The Differential: Medscape Med Students Blogs

Terrible at Goodbyes

Pin-Chieh Chiang -- This is my third draft trying to write this blog, which will also be my last entry. I have always been terrible at saying goodbye. Should I leave with some words of wisdom? Or a funny last story? How about I just write as if I’m giving an update about my life?

I’m currently sitting on my bed which I share with my husband and daughter in Shenzhen, China. Through our bedroom window I can see Hong Kong and the bridges that connect the two places. This is my vacation block and so far I’ve spent the last three weeks doing only one thing: being a mom. Each day I’ve looked after my baby’s sleeping, feeding, bathing, and playing. This is the most child care I’ve done since her birth. Typically during rotations, I’ll wake up and leave the house before she gets up. Then daddy takes her to grandma’s house for the day while we both work. At night I see her for only 3 hours before she goes to sleep. Here it’s been 24/7 just being with baby; a very rewarding vacation so far.

My family is truly my number one priority, especially my bouncing bubbly baby girl. Medical school would be my number 2. With just these two priorities, it’s already sometimes too much for me to handle. This is why I’m saying goodbye and this will be my last post. I had a wonderful time writing for The Differential and I’ve enjoyed everybody’s comments.

When I look back through my blogs, I wish I had written more about Osteopathy. It’s more than just an extra set of tools of manual medicine, it’s also a way of thinking. One of my favorite teachings in Osteopathy is, “To find health should be the object of the doctor; anyone can find disease.” Since starting 3rd year rotations, I’ve been so focused on diseases and pathology, I’ve easily forgotten about finding the health in my patients. Then I was reminded of this concept by Dr. McAffrey when she gave a grand rounds lecture on Traditional Osteopathy. She told the audience that the first thing she does with any patient is list five healthy things about them. She challenged everyone to try and find five healthy things about their patients.

To end this blog, here’s a list of five healthy things about me: I’m young, in general good health, lead a fairly active life, have a supportive family system, and am trying for another baby.

The Choices Patients Make

Pin-Chieh Chiang -- Last Friday, I had just finished my last surgery for the day when one of the O.R. nurses gave me a heads up that an emergency operation was just added. It was a case of a 57 y.o. female with a ruptured viscous, and the case was listed as an exploratory laparotomy with sigmoidectomy and colostomy. In the rush of things, I didn’t get a chance to learn more about the patient’s history. What I did know was that she had presented to the E.R. with abdominal pain, nausea and vomiting, and an abdominal film had shown air bubbles under the diaphragm.

As we started the surgery, the other two surgeons discussed this patient’s case. She had had symptoms of abdominal pain for at least a year. On a CT scan a couple of months ago, it was discovered that she had colorectal cancer. Then, what really perked up my ears was that apparently this patient was already scheduled for surgery this day, but had canceled earlier in the week. It was obvious to the surgeons and me that this patient has just been avoiding and putting off surgery for a while now.

This surgery would teach me about more than just medical science; I was also forced to ponder the nature of doctoring and disease. I’ve always had problems understanding what was going through the minds of patients like her. Why would they delay medical attention for a condition so severe?

This patient reminded me of another case I saw during my first surgical rotation. This other patient was over 80 years old and presented to the office with a breast mass. When I went to do the breast exam, there was a huge mass eroding through the skin of her left breast. Her left breast anatomy was very distorted with the nipple completed inverted and axillary lymph nodes were very palpable. I asked her how long ago she had first been able to palpate a mass in her breast and she told me 1 year. She sensed the “why?” question that was in my mind, and without being prompted she explained that she felt like she was already over 80 years old anyway. The reason why she was referred to surgery this time around was for symptomatic relief; the mass was causing her too much pain.

During the rest of the ruptured viscous case, I pondered why such patients push off medical care for so long. It would be so easy for me to just blame the patients themselves for being careless with their own health. During the exploratory laparotomy, we found foul smelling pus throughout her abdominal cavity. There was an abscess near the posterior wall where the colon had perforated. Towards the last 45 minutes of the surgery, the patient became very hypotensive and was resuscitated with fluids and pressors. After the surgery, she remained in the O.R. for further resuscitation from septic shock and was directly taken from there to medical ICU.

At the end of the surgery the head surgeon made some comments that were very enlightening. She told me that she never passes judgement on her patients. Perhaps both of these patients wanted to spend more quality time with their loved ones versus subjecting themselves to aggressive treatment. Maybe there are no wrong decisions.

Chaos in the OR

Pin-Chieh Chiang -- It was just another day at the hospital, and I came early to pre-round and read up on surgeries for the day. Then I went to the O.R. for a surgery that was scheduled for 11 am. The patient was there and the surgery room was being set up. I went to write my name on the board, introduced myself to the scrub tech, and pulled on my gloves and gown. When I went back out to check on the patient, I found out the surgery was going to be delayed an hour. There were no anesthesiologists available; they were all tied up in surgeries that had started at 8 am.

I wasn’t getting a very good vibe from all this. It felt like déjà vu; just a week ago we had a surgery that ended up being delayed 3 hours, and my preceptor had to reschedule all her afternoon office appointments. Once again, just like the week before, we ended up waiting on two surgeries. We had office appointments starting at 2 pm. I was afraid that a 1-hour delay would become two hours and then 3 hours. My fear ended up being right.

In the meantime, my preceptor told me to observe other surgeries. I saw another surgeon scrub out and back in 3 times to grab tools that he needed but hadn’t been pulled for the surgery. Just recently, a new card system had been installed as an upgrade. However, for some reason or another, all the cards were coming out wrong and surgeons like this one were not finding the tools they needed when they needed them. I heard later from his medical student that this surgeon had gotten quite pissed off at his staff in the O.R.

At one point I also witnessed another surgeon blow up at the front desk because a certain device he needed to be implanted in the patient had not even been sterilized yet. He cursed and screamed and then stormed off. He left all the nurses scrambling to figure out where the system went wrong. One of the nurses quickly remembered that the patient had just been wheeled into the O.R. and was being put to sleep. She ran in to tell the anesthesiologist to stop since it looked like that surgery was going to be delayed as well.

Finally at 1:30, an anesthesiologist came to take our patient in. When I saw my preceptor’s face as she came stomping into the surgery area, I could tell she was extremely angry from all the waiting. The intensity level was at an all-time high. I felt like something was going to explode if it hadn’t already. Then, my preceptor saw that the anesthesiologist had used the perm-cath instead of starting an IV, and she asked if he had remembered to withdraw the heparin.  Perm-caths used for dialysis are normally heparin locked. When he said he had forgotten, that’s when my preceptor really exploded.

“You just gave the patient a bolus of heparin! How many times do I have to tell you people to withdraw from the perm-caths first? Do I need to supervise everything myself?”

In my head I’m thinking, “just stay out of the way” and “don’t get noticed.” I was just hoping my preceptor wasn’t so mad that she would change her mind about letting me scrub in. As it turned out, she didn’t, and she was able to quickly calm herself down. I was even allowed to assist and close. By the time we walked out it was already 4 pm and we had long missed our patient appointments. Our whole day had been spent on a 2-hour surgery. As I passed by the surgical front desk, I could hear the nurses muttering, “Just another day in the O.R.”

 

Legalities and Forensic Psych

Pin-Chieh Chiang -- My psychiatry rotation is over already; four weeks can pass by very fast! There is quite a lot about psych that is just unique, especially at my rotation site where the patients weren’t there by choice. Every single patient was sentenced to be at that hospital for some crime. For example, one patient attacked his neighbor because he heard voices telling him to. Such a patient was determined to be “not guilty by reason of insanity” when the crime occurred. Other patients are incompetent to stand trial.

Similar to being sentenced to a correctional facility, the patients are sent to this psychiatric hospital for a certain duration of time. What is completely different is that the sentence has no meaning as to how long the patient actually stays at the hospital. A patient can be sentenced for life, but released in several years. Other patients might be sentenced for several years and spend decades in this facility. The people that decide when the patient can leave are doctors and staff on the treatment team. As long as a patient adheres to the rules, demonstrates good behavior, and genuinely improves, they have a chance of leaving. Of course, it’s not as simple as just letting them walk out. The patients first move to open units, and then slowly integrate themselves back into the local community with help.

There are always a few who could have gone to a state correctional facility but chose to go to a psychiatric hospital, thinking that they would have an easier time. In a sense, these patients probably are having it a bit easier than being in jail. However, there are much stricter rules at psych hospitals that they have difficulty adhering to. A lot of these rules involve behavior and adhering with treatment activities. Had they gone to jail, they would have been released as soon as they did their time, but at this facility they might be kept much longer for not adhering to stricter guidelines.

Then there are the patients who are incompetent to stand trial. What they are really here for is to practice going to court. These patients attend mock trials where they learn various things regarding a court trial. For example, they learn where to stand and who the other people in court would be. Once the treatment team decides they are ready for a trial, they will return to court and they might be given a sentence that sends them straight back to the hospital.

For the most part it seems as if the law is the reason why these patients are stuck at this hospital in the first place. While I was there, I did encounter one case where the law released a patient with no regards to the doctor’s evaluation. One patient had entered as a juvenile and when he turned 21, the hospital automatically changed him to an adult sentence. The courts stepped in and stated that was illegal and he needed to be released immediately, whether or not he was stable to do so. I interviewed him and ask if he planned to continue taking the antipsychotics and visit a psychiatrist as an outpatient. He did not. Even though he clearly had psychotic symptoms and grandiose delusions, he never believed it himself.

Even though this rotation was a short four weeks, it was still a pretty heavy rotation in its own ways. While I don’t plan to become a psychiatrist, I definitely still have to admit it was extremely interesting to interact with the many mentally ill patients. It was even more interesting for me to see how the legal system tied in with the whole medical system.

Dealing With Non-compliant Patients

Pin-Chieh Chiang -- Imagine that you’ve finally finished all those grueling years of medical school and residency training, and now you’re ready to go out and medically treat people. You are all excited to practice medicine, only to realize that your patients aren’t following your treatment plan. It’s not only a bummer when that happens, it can also be extremely frustrating. While I was in my family practice rotation, I had the opportunity to interact with such non-compliant patients.

My first experience was with a diabetic patient who came in with a high fasting blood sugar in the 300s. Overall he felt fine, reported that his fasting sugars at home were in the 100s, and that he was taking his medication as indicated. I decided to order an HbA1c and it was 13.5. I’ve also had patients who came in with a tension-type headache who absolutely refused to take any medications. In contrast, I’ve also had a patient who was on a lot of pain-killers for her arthritis, but refused to take prednisone because she didn’t want to be on a “steroid”.

It’s very interesting to see the range of non-compliant patients and their reasons for not following the treatment regimens. It’s even more interesting when I can see from their charts that while they obviously do not listen to their doctors, they still continue to come back for their regular appointments just to start from the beginning all over again. I’m not talking about the patients who are in denial of their diagnosis, or the patients who don’t understand how to take their medications. I’m talking about patients who will openly admit to understanding everything but just do not want to take their medications. I’ve actually heard my preceptors say things like “there’s nothing more I can do for you since you refuse to take the medications,” and the patient just responds with a plain “okay”.

I always thought it was common knowledge to listen to your doctor and that your doctor knows best. Intrigued by this idea that there are patients who truly ignore their doctors’ suggestions, I decided to ask family and friends about their experiences. As it turns out, quite a few of them also fall under the category of being non-compliant patients. Without going into specific examples, I’ve learned that my own parents don’t always take the medications that their doctor prescribes.

It’s always frustrating when you have to deal with non-compliant patients. I was even more frustrated when I couldn’t convince my own parents to take their medications as their doctor says. I think the best way to stay sane is to admit that there is only so much that a physician can do, and at some point the rest is up to the patient.

Behind the Fence in Forensic Psych

Pin-Chieh Chiang -- The first memo I received about my psychiatry rotation said not to wear khaki or brown colored clothes. This is because I am rotating at a mental health hospital where patients wear those colors. And if I dressed in khaki or brown, the guards might confuse me for a patient and not allow me back outside the fence, or so I was told.

To get through the fence, I have to go through the sally port, a controlled entryway with three gates, where one must enter and close the first gate before opening the second to proceed, and so on. While in between gates, I need to show my badge to the guards who check through a glass window. Once inside, I take my duplicate badge to exchange for a set of keys and a personal alarm. From there I head towards the ward that I am assigned to, which is on the opposite end and takes me a good 15 minutes to walk there. On the way I usually see a number of patients sitting on benches or walking around. These are patients who have been on good behavior and have earned the right to be outside their wards. They are always friendly and ready to greet me -- in another place, I would never have guessed that most of them are schizophrenic.

I have to fight the habit of greeting them back, because during orientation I was given specific instructions not to engage the patients. Safety was emphasized many times, since this is not your typical psych ward, but a place where patients are sent by courts for forensic reasons. This means that most of these patients have committed some crime and were either declared not guilty by insanity or incompetent to stand trial.

So, I typically smile and just move on towards my ward. In contrast to those patients seen on the grounds, there are also patients who haven’t been on the best of behaviors and are basically restricted to the wards. That is where the set of keys comes in. There are about 10 keys that I am given, but as far as I can tell, I only need two of them. One of them gets through most doors and the other one opens office doors. As I go through each door I have to remember to lock it behind me once I’m in. There is even a lock for the bathrooms.

Psychiatry is not something that I’m interested in choosing as a specialty, but I have to admit that it is quite interesting. I’ve only interacted with a few patients, but so far each one has a binder thick of enough history to write a good mystery book. I’m amazed that this field is just so far beyond what the typical doctor-patient encounter would encompass.

No Hablo Espanol

Pin-Chieh Chiang -- There are many forms of barriers to medical care including lack of access and finances. For the patients that come to the community health clinic where I am currently doing my family practice rotation, there is also the barrier of language. This is a clinic where all the patients are either on government insurance or have no insurance at all. Many patients don’t follow up on their chronic condition until they need some type of urgent care. Many of the doctors complain about the lack of continuity of care, because the patients will jump around from doctor to doctor and clinic to clinic. Many of the patients are also Spanish speaking, and I don’t speak Spanish.

Instead of the open-ended question that I was trained to start with, I typically walk into a patient room and ask, “Habla inglés?” Typically the patient says no and I have to turn back around and find a medical assistant (MA) to help translate. Even then, I find a lot of difficulty communicating with my Spanish speaking patients. I marvel at my preceptors that manage to continue the patient interview as if a translator wasn’t even in the room. In other words, they are still able to directly address the patient. Whereas no matter how hard I try, I always seem to end up addressing the MA instead. I find myself saying things like “Can you ask her…” or “Can you tell him”.

The biggest challenge I have with needing a translator is that my evaluation of the patient is just not as complete. When I present to my preceptors, I’m often criticized for missing crucial information that I normally would ask. I find my train of thought gets easily lost in translation. I feel limited by only being able to collect information from the translator and not being able to read into the words of what the patient is saying. For example, I once diagnosed a patient’s aches and pains as some type of inflammatory arthritis. On her follow-up visit, she was angry with me because all labs returned normal and she still had aches and pains. My preceptor was able to realize that this patient who was undergoing menopause also had a lot of anxiety and depression. Since he’s changed her medications, she’s been doing a lot better.

Throughout the frustration, there lies a solution, which is that I need to practice my Spanish. As someone who plans to practice in California, I have a feeling that I will continue to encounter Spanish speaking patients in my future.

Finding the Cervix

Pin-Chieh Chiang -- A month ago I was on an internet forum and found an interesting discussion where a medical student was asking for advice on how to find the cervix. It appears that this person had had some bad luck and had never been able to locate the cervix without help. Fellow readers shared some good tips, so I bookmarked this forum as a reference I could use when I’m on my OB rotation later this year.

Little did I know, on my very first day of my Family Medicine rotation, I found myself wishing I had read through that forum more carefully. I just started a week ago and it already seems like it’s guaranteed I will do at least one pap smear every day. It shows how little I know about medicine when I didn’t expect to have to do pap smears in family practice.

Before this, I’d done only one pap while in medical school. When it came time to teach us how to do female and male exams, my school turned to an agency called Project Prepare. It’s a great program where the instructors are the patients themselves. My instructor walked me through how to do a breast and pap and then I performed it on her. This way she was able to give me exact feedback.

When I faced my first real patient, my mind wandered back to Project Prepare and thought how wonderful it would be if this patient also told me exactly where her cervix was. Needless to say, I had some missteps in the beginning. There were several times where I had to excuse myself, leave, and ask my preceptor to come in and help me.

The worst pap was the time when, due to a language barrier, I didn’t catch on that the patient had a previous total hysterectomy. So there I am wondering why the vaginal canal was so short and why in the heck could I not find her cervix. I had to ask my preceptor for help only to feel like an idiot that I didn’t put all the clues together. By far the most exciting pap was when I had a patient with uterus didelphys. My preceptor gave me a heads up on that patient and also some tips on how to approach the exam. I definitely hadn’t expected to see that during this rotation.

Early on, I expressed frustration over my inadequacy. All my preceptors kept telling me that practice was going to make the difference, just as a lot of the comments stated on that forum. I believe they were right, and during the past few pelvic exams, I’ve been able to find the cervix every time.

