Thomas Robey -- Fourth year students must fixate on personal statements and residency applications this time of year -– that’s why you’ve seen a few articles in that vein, and why I've been away from my desk. Not to fear, I'm back with something a bit more juicy on my plate today.
Recently, I was enjoying a pleasant Pacific Northwest evening at a lawn party celebrating a friend’s dissertation defense. The discussion moved from salmon burgers to medical education, and settled on topics related to the obstetrics and gynecology clerkship. It wasn’t long ago that I was in Fairbanks, Alaska delivering babies, so I thought I could add to the banter. Little could prepare me for an assertion that one of my more outspoken friends made. He said, “All medical students should be required to learn how to do abortions.”
That deserves a paragraph break. He went on to propose that all physicians be required to perform abortions if requested. This is related to the current debate in many states among doctors, pharmacists and lawmakers about whether a pharmacist is entitled to refuse a prescription of the high dose progestin “morning after pill.” You can imagine my friend's perspective that pharmacists must be willing to provide patients with their prescribed medicine –- especially if they are the only shop in town. Must also physicians provide every therapy at the request of a patient? For anything other than abortion, most people agree the answer is yes. For obvious reasons, dilation and curettage or mifepristone treatment for abortion are in their own category. It's funny that every medical student already has the skills to perform these procedures.
What many people don't know is that dilation and curettage is a very common procedure used for a number of uterine problems. And who hasn't prescribed medicines? So in that way, I could tell my friend that his first proposal is already being done. But what about requiring docs to do abortions? The majority of American physicians -- no matter their political views -- hold that if a woman asks for a doctor to terminate a pregnancy and that doctor's personal beliefs do not tolerate the procedure, the physician should refer her to a colleague who is able to provide that care.
This reminded me of an excellent teaching point my psychiatry attending made a few weeks ago. His patients are exclusively from our county hospital's population, which means he works with difficult patients who have been refused care (“fired”) by other psychiatrists. If you've done a psychiatry rotation, you know who I'm talking about. Some people with borderline personality disorder are impossible to work with; when everything is in black and white, it's hard to make stepwise progress. (By the way, on your board exams, these are the folks who say, “You're the only doctor who really understands me.”) These patients routinely get fired from practices. You're just another name on the list of many who've wronged the patient.
That is, unless you connect in a meaningful way. It may not work with everyone, but offering to fire a patient could be one step on her way to recovery. You've made a rudimentary connection with the patient, but for one reason or another, some cracks have appeared in the therapeutic alliance. When you say, “I don't think I can provide the best care for you. I can help you find another doctor,” some patients hear, “I care enough about you that I'm willing to send your business elsewhere so that you can get better.” In the three instances my attending offered to fire a patient, each decided to stick with him on new shared terms.
The same respect for the patient's priorities of care that the beleaguered psychiatrist has for his patient should be offered by the pro-life gynecologist. As entitled to her personal beliefs as she is, that doctor cannot provide the best care for her patient until she refers her to a clinic that will perform the requested procedure. Those who value the principle of autonomy in medical care will demand this be done. Of course, it's not so clear as this! The alternate view is that non-maleficence toward the conceptus demands the provider's refusal of the procedure. Currently, American law supports the former perspective over the latter, but that hardly solves the matter. In reality, many women first seek abortions from clinics known to conduct them. And for some individuals, there isn't a provider for hundreds of miles of where they live who will do the procedure. Maybe my friend had a good point, after all...
As a student, you may find yourself in the midst of conversations about the limits of patient care. When is it okay to fire a patient? Is it when there is no more need for treatment? Is it when patients go on Medicaid? When he misses three appointments? When she wants an abortion?
What happens when your idea of going into medicine to help people contrasts with those peoples' ideas about getting help?
Disclosure: Because this is a topic that many feel passionately about, readers may benefit from knowing that I support the perspective that abortion should be “safe, legal and rare.” I support sex education, contraception and waiting longer to have sex, am uneasy about practicing or procuring an abortion, and fully support a woman's right to seek that therapy.
Ben Bryner -- Here is a picture of me taken when I was an exchange student in Japan. It was back in high school, so if you can't recognize the teenaged version of me in the picture, I'm in the front row, in the center. As an exchange student I went to school with my host brother's class. This is me on the last day of school there. I'd been through a lot with the group; I'd fended off attacks with wooden swords in kendo, tried (vainly) to learn Japanese archery, struggled with calligraphy, etc. But although I wore the same uniform as all the other students at the high school, I kind of stood out. This is just the way things go as a pale teenager with curly hair in a midsize Japanese city. I stuck out enough that while I was at a baseball game (a major tournament game for my host brother's school team) someone from the local newspaper asked if they could take my picture. I got a copy of the paper later, and the caption read something like "The Tochiku baseball team is cheered on by a new blue-eyed friend."
