3rd Year Chronicles: Psychiatry

It saddens me to say that “psycation” is over. So ends the third rotation of third year. Ah well.

Psychosis Is Contagious

For this six week rotation, I spent the entire time at a state-run short-term mental health facility. If that conjures up a picture of old and slightly creepy-looking facilities, limited staff (budget cuts, of course), and the occasional co-worker or two that may have spent a bit too much time in psych facility – well, you wouldn’t be too far off. It isn’t the place that most people end up when they are sick – only the really, really sick ones that typically have no insurance.

I will say staff there were pretty great. Additionally, most of the patients there were very nice and wanted to be there (ok, well, maybe that last part isn’t so true) to get help. That said, a large number of patients were really actively sick with whatever psychiatric condition they had and as a result had fairly poor insight into what was going on and what needed to happen for them to get better. As a student, this meant that this was a great site to see people who were actively psychotic, manic, depressed, withdrawing, or what have you. It’s one thing to read about this stuff but then spend most of your rotation at a run-of-the-mill clinic and see people who are generally well-controlled and doing ok. It’s another thing to deal with this stuff every day for about six weeks, and I thought it was a great learning experience. 

The other cool thing about the psychiatry rotation in general was the fact that we were able to stick around one place for the duration of the rotation instead of switching gears every two weeks or so. This really allowed me to get to know a lot of the staff and patients and play more of a role (at least, as much as a third year can) in the treatment team.

Psychiatry in particular is very focused on peoples’ stories. Unlike most other specialties where diagnoses are made often from lab or imaging studies, in psychiatry you have to delve into people’s lives with them to sort out what is going on. As such, it’s probably fitting to include a few here – some shorter, some longer, some ridiculous, others more mundane, but all memorable and all of which played an important role in my experience. As I went through the rotation, I tried to jot down some of the more interesting ones and have included some of them below.

I should also note that, while some of the stories are humorous, my intention is to relate some of the stories that stuck with me for some reason – not to make fun of people for stuff that happens when they are sick. That said… you can’t make it through even six weeks of psychiatry without at least being able to appreciate the humor you encounter.

A Few Quick Stories...

 

• The very first patient that I saw was being spiritually drained by his "three baby mamas," which family later told us weren't even real. He later told us they only came to him when he was sleeping at night or napping during the day, and that they found him to be "seductive" because of how he dressed. He was diagnosed with bipolar disorder – he was actively manic when he came in and actually improved quite a bit before he left. Even when he left, though, he really wanted that baby mama thing to be real.

• Another patient was hearing voices. He had come in initially because people were trying to track him through the computer and hurt his sister, leading him to destroy the computer and whatnot. But now the voices were telling him to participate in community meetings and read a lot. So he did - found him initially with maybe twenty magazines meticulously folded in half on his bunk. I guess at least those are the good voices. 

• A couple of patients tried to have sex. That didn't go over so well. Not exactly a place ripe for ability to give consent. Also... public rooms. Enough said.

• There was one patient that was there when I arrived and left shortly after. I didn’t know her too well, but she usually just paced around with what psychiatrists call a “flat affect” and other “negative symptoms” of schizophrenia (essentially, she displayed very little emotion and tended to be more withdrawn, but would also just stand and stare at you). I tried to talk to her, but she quickly became agitated and said she didn't "want to be your project." Also said she was "trying to confuse herself." Why, you might ask? Her answer consisted of monkeys and zebras and jungles. I was confused too. 

• One patient told me “I think you are a Klingon.” 

• Another patient came in on PCP. Hit about 5-6 people over the weekend. He was acting up again Monday morning and put in seclusion. Proceeded to pee all over the floor, moon the staff that was watching over him, and then write on the window in the door using his feces. Don’t do drugs, kids. 

...And A Few Longer Ones

A little background for this one. So in the last week, two different things happened in different areas of the facility. First, one patient was brought into the conference room with the staff for a meeting to let him know that he needed to stay a little longer. He didn't like it, blew up, threw a coffee mug at the doctor (bad aim, fortunately), flipped a heavy wooden table, trashed the place, and scared everyone. Second, at intake, some dude broke one security guard's nose, another's wrist, and sprained or broke another guy's arm.

