Category Archives: immersion phase

Immersion Phase Update: Preparation for Internship (2/29 – 3/22)

This post is embarrassingly overdue.  Especially given the fact that I’ve been done with classes since the end of March.  Don’t judge me.

Anyway, my last ever class of medical school was called “Preparation for Internship.”  It was mostly lecture-based, reminiscent of my first 18 months as a medical student.  Faculty and residents taught us practical things about topics such as writing orders, approaching chest pain, and transitioning from full-time learners to part-time teachers.  Standardized patients helped us learn about ways to deal with drug-seeking patients or to gain informed consent for procedures.  We also had review sessions to practice components of the physical exam that are often deemed tricky by medical students.  Much of these 4 weeks offered a great review, but I was honestly a bit shocked about how much I had forgotten over 4 years and how much I would still need to learn and retain as a resident physician.

On the first Friday of March, the fourth years got together for our final class retreat.  Many of us hadn’t seen each other in several months or even longer, so it was good to be able to reconvene as a unit.  During the day, we reflected on our experiences as students.  We were even shown the personal statements we had written when we initially applied to medical school.  After having served on the admissions committee during this past cycle and seen some very masterfully written essays, I was a bit embarrassed; I felt that I could have done a better job writing about myself back then!  In any case, it was quite interesting to see how my perceptions of the medical field and my role in it have evolved since then.  After looking back on where we’d all come, we looked ahead, spending some time talking about logistics for graduation and also crafting the class oath that will be recited during the ceremony.  At the end of the day, we had a small pre-Match Day celebration during which classmates swapped both embarrassing and triumphant stories about the interview trail for gift cards.

And then came Match Day.  On Monday, March 14, I got the news that I’d matched into one of the 5 psychiatry residency programs I’d ranked back in February.  On Friday, March 18, toward the end of the Match Day Ceremony, after sitting through several speeches, celebrations, songs, and baby pictures, I opened my envelope and learned that I had matched at Vanderbilt–my top choice.  I kept it together while I was on stage (people said that I seemed really happy when I read the name), but as soon as I sat back down, I cried tears of joy and relief.  And the photographer got a picture of me crying and posted it online with the rest of the pictures.  But she’s awesome, so I forgive her.  I was especially happy because my grandmother got to see me match for her birthday.

The next day was Cadaver Ball at Marathon Music Works–what may have been my last (residents usually don’t go).  This year’s theme and many of the videos were based on Saturday Night Live.  The a cappella group performed on the big stage for the first time, and I also got to do a dance routine with some of the other 4th years.

About a week later, I went with several other Vanderbilt students to Austin, TX, for the Student National Medical Association’s national conference.  The focus for this year was on mental health disparities, so they had several workshops and talks geared toward that topic.  Additionally, they had practical advice for pre-meds, medical students, and residents about various points of interest (how to suture, how to study for the MCAT, what to consider when opening a private practice, etc).  There were also recruitment fairs for current medical students to learn about residency programs, as well as fairs for pre-med students to learn about medical schools.  Of course, I spent quite a bit of time getting to know some of the other students from Vanderbilt and other schools, and we explored the city some while we were there.  One of my favorite moments was during the banquet on the final night, when the graduating students were awarded with SNMA stoles and pins and invited to join the National Medical Association.  Hearing the names of so many other underrepresented minorities on the cusp of becoming physicians, and standing with them to take a picture was both refreshing and overwhelming in the best way possible.

So that’s my long-overdue update for March.  I’m graduating 2 days from now, at which point I will update you on the time in between.  If you’d like to watch the ceremony on or after May 13, click here.  Get excited!  I am!!

Immersion Phase Update: 2/1 – 2/26

I took a true “flex month” in February–no tests to study for, no interviews to travel for. I spent most of my time back at home; all told, I kept pretty busy with a number of tasks, errands, and events.

I spent my first week and a half in Memphis with my family, then headed back to Nashville for about 5 days.  I had been invited to participate in the Second Look Weekend that Vanderbilt Medical School’s Office for Diversity organizes for underrepresented minorities applying to residency programs.  Each participating department had its own set of activities for the day, and there were also a few social dinners and activities that all participants went to.  I enjoyed my time getting to know four other people who were applying for psychiatry, as well as others considering Vanderbilt for training in other specialties.