My experience in Japan was life-changing for a number of reasons, but perhaps mostly because it forced me to stand out. I was a fairly quiet kid before that, but in Japan it was pointless to try to blend into the background. Because of this, I started to become more outgoing and forced myself to get better at (and enjoy) meeting new people. When you look visibly out of place, you aren't that familiar with the language and you realize you know very little about the culture of the area, the only real options are to embrace your novelty and bizarreness and not worry about it, or to curl up into a ball and refuse to interact with anyone. (I tried the latter for a couple of days, but that was pretty awful so I switched over to the first.)
The lesson I took from this experience that's relevant to medical school was that it's difficult to be an outsider, but there's nothing you can do except to be open about it. On each rotation, you'll be thrust into a new system where you're clearly an outsider. Whether it's the operating rooms, the ICU or an outpatient clinic, everybody who works there normally knows what they're supposed to be doing and what roles different people play. There's no way you can know this going in, there's no way you can figure out who everybody is ahead of time, and there's no way you can hide once you get there. (Especially not in the OR.)
On the bright side, most people will expect to see unfamiliar faces from time to time, and usually you can find a sympathetic person to help you out. I have certainly benefited from the advice of a friendly nurse, an experienced tech, or a knowledgeable PA who have a lot of experience with a given service or clinic. Almost always this has been because I was open about being new to that area, having no real idea of how things go, and asking sincerely and politely for advice. Not everyone's willing to help, but most people are. So don't be discouraged. Also, when you rotate to a new service you should still have some applicable knowledge you can carry over with you; this was often not the case in Japan, like, for example, when it came to figuring out how to use the toilet.
But I'm getting distracted. The other point I wanted to make is that in your applications and interviews one of the goals should be to make yourself stand out. Everyone's busy enough (and human enough) that they'll be more likely to pick someone they can remember clearly. Given the sea of faces and conservative outfits that are present at these interviews, most things that make you stand out will work in your favor. (OK, obviously not if it's something embarrassing.) No big surprise, but it’s something I like to keep in mind during interviews or meetings.
When I got back from Japan there was definitely some reverse culture shock. And not just when I would see things like strangely huge containers of ketchup and mustard at the grocery store. It was also weird not looking so different. More comfortable, certainly; but each day didn't force me to reflect on who I was and what others were seeing when they looked at me. I guess I wrote that I expected something like that in my application essay for the program (and, like Dave Barry, when traveling to Japan I cannot overstate the importance of having somebody else pay for the trip), but I didn't realize how true it was. I also didn't realize it would be so relevant more than ten years down the road.
Are Doctors Supposed To Be Perfect?
Janus, the Roman god of doors, is represented with two faces. Reminds me of medical students. There’s the face we present in hospitals -– decent, wise, moral, caring, confident. And washed. Then there’s the one we have when we get home –- tired or angry or uncertain or petty. Essentially flawed.
There has been a recent debate in the UK regarding the withdrawal of an offer made to a prospective medical student by Imperial College London, when the admissions offices found that he had a previous criminal record. The student had taken part in a robbery at the age of 16, for which he’d completed the community service required and had done substantial amounts of volunteering work since. He was also a straight A-grade student. Opinion was divided about the decision. Some argued that ICL was wrong because the decision sent out the wrong message. Here was a person who had not only atoned for his punishment but had also turned his life around from his criminal past. The withdrawal, his supporters argued, showed that society was unforgiving of juvenile delinquents and would not allow people to change their ways, forever tarring them with the mistakes of their youth. On the other hand, there were those who thought that ICL had acted correctly because those within the medical profession should deserve the trust which our patients give to us; we should be above reproach.
But, of course, we’re not. Although most of the time, most of us are the consummate professionals and decent, moral practitioners that society wants us to be, we are still fallible because we are human.
We drink. We smoke. We lie. We are cynical. We eat chips. Everyone has moments of weakness. But, how much does this matter when it occurs in our personal life? Should the things we do as people outside the medical arena impact our reputations within it? Where does personal life end and professional life begin?
