I have began studying for step 2, my last big test before residency begins. For step 1 I felt like I used too many materials so I decided to limit the resources I use to three. UWorld, Master the Boards, and MedEd videos. I'm going to set small weekly goals for myself in concordance with the plan my mentor has set up for me. Ross provided a mentor for students who they felt would benefit based on low Step 1 scores, so I decided to utilize the resource.
My study plan for this week is to compete at least 2 Uworld blocks/day on tutor mode, read 40 pages of MTB per day, and complete at least 2 hours of medeq videos/day. I tried to keep it simple and manageable.
Wednesday, May 31, 2017
Monday, May 29, 2017
Other lost files
These
6 weeks have went by pretty quick. General consensus was that it was pretty
chill, but there was more work than I expected. On Friday we presented a
SOAP note (write up of history/physical/assessment and plan for a specific
problem) to one of the doctors at Cleveland clinic, which was pretty laid back.
We will be doing a lot of presenting cases on the island. Next week we have one
day at the cardiology clinic, OSCE final (practice for step 2 cs) and our final
exam on Thursday. I’ll stay in Miami for a couple days then it’s back home to
Bakersfield to start rotations at Kern Medical Center. I’ll be beginning with
family medicine.
Only
a week and a half left of IMF. Our typical schedule is 2 days of clinic
days, usually from 9-5. Most of that time is spent studying or talking
with classmates. On a lucky day we’ll see 4 patients, but usually
only 2-3 per day. This is because we generally only see the new patients,
as we are taking a complete history and physical. Otherwise the clinic is
very busy, and the doctor wants to go through the routine check-ups quickly by
himself.
The
good thing is that we are able to see pathologies that typically wouldn’t be
seen or heard in a primary care clinic. We’ve hear bruits, murmurs, seen
abnormal ECG’s, and abnormally high BP. I’ve also learned how to use the
electronic medical records system.
Las
Olas in ft. Lauderdale has an art fair 2 times per year. Artists from around
the country come to show off their work from woodworking to ceramics to a lady
who was literally selling toy frogs glued onto shells (that one confused
us).
One
artist was led a team of engineers, managed rental properties, and took classes
at university. In addition to this she created beautiful oil paintings, one of
the pieces took her 4 hours just to complete one of the eyes. I asked when she
found the time and she responded that she just doesn’t sleep much because she
feels a need to make time for all of her hobbies.
Starting
off in cardiology has been a good first rotation. We get to hear a lot of
pathologies such as bruits of the carotid artery, mechanical valves,
pacemakers, extra heart sounds, aortic stenosis, mitral regurgitation. So many
things I wouldn’t be hearing on a daily basis in another clinic. It’s
definitely a trial by fire event. Last week I got chewed out for not presenting
the patient in the manner our doctor prefers or reporting the wrong
finding on auscultation of the heart. I prefer an environment like this,
as I’d rather make these mistakes now before I’m the doctor of these patients.
The transition to clinical thinking has been more difficult than I
anticipated. It is no longer, just memorizing a mechanism of action, but
figuring out which symptoms correlate to how the patient is presenting and how
to ask questions in a manner to get that information from the patient.
For example, rather than asking if they feel shortness of breath, I
should ask how long do they walk before the feel short of breath and if that is
any different from before the precipitating event.
One
of the patients in our cardiology rotation stated that he keeps himself strong
by hittting himself on the arms vigorously. The 80 year old man
demonstrated by pounding his triceps with vigor. He also stated that
whenever he felt tired or sore he would throw himself on the floor then pop up
immediately. This man was full of energy, so whatever he was doing was
working, but probably not anything that I will try in the near future.
One
of the patients in our cardiology rotation stated that he keeps himself strong
by hittting himself on the arms vigorously. The 80 year old man
demonstrated by pounding his triceps with vigor. He also stated that
whenever he felt tired or sore he would throw himself on the floor then pop up
immediately. This man was full of energy, so whatever he was doing was
working, but probably not anything that I will try in the near future.
The
first week of IMF felt like a bunch of well intentioned, but mostly forgetable
lectures delivered from 8-5. It was tought to transition back to sitting
in a classroom for that long. Especially since I thought that many of the
orientation lectures could’ve been condensed into a powerpoint sent via e-mail.
I feel that a structured schedule can be bad because it leads to the
prolonging of the delivery of information. For example, if a speaker is
given 1 hour but only has 15 minutes worth of information to deliver they will
usually fill that extra time with fluff instead of ending early.
The
second half of the first week and second week was much more engaging. It
has been more work and reading than I had expected based on talking to previous
students. But it is a nice change of pace to actually be dealing with
patients on the cardiology rotation.
