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Fourth Year: Filling in the Gaps

Ben_3Ben Bryner -- At most US medical schools, the fourth year is the only year that differs very much from person to person. While the first three years consist of uniformly required classes and rotations, the fourth year usually allows you to schedule the individual months and their order. Some schools change the format around a little bit or let you take some electives earlier in the third year, but during the fourth year the ball is generally in your court.

While the temptation for some people is to convert the fourth year into a kind of "mini-internship," in which you would try to do month after month of rotations in your chosen field, I’ve been told that the true goal of fourth year is "filling in the gaps" in your education. So while you're exposed to a certain set of activities during your third year rotations, in your fourth year most of the hospital is opened up to you. The options include elective months on consult services, research months, months involved in specialties like radiation oncology that you haven't seen during the third year, etc. Also, this is obviously the time to travel (domestically or internationally) for an away rotation. Of course, applying and interviewing for residencies is busy, and there are a number of requirements that your fourth year has to meet (including subinternships). But the flexibility is there to allow you to fill in the gaps in your own medical education.

I decided to apply this principle to my life in general. So while I'm reading some textbooks to try to fill in gaps in my knowledge before residency, I'm also reading The Great Gatsby because I never ended up reading it in high school. It just seemed like something I ought to do.

Here are some of the other things I'm doing this year to fill in some gaps:

* Going through all my digital photos and ordering prints of the good ones

* Stocking up on things I'll need for next year (pens, socks, etc)

* Trying to fit more time for exercise into my schedule

* Building a robot to do my yardwork

* Learning how to breakdance

* Familiarizing myself with the recorded works of Mr. William Shatner

* Learning enough about pop culture in other countries to make references that are funny to more people reading this (still working on this one, sorry!)

So that's my list. I’m looking forward to making progress with all of these things. And if you see me around please DO NOT tell me what happens in The Great Gatsby. Thank you.

October 2, 2008 by Ben Bryner | Comments (3)

Choosing a Medical School

Ben_3Ben Bryner -- Interview season for med schools is getting underway; it's a nerve-wracking experience getting interviewed because the stakes are rather high, but it's an exciting time to see what the future may hold. Other Ben has made a great list of things to consider when choosing schools at which to apply and interview, and I agree with it. All of those factors are important when making decisions about where to go to school. But there's nothing like taking a look around the place to get a feel for it.

Maybe the most important thing to notice about a school is the overall attitude that most people seem to have there. This was a huge factor in my decision to go where I did; everyone seemed to be very upbeat and happy. You can also tell something about the school just from the number of students you run into. The number of applicants present for an interview day ranges from just a handful to a huge roomful, so you have to take that into account. But if a school can only manage to convince a couple of students to show up and say hello to a large group, that's not as encouraging as a big group of students stopping by to say hello and get some free food.

I remember interviewing at several schools where lots of students showed up at lunch to answer questions, some where only a few did, and one school where I think I met only two or three students. Most schools have a tour led by students, which is a great opportunity to ask questions while you get a glimpse of the place where you could be spending the next four years of your life. This last school, though, just had someone working in the office take us around the campus, and it was a lot less interesting. Even if it's your tenth interview and you're tired of wandering around medical schools, the tour guide can often be a good resource. For one thing, you have enough time with them to ask questions that require some thought, like "what makes this school different?" or "what do you wish you knew before you started?" Or, if you get a tour guide that's painting what you think is too rosy of a picture, you can ask something like "What are the things you like least about this school?" A thoughtful response is pretty useful, since you can put their praise in context.

Speaking of tours, one thing to pay attention to on your tour is the presence of construction. If the campus is busy with new buildings going up, that's a good sign that things are going relatively well at the school. If the most complicated construction project you see is some kids building a tower with Legos in the waiting room, that doesn't bode as well for the future of the school. Most of the time you'll get a tour of at least one of the hospitals you will be working in at that school. Most hospitals probably look more or less the same, but this is a time where you'll want to find out as much as you can about the clinical component of the curriculum. If you get a chance to talk to a clinical-level student, make sure you seize the opportunity to ask them as much about the rotations as you can. It's easy to get a feel for the preclinical (usually the first two years) curriculum, but I would argue the ways the third and fourth years are set up, and the quality of and expectations on rotations, matter even more. So if you get a chance to talk to a fourth-year, grab onto them and ask questions. If someone gives you the email address of a third- or fourth-year, follow up on it and ask how their rotations are going.

