The Differential: Medscape Med Students Blogs

What Is the Best Age to Start Med School?

Anna Burkhead -- The average age of my first-year medical school class was 24.5. The oldest member of the class was 41, and the mythical youngster was but a raw 19 years old. The most common age was probably 22 or 23, a good three months wiser since college graduation earlier that May. But some of us had taken time off between college and medical school to pursue another calling, profession, or mission.

Starting with the young one: Obviously this kid had been advanced for his years throughout his entire schooling. Probably started college at 16. I never even met this person, so I can’t make any statements about his maturity level. Of course, if he made it through college at that young age, applied and was accepted to medical school, he must be something special. He’ll graduate and become a doctor at age 22, and finish residency around 26. There’s potentially a very long career ahead of him, with many accomplishments to be made!

The mode of the age graph for my class falls right at 22, ie, a very recent college graduate. There are many people out there who advocate heading straight from college to medical school. I can see some advantages: no loss of momentum, younger age upon entering practice, the “just get it over with” factor. But, no offense to my colleagues who followed this path, there’s a lot of life experiences to be had besides that of a student. And I imagine it can be pretty tough to identify with a patient who makes minimum wage working 16 hours a day if you’ve never had a full-time job.

My class includes people who had all kinds of professions before embarking on medical careers. I was a high school teacher. I have friends who were researchers, bankers, architects, professional soccer players. In my experience, having had another job before medical school has been nothing but a positive thing. I had things to talk about in med school interviews, and people still want to know all about it, even now in residency interviews. Countless other benefits in terms of my own maturity, compassion, and work ethic can be attributed to my experience as a teacher. Not to mention I made a little bit of money in the working world! (A very little bit of money).

The 41-year-old woman in my first-year class had a long, successful career as a Physician's Assistant before applying to medical school. On the first day of class, one of our peers gauchely remarked that her daughter was older than some of us. (Note: there is no age requirement for medical school, and there is obviously no requirement for social appropriateness, either!) Although she has a good amount of experience, wisdom, and maturity over the rest of us, does being 15-19 years older than most of her class mean that her career will be 15-19 years shorter, after the same amount of resources spent training? I don’t know, and I don’t know if it matters.

Med school can be experienced in a completely different way as a youngster, recent graduate, worker with a few years under a belt, and veteran in another career. Of course I’m biased, and I prefer my path, but I can see pros and cons to each career trajectory.

Resolutions of a Fourth-Year Med Student

Anna Burkhead -- It’s finally 2009! This is the year that fourth-year medical students across the USA (and final year students all over the world) have been anticipating and dreading for untold amounts of time. It’s the year we get a diploma, the year we stop paying tuition and start paying income tax, the year we become doctors.

But before we get there, we have to survive the hardships and obstacles presented by the final year of medical school: the long hours… the never-ending exams… the…

Who am I kidding? The fourth year of med school rocks.

With the new year and the approaching graduation date in mind, here are my 2009 New Year’s Resolutions.

1. I will take the time to really look at the cities in which I’m interviewing for residency, as the schedule allows. Yes, I’ll be a resident at that program. But I’ll also be living in that city!

2. I will thoroughly enjoy my last “official” Spring Break.

3. I will not fall so in love with my iPhone that I forget how to use a computer. Admittedly, I did attempt for all of 30 seconds to write this entry on the iPhone, to avoid getting off the couch (again, fourth year rocks) but even with mini, stubby fingers, it was a bit daunting.

4. I will use my Step 2 CS trip to visit friends, with a minor interruption for that pesky test.

5. I will conquer my fear of airplanes -- an apparent necessity when flying somewhere practically every three days. I am tired of looking like a crazy person during the take-off!

6. I will try to attend every medical school class function between now and graduation. We’ll be scattered all over soon enough!

7. I will learn how to pack all of my interview necessities in one small (-ish) suitcase… Why is this one so hard for me?