The day after Second Look Weekend ended, Radial Grooves (the a cappella group I sing with) performed at the third annual Dr. Vanderbilt Pageant, a humorous competition between physicians that also functions as a fundraiser.  Physicians showed off their “evening wear,” lip-syncing/dancing skills, and trivia prowess.  This year, proceeds from ticket sales went to Primeros Pasos, a primary care clinic in Guatemala.

On Valentines Day, I got a last-minute ticket (literally) to see Brené Brown give a talk at Vanderbilt about shame, perfectionism, and vulnerability.  Then I headed to Marathon Music Works for a fantastic concert headlined by Madeon.  Unlike the last time I went to that venue for an EDM concert, I didn’t have to worry with a day or so of tinnitus afterward.

When I got back to Memphis, I joined a dear friend from high school for dinner and a Hillsong concert at the FedEx Forum.  It was such a great experience from both a musical, social, and spiritual standpoint.  My friend and I are both talking about how much we wish we could go again, especially since Hillsong is heading to Boston and we both know people I went to college with there.

Another highlight of my month was the amount of time that I had to practice driving.  When I first got behind the wheel again, my parents and I noticed that I had taken several steps backward in confidence and ability.  After a few days, though, I started to feel more comfortable driving.  I ran several days’ worth of errands around Memphis with one of my parents supervising from the passenger seat.  This past week, I drove myself to a nearby church on two separate occasions; it was my first time completely alone in the car, and I think I managed pretty well!

I did complete one or two big tasks related to medical school.  I finally sat down and really thought through all of my experiences on the interview trail in order to construct my residency rank order list.  I submitted and certified the list on the official website well before the February 24th deadline.  Now I and my classmates–and fourth-year medical students from institutions all over–are waiting to hear about the results of The Match.  Here’s an interesting article about the algorithm that handles applicant and program rank order lists.

So that’s what I’ve been up to on this month off!  In March, I will be completing my last medical school course and hopefully participating in Match Day.  Stay tuned…

Immersion Phase Update: Integrative Medicine (1/5 – 1/29)

January was a super rewarding month.  Working with one of the attending physicians I’d met on my PM&R elective in July, I landed a month-long elective at the Osher Center for Integrative Medicine at Vanderbilt.  Integrative medicine, also known as complementary or alternative medicine, focuses on holistic care of the individual–bringing together physical symptoms, behaviors, emotional health, relationships, and other aspects of a person’s life to promote overall wellness.  To do this, integrative medicine combines conventional medical care with interventions such as counseling, physical therapy, yoga, and acupuncture.  The chief complaint for most patients is some form of chronic pain–from migraine headaches to fibromyalgia–but they might also struggle with things like insomnia, anxiety, weight management, GI issues, or some combination of the same.

The philosophy of holistic care that clinics such as Vanderbilt’s Osher Center are founded upon is such an important one, but one of the unfortunate and sometimes frustrating observations that I had is that patients often arrive at this clinic as a “last resort” after seeing countless specialists in the community and considering myriad medications and procedures with no relief of symptoms.  Ideally, an integrative care model would offer a first look at the conventional and non-traditional options available to patients in order to deliver the best care possible for an issue, or perhaps it would facilitate preventive care before issues arise.  However, in the current health system, this is not the case.

Over the course of the month, I spent weekdays at the Osher Center and saw patients with physicians, nurse practitioners with medical or psychiatric focus, physical therapists (in exam rooms at Osher and in the heated pool at the Dayani Center on the main campus),  an acupuncturist, and a massage therapist.  I also participated in a few positive psychology/mindfulness meditation classes, tai chi classes, and yoga classes for patients.  There was even a workshop on sleep that I sat in on for a few afternoons.  I gained a lot from my experiences; I not only learned about how some of the recommended practices fit into patient care, but I also was able to take note of different styles of interviewing, educating, and motivating patients, which will no doubt serve me well later on in my own practice as a physician.  In addition to all of this, I discovered a few things–sleep hygiene tips, breathing and mindfulness techniques, and other little suggestions made to patients–that I want to actively incorporate into my own personal life.