That brings us to today. Similar situation – we had brought a previously psychotic (found naked on street "running from cops" and paranoid) and still somewhat manic guy in to let him know we needed him to stay a bit longer. He didn't like it and became agitated. We herded him out of the conference room (to avoid a repeat of the previous scenario). I tried to pull him aside and have him sit down – we had a decent relationship before this. He came with me and sat down, but as soon as he saw the doctor who said he wasn't leaving yet again, he jumped up and started posturing and yelling at him – lots of pleasantries that won't be repeated here. He proceeded to do this for about forty-five minutes. We cleared the main area, called security, and tried to verbally de-escalate him. It wasn't working, but security wanted to keep trying (to avoid situation two). We finally ended up having to grab him, restrained him, and gave him some emergency meds that calm you down and make you a little sleepy.

Shawshank Seizures

We had a patient that tried to escape a few times. His first try was a little bit after I left for lectures in the afternoon – he tried to grab a staff member’s key and make a break for it, attempting to kick down several doors in the process. Everyone there at the time tackled him, and pretty much everyone was sore or had a scrape or bruise to show off the next day. Then, the next morning, he tried to use a chair to break through the winder in his room. That didn't work, thanks to the shatter-proof glass.

The real topper happened a couple of days later. He suddenly seemed to be short of breath and having chest pain. Now, this guy is in his early twenties, hadn't had access to any drugs in the past several days, etc. Seemed like he was most likely having a panic attack (or faking symptoms to get to the ER, where it might be easier to escape). That seemed to pass, he stood up, and actually fell down and started seizing. He had about four ~30 second seizures in about fifteen minutes. We supported him as best as we could while trying to protect his head and airway. EMS came, took him to the ER, where he finally woke up and made a break for it. No luck there, though - security caught him, brought him back to the ED, he eventually returned to the facility.

The interesting thing about this guy is that he probably was having seizures. It turns out that you can have what are called “secondary psychogenic non-epileptic seizures,” which basically just means that you don’t have a seizure disorder or any pre-existing focus of abnormal electrical activity in your brain, but sometimes under severe stress/anxiety/emotionality, you can actually cause your brain to discharge abnormally and – bam – you are having a real seizure. Interesting stuff.

When Freud is Your Patient

 

In one memorable two day period, I had patients start to come at me three different times. The first time was with an old vet with a number of issues who really didn't want to be at the mental facility (no one does).  He started to raise his clenched fists as if he were about to throw a punch, but we talked through it. The next two times happened on the same day with another patient, 50-something year old male with active schizophrenia. We'll call him Paul. He was actually the patient of another doctor on the unit. He had been found wandering around some rail-road tracks. No one knew where he had come from – it sounds like he had a history of being a sexual offender and some other pleasant backgrounds. We later found out that he had worn out his welcome at several local nursing homes, and the last one apparently “forgot” to report that he went missing or something. Hmm.

Now, this guy was extremely disorganized, irritable, and very difficult to understand. He also was (as psychiatrists like to say) very "sexually preoccupied." What that actually meant is that he spent his first weekend running around exposing himself at the nurses' station, masturbating in the common area, peeing everywhere, and trying to get handsy with some of the female patients.  

So I walk in Monday morning and see this guy standing right outside the locked door separating the nurses' station from the common area. Hmm. It's not uncommon for schizophrenic patients to sort of just stand and stare for long periods of time, but I hadn't seen this guy before. I walk out into the common area and try to introduce myself. 

"Hello - what's your name?"

"(Incoherent mumbling....)"

"What's that?"

"Sigmund Freud" 

"Oh...ok.... Nice to meet you."  

"(More mumbling....)"

Hmm. Alright.

That was our first interaction. Later, I was walking through the common area and he approached me again.

"(Incoherent mumbling...)" 

"I'm sorry, what was that?" 

"(More mumbling...) ....Freud .... (mumbling) .... dissertation..."

"... Are you asking if I know Freud's dissertation?"

He nodded.  

"I'm not familiar with any particular dissertation...is there something in particular you are wondering about?" 

That's where it all went downhill the first time. After that, he just glared at me and went off on a rant about what I can only guess was about how inept the entire staff at the facility was. He started to come close to me, and it wasn't in an "I want to give you a hug" kind of way. I stepped back, but he kept coming and now I noticed that his left fist was clenched and heading my direction, as if he was threatening me or about to punch me. That's no good.

What I should have done at this point was just walked away. Unfortunately, my first reaction was to make more space and control what I perceived to be a threat. So I stepped back while placing my hand on his chest and used my other had to lightly redirected his left fist back to his side. We then had a fairly nonproductive conversation about how that type of action is inappropriate and not helping him, etc., and I left (and washed my hands immediately. This guy wasn't exactly an example of stellar hygiene).  