As long as one can always assume the role of the competent, caring and confident doctor at work, does it matter what one is like at play? Is it right for a speeding offense to be listed on the internet, accessible to the general public? How much does one’s behavior outside the medical world say about one’s competence as a clinician?
This leads to another issue. Let’s say a medic drinks more than they should on their days off, maybe even been brought into A&E with alcohol-inflicted injuries, but never turns up on duty drunk and disorderly. Can trust still be maintained despite this apparent separation? Or is there too much of a risk of the consequences of this behavior bleeding into the professional sphere?
The third issue relates to the perceived "severity" of the off-duty behavior. You might continue to trust your colleague if you knew they drank a bit too much at Christmas. Maybe even if they were compulsive gamblers or drove like a maniac. But what about behaviors which hint at a truly nasty side? What if they made racist remarks? Or participated in fraud?
The majority of doctors and medical students are, fortunately, free from serious bad behaviors. But even the purest of us will have aspects of our character which we would wish to remain hidden from our patients and colleagues. In fact, this selective presentation of ourselves to the world is usually intertwined with our notions of personal privacy. But should doctors lose this behavioral anonymity, open up to scrutiny and be judged whiter than white before earning the right to be doctors?
My First Time... Down There
Thursday, 6pm. Outpatient gyn clinic exam room. 10x10, maybe. Professional attire. Me, five female classmates, a female attending, a female resident, and... the patient, half naked.
It did not start well. “I’ve been at two other schools today, had about two dozen fingers up there so far, so be gentle, okay? I’m a little chafed by now, you know?”
No. As a matter of fact, I didn’t know.
The ladies in the room cringed. I cringed, too, out of a combination of imagination and extrapolation. She chuckled, intending to keep things on the light side rather than the morbid. I doubted any of us students had performed gynecological exams before med school, but I felt especially unprepared not having lived for more than two decades with a vagina of my own. All of the other students almost certainly had had multiple exams performed on them, so they at least had that going for them.
The resident instructed us on the various parts of the exam while the attending looked on: how to choose the appropriate speculum and how to manipulate it in practice, how to apply lubricant and how much to use (a lot), how to remove the speculum, that it’s important to warm up your hands, how much lubricant to use for your fingers (even more), where to expect to feel the ovaries, what to expect to feel, what to look for. The focus, though: what things to say (and how to say them), or, more aptly, what things not to say (or, worst-case scenario, how not to say them). For example, use proper anatomical terms rather than slang; always explain what you’re about to do to the patient using such terms before beginning; do not make off-color comments about sexual activity or really anything else that would cause any awkwardness (above and beyond what the both of us were already undoubtedly experiencing, of course). The list was long but seemed sensical enough.
Not ever having had to spread my legs to reveal my non-existent vagina to a gynecologist, it was much more difficult than I expected to place myself emotionally in the seat across from me. When you don’t have a vagina and have thus never had your vagina examined by a stranger, it’s incredibly hard to anticipate what will offend a patient and her vagina and what will be taken as a benign statement. Honestly, on paper, it really shouldn’t be that difficult, but when you’re nervous, and you’re of the opposite sex, and you’re examining someone’s genitals with seven female escorts scrutinizing you, and it’s a generally uncomfortable situation and would be even without the escorts, and literally the first interaction you have with this patient consists of inserting a clear plastic object with a mound of lube on top into her vagina -- well, that changes the game a bit.
I think I did okay, though. I was sweating profusely the entire time, which was both rather embarrassing and a bit cumbersome since my hands happened to be doing other assorted things at the time, but I managed not to get slapped by any party present (though I was insulted to hear that, despite having relatively large hands, my fingers weren’t quite long enough to perform a comfortable bimanual exam). The point of the exercise was not only to learn how to perform such an exam, but to learn how to perform such an exam while also conducting oneself professionally and to correct mistakes that one didn’t initially (or ever) realize one was making. And, despite my classmates’ aforementioned anatomy, we all made many, many mistakes, some of them repeated by every single one of us, giving me slight schadenfreude in that I wasn’t retarded in the absolute sense, just in the relative sense.
Then, it was over. I couldn’t tell you how to perform a gynecological exam today, nor would I want to do another before having a thorough refresher. But, the experience did teach me a little about how important it is to always watch what I’m saying to patients, how what we all say can often be misconstrued as offensive or off-putting, how ovaries are supposed to feel like walnuts and that I should just take their word for it if I can’t feel them, and how I should always use more lubricant than I ever thought necessary.