8. I will enjoy my LAST MEDICAL STUDENT ROTATION EVER (February -- Outpatient Medicine)

Match day in 2.5 months! Graduation in T minus four months!

Now back to my very, very stressful fourth year. :)

My Life These Days

Anna Burkhead -- Wake up. DID I OVERSLEEP? Did my alarm not go off?

Oh wait, I’m not on a rotation now, I don’t need to get up.

Get up anyways. Maybe some residency program coordinator on the east coast is an early bird, and is sending out interview invitations at this hour. Check my email. Wishful thinking.

Make some coffee. Read a news story online. Check email. Read another news story. Check email again.

Random cleaning / errand / meeting. Check email. No residency interview invitations.

Pick up suit from dry cleaners. Wonder if anyone notices or cares that I wear the same thing to each interview. Think about how I can’t afford another suit anyway because of the plane flights and hotel rooms. Check bank account balance, pout briefly.

Check email. WHERE ARE THE INVITES, PEOPLE?! Check Dermatology student forum to see if anyone else has gotten an interview invitation today. Feel better that everyone else is sitting in front of their computer repeatedly pressing “Get Mail” button in between idle online browsing sessions.

Write thank-you notes to interviewers. Lament the fact that today’s second graders are no longer taught how to write in cursive.

Check email. Check spam folder, just in case.

Phone call from a friend who’s out on the interview trail. Canned “I don’t know” when asked why the Dermatology programs wait until late in the season to offer invitations. Check email while on the phone.

Double-check arrangements for three piggybacked one-way flights so I can attend the most interviews possible. Try to forget that I hate flying.

Scroll through my ridiculously color-coded interview spreadsheet. Hope no one else ever sees it.

“Business Casual” for interview dinner. Eat well, ask a lot of questions, drink a little wine.

Lay out suit for interview tomorrow. Set alarm. Dream about March 19th.

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.

On the Bus

Anna Burkhead -- For several reasons, not the least of which being ridiculous gas prices and Chapel Hill’s amazing public transit system, I take the bus to the hospital every morning. It is clean, timely, and free. It runs early enough that if I get a head-start skeletonizing my notes in the morning, I can still get to the hospital early enough to pre-round in time for 7 am rounds.

The population of riders on the early morning bus to the hospital is a particularly strong reminder of the variety and diversity of healthcare workers. At 5 am, pretty much the only people riding public transit are headed to the university and to the hospital. I use the 15 minute ride to sit quietly and mentally prepare for the day. I also think about what the other riders are about to get into as their day at the hospital begins.

There are many nurses, nursing assistants, and nursing students who ride the early bus. I think of their upcoming hours closely monitoring patients, administering medications, and generally taking care of patients' each and every need.

There are a few residents who board the bus with me. I think of them rounding, frantically entering orders and writing notes, possibly catching a bite to eat at some point, going to the OR, going to the call room, going to clinic, going to the code, going to grand rounds, going crazy?

Cafeteria workers dressed in their white buttoned shirts and black pants take the early bus. I think of them in the hot cafeteria kitchen, dealing with stressed and hungry hospital patrons all day.

There is the occasional environmental services worker riding public transit at the dawn hour. I think of them working long hours trying to make the hospital a clean and safe place for patients, visitors, and employees.

Too often in the hospital we are surrounded by our own. Yes, I’m surrounded by nurses, assistants, technicians, cleaning crews, and food service workers all day, but my primary interactions are with other medical students, residents, and attendings. I am grateful for these early morning moments on the bus when I have a moment to reflect on and be thankful for all the work that goes on behind the scenes and all around us. Each of these dawn bus riders is vital to the daily operations of hospital life, and I love that moment of shared purpose as we travel to do our very different jobs in the very same place.

What Would You Give?

Anna Burkhead -- Donating your long hair for cancer patient wigs? Easy.

Donating blood? Easy.

Donating platelets? Easy, I hear, though it takes a little time.