Whenever I'm leading a tour I try to make sure we see the hospital cafeteria. It's a decent place with a wide range of choices if limited variability, and it has an especially nice view of the leaves changing color in the fall. It may sound like a waste of time to see that, but you spend enough time there during third year that it's definitely worth considering. Maybe not to the point that I'd choose one school over another solely on the basis of the cafeteria, but it's fine to make that part of your overall evaluation of the place. Obviously you should pay attention to the presence of study rooms, computer labs, and other med student-specific study facilities for those same reasons.

And on the way back from an interview you should take the time to write down your thoughts. You can do this in a standardized way, like making up a form to record all your thoughts about the school in various categories (for example, "coziness of lecture hall seats," "number of students in anatomy lab groups," "number of weeks I think it would take to find my way around this building," etc.) This is fine, but more important, in my opinion, is writing down the impressions you had about the place, the things that differentiate it from the other schools you've been to (or if it's early in the season, things you think are different and want to pay attention to at other schools), and what was really exciting about the school. No matter how thrilling that detail of that school's small-group case discussions seems at the time, by the time you do a few more interviews each school will start to blur together. Needless to say, it's embarrassing to make your decision, matriculate, and then show up the first day of school expecting to be at a completely different institution, so take the time to write down everything you can about the school as soon as you get a chance to sit down.

September 24, 2008 by Ben Bryner | Comments (2)

Standing Out

Ben_3_2Ben 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."

Class_nocoat_8My 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.

September 15, 2008 by Ben Bryner | Comments (6)

Making Yourself Indispensable

Ben_3Ben 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.

August 27, 2008 by Ben Bryner | Comments (1)

Getting Oriented

Ben_5Ben 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.

August 21, 2008 by Ben Bryner | Comments (2)

Calm Before the Storm

Ben_3Ben Bryner -- I'm writing this post from the top of a small cliff overlooking Lake Michigan, taking a few well-deserved days off between my year of research and starting my fourth year back up. I can hear thunder rolling across the lake, which reminds me that in a few short days I'll be starting a sub-internship, or a clinical elective in which I'm expected to take on duties similar to that of an intern. Most schools require med students to take two sub-internships, and offer varying degrees of choice in where to take them. Since I'm going into general surgery I'm doing my second sub-internship (I did one before taking time off for research) on one of the general surgery services here at my university's hospital. The sub-internship has a lot of advantages over the third-year clinical rotation (or clerkship), namely that you don't usually have a shelf exam at the end of it, don't have to go to lectures required of all third-years, and in a lot of cases have more independence and can choose what you want to take from the experience.

My first sub-internship was on the vascular surgery service, and I was lucky to have a very supportive team that basically said I should do whatever I would learn the most from that month. If there's one thing that makes the fourth-year sub-internship harder than a clerkship, it's that you don't have a clearly defined place to go every minute of the day and can't expect your interns to tell you what to do. (Obviously when on a third-year clerkship you should take some initiative, but when you haven't been given at least some idea of what to do, it's usually in your best interest to go study for the upcoming exam.) But I think this is less of a drawback than it is an advantage; you can learn a lot more about the given field and can steer your time toward activities you think will be helpful.

On my last sub-internship I spent some time in the OR, but I wasn't trying to spend all day there. Don't get me wrong, I love the OR; it's almost as enjoyable as a cliff overlooking Lake Michigan (well, in a very different way), but I didn't want that to be the only element of the sub-internship. So I spent a little time in clinic and a lot of time following the interns around the floor and the ICU to learn more about managing postoperative patients. That was a very good learning experience since I had some excellent interns.

So a sub-internship is often flexible, but note, though, that I’m not implying that sub-internships are easy. The hours are long, call is usually frequent, and especially if you're doing a sub-internship in the field you're interested in, the pressure's high to do well.

