The Differential: Medscape Med Students Blogs

My Battle With Time

Jeff Wonoprabowo -- Time is like water. You can see it. You can feel it. And when you think you have it under control, it slips through your fingers.

I've been having trouble concentrating and staying focused. At the end of day, I often feel like I wasn't as efficient as I should have been. Frustrated with my inefficient studying, I lamented about this to someone who recommended a book titled “Procrastination: Why You Do It, What To Do About It.” I was specifically directed to chapter nine which was called “Learning How To Tell Time.”

As I read the chapter I was constantly thinking, "Oh, that sounds like me sometimes." Okay, well maybe it sounds like me more often than not.

I have long accepted that I am a procrastinator. It may run in the family, I don't know. My younger sister tells me that she is this way, too. I think we do our best job when a deadline is looming overhead. And while this may be okay during high school and undergrad, procrastination can be horrible in medical school.

From the book I learned that procrastinators like me have a "'wishful thinking' relationship with time -- [I] hope to find more of it than there really is," and procrastinators "prefer to remain in the vague realms of potential and possibility."

Whether I like it or not, I am going to have to confront my "wishful-thinking approach to time." There are a number of things I've thought about doing to help me be more efficient and less prone to distractions.

1. Physically distance myself from distractions (e.g. go to the library).

2. Keep study and fun areas separate.

3. Actively use my whiteboard (I have a huge 4 feet by 8 feet board on my wall).

4. Try to make the material real to me by imagining a close friend or family member sick, or that I will have to teach the material to an imaginary teenager.

5. Take regular, short breaks.

So far, those are the weapons in my arsenal for my battle with time. How do you stay focused when you'd rather go out and play, read, or do something else? I'd love to hear any suggestions!

Medic-Chat

Lucia Li -- “The time to stop talking is when the other person nods his head affirmatively but says nothing.”

Left to our own devices, we medics can be pretty lousy conversationalists. We are those awful people who no-one wants to invite en masse to parties because we congregate by ourselves in a little corner and talk about things sane people try to avoid.

My non-medic friends in college used to jokingly ban all “medic-chat” from parties, claiming that it demonstrated that we had no lives outside medicine (probably true) and that it was boring (evidently a falsehood). It’s a sad fact of life that we medical students talk about virtually nothing else but medicine (occasionally, we talk about medical school). And it’s actually very hard to not talk about medicine even when talking to non-medics. Ironically, that’s often when I talk about medicine the most, probably because I spend so much time in medicine that I have lost confidence in my ability to hold a decent conversation in anything else when wrenched from that bubble. (My non-medic friends would remark that medicine doesn’t make for a decent conversation either.)

But I am a staunch defender of “medic-chat”. Irrespective of whether medicine is a fascinating topic of conversation or not (it is), we medics would not survive as a profession without it. We certainly wouldn’t get through med school without it.

The practice of medicine is all about teamwork; talking about our jobs outside when we’re not working is just one part of that. Shared experiences forge stronger professional relationships and camaraderie. After a tough/ disappointing/ hard/ long day at the hospital, talking to a fellow medic about it is often just what’s needed to help you deal with it and, more importantly, make you want to go back in there and do it all again.

But by far the most important part about "medic-chat" is that it’s with other medics -- people who understand what it’s like, both the good bits and the bad. In the hospital, so much of what we are privileged to hear, see, and do is unique. Some of it is downright traumatic, revealing humanity at its worst, its most vulnerable. Acting as each other’s counselors, we don’t judge if another medic is less that PC about something, we understand the little triumphs, and we sympathize with the failures.

There will always be times when medicine is the last thing I want to talk about. But, when the going gets tough and I just have to deal with what’s coming, it’s the medic-chat that will see me through.

A Taste of My Own Medicine

Kendra Campbell -- I’m sitting in my bed in my apartment in Brooklyn, New York. I am wearing comfy sweatpants and have my blanket pulled up as high as it will go while still allowing me to type. I have two pieces of toilet paper, crumpled up, stuffed in each nostril, soaking up copious amounts of mucus. The heat in my apartment is turned up to the max. My bedside table is littered with cough syrup, nose spray, ibuprofen, tissues, water, orange juice, chapstick, day time cold meds, vitamins, and honey. Every few moments, I have to stop typing to cough up some mucus into a tissue, or to change the “snot plugs” in my nose.

