The Differential: Medscape Med Students Blogs

To Be, Or Not To Be (In Class)

Jeff Wonoprabowo -- As a first year student I attended the majority of lectures. There were, after a while, a few professors whose lecture style I preferred not to listen to. And there were a couple of days when I woke up and just had to sleep in another hour and would skip the first class. But all in all, I think it's safe to say that I attended over 80% of lectures.

It wasn't because I had figured out that I learn better through lecture. It was because of fear. I had this paranoia that I would miss something important. Maybe the professor would say something like "Know this for the test," or "This part isn't important." I was always amazed at classmates who never came to class. On exam days I would occasionally see someone who I didn't recognize at all.

Since we returned from Christmas break, I attended the first lecture to pick up the class notes, I attended a Pharmacology Lab which was not optional, and I attended a Religion class that requires attendance. Aside from those three, I have not attended any other lectures in three days. I am trying out this self-study thing.

The good thing is that I'm trying this out at the very beginning of the quarter. I've decided that the experiment will not last longer than a week. Hopefully that will be enough time to figure things out.

Maybe it isn't a good idea to mix things up right now. I really hope I'm not trying this because I'm lazy. I am hoping that once and for all I will be able to know whether I study better with lectures or on my own. Although, in reality, the best will probably be somewhere in between the two.

I'm curious how others here study. Do you attend lectures? Do you skip all? some? none? Anyone else feel paranoid about missing "important info" by missing lectures?

My First Autopsy

Jeff Wonoprabowo -- The woman instructed me and my classmates to gown up. I wasn't sure who she was. She never introduced herself. Maybe she was a nurse. Or maybe one of the investigators. After I had put on the shoe covers, mask, hairnet and gown, I was led into a large room that had a number of exam tables lined up along the walls, each next to a sink.

I had been to an anatomy lab with cadavers before. But this sight was strange. The bodies lying on the metal exam tables weren't donated to science. They were waiting to be autopsied by a medical examiner.

My partner and I soon found out we would be observing Dr. X (identity withheld) perform an autopsy on a homicide victim. The victim, who I'll refer to as Joe, lay waiting on the table, his eyes still open. He was a little bloody. I could see the bullet wounds. Some were small with superficial, circular abrasions indicating an entry wound. There were, of course, larger wounds that appeared to be exit-wounds.

Dr. X called and pointed us towards the report that had been filed about Joe. The first page contained a written note about what was found at the scene. The next few pages included color photographs of the crime scene. X-rays of Joe's chest and abdominal area hung on a nearby wall.

Five hours later, Joe's heart, lungs and liver had been removed, cleaned and weighed. Over ten blunt-force trauma wounds and twenty-one bullet wounds had been labeled, photographed and measured. Entrance and exit wounds were connected -- at least as best as one could, given the circumstances.

After five hours I left. My legs were tired. Maybe I'll cross off surgery from "my list." I also left with a renewed sense of how delicate life really is. Nothing slams that home more than seeing a human being whose life was ended prematurely under a rain of bullets. I couldn't help but think of the men and women in the armed forces fighting overseas.

Many of my classmates got "lucky" and only had to witness a 40-minute autopsy. I'm glad I got to see a homicide autopsy -- even if it was five hours long.

I'm Trying To Grow Up

Jeff Wonoprabowo -- As I write this it's raining outside. It's finally starting to feel like winter here in southern California. I used to love these rainy days as a kid. Playing in the rain was always fun. And I loved sitting in the car when it poured outside and the streets were filled with rushing streams of water. I used to hope my mom or dad would drive through the water. They didn't like to. I never understood why. But on occasion it was unavoidable and then I would sit wide-eyed as the water splashed high and the sound of the water hitting the bottom of the car echoed through our minivan.

The rain isn't as welcome these days. Sure, it's nice to be inside on a rainy day. But the joy of playing outside isn't quite the same. I drive my own car now. Going somewhere when it rains just means I get wet and the inside of my car will probably get dirty, too. And I don't drive through puddles. Who knows what could be hiding beneath the surface?

I've changed. And maybe that's part of growing up.

In high school I found my anatomy and physiology class absolutely fascinating. That class allowed me to realize my own interest in the human body and how it worked. In high school, though, I didn't know what it meant to be a doctor. I didn't know what it would take. I didn't know what kind of lifestyle the residents had. But I liked the idea of being a doctor. You could help people. You could make things right.