Later in the day, I was out in the commons area again on my way to whatever my next task was. I don't even remember what started things this time, but this guy wasn't too fond of me now. He comes up to me and starts to incoherently mumble rather aggressively in my general direction. 

"Can I do something for you?" 

"(Angry mumbling)” 

"...Ok. I'm sorry, I'm having a difficult time understanding what you are saying." 

Now he steps towards me again and quickly grabs my tie. Nope - that's not going to end well. I grabbed it back before he did anything and just walked away. He was just looking for trouble at this point. 

Fast forward to the next day. Just as I walked in, this patient had hit another patient in the jaw. Nice. The day after that, I walk in to him getting into it with the staff because he had stolen some clothes that belonged to another patient and refused to give them back. We finally convinced him to give them up, but he almost immediately walks over and tries to take another patient's set of colored markers.

"Paul, you can't take those markers. They don't belong to you."

"(Mumbling...)"

"What?" 

At this point he mumbled something about how it didn't matter, and wanted to know how much she paid for them. 

"None of that matters. They don't belong to you, and you can't take them. Go sit in that chair." 

"It does matter!" 

Every once and a while, a coherent phrase slipped through his "mumbliness" – that was actually a somewhat encouraging sign. 

We went back and forth a little bit. I eventually walked away after the other patient had recovered her belongings to take care of another task, but no sooner walked back to the nurses' station when I looked back and now Paul was trying to corner another patient. The other patient slipped around Paul and around a corner out of sight, presumably into his room. But then Paul followed. Of course.  

I walked back out into the commons area and over to that patient's room. Paul was standing in front of the closed door, tugging at the door handle. I couldn't tell if he was trying to get in or barricade the door so the patient couldn't get out. Either way, this wasn't ok.

"Paul, stop that. You can't go into other patients' rooms." 

"(Mumbling...) why not... (mumbling)?"

"You aren't allowed in there. You can go into your room, though." I pointed at his door, just down the hall.

At this point he changes course and starts asking me questions. I make out something to the effect of "who are you?" and told him I'm a medical student. He said something about "....study... anatomy... " and I said yes, we do study anatomy. He then appeared to want to challenge me again and seemed to ask something about phalanges. I responded with something about fingers and he seemed pleased. At least I finally got a smile out of the guy. 

Shawshank, Part Two

One Friday, I was sitting out in the common area during my lunch break trying to study a bit. We had just received a new patient. Now, upon arriving, most patients' first question was something along the lines of "When can I leave?" This patient in particular – we'll call him Timothy – did not want to be here. He came out of his room and started pacing around, talking about how he didn't need to be here and how he was going to pick up a chair and smash through the (shatter-proof) glass door leading outside (to a secure patio) and escape if he didn't get out of here in five days. He eventually calmed down after a staff member started talking to him and offered to play ping pong with him.
  

Fast forward about twenty minutes down the road. I'm now sitting in the office with the doctor I'm working with, and we hear a loud BANG BANG BANG coming from somewhere outside the door. Initially, we thought it was Paul again – he would get riled up every once and a while about something or the other, usually about how he wanted a cigarette. I walked outside of his office expecting to see Paul at it again, but the noise was coming from the side of the facility opposite Paul's room. Uh oh.

We all run over to the room that the sound is coming from and crack open the closed door to reveal Timothy using a small bed-side table to repeatedly hit the (once again, shatter-proof) window in his room. Oh boy. He sees us and starts to charge at us with a crazy look in his eyes and the table over his head. 

That door was closed so fast you wouldn't believe it.

At this point, we signaled the nursing station to call security. After a moment, Timothy realized he wasn't getting anywhere with the table vs. window scenario and stormed out of his room. He was empty-handed, but didn't exactly look to be in the greatest of moods. We tried to verbally de-escalate him, but he wanted nothing to do with it. He stomped on over to the middle of the common area, picked up a chair, and started throwing it against the door leading to the enclosed patio.

Well, he wasn't kidding earlier, apparently. 

Unfortunately for him, these doors and windows had been built with this type of scenario in mind. After a couple of tries at the door, he gave up and ran over to the nurses' station. Now, the station was enclosed with the same type of glass, but I guess I figured that body-slamming it might work.

It didn't. 