This
is an overdue post, but I passed the step 1 exam! 7 sections of 44 questions,
and 45 minutes of break is over. It was such a relief to be done and have
the freedom to not be studying or feel like I need to get back to studying.
There were definitely some questions that had me thinking I was sitting
down for a radiology or pathology specialty board exam rather than an exam for
second year med students, but I just mentally marked those questions as
experimental. This only worked for so long, as there’s no way half of a session
on the exam is experimental lol.
The
test didn’t seem that long, maybe because of the adrenaline or because of the
many practice questions I had done. I passed with a modest score of a 210,
which was a little lower than I hoped for but close to averages for family
medicine residencies, which I am hoping to match in. So overall I’m pleased,
and my score went up quite a bit from the first NBME practice exam that
correlated to a failing score.
After
spending months studying for the step, I decided to… surprise… do more
studying. But this time it was mixed in with some fun. I stayed
with a Spanish speaking family for a week and took 6 hours of class studying
Spanish in a town called Heredia in Costa Rica. The Sunday I arrived, we
took a trip to a beautiful volcan, Volcan Poas, which was a volcano in the form
of a crater. My host parents were a sweet 73 year old woman, her 79
year old husband who still worked near a waterfall. Everyday she would
cook breakfast consisting of tropical fruit and eggs or oatmeal. Then I
would take private classes with an instructor. Our sessions were fairly
casual, discussing verb tenses one moment and our shared disdain for Trump the
next moment. Then I would return home to chat and eat dinner with my host
family.
Over
the weekend, I visited a hostel near Jaco beach called, Riva Jaco. It was
a decent hostel, with bamboo tents and mattresses outside and bunk beds inside.
Most people staying there were Germany, a couple form Austria, a couple
of women from Costa Rica, and one person from Oregon. One couple from
Germany rode their bike much of the way from Southern California to Costa Rica
over the course of months. I couldn’t imagine riding my bike more than a few
miles, let alone through Central America, but they were the type of people you
immediately exude an adventurous personality. That weekend we went
clubbing and I did some surfing, and a lot of falling, at Jaco beach. I
returned to my host family for a day, then it was time to go back and prepare
for the trip to Miami for IMF.
I
started the day with a short run, prayer, and some sweet potatoes and eggs.
Then I was off to begin the most important test of my life. I
walked into the test room and attempted to suppress the pressure that
accompanies a test of this magnitude. Questions of what would I do if I
don’t pass, are you prepared enough? I changed my thoughts to thoughts of
how far I’ve came to get to this point, how much I’ve studied, and how I’m
proud of the effort I’ve put in prior to the test. I would be able to
live with any result I get whether favorable or not.
The
test is composed of 7 blocks with 44 questions each and 45 minutes of break
time (could be up to 15 min. more if you skip through the tutorial).
After opening the tutorial, I started to jot down some equations of the
“whiteboard” provided instead of scratch paper I wrote some of the epidemiology
questions and the “qiss qiq siq sqs” mnemonic then proceeded to the first block
Some in the blocks seemed like as if I was just doing another practice
exam, others contained images or content I wasn’t familiar with. It was
definitely a beast, but I feel like I passed it. I’ll find out in a
couple of weeks.
Once
I finished it was a relief just to be done with studying for a while and
putting an end to the anticipation. I then proceeded to pack for my week
long trip to Costa Rica.
The lost files from another site
Pediatrics
has been a blast so far. I’ve found myself paying more attention to
minute detail with infant and small children, as they are not able to describe
the extent of their illness. This forces me to consider more options, and
really become a better diagnostician, as the differentials aren’t eliminated by
the patients’ narrative as they tend to be with adults. The harder part
can be the physical exam with a fussy patient.
What
used to be a routine procedure, has suddenly become more complex. The general
physical exam with adults follows a pattern that becomes routine, however
with the children, the order varies with each patient. There are the
children who have no problem being placed on the exam table and being poked and
prodded in the ear canal and nose. Then there are those who are a ticking
time bomb. They are placed on the examination table and give that look of
concern as the stethoscope touches their chest. They then glance at the
mother then back at me with that “stranger danger” look quickly followed by a
trembling of the lower lip. Sometimes a sticker is enough to console
them. Other times, they have had enough and and are hungry, tired,
constipated, and/or have had enough of my face. They let out a scream
that lets me know I am a nuisance and then I proceed to the more invasive parts
of the exam: looking into the mouth. Then proceed to look into the ears
with the parent/s holding their arms as I stabilize the head and look into the
ears and nose. Then the hard part is over, they hold their parents and
look at me with a piercing glance. One 3 year old patient then proceeded
to tell me to “go away.”