Aside from observing and absorbing information from clinical experiences and the database of articles I’d been sent on day 1, I was asked to give a presentation on an integrative medicine topic of my choice.  So, during the last week of my rotation, I presented a short talk on how music can fit into the philosophy of integrative medicine.  It was well received and greatly appreciated by those who could attend, much to my relief (I guess oral presentations will always make me nervous).

As if this elective wasn’t enjoyable enough on its own…I had a pretty active life outside of clinic as well.  I got to sing with the worship team at church again, singing vocals with just two other people instead of being one voice in a full ensemble.  I was super nervous, as I’d never done this before, but now I’m hoping for the chance to do it again sometime if they’ll have me.  I also put a few new covers on my YouTube channel; one of them was even shared on Twitter by the original artist, which was super exciting!  In addition, I started to think about my rank order list for residency programs, meeting with people and getting advice from faculty both inside and outside of psychiatry.  I still have about 3 weeks before the deadline, but it’s quite a daunting thought just the same.

Now I am off for the entire month of February, taking one of my remaining “flex months.”  I’m spending most of that time in Memphis, keeping busy in a number of different ways.  Check back here at the end of the month for an update (hopefully)!

As always, thanks for reading.

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.

Immersion Phase Update: Emergency Medicine (8/3 – 8/28)

The month of August was a whirlwind.

I completed my required Emergency Medicine rotation this month, which was an experience unlike anything I’d had before.  At Vanderbilt, this rotation consists of daily morning lectures, case conferences with residents, several shifts in affiliated emergency departments, and a couple of exams.  In essence, it’s a miniature version of a third year clerkship with a dash of first year didactic learning–lots to know, lots to do, lots to be evaluated on.  There were less than 20 of us on the rotation, including several visiting students hoping to match into emergency medicine.

To be honest, I was interested to see what sitting in class for roughly 4 hours each morning would be like after so long.  I wondered if I’d take better notes, if I would feel more confident about speaking up in class…whether my attention span had gotten better or worse since December 2013.  I took slightly better notes (having an iPad with a dedicated note-taking app helps), but neither my shyness nor my attention span had improved much.  Our lecturers expected class participation, and the class was small, so often I was called on directly to read an example EKG or to answer a question; otherwise, I kept pretty quiet.

For the most part, the lectures themselves were excellent.  Most were 50-minute overviews of various topics that we would encounter on emergency medicine–everything from pediatric emergencies to toxicology to environmental exposures (frostbite, snake bites, and everything in between).  The majority of the lecturers had their own quirks or teaching styles that made them quite engaging.  One of our main lecturers frequently quizzed us on buzz words for particular conditions–ventricular fibrillation = “shock,” hyperkalemia = “EKG,” hyponatremia = “be careful [when correcting the abnormality],” and so on.  He also made countless Seinfeld and “classic” movie references and expressed his disappointment when we didn’t know where they came from (coincidentally, I had just started binge-watching Seinfeld at the beginning of the rotation, so I was pretty happy about some of the quotes he pulled out).

In addition to traditional lectures, we also had a few simulation and procedure labs.  The first lab was an overview of how to suture, how to do a spinal tap, and how to intubate (I was pretty terrible at all of these).  We also had a lab on how to apply splints to fractured limbs, during which we covered each others’ arms and legs in plaster and ACE bandages.  The most rewarding labs were done in the simulation center, where we interacted with simulation robots that can be made to blink, talk, and even sweat.  We were divided into groups, given a patient’s age and chief complaint, and asked to manage each case, asking for vitals, ordering labs, starting medications, and calling for consults based on what we were told and what we saw on the monitors.  Afterward, we had debriefing sessions during which we learned what the key teaching points and optimal management strategies were.  I wish we were able to use the simulation center more throughout medical school; it’s a great way to learn how to diagnose and treat in real time.