I Need My Patients as Much as They Need Me
Kendra Campbell -- Before I start, I want to take a moment to thank everyone for all their comments on my last post. I enjoyed reading all of them (even the negative ones!) and I appreciate everyone taking the time to leave me helpful advice and thoughtful words. To provide a very quick update, my surgery rotation has been going so much better! It turns out that my first week was just a horrible combination of a heavy patient load, not knowing the hospital, being new to rotations, and a bunch of other things. Since then, things have been going much more smoothly. (Although I still have a lot to say about medical training, which I’ll share in the future.)
Today I had an encounter with a patient who spoke very little English. Her doctor had explained to her that she needed an above the knee amputation, but hadn’t done the best job of explaining it to her in a way she could understand. In addition to that, I don’t think the doctor realized how much of their conversation had been lost in translation. When I came in to examine her, I could tell that she was very upset. I had to contact a few people and find a way to explain to her what was going on. After I helped, she thanked me profusely for taking the time to help her understand her options.
Afterwards, I felt so glad that I had paused in my busy day to help ease her anxiety. The time I spent running around trying to figure things out turned out to be much more appreciated than my cleaning and dressing of her wounds. It made me feel like more of a doctor than auscultating her heart or percussing her abdomen.
The past two weeks of my surgery rotation have been so empowering for me. I’ve finally had the opportunity to spend lots of time with my patients. I’ve been able to really get to know them. I’ve even had the opportunity to participate in their care and operate on them. I’ve seen their progression from the emergency room, to being admitted, to being prepped for surgery, to their actual operation, and then to their experiences post-operatively. No longer are they just a series of lab values or vital signs. I know their stories. I’ve aided in their care.
This is what makes me get up at 5:00 in the morning. This is what makes me be able to work for 12+ hours. This is what makes me want to get up in the morning and do it all over again.
Many times I have thought about doctors who choose fields like research and healthcare policy, where there is less patient contact. Honestly, I don’t know how they do it. I sometimes say that I am selfish because I don’t think I could do it. Yes, they might be able to help more people in the end, but I guess I need that instant gratification. I need to see that smile on my patient’s face. I need to hear their words of relief. I need to touch them and ease their suffering when possible.
I’ve received so many kind thanks from patients over the years. But I want all of them to know that I’ve received so much from them. They keep me going. They are more of a gift to me than I think I’ve ever been to them. And that’s something to be thankful for.
No Downtime in Second Year
Jeff Wonoprabowo -- You can't afford any downtime. That was the message I heard from one of our professors (who also happens to be one of our deans) during the orientation to second year. As he is one of the course directors for Pharmacology, he suggested that we make flash cards. And those flash cards, he told us, should always be with us. Because should we find ourselves with a little spare time, we can pick them up and look at drug names, their mechanism of action, and what they are used to treat.
It's all quite overwhelming. The night before orientation -- and even walking to orientation -- I was very excited. Almost the kind of excitement I felt coming back from summer vacation in elementary school.
The excitement, though, has dwindled. Although it isn't all gone. I'm still pretty hyped. But the anxiety has also gone up.
I'm worried about the course load. The people I've talked to/heard from say that it's just harder than first year. A lot more stuff.
But I'm also looking forward to learning about diseases. The curriculum here at Loma Linda has us learning "normal" during first year and the diseases during second year. It should be fun.
I also got pretty excited when I saw that, scheduled on our first Friday, was a lecture entitled "Overview of Mental Disorders." After reading Kendra's post on Med Student Personality Disorders, I can't wait to hear what I have! And that's the way it is with the rest of our schedule. To my inexperienced eyes, it looks like the year will be jam-packed with info. But the info looks more clinical than last year. And for someone not interested in research as a career (at least not at this point), that is always a good thing!
Before orientation, I joked to my cousin that my excitement would be gone within two days. I certainly hope it stays a lot longer than that.
Anna Burkhead -- This week, ERAS (Electronic Residency Application Service) opens for fourth year medical students all over the world to submit their applications to US residency programs. However, if you’re anything like me and my neurotic friends, today certainly isn’t the first day you’ve logged in and browsed through the application system. (Not to worry anyone! If today is your first day on ERAS, you still have plenty of time!)
I am applying for Dermatology residencies, with an Internal Medicine preliminary year. Since Dermatology is considered to be quite a competitive specialty with a low match rate, I have to apply to a large number of programs. The reported average number of programs applied to is 55. Right now, I have 53 programs on my list! I have yet to preview my invoice for my application. I may just have to shut my eyes, enter my credit card number blindly, and hit submit, so I won’t have some sort of respiratory arrest before my application goes out!
