Does Med School Have To Be Torture?
Kendra Campbell -- I just finished my first week of my third-year surgery rotation. I have no better words to describe it other than pure hell. I was unfortunately assigned to night call for my first week. For four nights I endured 16 to 18 hour shifts with no sleep, no food, only small sips of water, and no time to sit down. In addition to the grueling hours, I was subjected to the fierceness of our residents.
On my very first night call, the residents began rounding on the patients at around 6:30 a.m. I hadn’t slept or eaten in almost 24 hours. I was empty in both body and spirit. When the resident asked me about the ins and outs of one of my patients, I had to admit that I simply didn’t know. Not only had I not realized that I was supposed to be monitoring them, but I couldn’t even figure out how to answer his questions because I didn’t know how to use the electronic medical records system (we had received no training). He knew it was my first night of surgery night call. I admitted to him that I had not been trained on using the system, and that I was completely new to the hospital. But it made no difference to him. He laid into me so hard, that I felt like I was being physically ripped apart. I held back my tears and quietly told him that it wouldn’t happen again.
I’ve only experienced one other clinical rotation before surgery, and it was entirely different. In my psych rotation, I knew what the expectations were, and I was able to surpass them all. The hours were reasonable, and the residents and attendings were kind and understandable.
My first week of surgery has been the polar opposite. I’m starting to understand what sleep deprivation can do to my body and mind. I’ve realized that I simply lose the ability to think without sleep, food, or water for 24 hours. Every part of me begins to break down, and my defenses are lost. Welcome to medicine?
From what I can ascertain from my first week, med school rotations (and especially surgery) are very much like boot camp. You’re expected to challenge yourself physically and mentally in every way. You’re looked down upon if you complain. Failure is not acceptable.
A year ago, our very own Medscape editor, Christine Wiebe wrote an article on med student hazing, and I was very much interested in reading it at the time. However, now that I have walked a mile in the shoes of a lowly med student being yelled at by a so-called “teacher,” I understand all too well the devastating consequences of med student abuse.
At the end of only my first week of surgery, I feel like a shell of a person. I don’t have the energy to give 100% to my patients. I’ve lost all hope, and the first night I seriously considered running out of the hospital. I felt all my compassion exiting my body like the sweat rolling down my temples. I simply didn’t care.
I understand that medicine is a challenging field. I realize that the “weaklings” might not succeed. I understand that doctors are responsible for making life and death decisions, and hence should be held to the highest standard. But I can’t say that I agree with torture as a means of “weeding out” the weak ones. And I now realize why I’ve met so many less than compassionate physicians. I guess I just want to believe that there’s a better way.
All I Need to Know for Step 2 I Learned From Television
Colin Son -- I have a friend who likes to pretend he is an attorney* and he hates the television show "Law & Order". The pace and the drama of the show are so much more than what being a criminal attorney is really like. Apparently. Personally I think he’s just being prudish. I get a lot out of shows set amongst my future profession.
For those who may not know, the United States has three licensing exams which all states require future physicians to pass as a prerequisite for getting a license. The first exam, the USMLE Step 1, covers basic science material like biochemistry and physiology and pathology. The second exam, the USMLE Step 2, covers clinical science topics like how to treat hypertension. The third exam, the USMLE Step 3, is usually taken after graduation and covers, more in depth, the clinical practice of medicine.
I take the USMLE Step 2 this week and I’ve been preparing diligently for it; mostly by watching medical dramas and sitcoms on television.
From shows like "House" I’ve learned that the old adage "when you hear hooves think horses not zebras" is baloney. I now know that a dyspneic asthmatic actually has C. psittaci and not an asthma exacerbation, even if the question stem doesn’t mention birds anywhere. I also know that breaking into patients' homes or places of work can be a valuable diagnostic tool.
From shows like "Grey’s Anatomy" I know that all of my fellow residents and the ancillary hospital staff, at wherever I go to residency, will be attractive. Such gives me motivation to pass my Step 2 so that I can get to residency.
From shows like "ER" I know that everyone who comes into the emergency department should get immediate CPR. On a Step 2 practice question I was doing, a mother brought her young son into the ER for bilious vomiting and the question asked for the next step in management. The answer choices didn’t include CPR, so I had to write it in myself. Also, I’ve learned that CPR often works.