Of course, this is just my experience, and maybe at your school a surgery sub-internship involves more time in the OR, or more time in the ICU, or maybe you spend part of your day wheeling a soft-serve ice cream machine around the wards dispensing cones to hungry residents. Certainly the details will be different everywhere, and on the first day (or before) you should try to find out as many of your expectations and duties as you can, since you probably won't have a formal orientation session like on clerkships. Any rotation depends on your team as well, obviously. But it's a very exciting experience, one where you can get whatever you want out of it, and one of your last chances to be in an environment where you can devote most or all of your time to learning about medicine.

August 4, 2008 by Ben Bryner | Comments (1)

The Times They Are a Changin'

Ben_3Ben Bryner -- Dr Jules Dienstag, dean of medical education at Harvard Medical School, wrote an excellent op-ed suggesting changes to premedical education (free here) in this week's New England Journal. (Contrary to this blogpost’s title, Bob Dylan has not weighed in on the issue. Sorry.) Dean Dienstag’s article has been getting some attention due to his suggestion that a full year of organic chemistry might be overkill, which is kind of like suggesting that a big scoop of ice cream on a hot day might be yummy.

Some people think that organic chemistry is a crucial part of the curriculum because it "weeds out" those who won't be able to hack it in medical school. Of course, this is the wrong approach to designing premed education; there's too much important knowledge to be gained in college and school that setting up barriers without further educational value is a terrible idea. Challenging but useful classes will be the cornerstone of premedical education, and if any "weeding out" really needs to be done, it can be done by the demands that a pre-med be involved in research, volunteering, shadowing, etc on top of classes. Successfully juggling all these demands is more impressive (and more akin to what a medical student has to do) than being able to push around electrons.

I've got no hatred toward organic chemistry; it's interesting on some level and I've had classes that were much worse. But organic chemistry has really only come in handy once during medical school, and that was when I used my textbook to kill a bat that had gotten into my house.

I'm certainly no expert on education. But here would be my suggestion for the ideal mandatory pre-med curriculum, (setting aside the problems of finding enough resources to teach these classes and their compatibility with med school curricula):

1 semester general chemistry

1 semester organic chemistry

1 semester biochemistry

1 semester math

1 semester statistics

1 semester physiology

1 semester cell biology

1 semester genetics

2 semesters of other biology electives

1 semester economics or ethics

2 semesters writing (at least some with a scientific focus)

This sounds like a lot, but it would fit with most requirements for majors (I took statistics and economics to fulfill my major requirement, English was required for everyone, and I still took several more science courses) and is about the same amount of time required in absolute terms. I think it would also be OK for schools to allow some of these classes to be taken during the senior year, with the offer of admission contingent on passing them. And it's pretty reasonable to expect premeds to carry a very full courseload -- it only gets busier from there -– and to take advanced, rigorous versions of these classes.

Dr. Dienstag draws the line at teaching things like ethics, health policy or health economics in college, arguing that med schools are better equipped to do things like that. Sure, colleges aren't going to bring students fully up to speed on those health-specific issues. The problem is that in my experience, med schools have too few resources to systematically teach the general principles of those fields. Instead, ethics and health policy and economics have been haphazardly thrown at us in random hour-long lectures throughout the four years. Part of the problem is the lack of planning and time devoted to the topics, but part of the problem is that lots of students at this stage don't have the background to dive in to a discussion of health-specific economic issues. Thus my suggestion that the fundamentals of some of these areas be required. Also, in the era of evidence-based medicine, med students clearly need a background in stats that med schools aren’t providing.

This gets at the heart of what colleges and med schools do best: colleges are great at helping students build broad frameworks, and med schools are good at adding on specific information in given areas and helping students develop specific new skills. The times that med schools run into a much greater obstacle, in my opinion, is when they try to teach concepts in areas where some people have an extensive background and others have none. (This also extends to the challenge of teaching empathetic interactions with patients, which is another topic).

Dr Dienstag hints at the possibility that the traditional forms of requirements of pre-med education will “give way to more creative and innovative courses that span and unite disciplines.” I hope so. Just as work hour restrictions have forced residency programs to trim as many nonessential activities as possible from their trainees’ routines, premedical education needs to be reshaped into a rigorous but broad program to prepare future doctors. Given the immense amount of time that future physicians devote to their training, and the overwhelming volume of knowledge they need to acquire, there’s really no time to waste.