Of course, in addition to lectures and labs, there was also “on the job” training in the form of our shifts.  Each of us had a total of ten shifts scattered throughout the month and at different times of day: five at the Vanderbilt Hospital adult ED (one in the triage area, two in the high acuity “A Pod,” and two in the lower acuity “B Pod”), two at the Children’s Hospital ED, two at the VA’s ED, and one at the Sumner Regional Medical Center in Gallatin, Tennessee.  Each type of shift required a different level of responsibility from medical students.

  • The triage shift was a time for us to work with EMTs, going to Rapid Response calls in the hospital and learning to start IVs on patients who came in from the waiting room.  Unfortunately, my shift was pretty quiet, so I didn’t get much practice, although one of the EMTs offered to let me stick a needle in his arm (I declined, although I’m not sure whether he was joking).
  • On the A Pod, where trauma cases as well as seriously ill patients are seen, our role was mainly to see patients with the residents, go to the trauma bay when patients were brought in, and assist where we could with procedures, updates, and other tasks.
  • On the B Pod, we served as the main “resident” seeing some of the patients, presenting to the attending physicians, writing notes, and signing out to other providers at the end of our shifts, provided that it wasn’t too busy in that part of the ED; otherwise, we functioned much like we did on A Pod.  One of my shifts–my first–was a typical B Pod shift, which was so fast-paced that I could barely get used to it.  On my second B Pod shift, both the waiting room and the ED were full, so residents and attendings saw all of the patients themselves while I acted as a “sponge” and learned as much from them as I could.
  • Peds was similar to B Pod–seeing patients solo, presenting to attendings, writing notes, keeping family and staff informed–with the added opportunity to see pediatric trauma cases.  One of my Peds shifts happened to be my one “overnight” shift (10pm – 4am).  Surprisingly, I was pretty functional during those 6 hours.
  • At the VA, medical students did not have computer access.  Instead, when a patient came in, the attending or resident might tell us about them, hand us a short information sheet about why they’d come in, and have us see the patient first.  For other patients, I simply shadowed the resident.
  • The Sumner Regional Medical Center shift gave us a chance to see what care is like outside of the Vanderbilt system.  It’s a smaller ED that is a bit slower-paced than Vanderbilt even though it is still fairly busy.  Patients are sometimes “transferred out” to different facilities for a higher level of care, a process that we do not encounter at Vanderbilt since it is typically on the receiving end of such transfers.  On my Sumner shift, I did not see any patients who needed to be transferred, so it was reminiscent of a VA shift.

It was often difficult for me to figure out how I best could function on my shifts, but once I got the hang of things, I enjoyed the clinical experience and was able to learn more about the medical knowledge and thought process required of an ED physician.  In the ED, a huge part of the work is determining the patient’s disposition, deciding whether the patient should be admitted to the hospital or whether s/he can go home.  This decision often requires the provider to rely on an understanding of the patient’s past history, lab and imaging results, and sometimes his/her instincts about “how sick” the patient was upon arriving to the ED.

Surprisingly (to me at least), my experience also dispelled a quiet myth that there isn’t any continuity in emergency medicine.  While it is true that ED physicians usually don’t see the same patients over and over again, I worked with several attendings who followed up on patients after their shifts were over, seeking to learn about their working diagnoses or their hospital course.  One attending I worked with on my second Peds shift made sure to tell me about the results of one patient’s lab work the next day after class.

As I mentioned, this rotation had a few exams.  One was for Advanced Cardiac Life Support certification.  We spent a considerable number of our lectures learning how to manage various situations, such as encountering a patient in cardiac arrest or someone who has an abnormal heart rhythm on a monitor.  They stressed how much we would need to study to pass the certification test, telling us to make flashcards and quiz each other.  I came into the ACLS certification extremely nervous, but it ended up not being too bad.  So I’m officially ACLS certified to do CPR and run codes…although I hope I never actually have to use that knowledge.