From shows like "Scrubs" I know to watch out for the janitorial staff at whatever hospital I’m rotating at as a resident. Also, that I can spend large parts of the day when I take Step 2 daydreaming and fantasizing and still finish the test with ample time.
I feel really well prepared to head into the testing center and conquer my test. I owe it all to Hollywood and its accurate portrayal of medicine on television.
*Okay, he passed the state bar and is an actual practicing lawyer.
Making Yourself Indispensable
Ben Bryner -- Recently I heard a talk by a physician from New Zealand who does a lot of health work throughout the Pacific islands. He was talking about the keys to success of health programs, specifically advice to those trying to set up programs in other countries. He made several comments on various ways to establish and maintain these programs, and he placed special emphasis on "investing" in those whom the program was designed to serve. In other words, no matter where you're trying to set up a health program, at home or abroad, the key to making it sustainable is to avoid making it dependent on you personally. Instead it should be dependent on the people who work there and who it's designed to serve. His advice was "make yourself redundant." Sound advice, similar to what I'd heard other people experienced in the field say before; but I liked the way he summarized it with that phrase.
This is in contrast to the advice I'd give to someone trying to do well on a sub-internship, which is, "Make yourself indispensable." This is some pretty common advice for people in the workplace, where the idea is that if your boss doesn't know how he or she would be able to function without you, you're unlikely to get fired. As a sub-intern, often your roles aren't fully defined and you have some latitude. You can often choose what you want to do with your time and what you want to learn. On the other hand, there are lots of things you can't actually do because you're only a medical student. So you will never be literally indispensable, but I think the best strategy for a good evaluation is to try to make yourself as close to indispensable as possible to your team members.
Sometimes this means taking on a complex job, sometimes it means taking on scut work. The point is that you have to try to enthusiastically make yourself a key part of the team, regularly taking on a recurring task that you get, and by remaining flexible. I think that last point is one of the most important ones; often the sub-intern is the person on the team with the least amount of fixed responsibilities, so you can often be the one able to take on a job that may take a lot of time or take you away from the floor. It's often less than exciting in the beginning, but the more you take on and handle competently, the more likely you are to be assigned more interesting tasks.
So the focus in the global health situation that the speaker was describing is on the well-being of the institution, while the latter advice focuses on the well-being of the individual. It may sound selfish on the surface, but it isn't really. Of course, the needs of patients always come first in the hospital; but the sub-internship is the last real time that education is your primary goal rather than patient care. It's also the last time you're paying to be there and be educated instead of being paid to work, so you should try to get the most learning out of it as you can as well as trying to get a good evaluation that will allow you to go on and learn how to truly care for patients.
And of course, every team, every service, every department, and every school is different, so always try to figure out specific expectations. But it should hold true that if you become a reliable and capable part of the team you'll get a better learning experience; and if the team wishes you were still around after you rotate to the next service they'll be likely to give you a good evaluation.
Evaluations are important, obviously, but they aren't the only thing either. I've tried to take advantage of the flexibility of my sub-internships to spend time getting to know patients, who you can nearly always learn something from. Most of this advice is probably obvious, and hopefully it is applicable to your sub-internship experience, but if you have something to add or disagree with, please feel free to comment. I'm trying to figure out how to be useful and flexible one day at a time as well.
You Are What You Watch?
Medics are split into 2 camps: those who hate medical dramas and those who love them. I’m firmly in the latter. "Grey’s Anatomy", "House", "ER", "Scrubs", "Casualty" (a UK version of ER) … sad though it is, almost any TV series set in a hospital will have me tuning in. You’d think I get enough medicine in my day job, but apparently not. In fact, I never used to enjoy these programs until I became a medical student. Some of my medical friends joke that it was programs such as these that first got them interested in medicine whilst others claim that watching them reminds them of the light at the end of the dark tunnel that medical training can sometimes be. If you are a medical TV addict, I suspect you’ll have other reasons of your own, which I’d be really interested to hear about. Meanwhile, here’s what they mean to me:
Scrubs -- This show does, indeed, speak the truth. It paints such hilarious caricatures of the worst of hospital life that you can’t help but laugh, rather than cry.
House -- The one we should all aspire to be. In terms of knowledge if not in grumpiness. Plus, it was the first program that really made the medicine, the chase of diagnosis, interesting, rather than the lives of those who practice it.