Getting Caught Unprepared

Pin-Chieh Chiang -- It was the last week of my first General Surgery rotation, and in fact the last day of surgeries that I would be scrubbing into for a while. There’s never a good excuse for showing up unprepared, so I won’t give one, but the bottom line is I didn’t read up on the surgeries for the day. Somewhere in the back of my mind I was hopeful that my preceptor wouldn’t notice. I only thought this because he never really asked many questions before. In retrospect, my preceptor would always ask one or two questions and when he realized that I had done my homework, he would leave me alone.

This time, it was pretty obvious that I had not done my reading and he smelled my uncertainty. With both my hands holding onto retractors and my legs getting numb from fear and standing all day, I had to make a quick decision. Do I lie and try to swim my way out of this one or just tell the truth and sink? To be honest, I just can’t lie. Plus at that moment, I didn’t feel very confident in myself that I could be saved either way. So I told the truth once again hopeful that he would let me go for being truthful.

I had no such luck. My preceptor was not going to left me off the hook. He drilled me into the ground. I literally felt like I was buried. He even made a point to say, “Because you’re not prepared today, I’m going to make you sweat.” Let’s just say at the end of the surgery I felt too beaten to follow him out like I usually did before. While I stayed by the patient, the anesthesiologist, the anesthesiologist’s student, and the scrub tech all took turns consoling me.

There were many things about the experience that made me want to hang my head in shame; realizing I had not read and was caught by my preceptor, not being able to answer his questions intelligently, and knowing that three people had witnessed this event. However, I think the worst part about the whole experience was in the end when my preceptor was closing. He said, “I was going to let you close, but because you didn’t come prepared, you just lost the privilege.”

To end on a positive note, this was just one of the many valuable lessons that I learned on this surgical rotation, which I thoroughly enjoyed. Like how Ali put it – “Surgery is addictive!”

Learning Pager Etiquette

Pin-Chieh Chiang -- This might sound silly, but I really did not know what was involved in using a pager, let alone actually paging someone. I remember a time when pagers were the hottest gadgets, but that was literally a decade ago. Since then cell phones have taken over and pagers have became a thing of the past.

This is of course not the case in the hospital. As far as I can tell, almost every doctor I’ve encountered carries their own pager. I frequently notice the pager when my preceptors get paged and they take a break from what they were doing to go return the call. Other than that, I never really gave pagers much more thought, until I had to page a preceptor myself.

There have been plenty of times when I couldn’t seem to locate my preceptor. I knew we were supposed to meet at a certain time but don’t know where. Or we were supposed to meet at a specific place, but he hadn’t shown up and 30 minutes had passed. Early on, I wasn't sure if I should page my preceptors or not. Somewhere in the back of my mind I had reserved paging a doctor for only life-or-death situations, and I didn’t believe I qualified. I was also worried that I would be annoying them or interrupting something extremely important. So in the beginning I would always first try to hunt down my preceptor and stake out what I thought would be the most likely locations to find him. When I worked in a team, we usually split up going to different areas of the hospital. It seemed to work well at first and then I found myself in situations where I was touring the whole hospital without any signs of my preceptor. I started to worry that I was wasting time and my preceptor would think badly of me because they did not know where I was.

So finally I got the courage to start paging my preceptors, and now I have learned the amazing truth that it’s really not a big deal. Remember to press the pound sign at the end of your page – I had to figure that out the hard way. If you leave the extension of the phone you paged from, don’t walk away from that phone – thankfully it was a colleague of mine that made this mistake and not me.

The bottom line is to learn to deal with pagers; they’ll probably always be in your life whether you’re paging someone or the one getting paged.

Temptation to Slack Off

Pin-Chieh Chiang -- Before 3rd year began, my class had an orientation to clinical rotations with the Dean of Clinical Education. Among the many things she talked about, one particular item stood out for me. It was the topic of performance and how every little negative detail will find its way to her office. This includes things like being late, clashing with the nurses, and anything that made you a burden to the team. What struck me as strange was the idea of performing below par. How bad do you have to be for the Dean of Clinical Education to become aware of the situation?

Now that I am on rotations, I can see why creating negative vibes can be an easily made error. Take the concept of being on time. Last block my preceptor told my colleagues and me to arrive at the hospital at 7:30 am to read an EKG book for 1 hour. With nobody to keep tabs on us, pretty soon some of my colleagues were arriving later. It was tempting to consider taking the book home to read so that we could sleep in. However, I knew I would never be able to read with a baby at home so I stuck to the 7:30 time until I finished the book.

Then there’s the possibility of not getting along with staff. I’m sure we’ve all heard stories about nurses being mean to medical students just because they can. I’ve definitely met a few of those, but honestly for the most part I haven’t had much trouble. Almost every nurse I’ve interacted with so far has been extremely helpful. A couple times I made some simple mistakes of forgetting to wear my badge or not closing the curtain when examining a patient and I would get chewed out by the nurses. Still, a good apology and a promise to never fault again always seemed to ease their minds.

There have also been a couple of times where I had ambiguous instructions from my preceptor. I would be told to go ahead and take the day off or go round on this list of patients “if” I wanted to. When I first heard this, I thought, “Maybe, just maybe, my preceptor doesn’t want me to round on his patients.” Then I came back to reality and decided I really wasn’t going to be let off that easy.

I can see why it would be easy to slack off on rotations. It’s tempting to think that once you leave the hospital or clinic, you are done for the day. I love the idea of ending early to go home and catch up with my daughter. However, the truth is the work never ends even when you leave the hospital. My preceptors aren’t done, they still carry their pagers. For me, there’s always more reading that can be done. The key is to not fall for the temptation to slack off, because rotations are really what you make out of them.

Getting Your Life Back

Pin-Chieh Chiang -- Let’s face it: life during medical school is far from normal. In fact, once you start the journey, your life will probably never be quite the same again. Can you remember a time before when you studied this hard? Personally, I’ve wondered if I’ll ever get rid of that constant feeling that I should be studying for some test.

Recently, though, I feel like my life is finally returning to some sort of normalcy. This is compared to the first two years of medical school that was just a constant cycle of studying and taking exams. During nights and weekends, I would feel guilty if I wasn’t cramming for something. Also, having a baby definitely added an ingredient of chaos in there.

Since third year has started, I must say life has been more enjoyable. I love being out in the field and actively participating in medicine. This doesn’t mean that the workload has disappeared; that would just be wishful thinking. There is always plenty of work to do in the hospital and I always feel like I’m going from one thing to the next. Still it’s a type a work that I’m enjoying much more than learning passively in the classroom.

I’ve always heard horror stories about third year, about constantly being on call and never getting enough sleep. Or the story about the preceptor out to make students cry. Or just being pimped questions you’ll never know the answers to. I’m sure those stories are true, and I’ve experienced it a little bit myself. But it is great to know that for the most part, third year is not that bad and can actually be quite fun.

If the past two years were about working into the wee hours of the night, this year so far has been about starting out my day early, pre-rounding, and reading in the morning. Then I go through my day at the hospital or clinic, but once I’m done and leave for the day, I’m actually done.

It’s great to be able to go home, look forward to family time, and even participate!

Aww... Those Undergrads

Pin-Chieh Chiang -- I’m done with my Internal Medicine rotation and this week I started General Surgery. When I first arrived at my preceptor’s office on Monday, I received a little surprise. The receptionist told me to come on in and that the other students were already there. Other students? I thought I was the only student assigned to this preceptor.

That’s when I met the two undergraduates that had been following my preceptor all summer. One is about to be a junior and the other a freshman. I wasn’t quite sure how having two undergrads around would affect my experience. I was relieved when my preceptor made it clear that I would be expected to scrub in on surgeries while they can’t.

Since they have been around all summer, most of the hospital staff is used to seeing these college students hanging around my preceptor. I realized I had to make it very clear when I introduce myself that I’m a medical student. This way I don’t get kicked out by the anesthesiologist as much as they do.

My preceptor also takes his time to teach these students. It’s great, because it means I don’t get pimped as much. However I do get a lot of questions from the students. For example, the junior undergrad gave a presentation on pleural effusion. She did a great job, except she didn’t know what the terms “dullness to percussion” and “friction rub” meant. I explained it to her and chuckled to myself that apparently I did learn something in medical school.

I thought at first I’d be annoyed with having two undergrads hanging around, instead so far it’s been okay. I definitely can’t complain when they grab me lunch because I’m too busy going from surgery to surgery.

Delivering Bad News

Pin-Chieh Chiang -- One thing that medical school definitely doesn't prepare you for is how to deal with the dying. Personally, I've been in fear of these moments for a long time. How do I give family members bad news? An even more difficult question is the "when" -– it's not as clear as I had thought.

So far, I've witnessed three separate events when my preceptor had to deliver bad news to a patient's family members. Each time I've been awed at how he was able to do it so gracefully and how he always seemed to know when and what to say. The first time, an elderly patient came into the ER presenting with weakness. He was admitted for observation. The next day, some of my classmates saw the patient walk up and down the hospital hallways giving the nurses a hard time. In the afternoon, the man's family wanted to bring him home for long-term care. That is when my preceptor told them that the patient was going to die and it was better to just let him be.

Although I tried my best to hide it in my facial expression, I think I was just as shocked as the family. They asked how much more time the patient had, and my preceptor replied with "days". I wonder if it was the downhill progression that clued him in. By the time we rounded later in the afternoon, the patient was extremely weak and bedridden. My preceptor was right, in several days the patient passed away.

Each time my preceptor has delivered bad news, I’ve also been amazed at how calmly the patients’ families received the news. The reaction I had expected was always based on television shows. I assumed every family member would break down crying and tell you what an incompetent doctor you are. Instead, I’ve only witnessed the opposite so far.

I still expect to encounter some family members who break down, but it’s great to know that it won't always be that way. In fact, these three experiences have given me confidence in one very important way: I now know that with years of experience and some inner compassion, these very traumatic events can be predicted, and even handled gracefully.

I Passed My Boards!

Pin-Chieh Chiang -- My husband and I have been waiting patiently for two pieces of mail that finally arrived. One was my COMLEX score and the other was my USMLE results. Finding out that I was able to pass my boards was the biggest relief we've had in these past months.

Ever since my delivery on March 25th, it's been a difficult challenge to get back to my studies. As many of you can appreciate, I was basically out of action for the first 2-4 weeks. Even when I went back school, it took me even longer to regain my full energy. When I took my NBME practice exam at school, I scored somewhere in the 150 range. Passing is 185.

Don't forget that I also had to pass my classes. Students who don't pass their classes are not allowed to take the COMLEX until they retake and pass their final exams. Luckily that wasn't the case for me. After I finally completed finals in early May, I worked my butt off for the next 5 weeks. Even so, the results weren't exactly promising. On NBME practice form 1, 5 weeks before the exam, I was scoring 165. On NBME practice form 3, 2 weeks before the test, I was scoring 180. I contemplated delaying the exam, but I decided I just wanted to get it over with and move on with my life.

Final results… well, let's just say I scored about average. As uninspiring as that may be for some, my final score was far above anything I could have hoped for. My situation was a little unique, but in my case, my goal has always been to balance career and family. I hoped for a score that would give me some flexibility "geographically" and allow me to pursue a primary care program that matched my personality. I believe with my final score, I've made it.

Who "Owns" Your Medical Education?

Pin-Chieh Chiang -- I remember spending days, weeks, even months wondering about the choice of a medical school. I weighed all of the factors… location, curriculum, anatomy lab, commute, residency match lists… and after a long, careful process, I made my decision. With that out of the way, I thought my schedule for the next four years was now clear: I’d work hard, study every day, listen to my instructors, and eventually graduate with sparkling credentials, ready to continue with my perfect career.

I was a student, and 16 years of previous schooling had taught me that professionals with far more knowledge than I had would now be pouring their wisdom and knowledge into my empty brain. It was their job to teach, and my job to learn.

But gradually, I’ve come to realize it’s not quite that simple. The past two weeks I've been dealing with a new problem that has taught me many new things about medical education.

Partly because of my geographic limitations, my third-year schedule was set up primarily with preceptors at local hospitals. I was double-checking my rotation schedule recently when I saw that I no longer had a preceptor assigned for my first general surgery rotation, starting in 4 weeks. I emailed my rotations coordinator and she confirmed my fears that it wasn’t just a computer glitch. Apparently, there was some miscommunication between the surgeon and my school. The surgeon was assigned 24 students for general surgery, when the doctor actually does primarily vascular surgery.

What happened? Shouldn’t someone be stepping in at this point, solving this problem, and letting me focus on just learning?

Long story short, I’ve been spending the past two weeks calling surgeons in the area to see if they would be willing to train me. I used my school’s database of surgeons as a resource. Several surgeons were either retiring or leaving their practice. Most just said no, they did not take students. Fortunately, there’s a happy ending: I was able to find an excellent surgeon (who also happens to be chief of trauma surgery at his hospital) who is willing to be my preceptor.

But I’ve been very perplexed by the whole situation. First, no one from my school contacted me to inform me of the situation; they would have assigned me to a different preceptor, but who knows whether they could have accommodated my geographic requirement. And second, it turns out that excellent doctors aren’t always interested in being excellent teachers as well. I’m not the only one in my class forced to face this problem.

The answer, apparently, is to be proactive. Despite what you pay in terms of tuition, only you own your medical education. Your instructors may be practicing professionals first and foremost, and your education is low on their list of priorities. Your school will (probably) meet their contractual agreement and provide you a medical education that meets all of the requirements of the licensing bodies, but it may not be the education you really want.

Does anybody else have to go through a similar situation? Are others also finding that in medical school, the pampered days of passively receiving education is finally over? Is this something common that I just didn’t know about before starting medical school?

The Importance of Presentations

Pin-Chieh Chiang -- Right after my board exams, I started my 3rd year of medical school. This means I’m finally out of the classroom and in the hospital. I’ve been spending the last two weeks in Internal Medicine, feeling like an idiot at every moment but loving it at the same time.

Once again I’ve been in another transition period in my life, but definitely one of the more fun ones. I guess the most interesting thing I’ve noticed since starting rotations is presentations. It seems like every day I’m either preparing for a presentation or giving one.

I remember during the first year of medical school being surprised that we had group projects and presentations. For some reason I had assumed we would just be studying and regurgitating for 2 years straight. Of course it made more sense after I thought about it and even more sense now that I’m experiencing it -- it’s to prepare us for our clerkships.

It was really easy to dread those presentations. With all the other things to study piled up, who had time to focus on presentations during those first two years? However, my professors kept repeating over and over again that we better get used to it for rotations. They really weren’t kidding. Everything they said was true, including simple things like the importance of speaking up and making sure you know how to pronounce those drugs.

I work in a team of 4 and every Monday we take turns presenting for Journal Club. Wednesdays we present for 1 hour during lunch on a pre-assigned topic. We also present when we round with our preceptors. Monday through Wednesday it’s pretty much guaranteed that we will be asked to present a case. Thursday and Friday is by luck and chance, but we might as well be prepared for it anyway, because the first time we weren’t prepared it was a very miserable time for all of us. But we’ve also been criticized for spending too much time and over-preparing as well!

I *Heart* Dr. Goljan and USMLE World

Pin-Chieh Chiang -- I'm happy to announce that I finished my step 1 board exams! USMLE was last Saturday and COMLEX was the Saturday before. I walked out of USMLE in a daze; I just couldn't believe I was done. Honestly, I thought I had another 50 question-block to go after the 7th block. Thus I was really shocked when the test ended. I thought USMLE would have 8 blocks just because COMLEX had 8 blocks. I guess the extra 50 questions are the OMT questions that we have.

USMLE step 1 is actually optional for me. COMLEX is the one I need to graduate and become a fully licensed Doctor of Osteopathy. So it might seem completely bizarre that I would subject myself to two board exams. Like me, most DO students take USMLE because either they plan on applying to allopathic residencies or they just want to keep their options open. Quite a few allopathic residencies also accept COMLEX scores, so it's always hard to decide if one should really take the extra test or not. I contacted the residency program that I have my heart set on and they definitely recommended that I take the test.

Either way, the best source of study materials for both exams was definitely Dr. Goljan and USMLE World questions. I would be surprised if you have not heard Dr. Goljan speak yet. He's a pathology professor at Oklahoma State University Center for Health Sciences (an osteopathic institution by the way). He's posted all over the forums and people are selling his notes left and right. Everybody in my class has a copy of his audio lectures passed down from the class before us. I don’t know who was the first person to record his Kaplan lectures, but thanks a bunch to the person that did it. Pathology was definitely the highest yield subject on both exams, so having a good foundation in that subject is really important.

I used Dr. Goljan’s lectures and his rapid review book as my main studying tool. After each chapter in his book, I would use USMLE World’s qbank practice questions. USMLE World has extremely tough questions, but the explanations were great and I learned a ton just by doing the questions.

In the end, I really wish I hadn’t spent the money on Kaplan. I started out using Kaplan, but the online lectures weren’t that great and USMLE World’s questions are just plain better. If I could go back I would definitely spend even more time listening to Dr. Goljan. Thanks to Dr. Goljan, and if he ever makes his own audio lectures for sale, I would definitely be the first to buy them!