It's a little different now. Sure, I still believe that you can help people as a doctor. But I have a better idea of what goes into the making of an MD. Medical school is tough. (I heard that before, but now I know just how tough.) Residency is long, the hours are grueling. And attendings have to worry about the practice of medicine in the 21st century. It's no longer just about patients. Modern practice involves worrying about being sued, malpractice insurance, billing insurance companies that hardly ever pay what you bill, and dealing with endless bureaucracy and time constraints.

I guess I've changed in this area, too -- at least my understanding has. And I guess that's also part of growing up.

Later today I'll be going out to meet some friends for lunch. The rain will probably hit me on my head and, with my boots on, I'll probably walk through a puddle on purpose. It won't be the same childhood glee, but the amusement will still be there.

And when I once again come face to face with real patients instead of an exam, I know that the same wonder I had about the human body will return. It'll be tempered with the realities of modern practice. But at least the wonder hasn't died.

I guess growing up is about finding balance between childish naiveté and cranky, old cynicism.

Struggling To Be Best

Jeff Wonoprabowo -- People say that you need to know your own limitations. I think that you need to do more than that. You need to learn to accept those limitations. For most things, it is easy for me. I can accept that I'll never run like Usain Bolt, swim like Michael Phelps, ride like Lance Armstrong, or hoop it up like Kobe Bryant. But for other things, it can be hard. Who really wants to accept that they aren't as good as they thought they were? Or that they just can't achieve the same things others can? I sure don't. It's a humbling experience.

Before medical school I heard people say that the entire medical school class would be people who, for the most part, were at the top of their respective undergraduate classes. And they were probably also near the top of their high school classes. But within every medical school class, there will always be someone ranked first and someone ranked last. And nobody ever entered medical school planning to end up at the bottom.

The problem is that, in general, the kind of people who make it into medical school are pretty competitive. They want to be the best. And it is pretty difficult to not have the class ranking one is used to having.

Maybe the solution is to just be content. I guess I may have to accept the fact that I am not the best. But maybe I can hold on to the idea that my best can still be very, very good. And when I try to think like this I feel better -- I feel that as long as I give my all, I will be content with my performance.

And then I think about people who have risen to the top of their fields. Did they ever just "let off the gas pedal" and accept that they weren't the best? Did they ever feel that "just good enough" was really good enough?

How does one navigate between the desire to be better and the wish to be content with a job done well enough? I don't know. I wish I did. I guess I'll struggle with it some more.

My Christmas Rush

Jeff Wonoprabowo -- The Christmas season is here, and it seems like there is no forgetting it. All around, decorations are being thrown up, lights are being strung, and commercials are insisting that with just one more purchase we will achieve happiness for ourselves -- or our loved ones.

The Holiday season is also a tiring one. Everyone is frantic. It's a hectic time. It's the Christmas rush. People are scrambling around town hunting down that perfect gift. They're checking their schedules, planning parties, writing cards, and making trips to the post office to send parcels to distant friends and family.

And all of this is done with one date in mind: December 25.

I started thinking about my own December. It has definitely begun with a rush. My rush, however, is not about racing around finding the perfect gift, scribbling out greeting cards, or mailing packages. Actually, I'm thinking I should send a Christmas gift to my sister who is spending the year studying abroad in Argentina.

I find myself rushing full speed ahead towards Christmas vacation. The only thing in my way is a week of exams. Two of the eight exams will be NBME subject exams -- affectionately referred to as "mock boards" by many.

The full speed hurtling almost feels like I'm lying on my back speeding down a mountainside on a street luge. No, I haven't tried it. It looks fun -- and terrifying at the same time. Those guys have to manage the twists and turns. Fortunately they probably know the route beforehand so the turns aren't totally unexpected. But at those speeds, even the expected seems unexpected.

Maybe the equivalent for medical school would be trying to remain flexible amid the fray -- which has been difficult for me. I'm the kind of person who likes to know what's going to happen during the day. I'm the kind of person who doesn't like to begin studying if I know I'll have to stop in 30 minutes. It may sound silly, but I feel like it interrupts the momentum.

Student life -- and I guess life in general -- is full of interruptions. I remember being excited that I had a whole afternoon free to study (yeah, I know that sounds sad) only to find out I had a nail in my tire that needed fixing. So instead of sitting in the library for the entire afternoon, I ended up sitting at Walmart's tire shop reading microbiology notes while waiting for the repair. It felt like I lost time because of this interruption.