Grey’s Anatomy -- Very pretty. Full of beautiful people, sexy medicine, sweeping storylines … what’s not to love? And it’s really one of the only programs that really ram home the difficulties in the lifestyle of surgery -– the hours, the sacrifices -– whilst still making it seem worthwhile … thank God!
ER -- Who doesn’t love ER? Written by ex-medic Crichton, this series has actually taught me medicine or at least reinforced it. That episode with the blackout in Season 4, where Carter stops someone’s tachycardia by plunging his face in ice-cold water… the diving reflex has never been illustrated so well!
Nevertheless, no matter how realistically the dramas claim to portray the life of doctors, this is pure escapism. The image of medicine given is essentially shiny. The struggles and worries that face these TV doctors may be realistic, but the way the characters deal with them is only possible in the fantasy land of TV medicine. For example, in the modern NHS, what house officer gets assigned only 1 case for the entire day, giving them time to agonize over the ethics of it? Or the way the characters interact, whilst honest, borders on unprofessional in many cases. The characters themselves are caricatures of medical stereotypes; most medics are made of varying proportions of those traits! But, frankly, when you’ve got the likes of McDreamy and Carter on-screen, who can begrudge a little suspension of reality?
How Good Do You Want To Be?
Jeff Wonoprabowo -- I've been obsessed with these Olympics. It's been so inspiring watching the athletes compete. The last event I saw was the Women's Beam Final where America, led by Shawn Johnson and Nastia Liukin, won the gold and silver medals. After Shawn Johnson won the Gold Medal, the commentator talked about her background.
Ten years ago she bounced into Chow's (her coach) gymnasium and began training at the age of six. During those years of training her coach asked her an important question: How good do you want to be?
That is a question every athlete must answer for himself or herself. The top athletes in the world only want to be the best. And they put their whole soul into achieving their goals, putting in hours and hours of training every day. The answer to that question determined what kind of training Shawn Johnson would need; it dictated the course of her childhood, finally culminating in an Olympic Gold Medal.
A couple of weeks ago I asked why we, as medical students, should bother learning something we'll eventually forget. A number of people commented and left what they felt was the reason for learning such things. And I think they are all very useful answers to this question.
For me, the answer is best phrased in the question I heard while watching the U.S. Women's Gymnastics competition -– the same question Shawn's coach asked her: How good do you want to be?
At the end of my first year I spent almost two weeks on the General Surgery service. On the last day I was there I spoke with the chief resident who was less than a week from completing his general surgery residency. He spoke about his training and how he felt it was very well rounded. Because he had to rotate through many services, he felt comfortable speaking to internists, neurosurgeons, orthopedic surgeons, radiologists, etc. Even though those areas were not his specialty, he knew enough to communicate intelligently about a patient. These days, with multiple teams caring for a single patient, effective communication between healthcare providers is crucial.
Someone commented that a doctor with a broad base of medical knowledge is a well-rounded doctor.
A well rounded doctor means better care for patients. And it's all about the patients, right?
So... How good do you want to be?
Medical Education for Real Life
Kendra Campbell -- Yesterday was an uncharacteristically eventful morning. I awoke to the sounds of my doggies whining and I immediately knew that the only way to shut them up was to take them for a walk. I woke up my partner, Micah, and we hooked their leashes to their collars and headed down the stairwell of our apartment building. Halfway down, we saw a young man sitting beside a slumped over female on one of the stairs. While he looked distressed, it seemed like he had everything under control, so we just continued walking.
After taking the dogs to the park to do their business, we returned to our apartment building. Before we even got inside, the young man from the stairwell rushed out of the front door with a frantic look on his face. “Please, can you help me?!” he screamed anxiously. “Yes, what is it?” I replied. “My friend, I can’t get her up...please help!”
As soon as I heard those words, I spontaneously switched gears from doggy walking to emergency mode. When I opened the door to the apartment building and saw the young girl sprawled on the floor in front of the stairs, I immediately began creating a differential diagnosis. Could she have fallen and fractured her skull? What if she had become severely hypoglycemic and had a syncopal episode? Could she have just experienced a tonic clonic seizure? Perhaps she had a myocardial infarction secondary to a cocaine overdose? And of course, the most immediate possibility that came to my mind was that she was simply very drunk.
I was suddenly acutely aware of the details surrounding me. I noticed that the young man had a fairly heavy smell of alcohol on his breath and that his clothes were stained with paint and dirt. I surveyed the area and checked for any sharp or otherwise dangerous objects and saw none. I observed the position of her body and deduced that she most likely had not fallen down the stairs.
