressure, or let them check the patient’s cervix for level of dilation…others didn’t.  In addition, it was easy for medical students to miss important events just because there wasn’t a good place to stand that wasn’t in the way of the housestaff and nurses.  Even the course directors referred to the workroom in the back as a “black hole” where med students were often forgotten about…at least until the residents started typing their notes there during some of the night shifts.

Despite these setbacks, I had a great time on the service once I got used to the general flow of things.  I even liked the 6pm – 6am night shift more than i thought i would; it wasn’t too hard to readjust my sleep schedule, and I always shared the shift with a classmate or two (one girl even introduced me to the cheap but delicious white chocolate caramel cappuccino from the hospital cafeteria one night).  I didn’t get to “catch a baby” during a vaginal delivery, but I did deliver a few placentas and encourage a patient or two during labor–of course, I also witnessed the first moments of some beautiful babies.  And I got to see the organized chaos that is a stat c-section.  I didn’t even have time to scrub in; the baby was out in half an hour tops.  And most of the residents and attendings I worked with tried to take time out to teach us students about a topic that was applicable to both the shelf exam and the wards.

The highlight of the rotation by far was when I got to scrub in for the c-section of a patient I’d seen during a direct observation session a few weeks before.  When I went into her room to greet her before the operation, her face lit up, and she introduced me to her entire family as “the med student I was telling you all about.”  during the operation, the resident let me deliver her baby, guiding my hands through the process.  I probably won’t forget that patient or that experience any time soon.