With a list topping 50 programs, there are certainly ones I’m more interested in than others. In fact, when I’m poking through the super-elaborate spreadsheet that I’ve made detailing program characteristics, I occasionally catch a glimpse of a program name and find myself wondering what state it’s in.
When and if (please when!) interview offers start coming in, I’ll have to do some better research. When applying for medical school, it was easy for me to keep my programs straight, since I only applied to two. But for residency, my ideal plan is to interview at about 15 programs, and that will require much more careful research and documentation.
Right now, ERAS is the topic of choice in every medical school circle I’ve been a part of for the past few weeks. Not that I’m complaining; I certainly have just as many questions and complaints as the next Joe, MS4. However, I am looking forward to the few months during which we’ll be at an ERAS standstill. Applications will be out, with no changes to be made. We won’t expect interviews to be offered until a few months later (at least that’s true for Derm, most of the interviews are mid-December and the whole of January).
I have one reminder to myself for every time I stress about ERAS and applications. I have about eight months left out of four years of medical school. That means I’m about 83% done. In other words, the “damage” is done. I have done nearly everything I possibly can in order to make myself a good candidate for a Dermatology residency. This ERAS stuff is basically just wrapping all that information up and sticking a big fancy bow on it.
Psychiatry Just Isn't For Me
I’ve just finished my first specialist attachment, 6 weeks in psychiatry. I must say, I am so relieved and happy that it’s over. Not that is wasn’t useful, but it just didn’t float my boat.
When I was much younger (and thus, much less wise), I thought psychiatry would be a really cool thing to do. But I suspect I just wanted to peer over horn-rimmed glasses and say things like “so, tell me about your dreams”. Unsurprisingly, psychiatry isn’t quite like that. It’s a true Cinderella specialty -– underfunded, understaffed and seriously underappreciated. And this is one of the major reasons why I couldn’t do it; most of us going into medicine have at least a smidgen of altruism, but with Autonomy being one of the 4 ethical principles, it just feels unsettling and unfulfilling treating people who often do not actively seek or even want your help.
Another major reason is the science behind psychiatry or, rather, the lack of it. When we did experimental psychology as part of our basic neuro teaching in pre-clinical studies, it was absolutely fascinating to learn about the animal models, functional imaging studies etc. of all the different disorders, but clinical psychiatry just does quite cut the mesh for me. There’s very little evidence regarding many of the interventions, for example, psychotherapy. Not to mention the fact that disorders are not characterized by their aetiology, but their presentation. On the one hand, this really makes psychiatry a clinical speciality –- the clinician’s experience, handling and interaction with the patient is absolutely key. And this also makes this speciality a brave one; treating people with drugs and treatments for which the mechanism of action is ill understood. But on the other hand, the subjective nature of this doesn’t sit well with how I would like to practice as a doctor.
Ultimately, I think what really sealed it for me was the lifestyle. I do not appreciate being bored and quite enjoy being time-pressured, having never really experienced anything else. It may have been the attachments I did, but the pace of life in psychiatry is interminably slow in comparison to the cut and thrust of hospital medicine or surgery. This is also one of the reasons why I don’t think I could do general practice. It’s telling that the 2 weeks of psychiatry I vaguely enjoyed were the ones I spent with the Crisis team! Choosing a speciality is about a lifestyle as well as the medicine, and psychiatry disappointed me in both regards.
Psychiatry is a marginalized speciality; many doctors view it as "not real medicine", psychiatrists themselves get lumbered with unflattering stereotypes, and you practice it knowing that you very rarely cure anyone. For this reason, I have huge amounts of respect for the people who go into it, either as nurses or doctors. My experiences are obviously by no means unique (otherwise we’d have too many psychiatrists!) but I don’t mean to denigrate this fine speciality. It’s just not the speciality for me. So, roll on the next attachment…
I’d Like to Do A Little More Than Survive
Colin Son -- I’ve heard some bad stories of students on Sub-Is. These fourth year medical student rotations here in the United States are so named "sub-internships" because they’re designed for the fourth year student, depending on the school and the service, to take on varying responsibilities as would be expected of an actual intern.
If you’re doing the rotation in a specialty you’re interested in pursuing as a career, there can be some pressure associated with the Sub-I rotation, as you might imagine. If you’re doing the rotation at an away school and using it as an “audition” for the residency program at that school, then the stress can be multiplied a few fold.