I leaned down to her and asked her loudly if she was okay. “No, he won’t leave me alone!” she replied. I asked her if she’d been drinking and/or done any other drugs and she admitted to drinking but denied using anything else. She was obviously agitated and as I leaned towards her I could detect alcohol on her breath. We went back and forth for a few minutes and she became increasingly belligerent and verbally abusive. She started screaming profanities at me and the young man, who I discovered was her boyfriend.
To make a long story short, I eventually realized that she was just very drunk and upset with her boyfriend. He was trying to get her to the car, and she kept physically attacking him and screaming. She made threats to attack me and called me some very unpleasant names. By this point, I had switched gears yet again into more of a psychiatric emergency mode. I tried using some techniques to calm her down and diffuse the situation. Luckily, having been called every name in the book already, her comments failed to offend or upset me.
After over an hour of failed attempts, I realized that I had no other choice but to call the police. So I dialed 911 and waited for the cops to arrive. They showed up just a few minutes later and I gave them a full report, including my information in case they needed to question me again. The police also failed to reason with the girl, so they eventually handcuffed her and hauled her off in a van to the police station for booking.
For the rest of the morning, I thought about the sequence of events surrounding the girl. I wondered if I would have responded to the situation the same way before going to med school. I guess most of it was really just common sense. But on the other hand, things could have turned out differently. She could have had no pulse, or been in the middle of having a seizure, and things would have been more serious. I don’t know if I would have responded as calmly or even remembered what to do. At the very least, I guess I gained some practice that I can use with actual patients in the future.
A Difficult Meeting
First, a little background. I have not had a formal course in medical ethics and law, so I’m trying to pick it up from various attendings on my rotations. One basic of medical ethics is privacy. Without a patient’s permission, doctors cannot disclose information regarding their medical status to others, including family members, provided that the patient is a competent adult. This rule becomes clouded with unconscious patients. If a family needs to make life-or-death decisions for an unconscious patient (for example, the decision to take a patient off life support), it is important for the family to have all the available information. In this situation, as I understand it, it is permissible for the doctor to share information about the patient’s medical conditions with the family, in order for them to make an informed decision.
A few days ago, a patient on the general medical floor coded, was intubated and stabilized, and subsequently transferred to my ICU team. The patient had AIDS and cryptococcal meningitis and was non-adherent with medication regimens, and had suffered a respiratory arrest. After the arrest, the patient had fixed and dilated pupils, no withdrawal from pain, no purposeful movement, and areflexia, and was diagnosed with clinical brain death. An EEG was ordered. However, the EEG findings did not meet criteria for brain death, although there was very little electrical activity in the patient’s brain.
The chances of this patient recovering were essentially zero, and my attending called a family meeting to discuss the next step. A few matters were anticipated to complicate the meeting. The patient’s family was Spanish-speaking, and so an interpreter was called. Also, although the patient was a male, it was unclear what gender the patient lived as on a daily basis, and we wanted to respect the patient and the family by referring to the patient with the most appropriate him/her pronouns. Most importantly, the family did not know about the patient’s HIV status.
Before the meeting, my attending explained to me the need for family to have all the relevant information in order to make the decision about taking the patient off the ventilator. However, he said that he’d “feel out” their feelings on the decision, and if it didn’t seem necessary to reveal the HIV+ status, then he wouldn’t.
It was evident from the first minute of the meeting that the family thought it was best to take the patient off the ventilator. This made the discussion easier from the start. However, one of the first statements made by one of the brothers was that they wanted to donate the patient’s organs, particularly the heart. Everyone on the medical team knew that an HIV patient’s organs would not be accepted for donation. But, this was an extremely generous suggestion, and so my attending gently explained that although he’d look into the possibility of organ donation, some patients were ineligible for various reasons. He did not reveal the HIV status at that point.
Minutes later, a sister asked a very intelligent question. She asked how a regular person could get this strange type of meningitis. My attending explained that the patient’s immune system was not as strong as other people’s. He did not reveal the HIV status at that point.
Towards the end of the meeting, after a few minutes of silence, one of the siblings spoke up and said, “I heard that there was HIV.” At that point, my attending confirmed the patient’s HIV positive status and explained its contribution to the situation. The family did not seem shocked or more upset than they already were.