Yesterday, I took the exam for emergency medicine.  This was my first computerized NBME shelf exam; I’m on the fence about whether I prefer that method to Scantrons.  In any case, the exam was pretty difficult, and I wasn’t the only person who thought so.  It felt like a combination of all of my other shelf exams, with the addition of weird things that an ED physician would be the first person to see, like animal bites, acute wound care, and fractures.  I came into it thinking that I hadn’t studied nearly enough, and I left feeling like studying more wouldn’t have helped.   Speaking of studying, for anyone who’s wondering, I only used PreTest.  I don’t even think I got halfway through the book, but I’m still proud of the amount that I was able to do in about a week and a half at the end of the rotation.  I’d planned to also read through First Aid for Emergency Medicine, but that didn’t happen either.  In any case, the test is over, and hopefully I passed.

Somehow I still managed to do “other stuff” this month.  I was able to arrange my schedule such that I only missed church on one Sunday morning and one Wednesday night.  I attended a gathering for members involved in the worship ministry and am still hoping to get more involved myself.  The Psychiatry Interest Group had their first event, a barbecue hosted by one of the current psychiatry residents, and SNMA had their introductory meeting as well.

All told, this month was exhausting.  I’m not going to say everything went well or that I didn’t feel overwhelmed some (read: most) of the time.  If I could do this month all over again, I’d definitely do things differently.  But now that the rotation is behind me, I can’t deny the fact that this was one of the most educational months that I’ve had since starting the Immersion Phase back in January.

Immersion Phase Update: Physical Medicine & Rehabilitation Elective (7/5/15 – 7/31/15)

As I alluded to in my last post, this past month I took an elective that offered an introduction to physical medicine and rehabilitation (PM&R).  This specialty looks at restoring or maintaining activities of daily living, mobility, functional capabilities, etc, in patients with permanent or temporary disabilities.   It’s a broad field, dealing with everything from chronic musculoskeletal pain to cerebral palsy to traumatic brain injuries.  Physicians in the field–known as physiatrists–work closely with physical, occupational, and speech therapists in both inpatient and outpatient settings.  The department and the residency program are quite new to Vanderbilt, but they welcomed me with open arms for the month and taught me so much about the specialty.  I initially chose this elective because I’d had absolutely no exposure to PM&R, and I was pleasantly surprised by how much I enjoyed it–in fact, I’ve been recommending it to just about every medical student I’ve talked to.

Throughout the month, I rotated through a number of outpatient settings that gave me a better idea of the breadth of PM&R.  I saw more typical clinics that served pediatric and adult patients presenting with mainly orthopedic or neurologic chief complaints.  I got to observe several procedures, such as botox injections (for limb spasticity, not for cosmetic reasons), spinal injections, and joint injections.  I even helped out with a few of these; for the most part, I simply helped the physician draw up medications into syringes or held the ultrasound probe, but one morning the attending let me inject steroid into a patient’s hip.  I was so excited to do this, even though the attending was holding my hands the whole time.

I was also placed at fairly unique clinical sites that medical students usually do not get the chance to experience.  In “wheelchair clinic” at the pediatric rehabilitation suite at 100 Oaks, I observed a physical therapist and equipment vendors as they fit children for colorful wheelchairs and car seats.  When I shadowed the physical and occupational therapists at the VA, I learned about everything from paraffin baths for arthritis to dry needling techniques for painful trigger points; I even got to go inside a balance assessment machine, which uses various tests to determine the level of function of certain neurologic components of balance.  I also observed a physical therapist in what is called lymphedema clinic; this site typically serves patients who have swelling due to lymphatic issues or muscle tightness after surgery, and the therapists there recommend equipment and perform maneuvers to help decrease patient discomfort.  On two mornings of the elective, I went to the Dayani Wellness Center, a fitness center geared toward patients with heart diseases, lung diseases, and other similar diagnoses; nurses, exercise physiologists, and other personnel create workouts, hold fitness classes, and use health coaching strategies in order to help patients meet their exercise and nutrition goals.