You might have guessed by now...I am sick.

What started out as a minor cold eventually turned into bronchitis, and I somehow then developed pneumonia. Life definitely sucks right now.

Yesterday was quite an interesting day. I came into the hospital at 8:00 a.m. for morning rounds. My attending physician took one look at me and told me to go home and to get checked out by a doctor. Since I have no primary care physician in New York, and since I didn’t feel like calling around to various doctors, only to be told that they weren’t accepting new patients, and since my health insurance is so crappy that I knew I’d be paying out of pocket anyway, I decided to take the elevator down to the Emergency Department of the hospital.

Now, at this point, I was still wearing my white coat and stethoscope, and when I approached the ED check-in counter, the friendly nurse immediately said, “how can I help you doctor?” When I told him that I needed to see a doctor, he promptly recorded my details and alerted the triage nurse to come take my vitals. Since I had to take off my white coat to have my blood pressure taken, I went ahead and left it off the rest of the time. Now, I was no longer a med student/fake doctor, but had joined the ranks of the patients.

After getting my vitals, the triage nurse handed me a cup and told me to get a urine sample and bring it back. All of the ED bathrooms were occupied, so I walked down the hallway to find an available bathroom. The only one I could find had a broken lock, but I decided to use it anyway. Halfway into giving my “sample” an elderly hispanic man opened the door, was surprised to see me hovering over the toilet with a plastic cup between my legs, mumbled something in Spanish, and then promptly closed the door. Yes, I was definitely now a patient.

I returned to the nurse, gave her my urine sample, and sat back down in the ED waiting area. Many hours went by, and many of my fellow med student friends came by to check on me, and upon realizing how long I’d been waiting, suggested that I use my med student status to get bumped up in line. They had apparently done this many times before. I thought about it, and decided that I didn’t want to. My visit really wasn’t an emergency, and I didn’t think it was fair to go ahead of all the other people who had been waiting just as long. It eventually became obvious to me that had I kept my white coat on, I would have received different and mostly likely faster service.

If I had to do it all over again, I would do it the same way. I kind of liked the anonymity of being just another patient, and not a medical student wearing a stethoscope. In fact, I think the only way anyone could tell that I was not an average patient was by the color of my skin (most of our patients are latino/hispanic or black) and by how I described my symptoms.

In fact, I think the doctor who eventually saw me thought it was a bit entertaining that instead of listing my symptoms as a runny nose, watery eyes and coughing up blood, I complained of rhinorrhea, excessive lacrimation, and hemoptysis.

Ahhh, the joys of being a patient! Now please excuse me while I change my snot plugs.

The Inner View

Thomas Robey -- “That's it?”

I walked out of the emergency department where I just finished interviewing, wondering where the time had gone. Granted, this was my first residency interview. Many of my peers are in the midst of a grueling travel schedule. How many more will there be? I have no idea. Will they all fly by as this one did? Will I find myself out on the street wondering, “what next?” The likely answer is no. A lttle bit of preparation could go a long way. My goal is to be able to think by the end of the mind numbing exercise in self reflection known as the match.

What are your strategies to deal with the same questions and the endless slide presentations that you encounter on the interview trail?

Here are my once-tested tips on interviewing:

1. Physician, be thyself. It's probably less tiring if you do not need to put up a front of who you are all of the time. It's not in your best interest to pretend to be different than you really are. Plus, that's a lot of work!

2. When you answer a question, use specific vignettes. Think of this as "evidence-based interviewing." Your evidence is examples from the past. Plus, people remember stories better than abstract ideas.

3. Prepare for common questions. Each field will have a couple of common questions that are asked in the interview. Stock questions include, “Where will you be in 5 or 10 years?” or “What is the air-speed velocity of an unladen swallow?” Colin provided some of his stock answers in a previous post. Be sure you are ready to talk about your hobbies. I spoke today about Wunderkammern.

4. Have two or three questions about the program that you are ready to ask when the, “Do you have any questions about the program?” question comes along. I'm interested in knowing what kind of social and professional support I'll get as an intern and how the program can nurture some of my specific interests, so you can bet I'll be asking that of my interviewers.