As the meeting closed with a prayer from the hospital chaplain, the family seemed at peace with their decision to stop the ventilator, and the medical team was satisfied with the outcome. A few hours later, the patient was extubated, and died within ten minutes.
This scenario was not an easy one, and not clear-cut in any way. I thought my attending did a superb job in discussions with the family, both in his respect for the patient’s privacy and the family’s need to be as informed as possible. I was relieved that the HIV issue had been broached by the family; it seemed more appropriate to tell them, and I was glad that the family understood all the conditions that led to the patient’s death.
Medical ethics is not simple. There is no tell-all handbook which, after reading, makes every decision clear and easy. As medical students, the best way to learn how to handle these difficult and ethically-complicated situations is to watch and listen to doctors we respect. In time, the situations will be ours to deal with, and we need to be ready.
The "Paperwork" of Applying to Residency
Colin Son -- It is coming up on crunch time if you are a fourth year medical student. For most, the residency application service, ERAS, has been open for a month for students to fill out. Come September 1st, students will be able to submit their application.
You fill out your personal information online. Your personal statements, letter of recommendations, and photo are uploaded. That means that you fill out all of your information only once. Such wasn’t always the case. There was a time, not so long ago, when there was no centralized electronic application.
I remember filling out my fair share of paper applications when applying to college. That was for nine schools. If you want to do something fairly competitive for residency, it isn’t atypical to apply to thirty or forty or more residency programs. Imagining filling out thirty applications by hand is a little depressing, even from our current, easier, time.
With the benefits of the current system recognized, there are some things which are annoying me about ERAS and the current way we apply to residencies. Largely, I feel the full potential of a centralized electronic application isn’t being realized; that ERAS remains too much work.
The majority of my criticisms revolve around the difficulty in designating the programs you want to send your application to.
Imagine a student applying to twenty internal medicine programs and he wants to stay in a specific geographic area. Currently he has to search for each individual program, either by knowing its ACGME ID number or by searching by state and specialty and then scrolling through a list of programs. He has to repeat the process for all twenty of the programs.
On top of that he has to specifically designate which letters and which personal statement he wants sent to each individual program.
There is some sense behind this. Requiring students to meticulously enunciate which programs they’re applying to and what they want to include in their application to each individual program limits errors. As well, the powers that be are distinctly against students casting their nets too wide. For instance, despite the fact the electronic processing and transmission of a student's application is essentially a flat fee (i.e. it costs the same for one program to download your application as fifty programs), ERAS dramatically raises the application fee the more programs a student applies to. Consider that for the first thirty programs a student applies to the cost is $290 but to apply to another ten programs on top of that, for a total of forty, would cost $540. The costs serve merely as a deterrent so that students don’t simply ‘pan-apply’ and clog up the system. In the same sense, making students individually look up each program may act as a barrier to applying to a huge number of programs.
I’m not completely sold on this reasoning however.
The way ERAS should work is that you should be able to add programs in batches based on criteria. For instance, in the example above, the student should be able, with only a few clicks of the mouse, to add every internal residency program in his home state and the states bordering his.
In a similar way, you should be able to batch edit your application to programs. If you only have a single personal statement uploaded to ERAS, having to individually designate that personal statement to be sent to every program is just fruitless work required on the part of the student.
I’m also not comfortable with the onerous restrictions placed on the number of programs students can afford to apply to. I’ll throw in my personal story here. I’m applying to a pretty competitive specialty and so I want to apply far and wide. There are currently forty-six programs on my ERAS list.
That isn’t excessive and it isn’t going to clog up the system. At least I don’t think so. But the rapid rise in the cost of the application when applying to more than thirty programs makes my ERAS application financially difficult.
I’m in a significantly better place than if I was trying to apply to forty programs on forty paper applications, but that doesn’t mean ERAS is without room for improvement. With any hope the next generation of fourth year medical students will have the entire residency application process even easier.
Ben Bryner -- One of the hardest things about a new rotation is getting oriented. Often the actual work you are expected to do is not that complicated, but figuring out what's going on is more complicated. On any given rotation you have to figure out where your patients are, where the conference room is, who gets what done, what tasks take top priority, etc. It can be difficult piecing it all together.