Breastfeeding Isn't as Easy as You'd Think

Pin-Chieh Chiang -- I’ve wanted to write about my breastfeeding experiences for a while now. However, every time I try to put my experience down on paper, I can’t seem to find the right words. It’s a very controversial subject and everybody has their own views. All I can say is that it has been much more frustrating than I imagined it would be.

Don’t get me wrong here, I love breastfeeding my baby. It’s everything else that’s the problem. From the very beginning I was supplementing with formula, something I had promised myself I would never do. But when you have a baby who is crying nonstop due to hunger and who just can’t seem to get enough from you, it’s time for formula.

When I told people I was already supplementing, the reaction I got was shock, as if I was committing a huge crime. The word “formula” was pretty much equal to “evil” in a lot of people’s eyes, especially at a medical institution. Because people were so quick to judge, it made me learn very quick to keep my mouth shut about this issue. I already felt guilty enough. Everything I learned about breast milk boosting immunity, decreasing SIDS, promoting growth, etc kept haunting me. If my baby gets sick right now, is it my fault, does that make me a bad mother?

So I tried to eliminate the formula as my breast milk came in. At about 2-3 weeks I was able to switch every other meal with breast milk (this is including pumping when I wasn’t breastfeeding). Sometimes I was even able to skip the formula. I was truly happy and I kept thinking this is one bonding experience with my daughter that nobody could take away from me. Then I went back to school, started pumping more, and my daughter began to show a preference for artificial nipples.

It has gotten to a point now where I am solely pumping because my baby now refuses to breastfeed. Pumping is definitely nowhere near as satisfying as breastfeeding. Plus I really feel like a cow being mechanically handled. Sure, many people view the pump as this wonderful invention that allows them to go back to work sooner. I see my pump and I think “evil machine created by men so that I have to go back to school/work”. Yet, I have to admit it does have its benefits in convenience.

Society is really designed for breast pumping, not quite for breastfeeding. In the future when I’m facing my patients, I’m not going to judge them if they choose not to breastfeed. For those who really want to, I’m going to support them and advise them to prepare to give it their all.

My Better Half of Sanity

Pin-Chieh Chiang -- My 2nd year of medical school officially ended last Friday. Since then I have been trying to figure out how in the world I managed to pull these last two years off. First year was crazy enough, just trying to adjust to medical school. Then throw on top of that a wedding, pregnancy, and baby all during 2nd year. I would love to claim all the credit, and trust me I’m not giving up much, but for once I’d like to dedicate this entry to my husband.

Sure, I’m the one that has to deal with the stresses of medical school, but my husband is the one that has to deal with living with me. I’ll be the first to admit that I can get very irritable in stressful situations and the pressures for the last two years have been nonstop. Somehow he’s managed to be there for me and also stay out of my way as well.

Besides just dealing with me, he’s also been great at pushing me along. He can tell when I’m goofing off and need some extra motivation. There have been many times when he’ll just sit in the office with me and work on his computer, just because it helps me focus. In some ways he pushes me harder than I push myself. I often joke that he’s my greatest stress, but I must say that statement really isn’t fair at all. In the end he always says he wouldn’t mind a bit if I changed my mind about medicine.

Maybe my husband also worries more than me, or maybe he just thinks of all the questions before I do. Eventually, he started looking up the answers to his own questions, and now he’s quite good at collecting information for me. He’s the one that found Goljan audio lectures for me, or told me when and how I should sign up with COMLEX and USMLE. I remember the day I told him I might be interested in ob-gyn, and that night he researched the 8 ob-gyn residencies that are in the Bay Area.

These are just the little examples of how he’s truly been there for me. I don’t know quite how to put into words what a great partner he’s been. Thus, I’ve always been shy about writing or talking about him for fear that our relationship would be easily misunderstood. I don’t know if anybody else with a supportive partner feels the same way.

Why am I writing this entry for him? I thought this would be a good time for me to give him a little push of motivation. Keep up the great work, because guess what – it never ends. Now that school is finally out, I have boards, and after boards, I start rotations, and after rotations, I’m in residency, and after residency… well you get the point! We’ll catch up in retirement.

When OSCE Doesn't Count...

Pin-Chieh Chiang -- “I’m sorry, that's all the time that your insurance pays for,” I said to the patient as my preceptor called time. It probably wasn’t the most professional or appropriate thing to say. But why not add a little fun to OSCE (Objective Structured Clinical Exam), especially when it doesn’t count for a grade. I didn’t go quite as far as another classmate, who asked every standardized patient a very extensive sexual history, even though the directions clearly called for a “focused” history and exam.

In my previous life, I was once a standardized patient, also known as “the morning-after pill girl." Without going into too much detail, the student doctor was required to collect a sexual history and also provide some counseling in safe sex practices.

It seemed straightforward enough to me. But I was often quite amused by the number of mistakes students made. This included not washing hands, not starting with an open-ended question, and not collecting my sexual history. There were some funny ones where the students turned beet-red after learning my chief complaint. One student proclaimed that sex before marriage was against his religion. Another lectured me about how he only wanted to prescribe one pill so that I wouldn’t “get used to relying on it."

Then I crossed over to the other side. If you think being a standardized patient gave me a heads up, it really didn’t. I made all the same dumb mistakes, mostly because I was nervous. Twice I left my doctor’s bag outside in the hallway. Finally I switched to a bright orange bag and it amused the patients, but I never forgot it again.

I just had another OSCE last week. It was probably not a coincidence that I was in the last group of students. By that time, the rumors had already spread for a month: OSCE does not count for a grade. This time the professors were letting us off the hook and just wanted to give us a chance for self-evaluation before we go onto rotations. After learning that, I found myself much more relaxed with the whole experience. I received a positive feedback in communications. It felt like a nice pat on the back and made me feel better about going onto rotations.

It’s hard to imagine that in a little over a month; I’ll be facing real patients!

How Simple Life Used To Be

Pin-Chieh Chiang -- When asked to give an update about my life, I’ve been at a loss for words. Where do I start? It’s hard to even put into words how so many things have changed, yet still stay the same. I’m still a wife and medical student. I am still planning to take boards, and continuing soon after with rotations. However, becoming a mother isn’t just one more thing, it’s a lot of new things added into the mix.

If I thought being pregnant and going through medical school was difficult, that was nothing compared to this. Pre-labor, a professor advised me that if anything, having a baby would definitely help me prioritize my life. Now, I completely see the truth in her words. Anything I can cut out of my schedule just to spend more time with my baby, I have done. In actuality, it’s no longer “my” schedule, it’s “her” schedule.

It’s been a tiring first month. I’ve never been incredibly behind in my classes. I’m always on the brink of exhaustion. Don’t even mention boards around me. All at the same time though, I am very elated. As corny as this sounds - little babies truly are bundles of joy, besides the little bundles of everything else.

The Story of My Labor

Pin-Chieh Chiang -- I started feeling contractions on Thursday night (3/22), but I didn't know they were contractions then. It was just this weird feeling in my tummy that would wake me up temporarily, and I assumed it was the baby moving. Plus, everybody had informed me that I would "know" if it was a true contraction. The due date was March 20, and my doctor told me I was 3 cm dilated already on Wednesday.

On Friday (3/23), I skipped the last of my exams and decided instead to go for a long walk. I walked through the mall, the parks, my neighborhood, to the grocery stores and back. The next day, I did it all again. Finally at night when I settled down to watch TV with my husband, I told him about the weird feeling I had been having. I can best describe it as a "tightening" feeling. I kept thinking, they can't be contractions because they don't hurt, it must be Braxton Hicks.

My husband decided to take me to the hospital anyway. Here was the news flash: I was having real, painless contractions every 10 minutes. I was also 4 cm dilated. The doctor on call kept me on the monitor for an hour to see if I would progress. When I didn't, it was up to me if I wanted to go home or stay. The nurse said they couldn't tell if the baby would come in the next 12 hours or in the next 3 days. So I went home.

At 4 am the next morning (3/25), I felt my contractions come on harder. I woke up my husband and we started timing them. They were coming at about every 5 minutes, but they alternated between painless and slightly painful ones. We tried and failed to get some more sleep. By 6 am, I was definitely having real contractions and we headed towards the hospital, where I found out I was dilated at 6 cm and my contractions were coming every 3 minutes.

By 7:30 I was asking for an epidural. I asked the anesthesiologist to keep it at a low enough dose so that I could still feel my contractions. Finally, I was able to sleep for a little bit. At 10 am, the doctor back and broke my water. I was amazed that after all that waiting, how fast everything seemed to be progressing. I kept thinking that I wouldn’t deliver until late in the afternoon since it was my first. Instead, at 11 am, the nurse announced that I was fully dilated and could deliver at any minute.

Still, due to lunch breaks and the doctor attending to other deliveries, I had to wait just a little longer. Around noon the nurse came in to adjust my bed and taught my husband how to count as I pushed. The doctor came in shortly after and I started pushing. At 12:23, my baby Jiayin was lying on my chest and my husband was cutting the umbilical cord. All the nurses and the doctor were amazed by her size. When she weighed in at 9 lbs 13 ounces, one nurse said at that size, 3 hours of pushing and then c-sections are more typical. I felt truly fortunate. The nurses even joked that I would have to be careful with my next one, seeing how fast this one came.

Baby Jiayin had an Apgar score of 8 and 10 and measured 21 inches. I’d like to especially thank my professor, Dr. Cislo, and my classmates for all the OMT treatments these past 10 months. Also special thanks to my OB, Dr. Santoro, Dr. Blair for delivering Jiayin, and the wonderful nurses at Northbay Hospital. Finally, an extra thanks to the readers who sent us your best wishes!

It's a Girl!

Dear Family and Friends,

Thank you for your wonderful support throughout Pin's pregnancy. We're very excited to announce the birth of Jiayin Tang on March 25 at 12:23 pm. She weighed in at 9 lbs and 13 oz! 

Chon and Pin

Performance Anxiety Over Giving Birth

Pin-Chieh Chiang -- Throughout my pregnancy, people have been bombarding me with advice, including friends, family, professors, classmates, and occasionally even total strangers. I appreciate it, especially when I ask for it, and people really do bring up things that I haven’t had time to think about. But I have to say it’s been a little bit weird, kind of like how everybody just starts touching your belly without asking for your permission. And don’t play with my belly button just because it’s poking out now.

I never imagined that people (especially women) could be so opinionated about birth. Why do people care so much? It’s my birth, something that is happening to my body, not them. Is it because they really care about my birthing experience, or are they just trying to justify their beliefs? I can’t help but feel that it’s sometimes the latter, when most people sharing their “advice” with me have not even gone through their own birthing experience. Or people who have gone through it need to justify that they made the “right” choices.

People have shared their feelings with me about going natural versus c-section, no anesthetic vs epidural, different positions, trying a home birth, having a doula, midwife, or labor coach, to induce or not to induce, and birth plan, birth plan, birth plan. If I don’t respond the way people expected, I can see the disappointment in their faces.

The biggest problem is that there is this pressure of trying to have the “ideal birthing experience.” When mothers don’t meet those expectations, they can feel really guilty. It’s great when things work out, but most of the time, life does not go as planned.

What I’m really trying to say is that these next couple of weeks are going to be really hectic. I just want to pass my exams and give birth to a healthy baby, and I don’t need any additional pressure. Everybody just needs to sit back, relax, and enjoy the show. I’m going to give birth and it’s going to happen the way it happens, and the next time I write, it’ll probably be about the experience!

Pregnancy Update

Pin-Chieh Chiang -- Here is an update from my last entry: I’m not preeclamptic. But, my doctor’s warning was a good reality check for me. I’ve moved up my bedtime to 10:30 and I’m taking naps as soon as I get home from school.

I also have to rave about OMT (osteopathic manipulative treatment) again. One of my OMT professors treated my 2+ edema and now both legs are barely at 1 and have stayed that way since. Another OMT professor treated my ribs and it’s been so nice to be able to walk, laugh, and sleep without feeling pain.

Some of my professors are a bit skeptical that I’ll make it through block exams before going into labor. Exams start this Friday and go until next Friday, and my due date falls right in the middle. Over this past weekend, my baby has dropped into my pelvis, so the timing is starting to look a bit sketchy to me, too. And now reality has finally hit me - forget about exams, I’m going to have a baby soon!

My plan is that if I make it to the end of exams, I’m going to have classmates use OMT on me to try to induce labor (CV4 is a cranial technique that might or might not be able to do the trick). I wish I could find faculty for this, but they are all leaving for a conference during exams. Never in my life did I ever think I would be wishing for my professors to be nearby. I’m paired with a first-year medical student to let her observe my birth as part of an elective she’s taking. I’m definitely expecting her to use OMT to treat my pelvis before and after the birth.

Women Still Struggling to Combine Medicine and Families

Pin-Chieh Chiang -- Sorry for not posting for a couple of weeks now. I’m at 37 weeks gestation, so I’m getting pretty close to becoming a mommy. I’ve started taking birthing classes at the hospital 2 nights per week, which have really helped me prepare for my birth. I’ve also been packing my hospital goody bag and finalizing baby shopping.

A couple of months ago I was discussing pregnancy with other medical students on an online forum. I learned that I’m pretty fortunate to be going to a medical school that is willing to accommodate my circumstances. Another student at a different school wrote about how she would not be able to reschedule her exams and would just have to repeat her whole year. Another student who was on rotations could not get maternity leave.

Many readers left supporting comments, some not so supportive, and one posed a question: “What was it that we pregnant medical students expected out of our schools?” A couple of weeks ago, a residency director came to talk to my classmates about applying for residencies. He was asked a similar question and gave a very encouraging response. He said that females now represent about half of all medical students, and the medical system will need to find a way to adjust to them.

So far, I haven’t really needed any special accommodations. I still go to class, probably more often than average. I’m still involved in my school. I’ve founded the Tau Chapter of Sigma Sigma Phi, an honorary fraternity, and created the Summer Clinical Experience in Nanjing, China, for first-year medical students. I haven’t even asked for an exemption from the ridiculous “bathroom rule” during exams (once the first person turns in their exam, no one else can go use the bathrooms).

That is all great, until now. With my due date running into the next set of exams, the baby will have dropped into my pelvis and I’ll be peeing every hour, so I finally had to get a "medical exemption" from the bathroom rule. But seriously, while everything has been going well, I found out today that I might be on my way to preeclampsia. My doctor is worried about the signs he’s seeing; a climbing blood pressure, +2 edema, and slight proteinuria. I’m worried, too. If it keeps progressing I may need to be placed on bedrest.

It’s times like this that I am happy to know my school will be willing to accommodate me. It’s one less thing to worry about.

We Interrupt Class for Some Baby Thoughts

Pin-Chieh Chiang -- These past few months it has been kind of hard for me to write about medical school. While my classmates are focused on classes and grades, all I can think about is my pregnancy. I’m afraid that my readers are already tired of reading about this same topic over and over again. But I can’t help it, it’s a 10-month commitment and I’m sure it won’t stop once the baby comes.

Thus, this is really what has been going through my head:

"Water birth or no water birth?" "Squatting?" "Should I delay cutting the cord until it stops pulsing?" "Should I try clitoral stimulation during labor?" "Epidural?"

During Clinical Systems - lecture on pediatrics: "Wow that’s a lot of vaccines and a lot of ped appointments!"

During Immunology - lecture on vaccines: "Would my professor fail me if I opted out on vaccines for my kids?"

During OMT class: "I would love to do cranial on my kids if they have signs of ADHD." "I would love to correct my daughter’s sclerosis in the future." "I hope I can treat their otitis media." "Would my professors give my baby free treatments?"

During Psych - lecture on "Munchausen by proxy" and watching video tapes of parents suffocating their kids: "I want to cry."

During Path – lecture on neonatal infections: "I want to cry."

During Medical Microbiology – lecture on congenital infections: "I hope I’m safe, I better be safe, the doctors better have checked me, my husband better be safe." "I think I am covered by MMR vaccination."

During one of my doctor’s appointments, the nurse announces "you need RhoGAM" and I say "but I’m AB(+), isn’t it for (-) blood types?" She looks at my chart and goes "oh, ha ha, just kidding."

During lunchtime at school: my nappy time.

In between classes: "I need to pee." Or "I need a snack."

At my doctor’s appt last month: "You gained 7 lbs in one month! Eat healthier foods!" "Yes, doctor." "Your hematocrit is low – keep taking those prenatal pills!" Yes doctor."

At my doctor’s appt this month: "You’re doing great, it averages to 1 lb a week." "Yay!" "and no protein in your urine this time!" – "Wait, does that mean I had protein in my urine last time?!?"

At postpartum care elective class: "I should really breastfeed for at least 8 months – I’ll lose weight faster!" "There’s a difference between foremilk and hindmilk?"

And finally, "After my trial run with my first one, I can’t wait to do it all over again with a second one!"

More Needles, Again?

Pin-Chieh Chiang -- The first thing I noticed when I walked into my Primary Care Skills lab today was all the boxes of needles lined up neatly in the front. Then I saw the sharps dispensers at each lab table. Somehow I had forgotten that today was yet another needle day.

So far I’ve already had a class on injecting tender points and a class on drawing blood. Nobody is obligated to participate, but the rule is if you want to stick a needle, you have to be willing to take a needle.