I’m heading out for just such an away rotation out in Los Angeles to start this week. Although I ran through my Sub-I back at my school, this is my first away rotation.
Talking to residents, the main thing students seem to do to embarrass themselves is just show a complete lack of social skills. I’m pretty reserved and quiet and I am far from stuck up or a kiss up. I work hard, I’m always looking for more ways to help the team, and I have no problem being at the hospital as long as necessary.
But even if you’re not socially inept and you are a hard worker, there are other ways to make yourself look bad. There are stories, always, about students on clinical rotations and especially fourth year students doing Sub-Is having some... embarrassing moments. Stories of students whose scrub pants fell down in the operating room, who had trouble controlling their bodily functions, who prepped or put stitches in or did something else to the wrong patient down in the emergency room.
On away rotations, the situation is not made easier by learning a new hospital and a new system and new ways of doing things. The idea is to pay attention, learn quickly, and ask questions of hospital ancillary staff so you’re less of a burden to the team.
But I’ll be a little stoic about it. Everyone embarrasses themselves sometimes. Going and working hard and letting little screw ups slide off your back is the best philosophy if you can muster it. Besides, I’m well on my way to having a good rotation.
You see, I’ve made the drive out to Los Angeles many times and often not without it being eventful. One year, I blew out a tire in the middle of nowhere between Tucson and Phoenix at about 3:00 in the morning. The tire tread took off the back bumper of the car and the blow-out nearly caused a roll over. Another year I was in an accident in Fort Stockton, TX. It totaled my car. My family was on a camping trip and I couldn’t get a hold of anyone. Now there isn’t much to do in Fort Stockton, as you might imagine, and so I spent three days in my Motel 6 room watching Shark Week on the Discovery Channel until I got in touch with someone who could come pick me up.
This year, however, I am already safely out in Los Angeles. A good sign. Wish me luck and for more good signs as I run through this away rotation.
Lessons Learned From First Year
Jeff Wonoprabowo -- I'm sitting here in my room on the island of Kauai. It's the week before classes resume and my second year begins. Coincidentally, I've met two of my classmates on Kauai within two days of arriving on the island.
Being this close to the start of a new school year, I can't help but remember the feelings I felt before starting first year. I also can't help but think about what I've learned during the first school year.
My cousin, who is now an OB/GYN, told me to just study like I did in college. Unfortunately for me, I hardly studied at all in college. I was in an undergraduate program that was heavily math-based. I used to cram and be alright for tests because all I needed to know were theorems and/or concepts. The rest could be figured out or derived during an exam. Medical school was a big shift for me because now the majority of my studying consists of rote memorization.
So, from the perspective of someone who has had his share of first-year struggles, here are some of the lessons I learned from first year.
1. Figure out your learning style and figure it out fast. This one seems like it'd be common sense. But sometimes students find out that their way of studying isn't working and instead of changing their approach, they go at it harder. Personally, I felt that going to lectures helped me. But I know many of my classmates hardly ever showed up. If you thrive in a good group study, seek out some classmates and make a group. If not, then don't be forced into one. However, even lone "study-ers" can benefit from the occasional discussion with classmates.
2. Seek help. Students who make it into medical school are used to being near, if not at, the top of their respective classes. It might be hard to ask for help. If you need help, put aside your pride and ask for it. At my school there are tutors available for the first and second year students. I think that if I had sought out a tutor, I could have had some better scores. Don't wait until it's too late to get help.
3. Make time to do other things. It's really easy to get caught up with studying when the pressure starts piling up. But it's important to remember to make time to do things outside of schoolwork. Volunteer to tutor high school students. Take up a new hobby. Continue an old hobby. Go to the gym. Or even go and volunteer at a free clinic so you can get patient interaction. Don't let studying define who you are.
4. Study hard. Push yourself -- at least through the first semester. Then, you can decide how much you can afford to pull back while still attaining acceptable (in your eyes) scores. It's easier to "ease off the throttle" because you're studying more than you need to, than to "floor the pedal" trying to catch up at the end of the school year.
5. Finally, visualize. Remember the reason you wanted to go into medicine. Don't forget it. Then, picture yourself done with medical school and residency, and practicing medicine. Aim for that goal. Try not to let the stuff in between -- the grueling hours of studying in medical school or running around in residency -- get you down. They might be necessary parts of the journey, but they sure aren't the destinations.