By this time, security had finally started to arrive. Once again, they tried to verbally de-escalate him, and once again, Timothy wanted nothing to do with it. He continued to be aggressive - making fists, threatening staff, cussing his heart out, the whole nine yards. After a bit, security realized this wasn't going anywhere and took advantage of an opening in his tirade to tackle him.

Now, Timothy was a smaller guy, but he was strong. Three big security guys were having a difficult time just controlling his upper body while he was down, so the doctor and I jumped in to help hold his legs. We eventually got him back into the private room for restraints, and after a little bit of scuffling and spitting (on his part, anyway) finally had things under control. 

The next Monday when I came in, I heard that he did well over the weekend from the nurses. That's good. I walked into the common area, saw him sitting in a chair, and nodded at him to say hello. He glared back at me a little, but nodded in return. Good enough. 

Later in the day, I had just finished lunch and went back into the common area to study a little bit while things were quiet. All the patients were eating lunch. This one new patient we had who was actively psychotic for some reason had it in his head that Timothy was out to get him and kept intermittently yelling at him from across the room. To his credit, Timothy kept his cool and mostly ignored him. 

Mr. Psychotic, however, wasn't done. Once he finished his lunch (smart man), he got up and made his way towards Timothy, yelling all the while. We all started heading their direction, but Timothy had had enough by this point.

"I see where this is going." he grumbled. 

He got up quickly, took off his jacket, and before you knew it those two were going at it. Now, most people that fight at this mental facility honestly don't really even know how to throw a punch. Which is a good thing. But these guys - well, it obviously wasn't their first rodeo. Once again, security was called. 

We cleared the other patients out of the common area and circled around Timothy and Mr. Psychotic. For the most part, we don't have the staff to safely intervene between two aggressive patients so we just try to keep the other patients out of the way and only step in between the fighting patients if someone is really about to get hurt. These two were pretty much just grappling around on the ground at this point, so we were going to let them do their thing until security arrived. Timothy, though, was actually doing well in the sense that he was really just trying to hold the other guy and keep him from doing anything stupid. He quickly became fatigued, though, and Mr. Psychotic managed to get him in a headlock. That's no good. 

At this point, we jumped in and separated them. Security finally arrived after we got them apart. Mr. Psychotic got emergency medication and restraints; Timothy just requested some medication to help him calm down. 

Does Somebody Need a Hug?

 

On my last day, the staff all pitched in and brought various breakfast items to the morning meeting. It was very nice of them and it was really a pleasure to work with them all. At one point during to the day, though, I hear a commotion coming from the doctor's office off of the common area. Paul had somehow managed to get into the office and was refusing to leave, despite a tech's urgings. He sat down in a chair in the office and refused to move.

"I'm a doctor! I'm a psychiatrist!" he slurred.

Oh, Paul.

This tech had had enough. Paul had been in rare form all morning, and now he had bought himself a ticket to seclusion. The tech was determined to get him there. She pushed Paul in the chair he was sitting on all the way across the common area. It actually worked to get him into the back hallway, but then he plopped down onto the floor. Now, he had done this before. He would just lay down in some inappropriate place and just stay there, but he couldn't stay here and he knew it. He latched on to another tech's leg with a death grip and refused to let go. I got in there, pried his hands off, but then he latched on to my leg.

(At this point, he started to untie my shoe with his other hand and start mumbling about how they were his shoes or something. Oh, Paul...). 

He was just lying there at this point, latched on to me. I had him just stay there until security got there and while we administered some emergency medication, then extricated myself again from his death grip. But not to be outdone, he grabbed on to a nearby chart rack and shoved his head under it. 

*sigh*

We sort of all stood around him rather perplexed. Come on, man, really?

Finally, we pry first one hand ("Got it! Here hold this arm.") and then the other ("He's free! Pull him out!"). We tried to bring a wheelchair back, but ended up just carrying him back to the seclusion room.

I'll miss you too, Paul. I guess he just wanted a hug. 