Additionally, I spent a week with an inpatient attending at Stallworth Rehabilitation Hospital.  Before that particular week, Stallworth was simply the place where patients often got sent when someone felt they needed “inpatient rehab” after a stroke or some other debilitating injury.  I didn’t really know anything else about it, but I learned quickly.  Typically, patients spend about 2 weeks at Stallworth, receiving some combination of physical/occupational/speech therapy daily depending on their needs and goals.  If the patient was admitted for a spinal cord injury, they usually stay a few weeks longer and receive the same services during that time.  Physicians make rounds every weekday, talking to and examining their patients, assessing for new medical concerns, writing prescriptions, and other typical tasks.  Meanwhile, case managers work on discharge planning, figuring out where the patients will go–home or to a skilled nursing facility, to name a few options–and what type of follow up they will need with therapists or physicians after they leave Stallworth.  In addition, the patient’s team of nurses, therapists, physicians, and case managers meet together during the week to discuss medical, social, and other barriers that might lengthen his or her stay.  I found that Stallworth is an environment built upon interprofessional care, with the idea that many medical professionals can and should work as a team to effectively meet their patient’s needs.  This came in handy, because I was taking a concurrent class on interprofessional education that required me to shadow two care providers who were not physicians (I chose to observe a case manager and a speech and language pathologist).  In addition to learning about the system and general routine of Stallworth, I talked at length with the PM&R attending on various topics; it turns out that he is quite interested in the intersection between his field and neuropsychiatry, so we ended up having lots to discuss!

When I wasn’t doing work for the rotation, I spent quite a bit of time working on my residency application.  This past month, I met with the Dean for Student Affairs to discuss the medical student performance evaluation (MSPE) that will accompany the application.  At this point, I am up to my neck in editing my personal statement and curriculum vitae.  At the time of my last writing, I hadn’t started writing either of them; however, I was able to put together working first drafts of both while I was away in Detroit a couple of weeks before starting the PM&R rotation.  I’ve since sent them to several friends and faculty members and have received great feedback on both.  I am also working on finalizing the list of programs I’ll apply to, as well as collecting letters of recommendation.  In the midst of all this, I found out that I passed Step 2 CK, so I’m almost done with the exams whose scores I’ll need to include with my application.

Despite having my hands full with all of the above, I still had time for some extracurriculars.  A week after I got back from Memphis, two of my dear friends from church got married; it was wonderful to be able to celebrate with them.  A week or so later, I entered a vocalist search that EDM genius Zedd opened up to his fans; I wrote and recorded lyrics for a new instrumental track that he’d made, and although I haven’t heard back from the artist himself, I’ve gotten great feedback from friends since posting my vocal demo on SoundCloud and YouTube.  In addition to all this, I joined some of my classmates in welcoming the Class of 2019 during their orientation week; aside from making me feel really old, they seem like a pretty cool bunch of people overall.  Several of them signed up to join the a cappella group, and they eagerly showed up for our first rehearsal; despite some of them saying that they had never sung before, we were able to sight-read and sing through a song that the group had performed previously.  I was also able to go back home for a children’s and youth conference at my church there, during which I met Travis Greene, a gospel artist who sings one of my current favorites (it’s such a favorite that I did a cover of it on my YouTube channel).  And this past week, I went with a friend to Bridgestone Arena for the Nashville leg of Outcry 2015, a brand-new tour featuring Christian music greats such as Passion, Trip Lee, and Hillsong.  I was exhausted the next day, but it was totally worth it.

Thanks for reading!  Stay tuned for my next update.  On Monday, I start my month of Emergency Medicine, which will include lectures and ED shifts occurring at various times of day (and night).  Wish me well!

Immersion Phase Update: Step 2 CK (5/26/15 – 6/19/15)

Exciting news!  I just finished taking Step 2 CK (clinical knowledge), a formidable, 9-hour, multiple choice beast in the U.S. Medical Licensing Exam series*.  I designated this 4-week block as a “flex” month so that I could study (at home!) with no other obligations.

Most of my classmates who had taken CK before me said that it was better than Step 1 (back when I took the MCAT in college, I recall a then-medical student telling me pretty much the same thing).  Step 2 CK is less about hard-to-recall basic science concepts and more (but not completely, in my opinion) focused on sort-of-hard-to-recall clinical concepts.  Because the test is taken after core clinical rotations, it doesn’t take as much intense book review; it’s somewhat easier to retain information about a diagnosis when you saw it on the wards first.