Hopefully by the end of the day, the folks on the admissions committee will have better insight into your motivation and personality. My goal is to provide them with an “inner view” of my credentials. By now, we've undergone so much self-examination that a conversational interview should come naturally. My challenge is to get comfortable enough to let the good stuff show.

What are your interview pearls?

My First (Standardized) Patient

Jeff Wonoprabowo -- The document I downloaded told me that my first integrative OSCE (Objective Structured Clinical Exam) would have a patient with either a neurologic or cardiac complaint. These clinical exams, with a standardized patient (trained actor), are stressful enough for third and fourth year medical students -- at least I imagine they would be. Last school-year, one of my housemates (who was a 3rd year at the time) was preparing for a Psychiatry OSCE and he seemed pretty stressed out about it. He even asked me to pretend I was a patient so he could practice interviewing. Playing crazy is kind of weird.

Well, I'm in the fall quarter of my second year. "Nervous" would be an understatement for how I was feeling about the OSCE. "FINE" would probably be a little more accurate -- but only if you use the definition from the movie, The Italian Job (definition: "Freaked Out, Insecure, Neurotic, and Emotional").

The quick version of the story, the same one I told to a couple of my classmates after the OSCE, is: I started off great. I smiled, greeted, and then, I shook the patient's hand. And then it all went downhill from there.

I laugh about it now -- although I still cringe a little. I still have to make an appointment to go view my video with one of the staff members. That is one movie I am not looking forward to seeing.

Before the OSCE, I spent a lot of my time focusing on the exam part. I practiced and mentally walked through the steps of a cardiac and neurologic exam. Now, I wish I had spent more time going over the parts of the interview.

Before interviewing the patient, I could list off the Review of Systems and the various questions I needed to ask if the chief complaint was a neuro or cardiac problem. After the interview, a flood of questions I should've asked came into my head. For example, the patient's vitals were posted outside the exam room on the door. I jotted them down on my sheet of paper. I should have realized that her age was not listed and during the interview I never thought to ask. In fact, the interview was littered with mental lapses where I would forget to ask certain things or totally gloss over a detail that I should have investigated more deeply.

At this point, I'm chalking it up as a very useful learning experience. I'm glad we had the opportunity to try this during our second year, as it's one of those things that you just have to practice. It'll also make interviewing a real patient next year a little less intimidating, too. Interview skills will come with time, and each of us will develop our own style.

I've heard that we'll get credit for doing it -- and I'm hoping that is the case.

Surgery, Interviews, and Rock 'n Roll

Ben Bryner -- Like Colin, I'm on the interview trail, trying to line up a residency (although I'm applying into general surgery). I'm hearing some of the same questions as he is. Actually, nobody's really asked me what I would to if I couldn't be a surgeon. But my predetermined answer is: A sushi chef (like surgery, but more delicious) or a reporter.

One of the other questions that I've been told to prepare for is "What kind of people do you have the hardest time working with?" Obviously, this is a trap. (The old tried-and-true trap question, "What are your weaknesses?" is now such a cliché that I haven't heard anyone ask it.) So when someone asks you what kind of people are difficult to work with, you can't give the correct answer ("People that are both mean and stupid"). But this is fine, because the interviewer's point in asking the question is not to obtain information (everybody knows the right answer) but to see how you think.

So one way I've answered the question is to say that as a medical student, people who don't give you a chance to get involved are the toughest ones to work with. If a resident assumes I don't know how to take a history by myself and makes me just watch them talk to a patient, it's frustrating and I tend not to learn much from them. Or, one time when I asked a nurse how to log into a program for tracking patients, instead of doing so she said "I don't think you have access to that program" even though I did. That specific situation wasn't a real problem, but when enough people share that attitude, it makes it a frustrating place to work. Conversely, when an attending assumes I am interested in a procedure and lets me help at an appropriate level, I learn a lot more and enjoy it.

By answering this way I hope to show the interviewer that I like getting involved, am a team player, and will be interested in teaching students when I'm a resident. I have no idea if this comes across the way I mean it, but it's obviously better than some other potential answers.