Donating bone marrow for a stranger? Do-able, if you have guts. And Xanax.

Would you donate a kidney?

Recently I met a non-medical person who, during our conversation, told me that he was donating a kidney in the next month. The surgery was scheduled, his plane flight was booked. “Is it your sister? Dad? Cousin? Childhood friend?” I asked. “No,” came the answer. This person’s kidney was going to be transplanted into a total stranger.

“You know you only have two, right?” Of course he did. “You know it’s a big surgery, right?” Of course he did. This person appeared to know all the gory details of a nephrectomy, short of seeing it firsthand, as I have. The only flaw that I could find in his plan was that he was planning on taking only one week off of work, and the surgery was happening in Texas.

“What if you have kids someday, and one of them needs your kidney?” He had an answer for that too, albeit an optimistic one. He said that if the world progresses in the way he hopes, some stranger will generously donate his kidney to the child, as he was currently in the process of doing. “That’s a big risk,” I thought to myself.

I consider myself to be a generous person. Without hesitation I would donate regenerable body parts such as hair, blood, platelets, and bone marrow. However, when it comes to donating an organ like a kidney, only family and close friends need apply, and even some of y'all might not be eligible.

That statement may sound selfish to some people out there, as I’m sure it did to this man I had the conversation with. But if I’m going to give up an organ of which I have only two, I’m going to be pretty strict with my criteria. I want to know that my donation will be taken care of. I want to know that medications will be taken as prescribed. I want to know that doctor’s appointments will be attended as scheduled.

My interaction with this person made me feel a bit selfish for not wanting to open my own Gerota’s fascia, divide my renal vessels, and hand over one of my two precious urine-makers. But people, it’s a kidney!! What would you give?

ERAS Madness

Anna Burkhead -- This week, ERAS (Electronic Residency Application Service) opens for fourth year medical students all over the world to submit their applications to US residency programs. However, if you’re anything like me and my neurotic friends, today certainly isn’t the first day you’ve logged in and browsed through the application system. (Not to worry anyone! If today is your first day on ERAS, you still have plenty of time!)

I am applying for Dermatology residencies, with an Internal Medicine preliminary year. Since Dermatology is considered to be quite a competitive specialty with a low match rate, I have to apply to a large number of programs. The reported average number of programs applied to is 55. Right now, I have 53 programs on my list! I have yet to preview my invoice for my application. I may just have to shut my eyes, enter my credit card number blindly, and hit submit, so I won’t have some sort of respiratory arrest before my application goes out!

With a list topping 50 programs, there are certainly ones I’m more interested in than others. In fact, when I’m poking through the super-elaborate spreadsheet that I’ve made detailing program characteristics, I occasionally catch a glimpse of a program name and find myself wondering what state it’s in.

When and if (please when!) interview offers start coming in, I’ll have to do some better research. When applying for medical school, it was easy for me to keep my programs straight, since I only applied to two. But for residency, my ideal plan is to interview at about 15 programs, and that will require much more careful research and documentation.

Right now, ERAS is the topic of choice in every medical school circle I’ve been a part of for the past few weeks. Not that I’m complaining; I certainly have just as many questions and complaints as the next Joe, MS4. However, I am looking forward to the few months during which we’ll be at an ERAS standstill. Applications will be out, with no changes to be made. We won’t expect interviews to be offered until a few months later (at least that’s true for Derm, most of the interviews are mid-December and the whole of January).

I have one reminder to myself for every time I stress about ERAS and applications. I have about eight months left out of four years of medical school. That means I’m about 83% done. In other words, the “damage” is done. I have done nearly everything I possibly can in order to make myself a good candidate for a Dermatology residency. This ERAS stuff is basically just wrapping all that information up and sticking a big fancy bow on it.

A Difficult Meeting

Anna Burkhead -- This week I witnessed a difficult situation that was artfully handled. Allow me to explain.