As usual, I came into studying with a day to day schedule.  I’d planned to do all 2250ish questions in UWorld, with a second pass through as many possible of the ones I got wrong, and read Step 2 Secrets cover to cover +/- First Aid for Step 2 as needed.  By the end of my first day of studying, I realized that my plans were too ambitious.  By week 2, after changing things around 3 or 4 times and talking to a classmate about what her approach had been, I decided to ditch the schedule–and the review books–altogether and focus on UWorld questions alone.  It was for the best.  I didn’t get to take notes on difficult questions like I’d planned, but I was able to see every question at least once.  When I found myself struggling with particular concepts, I hit the books/old clerkship notes/the Internet in an effort to gain a deeper understanding.  Believe it or not, I even spent some time with our old friend First Aid for Step 1, as I had found some chapters particularly helpful in the past (looking at you, biostats).

Despite spending the majority of my waking hours studying, I still made time to maintain my exercise, Bible reading, and mindfulness meditation routines, as well as spend time with my family at church and around the dinner table.  They got used to me drilling questions on my iPad while eating and walking around in circles around the house in an effort to reach my daily step count.  Instead of cramming in isolation on the day before the test (read: just yesterday), I joined my mom for a brief day trip to Nashville; even though I hadn’t intended to study at all, I ended up reviewing more in the car than I probably would have if I’d stayed home.

The test itself was pretty challenging.  My ultimate goal had changed from “get a better score than I did on Step 1” to “stay awake long enough to answer every question and not run out of time.”  Armed with a couple of caffeinated energy bars (Larabar Cappuccino and Clif Peanut Toffee Buzz), a jacket, and the chorus of “Whom Shall I Fear (God of Angel Armies)” by Chris Tomlin running through my head on a loop, I felt pretty calm about the ordeal.  But I was still very tired.  I found myself zoning out often and had to pause frequently just to take a deep breath during each of the 8 hour-long blocks.  I only took 2 breaks (one after block 2 and one after block 5); a part of me is currently wondering if I should’ve taken one more to cut down on fatigue.  Hindsight is 20/20, no?

For the most part, I’m just relieved that it’s over.  And I’m relieved that I have about 2 weeks off before my next block, the Physical Medicine and Rehabilitation elective that’s offered at Vanderbilt.  Next week, my family is heading to Detroit with my home church for the National Baptist Congress of Christian Education, and the week after that should be fairly relaxing at home.  I’ll also (finally!) carve out some time to work on some important tasks that I’ve been neglecting due to busyness (practicing driving, working on residency stuff…)

*because I’m writing this a few hours post-test, I fully expect it to be somewhat incoherent.  Apologies.

Immersion Phase Update: Pediatric Genetics (4/27/15 – 5/22/15)

I spent another month at the Children’s Hospital, but this time I was on the outpatient side of things, in pediatric genetics clinic.  This elective is not one that most people decide to take, especially if they’re not going into peds.  But I’d come into medical school thinking that a career in pediatrics–maybe genetics–was a strong possibility (before med school, I’d even toyed with the idea of becoming a genetic counselor).  I shadowed a geneticist one morning as a first year and saw a handful of interesting patients and diagnoses.  By the end of that half-day, I wasn’t sure whether it was the career path for me, but I was glad to learn more about the process (3-year pediatrics residency plus a 2-year genetics fellowship).  Anyway, I digress.

Fast forward to last fall, when we registered for Immersion Phase courses.  At this point, I was still pretty clearly divided between psych and peds.  But I knew that no matter when or what I decided, I would take the peds genetics elective.

On this elective, I saw patients with genetics counselors and attending physicians during their normal clinic days and times.  Most of the time I shadowed the providers and interacted with our patients and their siblings, but sometimes they had me take the lead on getting the patient’s history, performing the physical exam, or even drawing out a pedigree to glean more information about family history (we learned some of the basics of pedigrees in school, but they are a lot harder to draw than they look). When I first started taking on roles in clinic, I spent lengthy amounts of time with the patients and probably slowed things down quite a bit, but I think I started to get faster in the last few days.