The Verdict

I don’t see myself going into psychiatry, but I was surprised by how much I did really enjoy it. I think I would miss more conventional “medicine” too much. Also, I was surprised by how mentally draining it was. This may have been a bit unique to the environment I was in, but unfortunately really sick psychiatric patients tend to have very little insight into their illness and the fact that they really need treatment to get back on their feet. This means that, for most of their 5-10 day stay with you, you are repeatedly trying to convince them to take their medication and meet with their therapists and whatnot. Sometimes people do amazingly, turn around, and have an amazing recovery. But you’ve still been fighting with them for the previous week and a half to get them there. Additionally, some patients are so sick or have been sick so many times that their level of functioning is markedly reduced (like Paul). While occasionally encounters like these can be entertaining, it’s usually just really tiring and more importantly pretty sad for the patient. All of this sort of combined to make this rotation particularly mentally and emotionally demanding, which I wasn’t really expecting.

That said, it’s an awesome field with many discoveries yet to be made. It’s probably actually somewhere on my list of possible specialties now (I really wasn’t considering it at all before), albeit low on that list (as in, if absolutely nothing else in the rest of third year jumps out at me, I might consider psychiatry). The people who go into psychiatry, especially a lot of the newer residents, tend to be awesome and fun to be around. It’s also a field where you can achieve a pretty decent work-life balance – at the risk of sounding like a whiny millennial, my family is important to me and while I’m all for working hard while you are at work and working particularly hard over the next few years and during residency, afterwards I’d like to be able to not spend every waking moment in the hospital.

My next rotation will be family medicine. It’ll be an adjustment going back to more “regular” or conventional medicine, but I’m looking forward to it. I’ve heard good things about the site I’ll be rotating at – it should be very interesting and a lot of fun.

3rd Year Chronicles: Pediatrics and OB-GYN

Third year has officially started. Well, it officially started a few months ago. I’ve actually finished two rotations so far and am currently on a week-long (and glorious) fall break.

I Finally Get to Hang Out with My Peers

The first rotation of the year was a six-week stint in Pediatrics. Some of the details of the rotation varied from student to student depending on how the lottery for the various sites worked out, but I spent two weeks in an outpatient clinic, one week on peds ER night shifts, one week on nursery, and two weeks on the peds inpatient service.

The outpatient clinic happened to fall around the tail end of summer, which meant I saw a lot of healthy kids for well-child checks and back-to-school sports physicals. Which is awesome – healthy kids are always a good thing – but it meant that the interviews and exams were getting a bit repetitive by the end of the second week. I did enjoy getting a peek into the long-term relationship that the physicians I was working with had with the families they saw – often, they had seen these kids that were now heading off to college since they had been in diapers. That was appealing to me in some ways, which is something to consider for future career choices.

The week of nights in the pediatric ER made up for the monotony of the outpatient clinic. I worked with a few different pediatrics residents overnight as they were rotating through the ER. One of the residents I worked with had a viral gastroenteritis and spent the better part of the first half of her shift hiding in the bathroom. Instead of going home, though, she grabbed a nurse that was walking by and asked him to start an IV on her so she could get some fluids. Two points for dedication, I suppose. Later, we were seeing a 17 year old male that had avulsed the nail of his right middle finger while playing hockey (it was puck vs. finger – through a glove, too). With the ER attending, she was trying to put a digital block in that finger, but was shakily heading the needle in the direction of the wrong finger. Thankfully, the ER attending smoothly redirected the needle towards its intended target without saying a word. Go home when you’re sick, folks. It was pretty cool to watch the attending complete the nail removal, suture an underlying laceration, and dermabond the nail back in place as a sort of natural bandage.

Also, I got to “fix” a patient. A 15 year old male came in with his mom complaining of a foreign body sensation in his left eye that started suddenly after he “flicked” his T shirt up at 2 am in the morning while looking at his phone (yep). I lifted his eyelid to examine him, had him move his eyes in a few different directions, and he suddenly smiled and said “It fell out!” Medical student to the rescue. Still got to do a fluorescein exam, though, which was fun.

After the ER, things slowed down a bit when I moved to the nursery. This was actually a lot of fun – what better way to spend the day than hanging out with a bunch of happy parents and new babies? We also rounded with the NICU team in the mornings, which was a bit less fun. The advancements in medical technology and our ability to keep severely preterm babies alive is remarkable, but that doesn’t make it any less difficult to see two-pound babies on CPAP machines.

The pediatrics rotation ended with two weeks on the inpatient service. I was actually surprised by how much I liked the pace of inpatient medicine (although my perspective was admittedly a bit skewed as a medical student). We actually had a pretty nice schedule – showed up around 7 am to pre-round on a few patients, write progress notes, round again with the team around 8:00-8:30 am, take care of whatever business needed to happen in the morning, have lunch, then spend most of the afternoon in an impromptu lecture, see new admissions, or study. We typically finished by 3:30 pm, which was awesome (unless we had call, in which case we stayed later into the evening).