First, a little background. I have not had a formal course in medical ethics and law, so I’m trying to pick it up from various attendings on my rotations. One basic of medical ethics is privacy. Without a patient’s permission, doctors cannot disclose information regarding their medical status to others, including family members, provided that the patient is a competent adult. This rule becomes clouded with unconscious patients. If a family needs to make life-or-death decisions for an unconscious patient (for example, the decision to take a patient off life support), it is important for the family to have all the available information. In this situation, as I understand it, it is permissible for the doctor to share information about the patient’s medical conditions with the family, in order for them to make an informed decision.

A few days ago, a patient on the general medical floor coded, was intubated and stabilized, and subsequently transferred to my ICU team. The patient had AIDS and cryptococcal meningitis and was non-adherent with medication regimens, and had suffered a respiratory arrest. After the arrest, the patient had fixed and dilated pupils, no withdrawal from pain, no purposeful movement, and areflexia, and was diagnosed with clinical brain death. An EEG was ordered. However, the EEG findings did not meet criteria for brain death, although there was very little electrical activity in the patient’s brain.

The chances of this patient recovering were essentially zero, and my attending called a family meeting to discuss the next step. A few matters were anticipated to complicate the meeting. The patient’s family was Spanish-speaking, and so an interpreter was called. Also, although the patient was a male, it was unclear what gender the patient lived as on a daily basis, and we wanted to respect the patient and the family by referring to the patient with the most appropriate him/her pronouns. Most importantly, the family did not know about the patient’s HIV status.

Before the meeting, my attending explained to me the need for family to have all the relevant information in order to make the decision about taking the patient off the ventilator. However, he said that he’d “feel out” their feelings on the decision, and if it didn’t seem necessary to reveal the HIV+ status, then he wouldn’t.

It was evident from the first minute of the meeting that the family thought it was best to take the patient off the ventilator. This made the discussion easier from the start. However, one of the first statements made by one of the brothers was that they wanted to donate the patient’s organs, particularly the heart. Everyone on the medical team knew that an HIV patient’s organs would not be accepted for donation. But, this was an extremely generous suggestion, and so my attending gently explained that although he’d look into the possibility of organ donation, some patients were ineligible for various reasons. He did not reveal the HIV status at that point.

Minutes later, a sister asked a very intelligent question. She asked how a regular person could get this strange type of meningitis. My attending explained that the patient’s immune system was not as strong as other people’s. He did not reveal the HIV status at that point.

Towards the end of the meeting, after a few minutes of silence, one of the siblings spoke up and said, “I heard that there was HIV.” At that point, my attending confirmed the patient’s HIV positive status and explained its contribution to the situation. The family did not seem shocked or more upset than they already were.

As the meeting closed with a prayer from the hospital chaplain, the family seemed at peace with their decision to stop the ventilator, and the medical team was satisfied with the outcome. A few hours later, the patient was extubated, and died within ten minutes.

This scenario was not an easy one, and not clear-cut in any way. I thought my attending did a superb job in discussions with the family, both in his respect for the patient’s privacy and the family’s need to be as informed as possible. I was relieved that the HIV issue had been broached by the family; it seemed more appropriate to tell them, and I was glad that the family understood all the conditions that led to the patient’s death.

Medical ethics is not simple. There is no tell-all handbook which, after reading, makes every decision clear and easy. As medical students, the best way to learn how to handle these difficult and ethically-complicated situations is to watch and listen to doctors we respect. In time, the situations will be ours to deal with, and we need to be ready.

Homesick

Anna Burkhead -- As I’m writing this entry, I’m seated in sweatpants on a horrid floral and fringe sofa. In a few hours I will hop in my twin bed and sleep until the night float team sends their 4 am page with the overnight admissions.

It’s not my first time on this couch; I spent a month at this hospital on the North Carolina coast last year. In fact, I requested to come back here for this month to do my acting internship in Internal Medicine. So I can’t complain too much.