5:00 Exercise
6:25
drive to hospital
6:
45 head to rounding room
7:00
night shift gives updates on patients
7:30-11:
Round on patients, individually and with resident/ Finish SOAP notes
11:-12:
Round with attending physician
12-12:45:
discuss plan and updates with patients
12:45-1:15:
lunch
1:15-1:45:
Update SOAP notes
1:45-7
(Options): 1) One of the three students goes to the FM clinic 10 min away
2)
One student can go home
3)
One student stays until 7 PM to study/ wait for another patient admit
and complete an
H&P/ Follow up with to-do items for patients
7-10:
??? Eat, study, read, piano, social activity, sleep
There
is no set schedule, really everything varies depending on how many patients we
have and how many complications they have, and which resident we’re working
with, some will keep us at the hospital longer than others. Also, each
student has a week of nights from 7pm-7am and a week at the clinic from 8-5pm.
Sometimes
I try to make the posts flow with a topic, I think I’ll now just go into a
random flow, if you hate it let me know. So much goes into rotations.
The other day one of my classmates was making a joke about how the other
students were sounding. A very knowledgeable yet pompous doctor, just ask
him and he’ll tell you his accomplishments, was passing through the hall and
the other students were hanging on to his other word and you could just tell
they were feigning interest. My collegaue was like I know I sound like
that too, trust me espeicially with the surgeon. He was like I’ll be “yes
sir that is the most amazing story ever, so extraordinary” lol. I know i
some of that, laughing a little too hard at the doctors’ jokes that aren’t that
funny, and just trying to be likeable, but when I notice I try to stop.
For the most part, I think i just try to do teh best for the patient, and
try not to care about what grade I’ll get at the end. Then there’s the
dilemma of studying to get a good grade on the shelf exam vs. studying the
disease of a patient and studying the disease of the patient that will not be
on the test. Then there’s the feeling that you’re not responsible for the
patient, because you’re not the doctor, you just gotta go home and study.
Feeling like you don’t really know enough to really make a difference,
but then realize that this is probably the most time you’ll ever be able
to spend with the patients. You are able to do more educating and more
thorough physical exam that the docs simply don’t have the time to do.
You’ll see the residents stressed from all the documentation, and you’ll also
be doing alot of the same documention thinking you’d rather be spending time
with the patient or looking up the pathophysiology of their disease, and get
disheartened because alot of medicine these days is simply that, documentation.
Then I spend time thinking about maybe I should just go into a concierge
practice or other priate practice and not have to worry about insurance, but
then realize that that will likely alienate the same underserved medicare
population that was part of the reason you went into medicne.
Then you look at the schedule and realized that you won’t be able to have
months off for vaction to travel or otehrwise like in undergrad, but then you
realie that you’re actually looking forward to going to work and that you’re
amking a difference in that patients life and that makes it all worth it.
Then the next day you don’t remember which types of bacteria are gram
positive rods when you just spent months studying for a test that covered all
that, and feel like stupid.n… Then you run up and down flight of stairs just to
get a hold of medical records of another hospital to get the records of another
hospital. Then get placed on hold, then find out that they never received
the fax. Then you wonder why in 2015 you can’t just send a picture of the
document or why there still isn’t a central database where all hospitals
can access a patients info. Then after many calls back and forth and
holds, you realize that the other hospitals’ records don’t match this
hospitals’ so the patient was given a higher dose of pain meds than necessary,
causing the patient to be somnolent and barely responsive. Then
you worry about whether or not someone will take you for residency and
after that how long it was pay off these pesky loans. Then you have the
nurses who treat you choose to be less than helpful, but you can’t blame
them cuz it because being nice probably leads to being overworked and over
questioned by these pesky students who don’t know much. But we’re still a
part of the medical team and want to be respected as such.
But we’re the bottom of the bottom because we’re paying to be here and
everyone else, including the janitor, is being paid to be here. Then you
think how great it is to be learning about the human body and get to see God’s
intricacies everyday, and find peace in the fact that you’re making subtle
differences in people’s lifes
Sometimes
medicine is like putting together the pieces of a puzzle. We had a
patient who has been in and out of the clinic and hospital, depressed from not
being able to determine the cause of his chronic illness. Over the years,
doctors had run multiple tests to determine the cause of his systemic skin
problems and lung problems. It got the point where we couldn’t provide
any answers, so we had to release him. Then suddenly an obscure lab
result led to further investigation and the eventual confirmation of a
suspected diagnosis. The patient was elated and for the first time, eager
to come back to the hospital. Now we can finally begin treatment with prednisone.