It might be surprising to know this, but truly just because we’re students going into the medical field, doesn’t mean we don’t have the same fears about needles. That vagal response is hard to control. Thus the other rule is if you think you are going to end up horizontal, start horizontal, and there are plenty of patient tables to lie down on.

Normally I’m not quite so nervous about needles. In fact I’m usually more nervous about sticking the needle into my peers, because of my lack of experience. However, normally I know when I’m walking into a needle lab and am more mentally prepared. It also doesn’t help that the last time I told my mother about my needle labs, she became very superstitious that this was bad for my pregnancy. Honestly, we’re only injecting very minor amounts of salt water into each other.

The motivation to want to learn these techniques is high. The idea is that by the time I walk into my 3rd year rotations next year, I’ll be able to at least say I’ve done a transdermal, subcutaneous, and intramuscular injection. I know full well what it’s like to be working in a hospital and feeling useless because I didn’t even know how to hold a needle. To put it plainly, it sucks.

It just works out that there is another classmate in my lab group that is also pregnant (there are three total in my class). When the professor demonstrated how to do subcutaneous injections into the abdomen, we exchanged looks and knew right away we should partner up for this lab. For the subcutaneous injection, we definitely both wanted to avoid the abdomen and practiced on the deltoids instead.

Learning how to do different types of injections and blood withdrawals is only half the lesson. The other half is the proper disposal of needles. Some professors prefer to recap first and others just go straight for the sharps container. Either way, they want to us to get into the practice of getting rid of that needle right away. I don’t know if this is accurate, but my professor stated that the chance of getting HIV from a needle stick is 1/300 (if the needle was for sure contaminated) compared to that of 1/625,000 from a blood transfusion. Either way I hope my future patients appreciate that my classmates and I are willing to practice pricking each other first.

My Advice: Take Electives

Pin-Chieh Chiang -- With so many things going on during 2nd semester of 2nd year, some people might think it’s crazy that I signed up for an elective class. After all, it’s time to start studying for boards, not to mention that my due date is at the end of March. Even I had to think it over for some time before I finally decided that I just had to take this elective on Postpartum Care, Mother/Infant Nutrition, and Breastfeeding. I guess I succumbed to the expectations when so many of my classmates joked about how this class seemed to be tailored just for me. This course is actually designed to teach us future practitioners to feel comfortable counseling pregnant and breastfeeding mothers in infant feeding choices.

After attending my first class, I decided I made the right choice, and I’m already looking forward to the future classes. I was also reminded of how I’ve always enjoyed taking electives.

Last year when I went back to my undergraduate college to be part of a med student panel, a pre-med asked what undergraduate classes the panel recommended to best prepare for med school. While everyone else on the panel responded with the typical “biochemistry, anatomy, pre-med classes”, I had a different answer. I explained that my choices might not best prepare them for medical school classes, but they might help them further their education in other ways. The classes I recommended were health administration and healthcare for the underserved community. Health Administration was actually offered by the MPH program and Healthcare for the Underserved Community by the SOM, but both classes accept undergrads. It was in these classes that I learned more about the medical field than I did in my typical premed classes, and they reaffirmed my reasons for going into medicine.

Last year I also took Pregnancy Partners, and now what seems like a perfect follow-up is Postpartum Care. I started these classes even before I had ever considered going into women’s health, which now might be a real possibility. Yet even if I wasn’t interested in this field, I’d still recommend taking electives in general. I love how I’m getting to know my faculty in a smaller classroom setting. I also believe I’m getting a chance to learn things that aren’t covered in the normal med school curriculum.

In Between Worlds

Pin-Chieh Chiang -- During my break these past few weeks, I’ve been trying to get the house ready for the baby. I’ve been cleaning out, packing up, and reorganizing. I’ve also been shopping for baby furniture: cribs, changing stations, etc. A fellow classmate that’s a father himself told me I would be getting that urge to "nest" when it gets close to the end of my pregnancy. This is not that "nesting" instinct taking over. This is still the "type A" medical student personality that needs to have everything planned and prepared ahead of time.

It hasn’t been an easy process. I’m also a pack-rat, which means I keep everything. I have old textbooks from freshman year of college, old pictures of friends and families, stuffed animals from my high school years, etc. I also have clothes from my high school years, because up until now, my size didn’t change that much. Now I have to just face the truth, that it will probably be a long time before I can slim back down to those high school size jeans again.

As I’m cleaning out my house, I’m realizing more and more how much of a cleansing process it is. It’s also helping me transition into my new roles. As a traditional medical student, one that went straight after college, I would have never imagined becoming a wife, daughter-in-law, and new mother so fast. I have friends who have just found jobs and are just getting into serious relationships. These are the same friends that are always asking me when will I "come back home". It finally hit me one day that it’s never really coming back home anymore, since I have a new home now with my new family; it’ll always be "visiting" my old home instead.

It’s also been hitting me just how much becoming a mommy will affect my future. In a couple of months, my classmates will be fretting about boards. I will too, but I will also definitely be fretting about being a good mommy. Then in a few months after that, my classmates will be transitioning to 3 year clerkships. I will too, but trying to figure out how to still breast feed while I am on clerkships. And the list goes on.

We’ve all heard about those mothers that try to have it all. I think I am in the stage right before it. It can be overwhelming. When people ask me how I’m doing, my answer these days is "good, I hope."

Thinking About Residency

Pin-Chieh Chiang -- I wonder if it is just natural to start thinking about residency in the middle of 2nd year, because that’s what I’ve been doing. Plus, a reader from my last entry asked about the residency application process in the US, and I decided to respond by writing about it in this entry.

Residency has probably been on my mind because it’s also time to sign up for boards. There are three parts to the boards, with the first part (Step One) being the most vital when applying for residencies. Most medical students take Step One between 2nd and 3rd year. At my school that means after mid-May to June 20th, the day when 3rd year rotations start.

Then, in two years around the same time, I will be applying for residencies. The most unique thing about applying for residencies in the US is the Match. Medical students rank their most preferred residencies, and residencies rank their most preferred students/applicants. Then a computer will ultimately decide who gets to go where by granting as many top matches as possible. So on the same day all throughout the nation, every student that has "matched" will know where they will be going for residency.

However, there is more than one match system. There is the DO match (osteopathic match arranged by the AOA) for DO students only, which occurs one month before the MD match (allopathic match arranged by the AMA). The MD match is the one most people are familiar with; all students can apply to it, whether they are MDs, DOs, US-foreign or non-US foreign. Both matches represent binding contracts, and matching in the DO match automatically drops your application from the MD match. I want to stay in the Bay Area, which has a lot more MD residencies in the field I want to go to. Thus I will most likely forego the DO match and apply to the MD match.

In terms of board exams for the two match programs, DO students take the COMLEX and MD students take USMLE. I will be taking both exams: COMLEX so that I qualify for my graduation, and USMLE for the MD residency. Some MD residencies actually recognize the COMLEX, but it’s not clear how widespread that is. So to be safe, most people in my shoes still plan to take both, especially to stay in an area that is more competitive to begin with.

If I’m lucky, there is one more thing that DO, US-foreign, and non-US foreign students can take advantage of that isn’t available to US Seniors (US medical students from MD institutions). If I happen to be seen as a pretty amazing candidate, a residency director has the option of offering me a residency spot outside of the match process itself. This would only happen if the program valued me above all other applicants; because these "pre-match" opportunities are very rare, I don’t think it’s wise to count on this actually occurring.

So where do I start? This all goes back to studying for boards, and I should probably start soon. I hope this answers the question from a reader and I hope that readers will once again share their experiences and knowledge on this particular topic.

Financial Realities of Medical School

Pin-Chieh Chiang -- Welcome to medical school. After all that hard premed work, MCATs, applications, interviews, you get accepted somewhere and you go. Then you get hit with all the financial letters: "have you applied for FAFSA yet?", "have you checked your credit score?", and "consolidate your loans now". What is all this about?

The average annual cost of medical school is $34,000, unless you are part of the lucky minority attending an in-state public school for $16,000. My tuition this year is $34,318. The budget my school gave after books/supplies/laptop, room/board, personal, transportation, and board review materials is a grand total of $61,170. Take that grand total minus tuition, and it leaves you $2,237.67 per month for rent, gas, utilities, food, etc, etc, etc…

It’s well known that even though getting into medical school is quite difficult, the drop out rate is quite low. I’ve often heard it said that the medical school has already invested so much time in you, they won’t give up on you that easily. How about the other fact that once you go through one year of medical school, you’ve accrued so much debt that you’ve reached a point of no return?

If I round that grand total to $60,000 per year (for easier calculating), $8,500 would be from subsidized Stafford loans, $30,000 from unsubsidized Stafford loans, and then the remaining $21,500 would be from private loans (assuming a perfect credit score). That’s $34,000 in subsidized Stafford, $120,000 in unsubsidized, and $86,000 in private loans over 4 years, adding to a total of $240,000 of medical school debt.

After medical school, you finally earn the right to be called doctor. But it’s off to an average of 4 years of residency, where the average pay is about $40,000 a year, and most people defer payment on their loans at this time.

All and all, 8 years after graduating college (if you’re a traditional student), you’ve got $240,000 in debt, plus interest. You’re finally making some good pay, say an average of $150,000. After tax, you keep maybe $80,000, and you are probably trying to start a family, buy a house, and pay bigger bills on top of all that. This is of course compared to your peers who graduated college with you but took a non-medical route. Sure, they started out making around $40-50,000, but by this time 8 years later, they are probably making over $100,000, with no debt.

Just goes to show, it’s really not about the money, and let me just say "delayed, delayed, delayed gratification."

Giving Thanks in Medical School

Pin-Chieh Chiang -- Since it's Thanksgiving time and all, I figured I could take this time to write about a few things I’m thankful for this year. It’s definitely turned out a whole lot different from what I planned for or expected. I know at the start of 2nd year, I was stressed out and almost wishing to be a 1st year again. Now with two block exams down, it doesn’t seem so bad, and so far 2nd year has been getting better.

So, besides all the usual stuff about thanks to family and friends, here are some things I’m grateful for in relation to medical school:

- My school’s faculty: I really appreciate how supportive my professors have been about my pregnancy. Everybody’s been nonjudgmental and concerned for my well-being. I especially have to thank the OMT faculty, who have been very accommodating about my requests for OB OMT treatments. I didn’t realize how much I would care about this, but it does mean a lot to me that this has neither increased nor decreased their expectations of me just because of my pregnancy.

- Curved grades and challenges: Curves pretty much ceased to exist during the first year of medical school. Then 2nd year started, and just to demonstrate how much harder classes are, the curves are back. I have to thank all my classmates who take the time to submit challenges to test questions. Just in Clinical Systems alone, my grade was bumped up 10 points, and it sure is nice to be in the passing range.

- Rotations exemption: My exemption request was accepted, so I am officially staying in the Bay Area for 3rd year rotations. This I am extremely grateful for, especially when not everyone was granted an exemption.

- Attendance not mandatory classes: Earlier on I wrote about whether I should continue to go to classes or try and study at home. This was during my first trimester of pregnancy when I was very fatigued. So far I’m still going to classes, but I appreciate the option and once and a while I still use it to sleep in on the mornings.

- Books online: I’ve been traveling a lot this school year. I went to Las Vegas for the AOA convention. LA for the USC vs Berkeley football game. I’m back in Las Vegas for Thanksgiving break. I was in Tahoe for my wedding. Even when I’m not traveling far, I’m traveling locally to my in-laws' place or to visit my own parents. Having books online, especially Harrison’s, has been a real saver on my back. I have to thank my school’s library for offering this service.

- Pregnancy: This has been a true blessing and I’m still taking it one day at a time.

I hope all of my fellow medical colleagues and readers also have a lot to be thankful for this Thanksgiving. If you would like to share your thanks, please do!

How Do You Compensate for Your Weaknesses?

Pin-Chieh Chiang -- I just survived my second set of block exams last week, and so far the results have been comforting. That’s 8 blocks down and 4 more to go. Only as a 2nd year now, I realize how good I had it first year. I remember feeling so lost last year, only to find that this year has been an even bigger struggle. Last year I had about 10 exams during block weeks, this year it was reduced to 7, but the load only feels heavier. As hard as the first year of medical school may seem, the truth is, my class’s average was around a B+. So it was quite a shocker after this year’s first block when the averages were in the low Cs. The biggest challenge has been a 10 unit class called Clinical Systems.

The theory is that the traditional students who went straight from college to medical school tend to do well during their first year. The first year is a continuation of the basic sciences taught in undergrad. So it’s the non-traditional students who tend to struggle, because it might have been a much longer time since they’ve last touched upon biochemistry. However, during the second year, it’s the nontraditional students who tend to come out on top. It’s because they are the ones who have had actually clinical experiences as PAs, nurses, and EM techs to complement their education.

I definitely know where my weaknesses are as a very traditional student. When presented with a patient case, I have a difficult time pairing the case with a diagnosis. I can only imagine the difference it would be to someone who’s actually seen real patients present with real symptoms. I’m not sure what I need is to "work harder," but instead "just different." Everything I’m learning this year is just not as instinctive.

How about you? Do you feel like some of your classmates have advantages over you in some topics? How do you compensate for your weaknesses?

I do have to add that I appreciate the older, non-traditional students of my class. They definitely bring a different feel to the classroom environment.

Frantic About 3rd Year Rotations

Pin-Chieh Chiang -- Talks about 3rd year rotations have already started at my school. Rumors are already spreading and people are starting to get anxious. For a school that doesn’t have its own hospital, Touro has 3rd year core rotation sites all over the place. This means I can end up next year anywhere from Northern California to Southern California, to Denver, Michigan, New York, and viva Las Vegas. There’s a limited amount of spots at each place, and the programs can vary remarkably. Some sites have been known to be well-structured for teaching and others might be simply what you can make of it.

So who gets to go where? The process involves a lottery system. It’s kind of like a practice for matching to residencies. In a couple of months, I will be listing my top three choices and feeding that information into a computer. A program will match my classmates and me to either our 1st or 2nd choices. The goal is to obtain the highest 1st choice matches. Past years have had success rates of around 80-90%.

That sounds fair – so what’s the catch? The problem is that some sites insist that a certain number of spots fill up, or my school loses the rotation site. So even though my 1st choice might be open, I could easily end up in my 2nd choice spot if there aren’t enough people applying there. Hence the many rumors flying around about how to play the system. I’ve been hearing strange advice such as listing my number 1 as actually my number 2, or putting in a highly competitive site in number 2, so I’ll definitely get my number 1.

The Dean of Clinical Education has met with my class and addressed these rumors directly. Her bottom line is, "don’t play the system." I think the anxiety is just coming from not knowing where we will be next year. It’s also nerve-wrecking not knowing what 3rd year will be like -- I’ll actually be working in the field and not behind books all day! The Dean has to keep reminding everybody that everything will be fine. She’s definitely done whatever she can to ensure improvements year after year.

Then there are "exemptions," and I might not even have to participate in the lottery at all. Anybody can apply for an exemption if they feel they have the absolute need to go to one particular site. I’ve turned in my exemption request. With a baby on the way, I just can’t imagine being anywhere else in the country without family support. I hope my school agrees with me. The committee that reviews the exemptions start meeting next Wednesday.

Rubbing Elbows With Real Docs at a Convention

Pin-Chieh Chiang -- Viva Las Vegas! I always enjoy any excuse for a visit to Las Vegas. This time I was there for the annual American Osteopathic Association Convention. Even though the convention was a week-long event, I was only there for the weekend and Monday to participate in student research poster presentations.

My husband came with me, and for some reason people just assumed he was there for the convention. People would first ask my husband if he was here for the convention and whether he brought his wife. I liked his response, “No, actually my wife brought me.” Still, he got to play blackjack with several Dos, including a child psychiatrist and EM doctors, while I sat in meetings.

My research is on the role of beta-catenin and how it is essential for optic axons to map and target specifically in the dorsal tectum of Xenopus tadpoles. It was interesting to see the number of different research projects that were presented. There were 18 entries just from my school. The backgrounds of the presenters varied markedly. I have a bachelor's degree, my lab partner who also came to present has a master's degree, and there were plenty of PhDs who attended.

Posters were set up around 10 am. Around 2-4 pm, everybody was required to stand by their poster for the competition. I don’t think I did very well, because my judges didn’t have any questions for me. I didn’t win anything, but I’m happy to say two 3rd years from my school won 2nd places for their posters.

The rest of the time I checked out the exhibits to see what free stuff I could get. There were plenty of pens and paper pads, but the exciting stuff I really wanted was the drug samples. Some people got an mp3 player. I grabbed a laser point that can also act as a remote to change PowerPoint slides.

My favorite booth was the one with all the ultrasound machines. I know I’m not supposed to be getting ultrasounds done for non-medical purposes, but I let my curiosity get the best of me. The last time I saw my baby, it looked like a bean. This time I saw a whole body, face, spine, hands, and legs. The best part was I got to transfer all the images onto my jump drive and just take them home with me.

Overall, it was tiring to be on my feet all day; I’ve gotten too used to sitting on my butt while in school. Still it was fun and exciting to be amongst the DOs and get a first-hand feel of what a convention experience is like.

Prep Courses: Are They Worth the Money?