I think it gets easier to get oriented each time you start a rotation. But it's still a significant challenge, and it can be a big help if someone can pass on their knowledge ahead of time. Right before starting the rotation I'm on now, one of the students from last month emailed me some rotation-specific tips that were helpful. One of my interns was nice enough to warn me ahead of time that the ICU had moved to another floor, so not only did I avoid being late the first day, but I also avoided thinking I was losing my mind for forgetting the way to the ICU. If you know people who are on your rotation after you, it's nice to send on tips because it will likely come around to benefit you later.
Of course, there's only so much somebody can tell you before a rotation. The number of decisions and instructions handled on any given day in an inpatient service is astounding. There's no way to predict what kind of patients will come in, what procedures will need to be done, or what exactly you'll be expected to do, so you'll virtually always spend the first few days getting settled in.
I guess I'd been doing that without really thinking about it, but it made sense the other day when one of the surgical critical care fellows was showing me how to perform a bronchoscopy. This procedure involves getting images through a fiber optic tube that is pushed down the trachea and into the lungs. The bronchoscope is kind of like an elephant's trunk because of the way it can curl up at the end when you raise or lower a lever. Like an elephant's trunk it can also suction fluids out of the trachea (hopefully suctioning as little as possible to let you see without drying out the lungs or removing too much surfactant). I don't know if it can pick up peanuts, and it doesn't make a trumpeting noise, so I guess the analogy is imperfect. Oh, right, and there's a camera in it too.
After performing all the necessary examinations of the bronchi and sampling fluid for laboratory analysis, the fellow let me try using it. He took a few seconds to show me the controls to move the tube end to one side or the other, as well as how to hold the scope and turn it to send the scope in a different direction, which was easy enough to understand. But it was a lot harder to actually use those controls; the images on the screen seemed completely disconnected from the movements of the controls. One of the nurses said "it's like driving backwards," and it was kind of true. When I tried to go right, the image on screen would move up, or some other direction.
For a minute or two I awkwardly twisted my arm around to various angles, looking between the screen and my hands, and asking which direction I was going. Then I thought I was starting to get the hang of it, sort of, but at that point it was time to remove the scope. (You can't leave the bronchoscope in for very long at a time since the scope is blocking much of the trachea; the patient is carefully monitored during the procedure to make sure that their oxygenation is adequate between glances down the scope). So I had a little basic information beforehand that was essential, but it was much harder to orient myself once I started the actual procedure.
In the same way, whatever formal instructions from the rotation director you may have or advice from another student, there will be a period at the beginning where you have to get yourself oriented. For that reason the first week of a rotation is never as enjoyable or educational as the last couple of weeks. I think it's important not to get discouraged during that orientation period, since it takes a while to really figure out what you're supposed to do.
The Importance of Being Earnest
Thomas Robey -- There’s been a little talk around this blog about applications to residency. It seems as though there are a few of us in the process of making that next step in medical education. I imagine there are more than a few readers who are applying to medical school, as well. Are you in the same boat as me?
If so, you’ll recognize some of our fellow passengers. They go by common names. There’s Ambition in the lookout post trying to figure out what the best course is. Her foil, Trepidation, refers to the navigational charts too often. Fortunately, Patience is on the rudder and keeps the boat on track even though he can’t exactly share with the others where the crew is headed. But Heartburn and Heartbreak are restless in their bunks waiting to make their appearance later in the voyage. Two crewmen are recklessly practicing their swordsmanship on the bow; Humility and Showman are tearing apart your personal statement with alternating sabre slashes. As captain of this ship, you’re having a tough go of keeping the crew in line. Mutiny is an ever-present possibility, as folks are feeling more and more lost at sea.
If you’re smart, you’ll hire on as your first mate a chap who goes by the name of Earnest. Let me introduce him to you:
ear•nest: [ûr'n?st] <ur-nist> – adjective
1. serious in intention, purpose, or effort; sincerely zealous: an earnest worker.
2. showing depth and sincerity of feeling: earnest words; an earnest entreaty.
3. seriously important; demanding or receiving serious attention.
4. full seriousness, as of intention or purpose: to speak in earnest.
It seems to me that this profession we are about to enter into, whether as students, residents, or (gasp) physicians is one not to be taken lightly. Along the same lines, the grueling application and interview process must not interfere with our dreams. All of the hoops along the way get us all down; the sincere zealousness of the undaunted applicant is what will get her through in the end.
At least, that’s what I keep telling myself.