The best thing about this month was the fact that I got to meet patients with diseases I’d previously only read about.  One such disease is Lesch-Nyhan Syndrome, whose features–abnormal muscle tone, self-injurious behavior such as biting the hands, sometimes even gout and arthritis–are due to a defective protein  that causes the body to not be able to recycle the building blocks of DNA.  The hand-biting can get so bad that most people with this disease have to get their teeth extracted to prevent permanent damage.  The patient we saw in clinic with Lesch Nyhan Syndrome was at the point where tooth extraction was part of the discussion.  I was asked to do a 30 minute presentation during the month, and I chose to talk about this particular patient both because I remembered this disease from my Step 1 studying days and because it sort of relates to psychiatry.  I can send any of you my presentation slides if you’re interested, but I’ll warn you that it might be better as a cure for insomnia than as an educational tool.

Learning about the tests available to facilitate diagnosis was also quite exciting. The field has made many advances, even in the past few years.  Some patients we saw were return patients from a couple of years ago, who had been told at that time to come back when a new test might be available to help them.  We were able to then offer those new tests in an effort to find a genetic cause of their symptoms and come up with a more concrete plan for long-term management.  Some insurance plans, such as TennCare, are also expanding their coverage for some tests.  I hope to be able to follow some of the patients that I saw, just to see if their test results reveal any answers a few months down the road.

In addition, there are a number of research opportunities for individuals with diseases that are likely genetic but poorly understood at this time.  One such opportunity that was recently introduced to Vanderbilt is the Undiagnosed Disease Network (UDN). The providers I worked with often recommended patients to this program when all of the genetic testing that had been done for them to date was not able to give a definitive diagnostic answer.  The idea at that point is that there may be new genes that have some as yet unknown role in known genetic disorders, or that patients may be presenting with genetic disorders that the scientific community has not discovered or studied yet.  UDN’s job is to help fill in some of the knowledge gaps that currently exist.  I hope that I am able to keep up with UDN proceedings somehow, because it is an exciting opportunity for Vanderbilt and the patients the institution serves.

In addition to the genetics elective, I also took a section on medical error and coping with making mistakes, something that I will invariably have to deal with when I am a physician despite having thought only a very small amount about it now.  And I took an “advanced communications” course, in which we learned how to provide care that seeks to meet patients where they are in terms of cultural background, level of education, degree of comfort with the clinical environment, and other factors.  We completed several assignments for this course, which included giving patients a “math test” of sorts to determine health literacy as well as rewriting a medical document to be at a 5th grade reading level (it is definitely as hard as it sounds).

All in all, this month included a lot of lost sleep preparing for clinics and pulling together presentations as well as a lot of moving parts during the day.  But despite the logistical hiccups I complained about on occasion, I can truly say that this class allowed me to see some aspects of medicine that I would not be able to experience otherwise.  I’m not going to be a medical geneticist, but my work as a psychiatrist will likely require some level of understanding of the genetic contribution to disease, as it is known that family history plays a huge role in many aspects of patient care in that specialty. 

Other things that happened this month: my mom came up for part of Mother’s Day weekend to spend time with my relatives.  I’ve started going back to church on Wednesay nights, and despite the fact that I go to bed a little later on those nights, I know for sure that this sacrifice is well worth it, as I have begun to connect to a community that I love and appreciate and that I feel appreciated me.  The “bible study girls” in my med school class resumed our monthly potlucks this month, which are always quite refreshing evenings of fellowship.  And my class held Parent Weekend this weekend, during which families were afforded a glimpse of what life is like for us students, including tours of the hospitals, suturing and knot-tying practice, and–an old favorite–organ recital, where we used to stand in a circle and pass pathological specimens around to learn what disease processes actually look like in the body.

Actually, we are on our way back to Memphis now.  I am taking my next month “off” to study for Step 2 CK, the next part of “the boards.”  I take it on 6/17 (prayers please); I’m a little nervous, but it will be good to go home for a while to study since I haven’t been back in almost 5 months.  In addition, the week after I take the test, I am going to Detroit with my church for the National Baptist Congress of Christian Education.  Before I head back to school, I’ll hopefully have time to attempt to get my driver’s license, figure out where I want to apply to residency (since that’s the question everyone, including myself, has been asking of late), and write my personal statement.  Nashville, I’ll see you in July!