Maybe I can explain my answer another way. If you've played the game Guitar Hero, you'll remember that there's a little meter on the side of the screen that shows you how well you're doing. The needle starts out in the middle as the song starts, and with each note you play correctly, the meter inches toward the green zone at the right of the meter. When you miss a note, the meter dips down toward the red zone on the left. For a lot of songs, if you're bad at the game like I am, before you can get past the tricky intro to the song, the meter hits the far left, the virtual crowd starts booing and the song stops abruptly. It's very sad, because if I can just get the song started I can move the needle to the green, build up some momentum and even if I fumble through the solo, can finish the song.

Sometimes it seems like every new resident or attending I meet has a little meter in his or her mind that tracks my performance -- how well I answer questions, how well I present patients, how efficiently I work, etc. If the meter stays in the green, I'm doing well and I get a good evaluation. If it hits the red I get ignored. Which all makes sense. The good ones start the meter out in the middle, giving me a chance to show what I know and show my interest. But some people start that meter out in the red, and before I get a chance to get involved, they've already decided not to bother teaching me, a mere student. Thankfully those people are a lot less common than the good ones in my experience. I haven't yet busted out the Guitar Hero analogy in an interview (it's time-consuming, for one), but I'm ready to do so if necessary.

Finding Out What You Want to Do

Colin Son -- I’m a fourth year student in the United States trying to get into a residency for next year. The interview trail is going reasonably well. I’ve managed to avoid being "pimped" on clinical questions and have been faced with only a few "difficult" questions -- the latter being those that exist merely to test your reaction under stress and your ability to think on your feet.

For the most part, my interviews have been congenial if not down right fun. And they should be that way as far as I’m concerned. I’m still not quite clear what a program truly gets when a faculty member makes an interview a minefield. This is a two way street, with the residencies evaluating the students and the students doing the same in turn. As one fellow interviewee said on the trail, "Heck, if they make the interview a pain… I won’t rank’em very high."

It is a little wearing answering the same questions over and over. One of the most difficult things is actually asking questions of your interviewers with some sincerity. And yet over and over, you ask the same questions of different faculty just to make it appear as if you have an interest and just to keep the conversation going. I’ll admit though, at times it is good to compare different people’s answers to the same question. I’ve found I’m running into a groove where I ask the same three or four questions at every interview, unless there is something really specific to the faculty or the program that hasn’t been addressed.

I’m sure the faculty get the same faraway glint in their eyes as the interview season drags on. So many applicants must look the same on paper, must give the same answers to the same questions, must have the same suits. But I’ll give myself some credit; my application has some unusual elements. Notable is my considerable political and health care policy experience and, maybe an even bigger conversation jumpstart, my time in film school. If nothing else, it allows me and my interviewers to talk about something different.

I’m also trying to keep my answers to typical questions lively and interesting. For example, I’ve been giving a lot of thought to the question that keeps popping up: "What would you do if you couldn’t be a physician?"

Here is what I have so far:

1. Writer/Filmmaker

I’m a writer at heart. If I had had the stamina to wait tables for five years, trying to break into the industry, I may never have even discovered my love of medicine. The ideal situation would be to make it as a writer, not limiting myself to just film and television, and then be able to pick and choose my own work to get behind the camera and direct. The beautiful thing about writing is you can do it from anywhere. I would love to be a world traveler. I wish I was writing at some Dublin pub right now.

2. Poker Player

A gambler is just what patients want in their surgeon. What can I say though, I love the card table. At least I’m not a craps player. There is some talent with a good game of hold’em. In fact, poker rewards some qualities you would want in a physician -- especially in a surgeon and more especially in a neurosurgeon. Despite what you see on edited televised tournaments, poker is often a game of considerable patience. A fine quality when a brain surgeon is spending eight hours delicately taking out a tumor. Poker also requires considerable nerves, which might not be a bad thing in the operating room. Amongst the best players it also requires an ability to remain calm; to take a “bad beat” as they say without going “on tilt.” I imagine that is what I would want of my surgeon, when something doesn’t go right in surgery.