On the other end of the spectrum I have felt like I gained time. A couple times I have gone to class only to have the teacher not show up, which left me with time I should've gladly embraced.

So it's a juggle. And I'm working on it. I still don't like things popping up randomly when I'm trying to study. But I have to "roll with the punches," learn to be flexible, and use whatever time I do find wisely. After all, medicine is not a field where daily events follow a script or schedule.

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!

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.

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?

My Temporary Insanity

Jeff Wonoprabowo -- Right now I am writing this a few days before midterm exams. By the time this post goes live on The Differential, I expect I'll be in the middle of exam week. Exam weeks are never fun -- at least not for me.

Usually I'm pretty sleep-deprived during exam week. I stay up as late as I can trying to get that last bit of info to stick, wake up as close to the exam time as I can, take the exam, eat lunch, short nap, and repeat for the next day. It's not the healthiest way to spend a week. But then again, medical school isn't exactly the healthiest way to spend four years.

Occasionally, when the clock reads something like 2:30 AM, I find myself doing the strangest things. Well maybe I should say I find myself doing normal things at the strangest time of day. In the middle of cramming, I might get up, go to the bathroom, spray some shaving cream on my face, and start shaving. Another time, I started cleaning the toilet bowl in the early morning hours. I think I may have started vacuuming once.

Who does these things in the middle of the night? It's like I am suddenly struck by compulsions to do things I should probably save for later.

I would like to think that I only do these things because I am desperately trying to find a reason to take a break. I just hope these stress-induced episodes are not indications that I might be predisposed to some psychological problem.

Maybe I just need to do a better job of studying in the weeks before exams. That way, on the night before an exam, I can go to sleep by 10:00 pm because I am so confident in the studying I have already done.

So the prescription for my temporary insanity? Efficient, daily studying... Who knew studying could be therapeutic?

Mind Your Manners

Jeff Wonoprabowo -- Always let the other person go first. That sounds like a very civil thing to do, doesn't it? It sounds like something that one might hear at, say, an etiquette dinner (a dinner organized for the sole purpose of teaching proper etiquette for formal/business situations). It sounds like something a father, hoping his son will grow up to be a fine gentleman, might say to his boy. But when I heard this advice during my first year of medical school, it was not meant to be a civil, polite gesture.

When the upperclassman told me to let the other person go first, he was giving me advice about blood lab. Now, when I wrote about drawing blood last time, I wrote that I had hoped blood lab would only involve finger pricking. I guess that was just wishful thinking. Or maybe selective memory blocking. Regardless, I should have known the blood lab would involve needles because I was told about it over a year before it happened.

The rationale for such advice? If your partner was horrible at drawing blood and  treated you like a pin cushion, you could be sure to return the favor when it was your turn to draw blood. This was, of course, for the sake of education. After all, we should know something about what our patients (or in this case, blood lab partners) have to go through, right?

In my previous post I wrote about my one-try successful blood drawing. I wish it were due to my own skill. But I was lucky to have a partner who was nice and had large veins that were easily visible and fairly superficial. So I take no credit for my success.

When it was my turn, my partner tied the tourniquet around my arm. I told him to go ahead and make it a lot tighter. After tightening it, he proceeded to examine my arm closely around the cubital fossa.

My brown skin mischievously kept the location of my veins a secret, and my partner asked one of the nurses for help. She came over, palpated my arm, and located a suitable vein. After showing him where it was and allowing him to feel it, she left.

I sat there waiting for the sting. The pain came, and I waited. No blood. The needle pressed further. No blood. The needle pulled back without coming out of my arm, changed directions, and again pushed forward.

The needle's under-the-skin directional change was definitely a weird feeling.

Again, no blood appeared in the tube. At this point my partner mercifully pulled the needle out and called for help. The nurse came, relieved him, and drew my blood.

I suppose I got off easy, though. The next day I heard from and of classmates who had to suffer through three or more unsuccessful attempts. One classmate finally had his blood drawn from a vein in the radial side of the wrist because all the attempts in the arm were unsuccessful.

Looking back, I wish my partner could have had the chance to try again. It isn't the most comfortable thing, but we all need to learn how to draw blood. And I wouldn't have minded if he needed to try one or two more times under the guidance of the nurse. And in feeling this way, it seems that I totally ignored the advice I received. I guess I'm just a rebel that way.