Third Year Thus Far

Four months into third year at this point, with 2/6 core clerkships down: surgery and psychiatry. I've even knocked off a fourth year specialty (neurology), with another in the queue (orthopedics) - in the interests of more personal/interview time for myself next year.

I'm not gonna revisit the specifics of each rotation I've been through. Instead, I'm going to touch on their similarities.

Studying
Yes, I've harped on and on about how third year's a stark contrast to the first two, in that we aren't buried in books all the time. Key phrase: all the time. Yes, it's still med school and we accordingly still have to study. After all, I couldn't have learned surgery or psychiatry magically. Granted, you learn to some extent in the hospital. But in my experience, the hospital is more of a platform to apply what's been read, reinforce your learning with real patients, and a chance to show attendings and residents what you know. It also lets them get to know you as a person, which I'll touch on later.

At the end of each rotation, there's a "shelf exam." Why the term shelf? No idea. But that clerkship final is referred to as the "shelf." It's national exam of 100 questions given over 130 minutes, with a bajillion answer choices at times. Seriously, the bubble sheets go A-K for some parts. Akin to Step I, it's not just straight up recall. The questions are clinical vignettes reading a paragraph long in which have you integrate a lot of information together and whatever experiences you have. Then, question style can be tricky: secondary or tertiary in nature and/or patient management related. The last option is particularly hard at this point in our careers. Oh and the time crunch is very real and pretty severe, even for the psychiatry shelf. At the halfway point of both shelves so far, I was disconcertingly behind halfway pace.

Bottom of the Pole
As med students, we're at the bottom of the medical hierarchy. Even M4s are senior to us. At this point, we don't even have the luxury of having gone through the core rotations like fourth years have. As such, we're there for purely learning purposes - much like anyone who's not an attending: chief residents, residents, interns, M4s. Unlike those people, our base of knowledge and clinical utility is pretty limited, making us remarkably well suited for scut work - grabbing paperwork, transporting patients, food delivery, etc. Also, since we're new to the scene and rotating through different styles of services, M3s are remarkably awkward for the first few days on service. It's like being a high school freshman again, but having to pay for that experience.

Evals
I already mentioned the shelf exam and what that entails. Of note, it's worth 1/3 of our grade for the rotation. The other 2/3 comes from the attendings, fellows, and senior residents on service with us. Quick summary of what goes into those evals: interpersonal skills, knowledge base, work ethic, professionalism, intellectual curiosity, communication skills, technical skills, etc.

Also of note, comments made in our clerkship evals show up in our med school records. Along with board scores, these third year comments and clerkship scores carry pretty significant weight in residency apps. With all this in mind, being constantly evaluated changes everyone's behavior, to varying degress among different people. Most people don't ask if/when they can leave - even if all our work is finished. Instead, we wait on seniors to give us the ok. Most of my interns and chiefs have been pretty good about letting me go within reason. Others, not so much.

On the other end of the spectrum, there are the ass-kissers. I.e. always volunteering to give a presentation, bringing in journal articles, and just brown-nosing it up. Best thing to do is to not get too annoyed and stay out of their way. Even more annoying and malignant are those who do the above, while also trying to actively outdo/outshine other med students even if it means intentionally making them look bad. There's an understanding among med students that we won't steal others' thunder or try to one up each other in the interests of getting a good eval. Some people obviously don't believe in that mantra.

Work
As I mentioned, M3's primary purpose on the team is to learn. I also touched on how there's some scut work. Outside of that, our work consists of a few basic things we can contribute to the team.
Pre-rounding:
This is basically work that happens before rounding on your service's patients with the team. It'll consist of checking up on overnight changes from nursing and other services. I'll also see if yesterday's orders were followed through on and note any changes in patient conditions. There's follow-up on any biopsies, imaging, and consults that were placed. I'll also see my patients, see how they're doing, and do a brief exam in followup.

Rounding:
We see the service's patients together as a team, usually with the attending. Updates are presented by the med students, residents (who carry more patients, including ours) fill in any gaps we miss, and the attending talks about the patient and elaborates on any teaching points. We see the patient together and then discuss the patient's assessment and plan.

Consults/Admits:
Throughout the rest of the day, we finish up and followup on orders, imaging, and testing ordered on our patients. While all this is happening, your service will get called throughout the day for patient admissions to your service (e.g. recent stroke patient to neurology) or consults from your service (e.g. new onset numbness/weakness in a heart failure patient on the medicine service).