3. King of England

I’ve got to throw something a little eccentric on the list. But seriously, to be part of one of the most storied families in the world would be an interesting experience. The thing that makes it attractive is to be able to live the lifestyle of the royal family while being able to devote your entire live to civic causes. No one doubts that Prince Charles, whatever you think of him personally, has raised the profile of key world issues. And the Princess, rest her soul, was a great humanitarian.

4. Ski Instructor

I have never met anyone with any skill on the slopes who didn’t dream of being able to fund their life by being a ski instructor. Granted, I imagine that teaching people to ski can get frustrating at times. The ideal situation would be to get paid for simply heading down the slopes yourself. Maybe instead of an instructor I could be a rescue skier or something like that, and help injured skiers down off the mountain. The important thing is to be on the mountain and be skiing. However it works, it is a dream job of mine.

5. Taxi Driver

I like driving. It really is as simple as that. If I could get paid reasonably well, then I would do it. I am, at times, a type A driver. But, I handle traffic very well and even clueless drivers; it’s only when I perceive that others are inconsiderate drivers that I get pretty peeved off and seem to compensate by driving pretty aggressively around them. I’m not sure what I would do if I moved to a cold environment for residency and had to sell my rear-wheel-drive convertible. I’m sure I’d manage; it would be a small sacrifice for training to do what I wanted to do for the rest of my life.

Anyway, any serious or non-sensical comments on how to make oneself endearing and interesting in an interview are welcome. I know that the interview process gets mundane for the interviewers as quickly, if not quicker, than it does for the interviewees.

And now, I’m off to yet another interview. Wish me well.

I Know You, I Know You Not

Anna Burkhead -- It was only my second day on the rotation when you were admitted after your tanker jack-knifed on the highway and you sustained 35% total body surface area burn from the gas explosion that followed.

I watched as my attending used the Bovie to perform escharotomy on both of your arms. I calculated your resuscitation fluids using the Parkland formula.

I learned how to do my first central line on you. I also did my 4th, 9th, 14th, and 20th central line on you. I’m sorry for all the pressure and needle pokes. Sometimes I could tell from your heart rate that you were in pain. I explained to you the need for frequent changing and rotation of central access in burn patients; I hope you understood.

I watched as the chief resident and attending trached you. You don’t have a lot of neck, and it looked hard.

When you were stable enough to go to the operating room, I put all 100 lbs of my body weight into holding up the hip of your 400 lb frame. It was a long operation. Your back was a massive area to cover with skin grafts.

When the graft on the back of your head sheared off because of your C-collar, I called Neurosurgery to talk about how we could clear your spine. You are too big to fit in an MRI machine. You weren’t responsive enough for flex/ex films. We didn’t have many other options, and the C-collar stayed.

I examined you in the most intimate of places when you developed a complication related to all your swelling.

Every morning I reported your ventilator settings, blood gas, and labs to my attending. Sometimes he asked questions about what to do about this lab value or that blood gas. Sometimes I got the questions wrong. Don’t worry, there was always someone overseeing me in your care. Sometimes patients don’t like medical students caring for them. I don’t think you are one of those people.

I talked to your brother every afternoon and updated him on your progress. I got so used to seeing him in the yellow burn contact precautions gown and gloves that I didn’t even recognize him in the cafeteria one day.

I followed you as a patient for the entire month that I spent in the Burn ICU. I talked to you every day, although you didn’t respond. Eventually you kept your eyes open and moved your arms a little bit. During rounds on my last day in the ICU, we decided to start weaning your sedation. I hope you wake up soon. I would like to meet you.

Visiting a Private Hospital

Lucia Li -- No one likes hospitals. It’s not always a pleasant environment to work in, and the more I do clinical medicine, the more I want to avoid ever being an in-patient. But, no matter how much I might whine about our public hospitals, I don’t think I could have it any different, as I found out when I went to visit a private hospital.

The first thing I noticed was the car park. It was surrounded by beautifully manicured lawns and untrampled flower beds. And it was free. Which is kind of ironic, given that the cars filling it made the car park look like some sort of car showroom. My battered little Clio looked distinctly out of place.