Pin-Chieh Chiang -- It’s that time again. When the prep course representative comes to visit your school, you know there must be a big test coming up. I’ve taken prep courses for SATs and MCATs. Now I get to look forward to that wonderful big end of 2nd year: boards. MDs in training take USMLE, and DOs in training take COMLEX. I will probably be taking both, but that discussion is for a whole other entry.

Statistics have shown that there are no differences in students’ performances on boards between those who’ve taken prep courses and those who opted not to. My professors have told my class many times that if we do well in classes, we will pass the boards. However, what if you want more than to just “pass” the boards? I don’t even want to start and think about the residency match process and all that fun of dressing up for interviews again.

So, a prep course representative came to my school a couple of weeks ago to give a presentation about what they offer. Just to show how nervous we already are about boards, all this was actually organized by fellow classmates. The representative explained to us what their classes were like, how their questions were structured so similar to the real thing, and the price breakdown. Basically, the grand package with all the questions, internet interface, and classes comes to $1099. Plus, if you sign up right then and there, you get this handy dandy orange book of questions that you can carry around with you anywhere you go.

Do I want to spend $1099 for a prep course? Do I really need this to do well on the boards? On the other hand, considering how much I’m already in debt for my education, what’s another $1099? I’ve wished I had first-hand knowledge of what’s it like taking exams without having gone through a prep course. However, I’ve always been the type that needed some hand-holding to get through the process. I can’t even follow a set study schedule for school, not even close, so where am I going to find the discipline to study on my own? As of now, I’m pretty sure I’m going to be following that prep course route all over again.

What do the rest of you think about prep courses for boards? For 3rd and 4th years who’ve recently gone through this process, what did you do? Any advice you guys can offer for 2nd years like me?

Me, the Obstetrics OMM/OMT Junkie

Pin-Chieh Chiang -- Now that I’m pregnant, I’m learning to appreciate osteopathy even more. First of all, I’ve been sharing my news with my professors, and everybody has been extremely supportive. I haven’t heard one discouraging comment at all. I’m giving this credit to the osteopathic principles and humanistic approach to medicine that my school teaches.

The other thing that I am picking up quickly is that Osteopathic Manipulative Medicine or Osteopathic Manipulative Treatment is great for pregnancy. As a pregnant person, there really is quite a limitation to what medicines I can take, not to mention what foods I shouldn’t be eating. OMM/OMT is a much more natural source of remedy. Even being sick with the cold or flu, I can ask any of my classmates to perform techniques such as rib raising or thoracic pump to boost my lymphatic flow and help my body fight the disease faster.

What I really have been using OMM/OMT for recently is joint aches. One of my professors made a comment that "you can breathe on a pregnant woman and she will articulate." Articulate basically means I "crack" easy, thus relieving the feeling of strain and soreness I’ve been feeling in my low back and behind area. This is all because of the hormone relaxin, which increases joint laxity. So my joints are hypermobile and easy to treat. But, for the same reason, I also fall easily into dysfunctional states, which I’ve definitely been noticing more and more.

Another very important reason for me to get treated is that I want to make sure my body is ready for when delivery time comes. I know it is early to be thinking about this, but it’s my first pregnancy and I am going to start now in order to decrease my labor time. I know from the many lectures my teachers have given that any abnormal positioning of my pelvic bones could impede labor. My professor often talks about how all girls have fallen on their behinds, which could bend the coccyx forward and get in the way of labor. Thus, this week I’ve already made an appointment with her to diagnosis the position of my coccyx. I’ve also been asking classmates to perform Muscle Energy techniques on me. It’s been helping me keep my pelvic, pubic, and sacral bones aligned. It’s also a great stretch for a lot of tiny muscles that are hard to exercise normally.

I’m definitely learning more and more about my own body through this whole ordeal. There are neat little facts like how my sacrum isn’t fused yet since I’m 23 and it starts to fuse around age 25. What I didn’t expect is that I’m turning out to be a fun project for some of my classmates. They get a chance to work on their obstetrics OMT/OMM skills, and I am falling in love with any OMM/OMT I can get my hands on.

Frustrated, On the Patient Side of Things

Pin-Chieh Chiang -- When we talk about barriers to medicine, we think about socioeconomic factors, lack of insurance, lack of accessibility, etc. What rarely comes up is how hard it is just to make an appointment.

As someone with health insurance, I assumed my access to medical care was quite open. As a medical student, I also assumed that somehow being more involved in the medical system gave me a better understanding of the inner workings.

When I first found out I was pregnant, I knew I should get an appointment with an OB/GYN at least for confirmation. So I tried hospital A, the closest facility to where I live. This was back in mid-July, when the receptionist informed me they were not seeing new patients until September. That was way past my initial OB workup period and well into my 2nd trimester.

Then I decided to try hospital B. But, in order to use that hospital’s services, I needed their insurance. I submitted an insurance application and waited for a response. I was looking forward to using their services, as I liked the environment. I had become familiar with the setting and facility during my Pregnancy Partner Elective last semester. It was located conveniently between where I live and my school, and I also knew who I wanted for my doctor. However, this was not to be, because in less than two weeks I received my letter of rejection. For the very reason that I wanted their insurance, my pregnancy disqualified my eligibility. If I knew such a policy existed, it would have saved me time. I never expected to be rejected, especially when I figured my husband and I could afford the costs.

I had no choice but to try one more time at yet another place a bit farther away, hospital C. I did finally get a first trimester appointment, but not without effort. I wasn’t allowed to make an appointment until I came in for a pregnancy test, even though I already had a transvaginal ultrasound done at my school’s clinic. I’m actually ok with needles, but it would have been nice if the receptionist had told me it was a blood test and not a pee test before I came in. After about 3 weeks of trying to get an appointment, I had to wait just a couple more days.

Sure enough, my blood came back positive for pregnancy. By that time, I was already at my 8th week. The first trimester appointment is normally done at 6 to 10 weeks and I was cutting it close. Due to the rush, I couldn’t get an appointment with the doctor I wanted, but at least I did finally get an appointment. I thought I had so many options to choose from, when really it all seemed to come down to luck. The good news is that my doctor is a D.O. who was highly recommended by my professors. The downside is that I will have to travel a bit farther than I had wanted to.

I’ve never been so relieved to be finally in the medical system!

Wedding Bells and Motherhood

Pin-Chieh Chiang -- As I start my second year of medical school, my personal life has also suddenly shifted into high-gear. Just a month or so ago, a wonderful surprise came into my life. I am expecting, and if all goes well, I will become a mommy in March of next year. To top off that wonderful news, surrounded by our families, my fiancé and I exchanged vows over Labor Day weekend and sealed our marriage.

This moves my plan for a family ahead 1 year; I had originally planned to try to have a baby during my 3rd year of medical school. But I'm taking into mind all of the advice that was given me to from that earlier entry: don't try to plan too much when it comes to starting a family in medical school. My priorities are clear.

Now that my first trimester or "danger time" is almost over, I'm sharing this happy news with the world. The most common two questions I've been getting are "if I'm taking my husband's last name" and "what about school?" I'm actually keeping my last name because this progressive practice is the typical choice on mainland China, where my husband is from.

As for school, I'm definitely sticking with it. The Pregnancy Partners elective offered by Touro already gave me a sneak peak at the last few months of pregnancy and delivery. This might also explain why a couple of entries back, I wrote about skipping classes. I've been having problems with my morning classes, but I blame that more on the pathology lectures than my actual pregnancy. It definitely doesn't help that I shouldn't be taking in any caffeine! I'm very grateful that most of my classes do not have mandatory attendance.

As far as boards go: most people take them in June, though they technically can be taken year-round. My Assistant Dean of Clinical Education says I can definitely use my first month of rotations as vacation time, which allows me to delay my boards to July. I've also met with the Dean of Student Affairs, Dr. Church. He assured me that maternity leave would be available if I need it, and all of my exams will be rescheduled as needed. Of course, the amount of time I need will determine whether I can complete my second year on time. But at this point in time, I'm expecting that taking a few weeks off won't keep me from graduating on time.

I understand this is assuming all goes well and no complications arise with the pregnancy. But I have my fingers crossed! I have my youth and health working on my side. I'm fortunate that both of our parents are in the area. I'm also fortunate that my husband's already working and we're pretty okay financially, considering my med school loans. The plan is to take it one day at a time. Who knows, maybe if all goes well, I'll take a year off in between 3rd and 4th year and try for a 2nd one!

 

Do Med Students Use Drugs to Boost Their Performance?

Pin-Chieh Chiang -- As medical students, we’re expected to spend most of our time in class and the rest of our time studying for class. That’s all fine unless you are like any normal person and you really can’t just continually absorb information for hours on end. For me, it’s really easy to just zone lectures out. It’s also easy to lose my concentration when studying from the textbooks -- it doesn’t help that textbooks can be simply boring and always remind me of the dreaded verbal section of the MCATs.

So there is a focus issue that many medical students need to address. The question is always "what is the quick fix?" The rumors are out there, that perfectly normal people take performance enhancement drugs without their doctors’ approval in order to perform better in classes. I’ve definitely participated in this line of gossip at my school. "Have you noticed that so-and-so’s eyes are always red?" "What about that one person that just doesn’t sleep the week before exams?"

I’m finding these rumors harder and harder to believe as I learn to deal with my own lack of attention span and as I get to know my fellow classmates better. I like to believe that because we are medical students, we are more focused than ever on remaining healthy. Sure, doing well in class is important, but not important enough to disrupt your own body.

At my school, the emphasis on osteopathic philosophies shines a different light on this issue. If my head is feeling clouded, I can easily ask any classmate to perform a suboccipital release on me (one of my favorite treatments). Besides having osteopathic manipulation as an extra option, inherent in the teachings of osteopathy is also the pursuit of a more well-balanced and natural life. If my classmates and I are going to become osteopathic doctors, it only makes sense that we start making an example out of our own lives.

Of course, that doesn’t mean we haven’t overdosed ourselves with caffeine. That happened first year as soon as I found out my school’s café sold coffee for only $1 a cup, 50 cents during exams, and sometimes even free. But then I learned that I suffer from withdrawal from coffee so I had to put a stop to that.

Instead now I focus on the basics of exercise and diet, and once in a while I drink tea. Due to a professor's recommendation I’ve taken up B-complex vitamins. They balance your neurotransmitters, keep you happy in the winter, and you pee out any excess because it’s all water-soluble. Personally I don’t notice a big difference except I find everything’s funny during exam week.

I’m sure there are plenty of different techniques used by different people. On the other hand, sometimes I get this feeling like I wouldn’t be surprised if by the time we graduate half the class is on Prozac and the other half are on anti-psychotics. What do you do to keep your focus on during medical school?

To Skip or Not to Skip (Classes)

Pin-Chieh Chiang -- There are two basic types of medical students: the ones who go to lecture and the ones who don’t. I’m typical of the first type. The honest truth is that I don’t have much discipline to study on my own. I was one of those who took prep courses for SATs and MCATs, just to have someone hold my hand through the process.

Yet, I’ve never been in an environment where time is so precious that I’m starting to feel going to class might not be the best way to spend it, especially 8 am classes. I probably should have noticed by now, since it happened during all of first year, but I am really sleepy in the mornings. Once I start napping in my morning classes, I end up napping throughout the day. It’s only a slight exaggeration to say my classmates expect to find me asleep in the middle of any class.

Is skipping class and learning on my own really effective, though? What if I’m missing pertinent things from the professor? That’s what kept me in the classroom last year. I had plenty of teachers who hinted at guaranteed test items. This year, maybe due to the huge flood of material in new classes like pathology, I am truly feeling at a loss in lecture. At the rate my professors are going, a chapter a lecture, the whole textbook will be on the exam!

If you are the other type of medical student, the type that skips classes – how do you do it? Is it feasible to read from the textbooks?  Is this a reasonable way to prepare for the board exams that await me at the end of this school year?

Getting Your Groove Back for Studying

Pin-Chieh Chiang -- My 2nd year has officially begun, which means I’ve been relearning my alarm clock and waking up for 8 am classes all over again. My lectures are now located in lecture hall A, which for some reason is a lot brighter than last year’s lecture hall. It’s as if the school was symbolically trying to say I now can see the light.

Some professors have joked with my class, saying that now that we are 2nd years, we are more knowledgeable and have a much better grasp on things. I hope they weren’t just joking, because I had my first pathology lab this week and I just had a miserable time. Maybe it wasn’t because I felt already so lost and confused in the subject, maybe it was because the room was too cold and the newly installed wireless internet was buggy. Once those things are fixed next week, I might feel more on top of things.

In the meantime, it’s only been a couple of days and I find it amazing how easy it is to slip back into that always feeling tired state. The only problem is, I haven’t really even started studying. Thus, I need to find my groove again and remember what my best studying environment was.      

Of course it really is hard to crack open the books during the first week, especially when I’m seeing friends I haven’t seen all summer. It amazes me how active my classmates all were. One went to Detroit to work in the hospital, another to Portugal, several to Costa Rica, a bunch to Africa, and more. There are also many who didn’t bother with travel, but stayed in the area for research or preceptorship or both.

I think my classmates and I truly took it to heart that this would be the last summer vacation in a long ways to come. Yet I have to say, no matter how great my summer was, it still wasn’t easy coming back to school. Just thinking about book fees gave me a headache. Thankfully, it has been a much easier transition than last year. Looking at the new first years, I can only think that at least I made it through last year and what’s another year to me?

Is everybody else excited about their start of the new school year? Anybody have tips on how you plan to get your mind back into the endless zone of studying?

      

Finding Time for Having a Baby

Pin-Chieh Chiang -- As a medical student, there are many questions that are constantly racking my brain. Sometimes they are about medical school and how one might survive and make it through to becoming a doctor. Other times, I realize medical school is only temporary, and the truly meaningful questions about life come to the forefront. Recently, the question that has been bothering me is “when is it the best time to have a baby?”

I guess the question that comes before that is “when is it the best time to have a wedding?” I thought that this summer, the summer after my first year of medical school, the last summer vacation of my life, would have been a great time. But it didn’t happen. I was engaged in February and we have scarcely begun planning our wedding. The plan is that it will happen within the next two years.

So back to my next most impending question, which is what is expected after a wedding: “when is it a good time to have a baby?” It might seem strange that I even worry since I will only be turning 23 this year. Yet, there are my parents who are ready to be grandparents asking me every time I see them. There is my fiancé, who is turning 30 and does not want to wait much longer. Finally, there is me thinking if I don’t darn pop one out before medical school ends, trying it in residency will be hell.

Reading online forums from doctor mommies hasn’t been very heartening either. It just seems impossible to plan. I could try for my 2nd year, but what about boards? I could try for 3rd and 4th years, but what about rotations, interviews, and applications to residencies? And even if I could schedule a month of 6 weeks of vacation leave, who knows if the baby will be on time, premature, or late.

Another option is to take a year off, depending if my school allows it or not. The upside is obviously I would have time with my newborn baby, and a year’s respite from medical school. The downside is that I would fall behind my classmates and graduate a year later. I wonder if this choice is very difficult for many women. For me, it is a hard choice because I am trying all my best to be a full-on career women and I’m pretty new at this job.

So, when is it the best time to have a baby? I still have no idea.

Balancing Relationships With Medical School

Pin-Chieh Chiang -- I know some time has passed between my last entry and this one. It's because instead of coming back after China, I went on to play in Europe. So after touring through France, Spain, and Italy, and effectively making my way around the world - I am finally back. Since being back, I've found out that I've been matched with a little sib, an incoming first year student at my school. Besides the usual questions of school, books, teachers, etc, she's asked me how I balanced between school and my relationship.

It's a great question. I'm not really sure myself. This is one subject that I believe my significant other knows about more than myself. The following is a collection of our thoughts put together:

Many of us have heard the depressing predictions of fights, tears, and breakups that seem to accompany a medical education. Now, there's nothing inherent in the study of medicine itself that makes relationships more difficult; you'll find nothing in your human anatomy or pharmacology textbooks that challenges a healthy, satisfying relationship. (In fact, practicing Osteopathic Manipulation Therapy might make your relationship a better one!)

In my fiance's opinion, it's the very nature of the medical student that makes relationships such a difficult puzzle. He would use a single word to characterize just about any medical student: "uncompromising." After all, those who "compromise" easily would've never survived college (with a healthy GPA), MCATs, endless personal statement rewrites, and cross-country interviews. Without a healthy stubborn streak mixed in with a dash of ambition, medical students wouldn't be where they are today. There are far too many easier paths they could've taken along the way (just look at your friends in dental school).

As it happens, it's precisely this attribute that makes relationships such a challenging subject. A healthy relationship needs... no, a healthy relationship *demands* compromise from both parties. Let us give you a few examples of the compromise that makes our relationship viable today:

First, in terms of geographic location, I considered my fiance's situation when I selected my medical school. Knowing that moving wasn't a professional option for him, I instead chose a medical school close by. In turn, he traded in his 5-minute bike commute for a 70-minute drive every day. This allowed us to live together, and our relationship has grown stronger even as my work-load grew exponentially.