July 23, 2008 by Ben Bryner | Comments (3)

CV Guide

Benbryner72x721Ben Bryner -- If I may pick up where Thomas left off in this post about personal statements, another one of the important elements of an application to med school (or residency) is getting your CV or resume together. (Review a discussion of CVs vs. resumes from the good people of the NIH here.) You don't technically need a formal CV to apply via AMCAS, the med school application service, or for ERAS, the US residency application service, since you upload descriptions of all your activities and experience to their websites and the program compiles a "CV" for you. But it's easy to adapt a CV to this purpose. And you do need a CV to give to people who are going to write your letters of recommendation. Plus, they're good things to have at your actual interview if necessary (to hand to the interviewer or to go over beforehand to make sure you bring up all the activities you want to remember).

There's not much to it besides gathering together the important stuff you've done, organizing it into meaningful categories, ordering it in reverse chronological order, trimming the explanations down to make it fit in your target zone, and then slapping your name and contact info on the top. Of course it’s time-consuming, and updating it is one of those not-fun activities I tend to procrastinate on. It plays kind of the same role that cleaning my room did was when I was a kid.

Anyway, you can find some good examples online, as well as some good tips. My advice, which you'll certainly hear elsewhere too: Pick a good font. It should be very readable, but getting away from Arial and Times New Roman is nice. Just don't use something like Comic Sans. (While it's hard to specify the very best font for a given situation, it's often easy to pick the worst for that situation: Comic Sans).

The other thing that lots of people will tell you to do is use "active" words in your CV. These words, like "spearheaded," "quantified," and "reorganized" make you seem more action-driven and emphasize all the things you can do. Our med school counselor sent around a list of these "action words," and you can find an alphabetized list here. Note though, that you should only use words that truly fit the action you're trying to describe. Have someone else read it if you're not sure how much sense it makes.

None of this is really anything new. So I'm going to do something different: I thought of a list of words not to use. Like the lists of "power words," this list isn't meant to be comprehensive, but rather to give you a sense of what words are good and what ones aren't.

Here are just a few words to avoid:

humiliated

crumbled

capitulated

absconded

indicted

fumbled

twiddled

undermined

swabbed (especially in the phrase "swabbed the deck;" this is an unimpressive entry-level task for pirates, and should never be used in a CV that will end up in the hands of a residency director, or in the hooks of a pirate captain)

hogtied

guesstimated

Bonus: Poor Adjectives for your CV

dainty

malodorous

perky

catastrophic

bitter

fancy

unexciting

apocalyptic

If several of these words were in your CV, then better to catch them now rather than later. If none of them were in your CV, then I'm sorry to have wasted your time, but I hope you can see the larger point. Your CV is a great opportunity to let your accomplishments shine, to prove to the world that you can do all the things you claimed in your over-the-top personal statement. Put in the time to create a solid CV so that all the work you put into your activities comes across, duly impressing the people determining your fate.

July 18, 2008 by Ben Bryner | Comments (8)

Horses, Zebras, Ninjas

Ben_3Ben Bryner -- I was reading this story the other day, in which a camp counselor was mistaken for a ninja, which then prompted a school lockdown. It reminded me of the old medical adage, "when you hear hoofbeats, think horses, not zebras." Briefly, if you’re in an area where horses are more common, when you hear hoofbeats outside, it's much more likely to be the sound of horses, not zebras. The idea is that when a patient presents with symptoms that are consistent with a common disease, but are also consistent with a much less common disease, you work under the assumption that it is the more common disease until you can confirm it. In other words, if you’re in New Jersey, a person dressed in a ninja getup is more likely to be a regular person who’s just into karate or dress-up than an actual ninja.

The saying is usually used to correct a student or resident’s differential diagnosis. When you’re on rounds and presenting a new patient with an unknown or not-quite-certain diagnosis, when you get to the end of your presentation, your attending will generally expect you to list the “horses” (the more common diseases) first and the “zebras” second. If you don’t, the attending may request that you do so by saying “Horses, not zebras,” or by the less-conventional technique of whinnying while slapping his or her legs to simulate hoofbeats.