It is important to have a diagnosis, because steroids can cause multiple
adverse effects such as impairing wound healing or worsening osteoporosis,
but with a diagnosis you have studies that can confirm that the benefits
outweigh the risks.
The
night shift hasn’t been so bad so far. Initially I was thinking that
I would have to stay up the whole time (7pm-7am), but I’ve been able to get
more sleep then expected if it’s a slow day. Yesterday, we only had
three patients, so I got a full night’s rest. The call room for the
students is pretty nice, with a computer, desk, bed, and bathroom.
Tonight
will be the first day of my week on the night shift. I’ll be working 7-7,
should be fun! There is a room for medical students to sleep in with a
desk for studying, but I guess it will depend on how busy we are to see if I’ll
be using that room or not.
I
always assumed that residency is when it would be really difficult to sustain a
relationship (especially a new one), as the partner realizes how little they
will see the resident who is usually studying, in the hospital, or too tired to
function. Boy was I wrong.
Today
I learned the formula to relationships during residency from a resident at the
clinic who is an expert on the topic. Apparently, the number of
girlfriends you should have during residency should increase linearly in
proportion to your year of residency. During year 1, you’re still trying
to figure things out with the hospital system, having increased workload,
complicated and chronic pain patients that get passed down from more senior
residents, and the other “hazing” that accompanies first year of residency.
Therefore, you can only handle one woman at a time. Then you
gradually get more and more accustomed to the processes, get better with time
management, and get faster with seeing patients, procedures, and paperwork. Naturally,
you use the extra free time to add another girlfriend to the roster.
By third year of residency, you’re pretty much a full fledged
physician, and you have more autonomy and ability to trickle tasks down to the
interns and 2nd year residents. Of course you then add the last
girlfriend to the roster. Today was the first time I heard of this,
but it’s common sense, I’m surprised they didn’t mention this during
orientation. It’s definitely something that needs to be addressed in the
future.
A constant
fluctuation of emotions, whether revealed or concealed, accompany the practice
of medicine. Death is one of these unavoidable triggers of emotions.
I experienced the death of a patient for the first time this week.
The art of being a physician is more than just knowledge of how to
diagnose and treat the disease, but also how to manage the expectations and
emotions of a patient and their families. When diagnosing a terminal
disease, whether it be pancreatic cancer, advanced heart failure, or chronic
organ failure, the hardest part is often breaking the news to the patient and
families. As difficult as this can be on the family, sometimes dealing
with sudden, unexpected deaths can be even harder. As doctors, we can
estimate, but we are never certain of when a patients life will end. You
can image the agony of a family who had no idea that a disease of a
relative would progress more quickly than expected. Words that will
forever remain unspoken, grudges that can no longer be rectified, or
expectations that will go unfulfilled. Sometimes the anger of a sudden
death or quick change from a stable to unstable patient, will leave the physician
as the blunt of the blame, whether justifiable or not. We are taught to
discuss the code status of the patient during the first visit, but it is often
a question that goes overlooked. Questions for the physician begin such
as when will be a good time to talk to the angry family about options for
resuscitation? How would the family react to 20 people in a room crushing
the ribs of an old man or woman in attempts for revival? Is the patient
competent to make their own decision? Which family member should have the
ultimate say? Is there a chance for this patient to regain
normal mental capacity?
Throughout
all this, the physician is required to maintain composure, suppress their
emotions, and address the family and develop a plan on how to proceed next.
Then go on to address other patients that have been squeezed into a
tight schedule without a moment to fully process the moment.
I
had a chance to witness residents an attending physician address this situation
with a level of empathy that cannot be feigned. They addressed the
families concerns and explained the disease, while walking a tightrope in
the middle of being too reassuring or too insensitive.
Family
med so far has been interesting. I split my time between the hospital and
a clinic nearby. According to the residents, these last few days have
been unusually slow, as we have only had one or two patients come in to the
hospital per day. However, the patients we did have were pretty complex.
I had the day off yesterday, but apparently one of the patients screamed
that she didn’t want to see another med student, but this morning she was in a
pleasant mood. The beauty of the rotations is that now I am able to make
connections between the information I learned in the textbooks and finally
apply it to a patient, it makes the studying and learning much more fun.
There is a steep learning curve when it comes to learning the electronic
medical records, drug names and dosages, questions to ask of the nurse, fax
numbers, interpreting lab values, and coming up with an assessment and plan to
present to the residents and attending physician.
It’s
starting to get real now. I begin my family med rotation tomorrow. I never
thought I’d be this excited to receive a pager, but they used to be so cool
when I saw the older people with one when I was just a young lad.
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