Second, we compromise on balancing the basics of everyday life. He compromises by making sure I never (ok, rarely) have to worry about dinner, dishes, or chores. I compromise by making sure I pitch in on major cleaning events every few weeks or so (coinciding with the completion of another block). This has to happen no matter how tired or worn out we might feel; these little chores are an important part of living our lives together.

Third, we compromise on our social lives. My fiance knows that he has to keep himself "entertained" with his own friends and activities rather than expecting me to act as his play-buddy. On the other hand, it's my responsibility to treasure the time I've been given by focusing it on my studies. The end result: I don't feel pressured to give him attention every day, but we still have a few days every month that we can devote to "date night".

After one full year, our worst fears have been alleviated. Both our relationship and I have survived my first year of classes; there's no doubt any more about how we'll survive my second year. But I know the compromises won't stop here; clerkships, followed by the incredible time demands of internship, residency, and beyond. Not to mention the possibility of starting a family! We're not far along yet where I have any specific predictions on how we'll face those challenges, but I know that as long as I give a little on my priorities while he steps back a little on his.... we really can live happily ever after.

How about you? Do you have any special tips that help you put a smile on the face of your significant other?

Leaving Jiangsu Province Hospital – Full Of Memories

Pin-Chieh Chiang -- As I headed towards Shanghai Pudong Airport today, I had the sudden urge to cry. I've had an amazing summer here in China and experienced more than I could have ever asked for. It’s almost unbelievable that in less than 5 weeks time I’ve been allowed to visit so many departments: neurology, cardiology, orthopaedics, neurosurgery, endocrinology, plastic surgery, and obstetrics and gynecology.

I’m really grateful that all the doctors at every department have been very willing to accommodate me into their busy schedules; I’ve felt like a special guest. Even still, I especially appreciated it when I was treated just as a medical student. For this I give my thanks to Dr. Adam Zhang, Chief of Plastic Surgery.

When shadowing Dr. Zhang, I was given a chance to prove myself as a medical student. When he tested my knowledge, he showed that he had expectations. When he corrected me where I was wrong, he showed that he had faith in me to learn.

Instead of spending only 2 days in plastics, I altered my original plans to 2 weeks. I’ve had to cut days from other departments and cancel my rotation in liver transplant surgery altogether. It’s not that I have this sudden interest in plastics. In fact, I’m still very unsure of what kind of doctor I want to be. But I had this feeling that I had found a mentor.

By the end of the two weeks, I’ve learned that I was more than right. Not only was Dr. Zhang willing to take me under his wing, but so were almost all the senior doctors in plastic surgery. The medical students and residents were also more than willing to help me get adjusted. Now when I scrub in on an outpatient surgery with a senior doctor, I know how to set up the tray, thread the needle, and prepare the local anesthesia. These may all seem like little things, but little things that have meant the world to me in these past weeks.

So as I headed away from Nanjing, I realized I couldn’t have been happier with my choice of interning in China. This has been an experience I will treasure and never forget. I got to encounter a lot of firsts. It’s been my first time admitting patients into the hospital, seeing them on the operating table, and finally observing their recoveries. It’s been my first time scrubbing in on surgeries, my first time removing stitches, and my first time feeling ever so closer to being a doctor.

For all this I have many people to thank, in particular: Dr. Wu Guan Lin (retired President of Jiangsu Province Hospital), Dr. Wu Tie (President), Dr. Song (neurology), Dr. Li (cardiology), Dr. Sun (Chief of Obstetrics and Gynecology), Dr. Zhang (Chief of Plastic Surgery), and Dr. Yao (Co-Chief of Plastic Surgery).  I would also like to thank everyone else in Nanjing and at the Jiangsu Province Hospital for making my trip so memorable. 

Falling In Love Again

Pin-Chieh Chiang -- Do you remember when you first fell in love with medicine, if you ever did at all? I'm not talking about the personal statements we wrote to get into medical school. I'm talking about the real thing.

Honestly, I had to write many different drafts before I came up with a personal statement that was finally presentable. Even then it wasn't close to the truth. The truth is – there has never been a "why" to wanting to do medicine. I just knew.

It's all the little things; like the first time I saw an open heart surgery, held a premature baby, or received that thankful look in the patient's eyes. There was something exhilarating about those moments.

Sometimes in medical school, it's easy to forgot about these little things and even easier to be overwhelmed by the workload. It's been a difficult, yet fun, and oh so very much worth it first year. The experience of being back in the hospital environment is on a whole new level now that first year is out of the way.

I love it even more now. I've been in the plastic surgery department this past week. I've been changing bandages, holding patients' hands, and scrubbing in on surgeries. It's really all minor stuff, but these little things mean the world to me.

I was worried at first that the patients wouldn't want to be dealing with someone like me, a foreign medical student who can barely speak the medical lingo here. Slowly and surely I have come to realize that they also appreciate every effort I put in. It's these moments that remind me why I love medicine. After my language-limited experience with Chinese patients, I understand it's effort and caring that counts.

I mean, what else is there to do?

Into the Heart of Cardiology, China-style

Pin-Chieh Chiang -- I couldn't imagine gathering family members of different patients together and talking to them at the same time. But that is what Chief Director Li did while I was shadowing him in the cardiology department.

He first decided which patients would go to the catheter lab the next day. Then he told the attendings and residents to gather the family members so he could inform them about two things: risk factors and money. Once everyone was gathered, he told the families about the risks, including death, and that they would need about 50,000 RMB (~6,250 USD). Then they signed forms of consent.

I had a thought: "What about the patients?" He responded that he expected the family members to decide whether or not to pass on the information. Most family members seemed to want the patient not to worry but to remain relaxed during the catheterization.

The next day, I went into the cath lab with Dr. Li. He collected the images he needed for each patient, then called the family members into the observation room. He showed them the problem and explained what needed to be done. In cases that involved placing a stent, the family could choose from 3 stents: a 16,000-RMB (~2000 USD) model made in China, a 20,000-RMB (~2500 USD) imported model, and a 30,000-RMB (~3750 USD) model imported from the USA. Some families chose the stent made in China, but most "wanted the best." (On a side note, the average income in Nanjing is 2000 RMB (~250 USD) per month, and people have health insurance that will cover between 30-60%.)

The day was great, and every patient case went smoothly until the final one. Dr. Li worked for hours on this patient. In fact, every Chief Director and doctor with a title came over to give it a try with this patient. In the picture you can see the LCA and branches pretty well. The problem was when they tried to image the RCA – they couldn't find it. Finally after hours and attempts by every doctor, they had to call it quits. In this final picture, they used the anastomosis between LCA and RCA collateral branches to finally get that faint hint of an RCA in the bottom middle there. The general agreement was that the opening to the RCA was blocked and this patient would need a bypass.

I love the similarities and differences all at once being involved in medicine in China. It's all the little things that make it even more interesting and worthwhile to be here. For example, while in cardiology I couldn't help but notice the pharmaceutical sales representatives that kept coming into the office. I received a number of free pens!

Not in Kansas Anymore

Pin-Chieh Chiang -- Summer is off to a great start for me. I've spent my first week shadowing doctors in the hospital. I follow them during morning rounds with the other residents, trying to soak up and apply whatever knowledge I can.

There's only one problem with this picture. I'm in Nanjing and my Chinese is pathetic, especially when it comes to medical terms. So when the attending says "dong yan" I can only assume he means oculomotor, "nao qu xue" means cerebral hemorrhage, and "babinski's" means, well, babinski's. His English is definitely better than my Chinese. Not to mention I'm barely a 2nd year medical student.

Initially when I arrived at the Jiangsu Province Hospital, everything seemed like a typical big university hospital similar to those in the US. Then I started noticing little things that seemed to stand out, like:

- Here, patients carry their own MRIs and CTs wherever they go.

- It's not just a big hospital, it's a huge hospital with 1000+ beds, soon to be increased to 3000.

- All the nurses wear cute hats.

- It is against the rules to wear my white coat in the cafeteria.

- Lunch break is 2 hours from noon to 2 pm, and people here take naps.

Besides working at the hospital from 8 to 5:30, I'm trying to adjust to life in general in China. I'm still a bit jetlagged; the two-hour lunch break helps. I guess I'm learning Medical Chinese, kind of like the Medical Spanish program I did last summer in Costa Rica. My hope is that by the end of 5 weeks, not only my medical lingo in Chinese will have improved, but conversational Chinese as well.

Confessions of a First-Year Med Student

Pin-Chieh Chiang -- I study too much and yet never enough. I would love to be the gunner in the class, the one sitting in front who knows the answer to every question. But I’m not. I know I definitely don’t want to be at the other end of the spectrum and so I’m not. I am somewhere in between.

I feel disconnected from my friends, old and new. My old friends are job hunting, working, eating lunch, clubbing, bar hopping, dating, etc. They sometimes contact me and I always say I’m studying. My new friends from medical school – well, we are always studying.

Except, I’m not always studying. I study too much and yet never enough. I sit with a book in front of me. It’s opened to the right chapter and maybe even the right page. But really my focus is on my computer screen. I play free cell, shop online, download music, draw cartoons, read articles (medical and non-medical), and most of all I pretend I will start studying in the next 5 minutes.

I’m late. I was always a punctual person, but now I’m always late to dates, dinner, movies, and even just going home. In fact I choose the later date to turn in my assignments. My professors understand.

This whole year I’ve shared a lot of laughs with my classmates, but mostly I’ve worried, stressed, cried, and lost sleep over medical school. I’ve worried about the year passing by too quickly and too soon and that I’ve barely learned anything. How could I ever handle the 2nd year?

Now it’s here, the last few days have come and I can’t wait for this first year to end. Somehow I’ve survived, have passed and am passing all my classes. I’m ready for the summer and for next year. Next year, I plan to study too much, but probably not enough.

Do You Have a Medical Directive?

Pin-Chieh Chiang -- It’s getting towards the end of the year and I’m learning about geriatrics and end of life care in several classes. As part of the theme, the medical directive was presented in my Intro to Clinical Medicine last week. It was the usual “how should we approach patients about this” and “why it’s important” kind of lecture.

Then, my professor talked about the “when”. The “when should we talk to patients about a medical directive” doesn’t seem to fit in with geriatrics. For example, my professor mentioned that Terry Schiavo was only 26 when she fell into her severely compromised neurological state. For the same reasons an elderly person would want to have a medical directive, a young person could want one, too.

So I started thinking. The medical system is changing from “what we think is good for the patient” to “the patient’s right to choose and refuse care”. It is also changing from “let’s spend innumerable amounts of money to let this patient live 6 more months” to ”let’s cut costs and focus on quality of end of life.” I’m exaggerating of course. However, this being fairly close to reality, then shouldn’t the medical directive be something that every patient just naturally has?

It seemed so simple before – just do what you think is best for the patient. What if the patient doesn’t want treatment, but couldn’t make their wishes heard? I don’t know how often doctors have to deal with patients who can’t speak for themselves. I would love some feedback if anybody has any experience in this.

This entry is dedicated to my Grandma who passed away a few weeks ago. Her death was unexpected and I am grateful that it was fast and mostly painless.

An Exhilarating Taste of Being a Doctor

Pin-Chieh Chiang -- My "Pregnancy Partners" elective this semester was definitely more challenging and meaningful than I ever imagined. Of course, those two things tend to go hand and hand.

Since magical things come in 3s, I had 3 main challenges.

The first was the unpredictable nature of medical insurance. My PM (partnered mother) enrolled with Kaiser shortly before we met. The problem was that the Pregnancy Partners program was affiliated with a non-Kaiser clinic. The solution came in two beautiful words: "labor coach." If I wasn't in such a panic, "translator" might have worked just as well. Anyway, I was able to go with my PM to all her Kaiser appointments as her labor coach, and I even translated for her when needed.

Another potential problem was the time commitment. Every student gets paired with a different pregnant mother, who comes with a different situation. Some might be having her first birth, some might not speak English, and some might be high-risk. My PM was considered high-risk, and she had to visit the hospital 2-3x a week for NSTs (non-stressed test) as her due date got closer. This meant that I had to go to the hospital 2-3x a week with her, which also meant skipping class 2-3x a week. I think it put additional stress on my grades, but I figure when I look back in a few years, I'll be glad that I selected this elective over a few grades.

My biggest worry was that my PM's due date was also the day I needed to leave  for China to set up my summer rotation there. Technically, Pregnancy Partners mandated that I not leave the area until my PM gave birth. I chanced it, thinking that she might be early, since this was her 2nd pregnancy. However, her 1st pregnancy was a c-section which I later learned doesn't necessarily mean an earlier 2nd delivery. As her due date got closer, it seemed like I might miss the birth, especially since she wasn't having many contractions. Then, a week before her due date, she told me she wanted to do a c-section because of the baby's growing size.

I was torn; I knew she wanted to deliver vaginally and this would be a disappointment for her, but from a professional point of view, it meant I would not only be present at the birth, I’d get to observe a C-section! To my amazement, the doctor scheduled her for a C-section and I got to see the birth of a beautiful baby girl the morning before I left for China.

As I sat on my plane headed overseas, my thoughts were focused on what this would mean professionally. I thought about how this had given me an advantage in terms of clinical exposure; I thought about the rapport I had established with the ob-gyn, and how she had agreed to act as preceptor for my school; I thought about the technical details she had shared with me after the delivery was over.  In my mind, the challenges and sacrifices were all worth it.

It was only after I returned that I realized how blessed I was. I visited my PM’s family again for a post-delivery checkup. I was stunned to find they had gotten me a present, a lovely set of fragrances and lotion! Me! I was so focused on being a translator and absorbing my clinical exposure, I didn’t fully realize how much they considered me part of the family. The PM shyly asked me if I’d be returning next year, and whether her friend could have me as a pregnancy partner, too.

I won’t be returning next year, but I hope the incoming first-year medical students that follow me understand that these experiences are amazing for more than just their technical clinical components. It’s also our first chance to make a difference, and to really get the experience of interweaving our lives into the lives of our patients. Do doctors ever get tired of that exhilarating feeling?

Spring Break in China

Pin-Chieh Chiang -- I've been spending my spring break in China. This time the visit is more for business than pleasure. I'm here to set up a 5-week summer rotation at a major hospital in Nanjing. For the past few months I have been in contact with the medical director. I've even written up a detailed proposal.

Now, I finally get to meet the medical director face to face. He introduced me to faculty member Dr. H, who agreed to take me under her wing. Together we went through my proposal and filled in the gaps. I'm spending 5 weeks in 4 different departments, and in each department they will assign me to shadow a doctor.

There are many reasons why I want to spend my last free summer in China. I love traveling. I want clinical experience. I need to brush up my mandarin. In Nanjing, I can also get to know my fiance's extended family better. I guess I like to bunch my goals together.

I'm excited for this summer, though not so much for the time leading up to it. Even though I brought my books along, I haven't been able to squeeze in much study time. Once again, I'm going to have to cram like crazy in the next couple of weeks. At least I've got something huge to look forward to.

Any Questions?

Pin-Chieh Chiang -- "Do you have any questions?" Here is a question that is dangerous. Dangerous, I say, because it's like opening a door and not knowing what's on the other side. On the other side could be a never-ending conversation, questions that can't be answered, or questions that are so simple that they are annoying. The response I typically give is, "no, no questions here."

Where have I heard this "any questions?" posed recently? I always hear it after lectures, of course. I think my professors cringe a little each time they ask it. I also heard it at the seminars I attended a few weekends back at a conference in San Diego. I had no questions to ask then, either -- how could I when I was only a medical student amongst doctors? Then I heard it tonight when I somehow ended up attending an investing group meeting, and 4 separate companies came to pitch their business. I had no questions for them because I was a guest and have no money to invest.

A couple weeks ago, I was asked if I had any questions by an OB/GYN doctor in Vallejo. No, I am not pregnant, but I am part of a Pregnancy Partners elective where I follow a pregnant mother. I was actually caught off guard since the doctor's attention had been focused mainly on the patient and I was standing in the corner the whole visit. My automatic response was the typical "no, no questions here," and I knew as soon as I said those words I would regret it.

"Yes!" should have been my answer. In fact, I have so many questions, such as "How do you do it? How do you get from where I am to where you are? How do you have so much passion for your job when the turnover rate is high and malpractice insurance is going through the roof? Will you teach me how?" I've been waiting for another chance, for her to turn her attention once again on me and ask that same question. But in the last two visits it hasn't happened, and I have this sinking feeling that I'm the cause of that lost opportunity.

Pregnancy Partners is ending soon and I'm thinking that tomorrow is my last meeting with this doctor. That means it is also my last chance to reopen that door. I'm working up the courage to just ask the questions that I've wanted to ask without waiting for her to initiate the conversation. If I don't, I will always regret the time I slammed the door on an opportunity to learn.

Burnt Out

Pin-Chieh Chiang -- What can I possibly write to represent my current mood? It's a feeling like I've failed at something, and I'm embarrassed to admit this because I'm not failing; in fact I'm passing all my classes. It is my performance in certain classes that disappointed certain people close to me. To me, disappointment is like this dull knife just slowly chipping away at a sensitive nerve.