Avg. work day so far: surgery (5AM~6PM), psychiatry (8AM~4PM), neurology (730AM~4PM)
Avg. work week: surgery (75-100 hours), psychiatry/neurology (40-50)

Caveats:
This is the basic framework of a workday. Each service at each hospital with different housestaff will have their variations. The biggest variation comes with the surgical specialties. Prerounding takes place earlier in the day, rounding takes place throughout the day between cases, and consults/admits/floor work are handled between cases or after the operating day is over. OR time makes the work day that much longer, because we still have to medically manage and followup on our patients. That unfortunately makes morning (pre)rounds particularly abrupt and impersonal - there's only so much time that each patient can get in the morning if you have 40-50 patients to see in an hour. Not mentioned are lectures we have to attend and presentations we have to give. These are usually either around lunchtime or during the afternoon. Also not included in the workday are the hours spent studying, prepping for presentations, and reading up on upcoming cases. On last caveat: this all describes a typical inpatient/hospital day. I've yet to be out in the clinics.

So that's basically what a third year rotation looks like. There'll be different flavors depending on if it's medical/surgical, where you're at, and who you work with - but it's all variations on the same theme.

Rebuilding Years

I'd consider myself a fan of most sports. That said, my teams are the Rams, Bulls, and Illini. And I'd consider myself a peripheral Blackhawks, Cubs, and Bears fan. Not a whole lot to be excited about right now.

Rams
I haven't gotten the chance to watch any of their games, but I think I'm probably better off that way. Seriously, we're not just losing. We're getting demolished to the tune of 24-108 over four weeks. In years past we could at least put up some points. Not so much anymore. I just glanced over the schedule and there's no game that made me think "Yeah, we should win that one." Maybe the Lions, but they're actually decent this year. Maybe we'll tie their record and put up an oh-for season too.

Illini football
I have watched most of their games. It's just straight up frustrating to watch their games. Aside from the Illinois State game, it's been a clinic in how to get in your own way. Big play? Well done, let's make sure it was run in an illegal formation. Or that somebody got caught for tripping. Or if we do gain momentum, let's kill the drive by throwing a pick or racking up penalties. Much like the Rams, the offense was the stronger unit of the two. You would think that after three years of Juice and Benn and a year with Dufrene that we'd have a pretty good offense. Apparently not so much.

Bulls
I'm actually excited about their season to start. Last year's series with the Celtic was a damn good one and isn't a bad thing to build from. I'm one of those that was happy to see BenGo leave. Yes, it's a huge scoring void and yes, we lost some "clutch shooting." Regarding the latter though, if you jack up enough shots on your own whenever the hell you want, you're going to hit some of them. Double-pump fadeaways from the corner shouldn't be a go to move.

Illini basketball
Like the Bulls, I'm pretty excited about this season. The first round exit to Western Kentucky was pretty disappointing, but apparently we couldn't stop Mendez-Valdez. Either way, I'm actually a fan of McCamey - hopefully he's more consistent this year and doesn't disappear for stretches in (or of) games. Our freshman class is pretty highly regarded too with Richardson, Bertrand, and Paul. That said our team is pretty young, having lost Brock and Meacham and with McCamey and Tisdale being juniors. Regardless, I have pretty high hopes for the season.

Chicago Olympic Bid
Ousted in the first round and it wasn't even close, since we were supposed to be one of the frontrunners. We got 18 votes in the first round, Tokyo 22, Rio 26, and Madrid 28. It was fun while it lasted. I think it would've been pretty cool to have the Olympics in Chicago. It also would've forced a pretty massive infrastructure upgrade and infused a lot of cash into the city. That said, Daley eventually signed over the city to be responsible for cost overruns. Overruns which would have happened and may have run into the billions. (In contrast to other cities being backed by their governments.) But I see that as the price of being able to get federal and state funding for infrastructure including the CTA, Metra, and highways while also fast-tracking said projects. The Olympics would've also stimulated the development of economically depressed parts of the city: around certain venues and especially in the proposed Olympic village area.

As for the sports that are happening now, the Illini and Rams are a combined 1-7. At least my fantasy team is at 2-2. Yay.

Only So Much To Do

I'm about a week removed from my psychiatry rotation and one week into my neurology rotation. From a medical standpoint, I'm liking neurology more than psychiatry. From a symptomatic, pathophysiological, and diagnostic perspective there's so much more going on. And I personally find it a lot more interesting. That said, with some conditions, there's only so much that can be done sometimes. To some extent, this also rang true with psych.