However, this living-out-of-a-suitcase lifestyle I’ve led basically during the whole of third year and now extending into the first two months of fourth year is getting tiresome. Before the beginning of my clinical years, knowing that my unmarried and childless status would mean more than my share of away rotations, I requested to be sent to my hometown hospital. It was nice for a while. I enjoyed not paying rent!

Last month I did an away rotation in dermatology at the University of California at San Francisco. While I learned a lot and got to know some good people in the program, it was a hard month for me. Being away from my home and my school (and my cat!) was very difficult for me.

On the last day of the rotation, I received a phone call from my apartment complex office back in Chapel Hill. They informed me that there was a problem with a major water leakage from a burst pipe into my apartment. It is unknown how long the stagnant water was sitting, because no one had entered the apartment. The office managers have been very good about keeping me updated and I am confident that things will get cleaned up appropriately. That said, I have not been able to return to Chapel Hill to check out the damage since it occurred. I’m basically taking a near stranger’s word as to what appears ruined and what appears salvageable, and I’m not there to “encourage” the cleaning and repair process.

I flew back from San Francisco and drove straight to this coastal hospital without passing through Chapel Hill. I will take my first glimpse of my water-logged home this weekend, when I return to Chapel Hill for a required practical exam.

While I’m bothered by the situation in Chapel Hill, I’m trying not to stress. After all, there’s not a lot I can do about it right now. I’m just feeling weary and tired of being away from home. Fortunately this is my last away rotation until February. In December and January I’ll be flying all over the place interviewing for residency, but those will be more tolerable short trips.

My apologies for this “downer” column. Medical school isn’t always peaches and cream, and it’s sometimes hard to live your normal everyday life and do your normal everyday things, especially from three hours away. But I guess learning to juggle all the responsibilities of being a student, learning medicine, and being a person all at the same time is part of this process.

Medical Monikers

Anna Burkhead -- Recently, two of the biggest movie stars in US pop culture celebrated the birth of their twins. Angelina Jolie and Brad Pitt added to their brood of children (twins make six!) with the delivery of a boy and a girl over the weekend in France. Their newborns' names: Knox Leon and Vivienne Marcheline.

Knox and Vivi join the cadres of celebrity babies with unusual names. But this trend is not limited to the rich and famous. When I was on my 3rd year OB/GYN clerkship, I witnessed and participated in many deliveries. Most of the names given to these precious newborns were unremarkable. However, of note, I did witness the christening of twins Mi'Angel and Mi'Joy, as well as a beautiful baby girl Taryntulla (you may need to say it out loud).

It made me wonder about the babies born every day with unusual monikers. Well, I did some scrounging around on the miracle that is the internet, and found more than a few names that are sure to make you furrow your brow. I was particularly fascinated with the medical-themed handles that have been reported on birth certificates.

First, two disclaimers: 1. Some of this is probably folklore. 2. Every baby is a precious gift, and even if the baby's name is Plantar Wart, Jr. he can still grow up to be a fine upstanding person.

Here are some gems I came across.

Enamel (pronounced EE-na-mul, like animal with a long 'e')

Urea (pronounced YUR-ee-ah, emphasis on first syllable)

Syphilis (pronounced suh-PHYL-us, like Phyllis with a –suh)

Eczema (pronounced as usual)

Ovary (pronounced oh-VAR-ee)

I'm not sure what the procedure of signing a birth certificate entails. However, I would think that a doctor, nurse, or other medical professional would be somewhere nearby and could potentially intervene, or at least verify, that parents know the meanings of these words, before they're inked in legal print.

Perhaps these words have ancestral or cultural meanings in particular families' cases. But in other situations, I could imagine these medical terms being chosen for baby names because they sound pretty, without actually knowing their meanings.

I'm sure there are some Labor & Delivery folks out there who keep lists of their favorites, either because they truly love the name, or they're truly fascinated by it. Let's hear 'em!