I can't say that I don't care what this other person thinks. And I do wish I could keep it separate, this person's hopes and dreams of me versus my own hopes and dreams. Most times it is a fine line. I appreciate knowing that someone cares even if expressed in this way, whether it be a parent, sibling, friend, aunt, uncle, teacher, etc…

This particular person in my life tells me that fear is good and should be something that motivates me to work harder. Sound familiar? The interesting thing is that this person is not in the medical field, so nope, not someone that was beaten down by this system day in and out. Perhaps this person does well by having fear themselves.

However, fear is not my motivating factor, has never been, and probably will never be. Instead, what I know drives me is anger -- being pissed off and frustrated. Anger directed at myself, at others, at the system is something that has driven me in the past to do well. How I would love to call on the powers of this anger to do well now, especially for this person close to me. Yet, though it might not make sense to this person, I would rather not. This is not how I want to spend my medical school days.

So this is what I write to represent my current mood: I am burnt out. I figure this blurb will either make absolutely no sense or absolutely perfect sense to you the fellow medical student reader. 

Who Knew It Would Be Like This?

Pin-Chieh Chiang -- I never thought I would be doing presentations in medical school. I mean, I barely did them in college. So I was a bit shocked when I first found out that I do indeed have to give presentations. But it was okay, because I figured it would be a rare event. Boy, was I wrong.

It started with Anatomy class, where everybody does two each semester. One is a "theory peer instruction" where I pretty much lectured on a chosen topic for 10 minutes, and the other is "round robins" where I taught fellow classmates a specific region on my cadaver.

That was fine. I learned a little bit more and was able to master a mini-portion of Anatomy. But then Problem Based Learning started, and I do a presentation every other class. Neuro snuck up on me and I didn't realize I had to do a presentation until the night before. In Genetics, I had to somehow work with 14 other classmates in a short amount of time to create a skit. Then there's the exception of when I prepared long and hard to present on Research Day.

That's a lot of presentations. It takes up even more time when I have to work in bigger groups. It is also really stressful -- somehow I just lucked out to be doing 4 presentations in the 5-week time of last block. Well, now I know. It's supposed to be good practice for rotations, when I'm going to presenting cases all the time.

Survey Says: Med Students Are Surprisingly Optimistic

Pin-Chieh Chiang -- I'm always trying to come up with new cartoon ideas, especially now that I am submitting them for my school's talent show. So, perhaps because I am in the middle of exams, I thought about categorizing medical students as to how they react or deal with stress. I came up with a few categories and I even created a poll. The poll, by the way, does not represent a random sample, participants can vote for more than one category, and it is still ongoing. Below are the results so far, which are in no way scientific or significant.

The OCD: everything needs to be organized! I can't start studying until my notes are labeled by dates and colored. 8%

The One in Denial: I am not a medical student. This is not happening. What do you mean we have exams tomorrow? 4%

The Anti-Social: Don't talk to me. Don't look at me. Don't breathe on me. 7%

The Social Butterfly: Isn't this awesome? We can study together, eat together, and sleep together, all 135 of us! 5%

The Snacker: Who wants ice-cream? Chips? Cookies? 10%

The One with Bodily Dysfunctions: Every other minute I find myself back on the toilet. I can't stop scratching; I think I'm breaking out in hives. Don't forget about all the gastric ulcer pains after each meal. 10%

The Review Session Addict: So after class ends, I'm going to go to anatomy review at noon, neuro review at 1, immuno review at 3, and then back to the anatomy lab after that. 5%

The Hypochondriac: I can't drink that soda, it has phenylalanine and I'm pretty sure I have PKU. Do you think my bloated belly means I have ascites or portal hypertension? I don't understand anything in class; I must have fetal alcohol syndrome. 3%

The Crammer: One week before exams? Great! It's my peak time! 11%

The Mental Breakdown: I cried and cried like it was never going to be sunny again and then an hour later I was fine! I can't sleep and when I do, I dream my cadaver is testing me. 7%

The Rare Optimist: Everything is going to be fine, right? 15%

If you are wondering why that doesn't add up to 100%, there are more categories that I have decided not to write about, and of course the "others" category which is 3%. I definitely go through phases of each category. It all depends on the subject I'm studying, my mood, and the weather. I'm going to finalize results after exams and then draw the cartoon. So check back for the posting of the cartoon.

Anatomy Buff, Me

Pin-Chieh Chiang -- By the end of last semester, we (my anatomy group members and I) were convinced there was a conspiracy of professors trying to avoid our group. The obvious theory is that the professors couldn’t do much with our first cadaver when it started getting moldy. Either way, my lab practical grade was on a gradual decline and I missed the guidance of my professors.

At the beginning of this semester we received a new cadaver, and I just had the best lab ever. Initially I found out that there wasn’t much more dissection to be done on my cadaver because I had chosen to flop the head (detaching the skull from the vertebra) instead of a bisection. For this particular lab to dig into the nasal area, we needed a bisected head.

So I actively sought out a professor to come tell me exactly what more I could cut. He poked around and started chipping at the petrous bone in the skull. He was going for more, but once he chipped a piece of the petrous bone off he stopped. He had somehow uncovered the ear ossicles, perfectly intact with the malleus still attached to the tympanic membrane. This might seem strange to some people, but it was really exciting for us to be able to visualize the three smallest bones in the body.

Next, I bugged another professor to come and bisect the head, mainly so that we could have more dissection to do. There’s something truly eerily enjoyable for me to be actively dissecting. Part of the process, the sense of discovery with each muscle, nerve, and vessel uncovered, definitely has a role in that.

Towards the end of lab, a third professor came by our table and helped orient us in our flopped and now bisected head. Of course it is just typical of me to have questions only after the professor leaves the table. Lucky for me, a 4th professor just happened to come by, and I got to get my questions off my chest.

So, in one lab, my group managed to create a unique view of the head, uncover ear ossicles, and get help from at least four professors. It was an extremely satisfying lab in which I felt my time was very well spent. I’m learning more and more on how to actively take charge of my education, and I definitely learn more by doing so.

Venturing Into the World of Research

Pin-Chieh Chiang -- Last week, at Research Day, three judges crowded around me while I attempted to present my scientific poster. All the words that I had been practicing for 2 hours with my research professor blanked out of my mind. I literally froze.

Then I took a deep breath and continued.

Funny thing about messing up, it was like once the worst had already happened, I could finally relax. The rest of my presentation went fairly well and I got to explain my research about ventral optic neurons targeting in the dorsal tectum on Xenopus tadpoles. I didn’t get the best poster presentation award, but it was my first time presenting a poster.

Once I was done with my presentation, I got to walk around and check out some of the other posters. Before then, I had no idea who was doing research and in what area. There were 14 student posters on topics ranging from Huntington’s disease, human thyroid cancer cells, type 2 diabetes, and more. I also took some mental notes for next year, such as I should have worn my interview suit.

The rest of the day consisted of research publication presentations, faculty and students included. It was great to see people from all the different colleges of Osteopathic Medicine, Pharmacy, Physician’s Assistant, Education, and Public Health there to support the presenters. I was especially happy to see that a fellow classmate was also a presenter -- the only other first-year medical student among all the 2nd years.

It is interesting to note that my school focuses on graduating primary care physicians, yet the research department has expanded rapidly in the last few years. I can’t speak for why others choose to do research, but I know that I enjoy it very much. I think research helps me better understand the underlying concepts in my basic science courses. Being in the lab gives my brain a break from the medical school world, while still being active in science. It may seem crazy that medical students have time to do research on the side, but I’d recommend it for anyone who is interested, because professors are always willing to work around busy medical students’ schedules.

Academic Bulimia

Pin-Chieh Chiang -- Do you feel like you have been binge-learning? Is there evidence of disordered studying in your environment? Do you find yourself visiting the exam room soon after you've studied to regurgitate the information you've barely swallowed? Are there signs of a rigid study regimen despite weather, fatigue, illness, or injury? Are you experiencing calluses on your fingers from too much note taking? Have you been withdrawn from friends and activities? Have you put on or lost an extreme amount of weight?

The questions above are adapted from bulimia, the eating disorder. If you answered yes to any of the questions above, you might be suffering from academic bulimia. I first heard this term during orientation from Dr. Troll, the Associate Dean here at TUCOM. I didn't think much about it until this past week when I attended a meeting about curriculum changes for next year. Dr. Troll led the meeting to explain the underlying concepts and motivations for the upcoming changes, and again discussed the concept of academic bulimia.

As I listened to him describe the cyclical process of cramming in and regurgitating information, I couldn't help but notice the reality of his concept. In some way or form, medical students have to deal with academic bulimia, especially when exams get closer. I definitely feel like I binge-learn. It's only the second week of this block and I am disordered in my learning and I just can't seem to keep pace with the lectures. Right now I am learning for the concepts and I know in just a few short weeks I'll be learning for the exams. Then I will purge in about 10-12 trips to the exam room and start all over again. However, I'd like to think that I'll manage to digest some information, because I still need it for that final purge of Board exams.

The Light at the End of the Tunnel

Pin-Chieh Chiang -- Happy Valentine's Day! A few significant things happened this past weekend, events that reminded me how life still goes on even if I am in medical school. The common perception is that your "other" life is put on pause when medical school starts, and most of the time it's hard not to believe that.

Then last Friday night, I got to meet up with an old friend that I haven't seen for 10 years. It's hard to imagine how we were barely in our teens when she moved away and how our lives winded up on such different paths. Here I am complaining about the difficulties of medical school and she's working on starting college all over again as a single mom.

Saturday was my chance to catch up with my family members. Including my boyfriend, we all got together for dinner as a makeup for missing Chinese New Years. Now that I think back, my mother didn't once ask my boyfriend and me about marriage. She did hint that this year would be a good year for the boar, which is what I am.

Finally Sunday morning came and I crawled out of bed at 6 am to get on a hot-air balloon in Napa Valley, courtesy of my boyfriend. The clues were there, but it was too early in the morning for me to pick up on any of them. For example, the pilot was constantly radioing the ground crew with specific instructions as to which road to drive up on and in which direction. Also, at one point our balloon was getting lower and lower. That's when my boyfriend looked off to the side and said, "Look, there's a sign with your name on it." I saw the ground crew holding up a banner that said, "Pin, will you marry me?" I was in delirious shock. I turned to my boyfriend and at that point he got on his knees and asked again. I'm sure it's not a surprise that I said "yes".

As soon as we landed, I called my parents. When they didn't sound surprised at all, I finally figured out that they knew. In fact, everybody at dinner on Saturday night knew except me. My sister even helped pick out the ring. So now I am officially engaged to my fiancé, whom I met 4 years ago on this very day.

Food Makes Me Happy

Pin-Chieh Chiang -- Besides worrying about classes, exams, and grades, there's another thing that medical students spend a lot of time thinking about, and that is food. This is especially the case at my school, which doesn't serve hot foods, or at least until now. Before now, I always had to spend some time every night thinking about what I should pack for lunch the next day. Sometimes I would even pack dinner if I planned to stay on campus to study.

I should mention that there are other alternatives, like hiking 10 minutes up the hill for hot food at the inn or driving off the island for fast food. Then there is the quaint café on campus that serves only kosher foods. I should also mention that my school is based on a Jewish tradition, hence kosher. The idea is to create an environment for Jewish students where they don't have to miss classes just to celebrate their beliefs. It works well for me, because last October I enjoyed only 11 days of school due to all the Jewish holidays.

So anyway, the little Jewish cafe provides kosher foods: some sandwiches, bagels in the morning, beverages, but mostly snacks. It also diligently provides coffee everyday for $1 a cup with unlimited types of creamers, and this is why students including myself frequent the place so much. Starting last week, the café decided to start serving hot foods for the first time in 8 years. On their menu is honey roasted chicken, zucchini chicken, breaded chicken, drumsticks, and baked salmon, all for $1 each with a free side of peas, corn, or cauliflower. There is also French onion soup for 50 cents.

I didn't realize this would affect my life in any way, but it has. Everyday this week I have been pounded with exams one after the other, but at least I can look forward to a relatively affordable lunch. I basically haven't had to worry about lunch all week, and it is definitely one less stressor, even if a little one. The food is actually really good, and it's just my luck that I am a chicken fanatic. There's no cheese in the French onion soup, but other than that, having something warm and soupy during these cold days is a great thing.

No Light in Sight, Just Dark Tunnel Ahead

Pin-Chieh Chiang -- I've been trying to avoid the subject, but I guess I can't any longer: blocks are coming up. Next week I will be swamped again with at least 2 exams each day. What I would do for a week in between classes and exams just to study. I think I had that luxury once in college. Instead, this is what I get to look forward to:

Monday: I am starting with BSF (Basic Science Foundations) -- Genetics unit. I've been going through the notes at a snail's pace, and the stack of lecture handouts is about 3 inches thick. I'm about halfway through and have reinforced in my brain how Mendel liked his peas. Now I just need to continue with the rest and learn about DNA, RNA, transcription, protein synthesis, biotechnology, cloning, and finally medical applications. Right after that exam, I'll have to cram in some studying time for the Physical Diagnosis exam in the afternoon.

Tuesday: This is "the" lab practical day, with OMT in the morning and anatomy in the afternoon. In OMT, I've been learning how to diagnose and treat dysfunctions in the neck and in the lumbar, pelvic, sacral, and innominate regions. Just to show how confusing this can be, there are 6 different types of dysfunctions that can occur in the sacral region alone, with multiple techniques and possibilities to treat each one. On this day I'll get to pick out of a hat and just pray that my brain doesn't freeze under the pressure of my professors' silent evaluation. After that I can look forward to being hungry as a side effect of formaldehyde while staring into cadavers for 60 minutes. I suspect there will be a lot of skulls and questions on what artery or nerve goes through this foramen or that hole.

Wednesday: If I studied well for Tuesday, I should get a break for Wednesday, because the exams on this day are the theory portions for OMT and anatomy. It usually works out for OMT that the concepts of lab correlate fairly well with theory. However, for anatomy the practical is purely identification and the theory tests a much higher level of understanding of clinical correlations.

Thursday: It may seem like there is only one exam on this day, but don't be fooled -- it's both lab and theory of Medical Neuroscience combined into one. This is probably the one time I'm grateful for the weekly quizzes, because they help keep me on my toes for this class. So hopefully by Wednesday night, it'll all just be review and not trying to cram in new material.

Friday: Finally the last day of the series. I have another BSF exam, the gastrointestinal unit, which by the way, the professors are barely halfway through teaching. Since this class just started last week, I am definitely behind. Plus I'm still trying to catch up on the first BSF unit.

Needless to say, I have a ton of studying to do.

Using OMT to Treat Torticollis

Pin-Chieh Chiang -- A few weeks ago, a special visitor came to my school: a 5-month-old infant with torticollis. Torticollis is a condition where the muscles of the neck are contracted, producing slanting and twisting of the head to one side. The baby smiled and sat on his mommy's lap while 40-plus medical students sat in a half circle around him. Even when my professor, Dr. Cislo, approached him, he didn't shy away.

Dr. Cislo did not touch the baby right away. Instead, she worked on making eye contact. She let the baby play with her scarf and fingers, while she slowly made physical contact starting at the extremities. All the while, she was getting the history and physical from the parents and giving us students a demonstration of the proper way to approach a baby.

For those of you who aren't familiar with OMT (osteopathic manipulative treatment), it involves using the hands to diagnose, treat, and prevent illness or injury. Dr. Cislo proceeded to treat the baby with OMT. "Babies," she said -- "you have to treat them wherever they are, can't just position them and expect them to stay still." She showed this by working around the baby and mother, changing positions and adapting to the baby as he was breastfeeding, getting burped, or just fussing around.

The baby cried during the treatments, and it was hard not to cringe for him. But Dr. Cislo is a professional and she would show the mom how little force she was using through each technique so as not to worry her. Just as Dr. Cislo was explaining, "You know the treatment works when the baby calms down, because his pain is released," the baby actually stopped crying. From that point on, he was much more compliant.

After the treatment, my classmates and I watched for the baby's reaction. He was being his smiling, bouncing self. Like any other infant, he was happily playing with his toes. It didn't seem remarkable… until the mother said, "That's the first time he's played with his feet." A few days later, the mother contacted Dr. Cislo to remark on how her baby has turned over for the first time and how he can tolerate his physical therapy sessions much longer now. The mother also mentioned the indirect effects such as the baby being more playful, staying awake longer, eating better, and using his left arm more.

That day, it was very inspiring to see my professor in her physician mode. I know that a lot of my professors are more than just the lecturer I normally get to interact with. It makes me look forward to rotations, to when I will get more chances like these to learn first-hand from my professors. It was also very awesome to be able to see OMT work outside of the classroom. Often in the laboratory setting, I rarely succeed in treating my partners with OMT. This is because most of the time my partners don't have any serious problems and also because I am still learning how to execute the techniques properly. Still, I definitely love all the concepts of OMT; otherwise I wouldn't be at an osteopathic school.

This isn't intended to be a comprehensive clinical study about the effects of OMT. But on that day, this mother and her beaming baby had nothing but thanks for Dr. Cislo's wonderful work.

"Electing" to Learn Even More

Pin-Chieh Chiang -- It’s hard to imagine that after 33 hours of lectures and labs a week, there are even more classes that students can opt to take, called electives. Why would anyone in their right mind enroll in an elective or even two? I mean, aren’t medical students supposed to not even have time to sleep? Here at TUCOM (Touro University – College of Osteopathic Medicine), however, electives are designed to suit medical students' busy schedules.