Psych
PTSD: it's pretty devastating and disheartening what combat can do. There are three symptom clusters that need to be met for PTSD: reexperiencing, avoidance, and hyperarousal. (Makes sense, but vets are evaluated in detail against these criteria for diagnosis. Why? Because the VA pays PTSD disability. Obviously, some people will take advantage of this.) Each of these symptom clusters affects people in its own way, each potentially functionally and/or professionally disabling. Reexperiencing is what it sounds like - vividly having to relive whatever combat situations they went through, either spontaneously or after a triggering stimulus. Bad as that is, a fair number of vets end up using to try and prevent reliving their experiences. A large number turn to alcohol and heroin, with a decent number also using cocaine.

If they don't use, then they may overreact to seemingly benign stimuli, like walking in public or fireworks. Some vets can't be in large crowds, because they can't account for the whereabouts and actions of everyone. Some can't handle loud sounds like fireworks or the L, and end up prone on the ground for minutes at a time. It's literally a reflex they have no control over. They can also end up withdrawing socially, becoming dysphoric, anhedonic, and hopeless.

And the last complex of hyperarousal can be pretty debilitating. Some vets will stay up all night, either because they're paranoid about someone coming after them or because they're having nightmares and/or flashbacks. They can also become irritable and prone to anger outbursts.

While interviewing a Vietnam vet, he straight up told me that I made him uneasy. Although he was pleasant and cooperative, he admitted that his instincts still told him I was an enemy and that he could picture himself killing me. I'm grateful he has some control over those urges. Either way, PTSD can be a devastating and disabling condition. It can push people to do things they don't want to. It can push seemingly highly functional people to use. It can ruin the lives of people only a few years younger than us.

Neurology
MS: multiple sclerosis is basically an autoimmune process that attacks the myelin sheath surrounding neurons in the brain and spinal cord, leading to both sensory and motor deficits, which manifest for years as acute attacks and eventually deteriorate to progressive decline. It's pretty disheartening (to me anyway) to see younger people with MS attacks, e.g. becoming totally paralyzed in their legs. Granted, they usually get better after a few days of appropriate treatment, but there's still some residual weakness. On top of that, there's sensory loss, possible incontinence, and not knowing when you're next attack might happen. Not the best way to live life.

GBM: glioblastoma muliforme is a high grade tumor of the brain (astrocytes) with a very poor prognosis - 6 months without treatment and a maximum of 18 months with treatment. This is the brain tumor that Senator Kennedy had. One of my patients was diagnosed with GBM in August. He initally presented with left sided weakness and confusion. After imaging, biopsy, and pathology he was diagnosed with GBM. Since then, he's had two 3 week stays in the hospital, 2 shunts from his brain to his abdomen put in (to drain excess fluid), and 2 emergency burr holes in his skull to drain the excess fluid and edema from the tumor. He's also had a few runs of seizures and almost complete left sided paralysis at this point.

ALS: amyotrophic lateral sclerosis, AKA Lou Gehrig's disease. This is also the disease Stephen Hawking has, though his extended survival is the exception rather than the rule. ALS is a progressive motor neuron disease, affecting them at two levels of the motor pathway - both upper and lower. As such, people gradually lose all motor function, with most people dying secondary to loss of respiratory muscle function. The prognosis is grim, with a three to seven year life expectancy depending on time of diagnosis. One of my patients has this, and its at a pretty advanced stage. He's lost movement of all four extremities, and is developing trouble speaking and swallowing. At this point, his care is all palliative, e.g. a feeding tube. One of the sadder aspects of his care is getting end of life affairs in order, including a do not intubate (DNI). Reason for this is that he may end up in respiratory failure, but if he's intubated without a DNI he can actually live for quite a while - albeit while totally paralyzed. He'd also be conscious with intact sensation. Horrible.

All these patients have made me realize that while there's a lot modern medicine can do, there's a limit to its efficacy. It's mind blowing to me - it's taken me a lot of time and energy just to get the bare basics of medicine into my head, nevermind the clinical experience needed for general practice or the minutiae, protocols, and therapies for a given specialty. Basically, I know there's some stuff in my head, but I also know I don't know a lot. It's even more humbling realizing that there are some things we just can't do anything about. That's one of the tougher things to deal with, especially since we're all wanting to cure our patients - not just stand by idly providing palliative care.