Then you walk in through the big double doors (more flowers, this time in pots) and are greeted by a shiny wooden reception desk nestled in the corner of a cozy waiting room. Key features include patients who are better dressed and have thicker wallets than their doctors (though I did notice that our consultant wore a tie for this clinic), a (free) coffee machine dispensing drinkable coffee in china (not paper) cups, and carpet (of the tastefully coloured, hotel lobby variety). And the staff are uncharacteristically calm. Probably because they have a working coffee machine and feet stamping isn’t nearly as effective on soft carpets.

And then there’s the consultation rooms themselves. They had curtains! Which not only looked like they had been brought in the last 5 years as opposed to the last 50, they also matched the cover on the examination couch, which matched the chairs. I half expected the nurses to have uniforms that matched the curtains as well. Most exciting was the discovery of an en suite off the consultation room. Not just a pokey toilet, but an actual bathroom, complete with shower and bath. The excitement really was a bit too much…

This visit certainly opened my eyes to what "the other side" was like. Now, I’m not going to debate the relative ethics of private health care. No doubt one day when I qualify, I will do my fair share of private work and will enjoy the rather cushy surroundings and financial benefits. More-hotel-than-hospital is probably what they were going for, and I think I’d love being a patient there. But, it was all just a bit too surreal for me. Call me old-fashioned (or masochistic), hospitals aren’t hospitals unless they have certain features. The walls a faint generic shade of pea-green, squeaky lino floors and that reassuringly distinctive whiff of scented cleaning products not quite masking the delicate undertone of melaena… now that’s something I understand!

My Weekly Anxiety Attack

Jeff Wonoprabowo -- I remember when I was in first grade, my teacher would split the class into teams and we would play trivia tic-tac-toe. Whichever team was able to answer the question correctly had the chance to place an X or an O on the board. At one point I answered so many questions in a row that she instituted a new rule: Jeffrey can't answer every question.

Somewhere along the way, I have no idea when, I stopped wanting to answer questions -- even when I knew the right answer. Thinking back to my college days, I don't think I ever raised my hand to answer a question or offer an opinion. I only did so when called upon. Maybe I didn't want to sound dumb saying the wrong answer, I don't know. All I know is that I've gone from an excited first-grader basking in the spotlight of answering questions to someone who would rather just sit quietly and let the spotlight fall on others. Now that I'm older and wiser, I know the value of being "cool." And it can be quite stressful being put on the spot, with the wrong answer, or no answer at all, rolling off your tongue.

In medical school, about once a week, we have a pathology session that involves team-based learning. During these sessions, the class is divided into groups of five (these groups work together throughout the whole year and various different classes as well). Each lab session is intended to help reinforce the material we covered in lecture during the previous week. And this is where I am guaranteed my weekly episodes of anxiety and stress.

At the beginning of the lab session the groups are all given a laptop and we take a group quiz on the computer. Once that is submitted, we receive a worksheet with about 12 clinical vignettes. We must determine the disease for each one and answer questions about each particular case. (These questions will ask for things like the mechanism, clinical presentation, comparisons with similar diseases.)

After about 40 minutes, our course instructor picks up a microphone and announces that our time is up. His assistant walks over to a group and hands the microphone to a person of her choice. At this point, Nervous Student (NS) has the eyes of the entire lab (almost 100 pairs) on NS, and NS has no choice but to take the microphone and announce his/her name and group number. And the encounter might go something like this:

Professor (P): "What does this patient have?"

NS (answering with a shaky voice): "Carcinoma-in-situ"

P: "And what condition most likely preceded this lesion?"

NS (drawing a blank): "Um..."

P: "Consult with your group."

After conferring with the group, NS replies: "HPV infection leading to dysplasia."

P: "Good, and will the biopsy reveal malignant cells penetrating the underlying basement membrane?"

NS: "Uh.. I don't think so."

P: "Of course not."

NS (sounding very confidant): "Oh, right. Of course not!"

Cue class laughter.

The encounter might seem quite benign. No harm, right? But every time I go to lab I am anxious and apprehensive hoping that the microphone is not pointed in my direction when it is my group's turn. And I get the feeling that I'm not the only one who feels this way.

Maybe it's good for me and will prepare me for the pimping that will come during third and fourth years. Then again, with all the stress and anxiety, maybe it's bad for me.

Oh, who am I kidding? Medical school is a big ball of stress and anxiety, and that much more can't be that bad... Right?