One such class is Medical Spanish, taught by our Medical Neuroscience professor. Like most electives, the class meets from 3-5 on Wednesdays, a time that normal classes are not in session. Classmates who are enrolled in this class say they are not stressed out by the extra load. As long as they maintain good attendance and good effort, they will most likely pass. There is a growing need for Spanish-speaking doctors, especially in California, and I wanted to take the Spanish elective. But, it conflicted with research.

Research is technically a work-study option instead of an elective, but it still is something extracurricular. The research faculty presented a seminar early in the year to inform students about the research they were doing and about any positions they had to offer. I was hooked, and ever since I have been meeting with my research professor once a week, along with 2 other classmates.

Since all electives are scheduled for the same time here, one of my research labmates decided to withdraw for yet another opportunity, called International Health. In this class, students meet every week to prep for their summer trip to Tanzania and, for the first time this year, Ethiopia. Once there they will be working with the locals on health education and field research.   

There is only one elective that falls on Fridays and it is called Pregnancy Partners. This class matches participating students with a pregnant mother, to follow her through her appointments and development and to even observe the birth. I chose to enroll in this program for the experience of being able to follow a patient over an extended period of time.

Sometimes, in the middle of another 48-hour marathon anatomy study session, the idea of pulling out time to study Spanish almost seems irrational. Yet these electives make a nice study break and complement the medical education with more tangible experiences. In the long run, they make the medical education experience even richer.

Rested, Rearmed, and Ready for Battle

Pin-Chieh Chiang -- Last week was the first week of my second semester as a medical student. My classmates and I have come back to the battlefield as tested veterans. We are no longer the novices we were a few months ago, newly arrived on the front lines and afraid of what we were going to face. This time, we came back ready to face our enemy: the hard-to-understand professors, the 16+ hours of labs, the group projects, and the wave after wave of attacking textbooks.

All of us spent the break re-arming for spring block exams in different ways. Some of us brought the newest toys: notebooks, tablets, and ipods. Some of us went for plenty of rest and spiritual healing: new hair styles. Some of us went for that spiritual armor: new winter clothes. One classmate in particular had the caduceus -- the staff of life coiled by a snake -- tattooed down his back.

Medical school did not change much while I was gone for those two weeks. In fact, I've found it to be exactly the way I left it. I have the same 8-5 schedule Monday through Friday. I even have the same biweekly meetings with my anatomy group to study anatomy.

Yet somehow, in some way, something feels different. Maybe it is that Public Health class has ended and we are starting Problem Based Learning. Or maybe it is that we finally got to unmask and see the faces of our cadavers. Or maybe it is that we are having our first annual TUCOM vs UCD-Med School Basketball Championship game. (Go Touro!) Or maybe this apprehensive feeling is us looking forward to our Winter Gala this Sunday.

Or maybe, it is we the students that have changed. My classmates and I have all survived first semester and we've left no man behind. This survival gives me a boost of confidence that I didn't have before. I know now that somehow I will make it to May and pass my classes. It hasn't gotten any easier -- if anything, the 2nd semester is only harder. Yet, I know what it is I need to do now, and I believe my classmates do, too.

Chinese Dumplings

Pin-Chieh Chiang -- This was our primary goal in Shanghai, to eat Nan Xiang soupy dumplings. The food is so good that we went back for a second time before heading back to the States. On the left is my boyfriend, Qiang.

Reflections and Advice

Pin-Chieh Chiang -- Happy New Year!

Often around this time of year, I like to look back on the past year and reflect. The major events of my life in 2005 were graduating college and starting medical school. Now one whole semester of medical school has already gone by. Based on my own experiences and the feedback of my fellow classmates, here are some thoughts about this past semester and perhaps some advice for future medical students as well.

One question I asked my classmates was, "Is there anything that could have helped prepare you better for your first semester?" The general feeling is that there is always something that can be done to help better prepare any person for medical school. Take an extra biochemistry course or study cranial nerves ahead of time, for example. However, that extra time of prepping will eventually use up the extra time available to play. Having fun before medical school starts to seem even more important, especially since there is plenty of studying to look forward to.

Another question I asked was, "What is the one thing you wish you had known about medical school before coming in?" Everyone had something to say about not really needing to buy all the "required" books. It's true; I bought all the books and have definitely not opened every single one yet. It is hard enough trying to go through all of my professors' lecture notes, let alone trying to read from a textbook. When I do need the textbook for a second reference, the library always has them readily available.

I remember the summer before first semester and how many questions swarmed through my head, summing up to the main questions of "How will I survive?" and "How will I live?" Now I know only a little bit better. I guess if one has made it past the application and acceptance stage, one should just trust that they have the qualifications to make it in medical school. I still have the same questions poking at me now and then, though. It's easier to just ignore them and somehow work through medical school day by day.

So now it's a new year and I'm starting my second semester of medical school. My resolutions are, as always, to somehow raise my grades, lose weight, be involved in more activities, spend more time with family and friends, and continue to travel whenever possible. It's just too bad that the first resolution on the list will most likely conflict with the rest. Yet, with everlasting hope, I still strive to work towards achieving some sort of balance.

From Lymphagions to a Hernia

Pin-Chieh Chiang -- Last time I wrote, I was in Shenzhen. Currently I’m writing from Nanjing, having just left Hainan, a beautiful warm island off the southern coast of greater China. I love traveling, I really do. I’m using this time to recharge for the upcoming second semester of medical school.

However, no matter how far I travel, medical school doesn’t seem to linger far behind. The first semester passed so fast that I didn’t feel like I really learned anything. Sure I’ve been taught plenty of stuff and studied for long hours, but truly, what did I learn?

Then there I was, at a massage parlor in Shenzhen, looking at the price list. My best friend pointed out that she might try the lymphatic massage and all I could think about was lymphangion, the smallest unit of the lymphatic system. My automatic response was that the massage needs to be done in 5 second intervals to be effective since the average contractile cycle of each lymphangion is 5 seconds.

Another traveling buddy of mine also got a massage. Afterwards her lower back was in pain and she worried if she was having kidney problems. Lloyd’s sign from physical diagnosis class clouded my head and I couldn’t stop thinking about it until I performed the test on my friend.

In Hainan, another person in my traveling group pulled me aside to talk to me about diabetes. This person has recently been diagnosed with an acute onset of diabetes, was monitored in the hospital for a few weeks here in China, and is now fine. There weren’t any questions asked, only a story shared about insulin shots, change of diet and exercise, and weight loss. I felt the only appropriate thing to do was say, “Well, it seems like you have it all under control now.”

 

Now in Nanjing, I’m with more family members and friends. I’ve come to learn that an elderly member has been living with a hernia for the past 13 years. This time I found myself at a lost for words. My first thoughts were surgery, but no, not feasible for a 90-plus-year-old person. Every time this person coughed, I winced, thinking about the sudden increases in intra-abdominal pressure pushing on the hernia. This person offered to let me see the hernia and even touch it. I was touched by this gesture and accepted.

I guess I have learned one or two things after all and it is a strange feeling having all these random medical facts and terminologies pop into my head at times. It is even stranger that people want to share their medical histories with me just because I am a medical student. I’m grateful for this and am adjusting all at the same time.

Vacationing in China

Pin-Chieh Chiang -- Right now I am in Shenzhen, China. It is an amazingly developed city, considering it has only 20 years of history. There is a Chinese phrase that goes something like, “You know you are in Shenzhen when you realize you don’t have enough money.”

I was walking around today just observing the environment. I noticed 2 professional looking people wearing white coats sitting outside with posters about stomach cancer in front of them. According to the poster, China’s death rate due to stomach cancer is number 1 in the world.

I was excited to see this kind of outreach available to the public and asked if I could take a picture. I was denied outright. That is when I took a step back and realized they were stationed right in front of a huge multi-floor pharmacy and they were most likely representatives. A few days ago I was in Shanghai and I noticed another outreach effort for elderly people about why calcium was important to supplement in their diet. I wonder if they were also pharmacy representatives like these.

I can’t say if the outreach was really for the people or more for the pharmacy company to boost their sales, though it is not surprising if it was more of the latter. Back in the US, pharmaceutical companies mainly target doctors, even medical students. My professors have forewarned us about pharmaceutical representatives visiting my school.

Here in China, the people are directly targeted. My impression is that most drugs do not require a prescription. Another interesting thing to note is that the attitude towards healthcare is definitely different. The “family doctor” doesn’t exist. People don’t tend to go in for checkups on an annual basis. When they choose to visit a doctor, they are most likely very sick by then.

There are 2 common options; to wait in line for a particular department or to wait in line for a particular doctor. Appointments do not exist here, and after receiving a number, patients could wait days for the more famous doctors. When they finally get to see their doctor, it is a quick 5 minute visit.

All this time I have been learning about how to take a thorough patient history and establish a patient-physician relationship. I even worry about my future patient encounters and how they are limited to 15 to 30 minutes. Here is a system where doctors are seeing patients every 5 minutes, enough time apparently for them to take down the symptoms and make a diagnosis, probably also a good way to cut down on healthcare costs.

For me, it is always very interesting how different healthcare systems exist in different countries. I am taught the American system and barely about the different healthcare system models in different counties. I don’t really have any concluding thoughts, I just find this all very interesting to note and probably good information to keep in mind.

Pin-Chieh Chiang -- Disclaimer: Sometimes a picture can represent my feelings better than words or, in this case, another cartoon. I actually do not drink any coffee during exams.

 

Hello, Obturator?

Pin-Chieh Chiang -- I just finished my anatomy lab practical. The greatest part was when I was in line waiting to go inside the lab, my classmate next to me sees the anatomy professor and says, “What’s his name again? Obturator?” When a professor’s name is confused with a part of the hipbone, that's funny. And then there was the test.

So, I file in with my classmates and I get a clipboard and get assigned to a table. There are 60 stations of mostly cadavers, some x-rays, and a few rest stations. I get 1 minute at each station and only that 1 minute. That always boggles me. Sure, I’ve done lab practicals in college, but I was always allowed time in the end to go back to any station I needed more time on. This is not the case in med school.

I had to hand in my answer sheet for the first half to get the second one, and of course as soon as I handed it in, I realized I had written lateral femoral nerve when it should have been ilioinguinal. I guess it’s good training for the real world, when I really can’t rely on second chances. Yet it still annoys me when that happens.

Another bad habit that I really need to stop doing but can’t resist is comparing answers as soon as the test is done. Now I know that either my classmates are wrong, or I really can’t tell the difference between a urethra and a vagina. Honestly, I can, but I make those mistakes when I assume the answer too fast, and I neglect to really look around in the body. At least it’s better than when I mistook a seminal vesical for an ovary on the mock practical. That meant I really couldn’t tell the difference between a male and female body. I wonder if my professors get laughs from this while grading.

Taking exams is very draining for me. It’s the same feeling I had when I was interviewing for med schools. The moment I was leaving an interview, the moment I was safe and not under scrutiny anymore, I would crash. Except now, I crash but I also have to study for exams for the rest of the week.

Even though tests are grueling, I’m still excited about this week, because it’s the beginning of the end. I mean, the end of first semester, of course. Technically, by the end of this week, I’ll be 1/4 of the way done with my first 2 years of book learning, and then it’s off to rotations. Scary to think that, isn’t it?

Starved for Time

Pin-Chieh Chiang -- People have commented on how calm I was this weekend, considering the doom to come ahead. My response is that I am in the calm before the storm.

Everybody deals with stress in their own unique way. I deal with it by being in denial. I can admit that I am in stress, but I have to try very hard to not give it a minute’s thought. The moment I do, I feel engulfed by it, this thing that clouds my mind. I need my mind to stay clear so that I can bear down and study.

Time, like money, is something I always feel I do not have enough of. I often feel like a little girl again, receiving allowance once a month, except this is once every 5 weeks for each block. At the beginning of each block, I feel bathed with plenty enough time to feel I have the freedom to do whatever I want.

Towards the end of each block, my time is nearly all spent. Like right now, I feel so squeezed for time I reduce my meals to energy bars and bread. Like money, towards the end, I am counting the loose change. I am counting the 10 minutes between each class to cram in some anatomy terms with my handy dandy flashcards.

While I am associating time as a type of currency, I couldn’t help but notice how I have to understand the “value” of things all over again. How do I choose how many hours to allot to each subject? Should I spend 2 hours for anatomy and 3 hours for medical neuroscience, or the other way around?

I feel disconnected with time. It seems to be never on my side. The week before block exams is almost always worse than the week of them. It is the time to study and cram as much as I can. Once exams start, it is too late to try to learn anymore, I can only focus on surviving day to day. I just have to remind myself that, no matter how bad things might seem at the present, in a few short days I’ll become wealthy yet again, with an additional Christmas break bonus. And just like when I was a little girl, I think I’m going to reward myself with some chocolate.

OMT Lab

Pin-Chieh Chiang -- While I was visiting friends and relatives over Thanksgiving break, someone handed me a copy of Solano, a magazine that covers this area of northern California. Its feature article celebrated the region’s best physicians, as picked by their peers. I couldn’t help but notice the DOs who made the list with backgrounds ranging from family practice to Ob/Gyn to pain management.

The magazine interviewed some of the DOs, and the question always asked was, “What is the difference between an MD and a DO?”

Here, it was simply answered by, “…The training is the same… in addition to what allopathic medical schools teach, we’re also taught osteopathic manipulative treatment (OMT).”

That is my medical education in a nutshell – the same as an allopath plus OMT. Once a week, I have an extra 4 hours of OMT, 2 hours for lecture and 2 hours for lab. Sadly, this also inevitably translates to 2 extra exams each block, 1 theory and one lab practical.

During my first OMT lab, I remember being nervous. No, nervous doesn’t describe it; the feeling I had was just plain weird. The required attire for females is a sports bra and shorts, so I knew I would be shirts-off in lab. I was also assigned to a male partner for my first lab. It was truly strange just touching another person, feeling for their vertebrae, scapula, and other bony landmarks. Not to mention how self-conscious I felt about my, “ahem,” love handles.

Now, 3 months later, I come into lab ready to strip off my shirt to play the patient or to acquire new skills for my hands. Sometimes, I forget the initial awkwardness that has already faded. But I was reminded of it during this mini-vacation when I brought my OMT table home to practice on my family. I found myself spending more time explaining how to relax and position their bodies than I would in lab with my classmates.

In OMT lab, I’m not just learning another set of skills. I’m also learning how to apply the osteopathic philosophy, which I alluded to in my last entry. The osteopathic philosophy is basically to view patients as an entire person, rather than just a single organ system or disease. It is also the belief that the body has an innate ability to heal itself. For example, I have learned techniques that help improve lymphatic flow and breathing that can help speed a patient's recovery of even a common cold.

Every week, I’m assigned to a different partner, female or male, big or small; it is another chance to work with another body type. Stripping to my sports bra might sound peculiar, but it is the reality of the profession, because patients are constantly in their undergarments or even naked under a hospital gown.

I think it is because of this OMT class that my classmates are as comfortable with each other as we are. I’ve definitely become a more “touchy-feely” person since school started. I also love being on the receiving end of the OMT treatments. On Mondays and Tuesdays during lunch, I used to rush to open clinic just to have the 2nd-years work on me. Now, most of my problems have been solved; I’m just waiting for a new excuse, like having my lower back pain act up again, to get more treatment.

What Is a DO?

Pin-Chieh Chiang -- Let me tell you a little about myself. I graduated from UC Davis this June (2005) with a BS in biochemistry. Less than 2 months after graduation, I started medical school. Now, I’m currently an OMS I (1st-year osteopathic medical student) at Touro University in California.

Just a year ago, I had only a passing familiarity with the term osteopathy. During orientation before school started, a survey was passed around asking, “Why do you want to be a DO?” The number 1 answer was, “I’ve always wanted to be an optometrist.” That was my first introduction to what a funny group of students I would be attending class with. In fact, we often joke among ourselves about how no one knows we exist.

The question medical students better know the answer to, especially during interviews, is, “Why do you want to be a doctor?” For me that question comes in 2 parts, the 2nd part being, “Why osteopathic medicine?”

Even considering an osteopathic institution is a big step. Most people have never heard of osteopathy and are nervous about things they’ve never heard before. I had friends who were nervous for me, warning me that I was making a big mistake. 

Somewhere between me realizing I liked the idea of osteopathy and thinking about where I wanted to spend my next few years, I decided to apply to Touro. Sometime before college, I had volunteered at a Buddhist-based hospital in Taiwan. I was told to hold hands and hug the patients as much as possible. The lesson there was about touch and how it actually helps in the healing process. So, 4 years later, I was applying for medical school and I learned about something similar but even better: the osteopathic philosophy.

I have to admit I was also nervous and unsure when applying. I wondered why I never heard about this group of doctors until then. The deciding factor for me was location. Honestly, if it hadn’t been a factor, I’d be at an allopathic school on the East Coast right now.

Four months in, I have absolutely no regrets, especially about osteopathy and medical school in general. This is, of course, me writing after I found out I managed to pass my 2nd block of exams. Wait 5 more weeks until my final block exams and I’ll be tearing my head off warning everyone to stay away from medical school.