So you should follow what I like to call the “Family Feud” strategy of presentations, based on the game show of the same name. (If you are wondering whether I think all of medical school can be reduced to elements of game shows, the answer is: No, only 80%.) The point of this show was to guess the most popular answers to open-ended questions, with one team trying to list off the top answers to build up points, and the other team waiting for their chance to pounce and steal the points by giving an answer the other team neglected. In a presentation, if you go through the most common possible diagnoses and then get down to the more obscure ones, it’s less likely that someone else on your team will steal the diagnosis you’re waiting to reveal, or that you’ll get interrupted before listing the most important diagnosis. Also, if you’re on a surgical rotation, you should look around after listing off more than two or three potential diagnoses, as your team has probably already moved on to the next patient.

This is not to say that you can ignore the zebras. You try to confirm the presence of a horse before moving on to investigate the presence of a zebra. And you do this mindful of the setting. If you are in feudal-era Japan and you see a shadowy masked figure running around outside, then “Ninja!” is a pretty good theory. By the same token, identical symptoms in a newborn, a teenager, and an adult may prompt very different diagnoses.

As long as you’re not in a true emergency situation, in which you have to try to rule out even uncommon diagnoses if they could cause death rapidly, taking the Family Feud approach to diagnosis has its advantages. Less money is wasted on low-yield tests and evidence-based medicine has a better chance of being followed. When you jump straight to the weird diagnoses, patients get scared, easy fixes get missed and everyone gets confused. Think of the kids in that school who are probably less likely to take a future lockdown seriously. They’ll laugh -- “What is it this time, a pirate in the cafeteria?” And then when ninjas really do attack, they won’t be ready.

   

And if you’re not ready for a ninja, you don’t have a chance.

July 8, 2008 by Ben Bryner | Comments (15)

Choosing a Specialty

Ben_3Ben Bryner -- If there's one thing I enjoy about medical school, it's talking to people about what specialty they're going into and why. Most students change their minds a few times during medical school. I was one of the lucky ones who knew exactly what I wanted to go into (surgery) after rotating there as a third-year, but for most people in my class it was not so obvious. It’s a hard decision; you’re making a choice that will affect almost every aspect of the rest of your life. At many schools, if you’re interested in a field that doesn’t have a required third-year rotation, it’s hard to get a lot of exposure to the field before your fourth year, when decision time comes up quickly. And if it turns out that you don’t like that one, it isn’t always easy to switch gears at a later stage in the game (but it’s certainly possible). To address this difficult situation, there have been a lot of different tools proposed to help you decide on a specialty beyond clerkship and elective experiences.

You might have already seen this graphic, which reflects the growing trend in medicine to reduce decision-making to following an algorithm. An even simpler method is the Goo Tolerance Index, which simply ranks the specialties by their exposure to “goo,” so all the student has to do is identify his or her desired level of goo exposure and pick from a short list. Both of these are pretty easy to use. Oddly, they both leave out OB/GYN (which would probably fit under the “crazy” and “high-goo” categories, respectively).

If you want to take a more comprehensive approach, you can take the Medical Specialty Aptitude Test online. It will ask you a series of questions (130!) and at the end will list the specialties you should consider. I didn’t get through all of them because it kept asking me the same questions over and over, but you might have better luck. Similar kinds of things are available at the AAMC’s Careers in Medicine site, but you need a password from your med school. And of course there are a few books on the subject.

But there’s no substitute for rotating on those services. Hearing about the field from others, shadowing, getting involved in interest groups, etc. are all somewhat helpful, but they can give you a very different picture of the field than your rotations. Of course, rotations are far from perfect tools for evaluating specialties. Since you’re mostly spending time with residents, you may get a pretty good idea of what the residents are doing, but not necessarily what it’s like to be a practicing physician in that specialty. And despite the fact that residency can be quite long and seems so imposing during medical school, it’s a lot shorter than your career. So it’s worthwhile to really try to get a feel for what the attendings’ workdays are like.

There are a lot of good choices out there, so good luck.

June 29, 2008 by Ben Bryner | Comments (6)