The Verdict

Overall, I really enjoyed the rotation. I don’t see myself going into pediatrics, but I really enjoyed certain aspects of the field. The final test at the end was actually pretty difficult – since it’s such a broad field, there was a lot of information to cover. Loyola uses the MedU pediatrics final, so we had the associated cases to complete during our rotation. I did those and most of the UWorld questions, and it seemed to work out fine on the test.

The Part Where I Deliver Placentas

After peds, I jumped into OB-GYN. It was actually nice to have these two rotations back-to-back, since there is a little bit of crossover in terms of the knowledge base you need to acquire and it helps to hit the ground running in OB-GYN with the peds stuff down pat.

I started off with two weeks in Labor and Delivery. This was probably my favorite part of the rotation – I felt like I learned a lot and really enjoyed the residents that I worked with. The hours were a bit longer than peds – throughout OB-GYN, the days usually went from around 6 am to 5-6 pm – sometimes starting or ending a bit earlier or later, but that was the gist of it. This was also the part where I delivered placentas during vaginal deliveries and where I got to see my first cesarean sections up close and personal.

For the second two weeks, I moved to a service called “Benign Gynecology.” This was basically a mix of clinic, surgery for “benign” things (like hysterectomies, cystectomies, hysteroscopies, etc.), and following any general GYN patients on the inpatient side of things. It would have actually been an enjoyable part of the rotation if not for also being the rotation where I worked under a rather… interesting intern. This particular intern will one day be an excellent physician and teacher, but at the moment is still trying to find her feet and seems to be channeling a lot of that frustration towards the medical students under her. She has very high expectations of herself and others, which is awesome, but did a poor job of communicating those expectations to us. Which meant that the entire two weeks was essentially a never-ending game of “guess what I’m thinking.” We as students did the best we could, but we all were incredibly relieved to finally get off that service.

OB-GYN ended with two weeks on the Maternal-Fetal Medicine service – these are the guys and gals who manage high-risk pregnancies – those with problems with the fetus (e.g. congenital issues) or with mom (chronic diseases, diseases related to pregnancy, etc.). It was mostly clinic – three days a week were spent doing repeat visits for current patients, and two days were spent seeing new patients and consults. Honestly, the rotation itself was enjoyable but the best part was working with normal people again and being off of benign gyn.

One of the patients I was following on the MFM service was a very pleasant lady who had ruptured her membranes early at 31 weeks gestation. She was in the hospital for observation and treatment and was now coming up on 34 weeks. At that point in her scenario, the risks of staying pregnant exceed the risks of preterm delivery. The plan was to induce her right at 34 weeks, which happened to fall on a day when I wasn’t at the hospital. Another medical student on Labor and Delivery was there, though, and told me about what happened. He had followed her for the induction process and helped with the delivery. Just before the baby came out, though, he had to leave the room to take care of another issue that kept him busy for a little while. When he came back, the hallway was quiet. Blood was everywhere in the patient’s room, and the husband was standing amidst the mess, crying by himself. The student rushed back into the OR to find out what was going on – it turns out, the patient had a condition called placenta accreta.

The placenta normally implants sort of superficially into the inner layer of the uterus, but in some cases, it goes too far. It can invade into the uterine muscle or even penetrate through the uterus into surrounding structures, like the bladder. Ultrasound during pregnancy can sometimes pick it up, but not always. When it does, delivery is usually performed by cesarean section and followed by a hysterectomy – there’s no way to normally deliver the placenta without causing massive blood loss. In this case, her placenta accreta wasn’t visible on ultrasound. The patient ended up losing about 4.5 liters of blood (the human body only holds about 4-6 liters), but thankfully they were able to quickly get her back into the OR, control the bleeding, perform an unexpected hysterectomy, and replace her lost blood.

A couple of days later, I had a free moment and ran by her room to see how she was doing. She was amazingly very positive, though understandably emotional – she was overjoyed to be alive and have a healthy baby, but obviously wasn’t planning on losing her uterus or coming that close to losing her life. Other people had talked with her about what happened, but she still had some questions and really just needed someone to talk to. One of the best parts of third year is that, in some ways, you are starting to become a part of the team and can actually begin to (cautiously) answer some of those questions, but you also have the time – sometimes – to just sit with your patients and spend more time with them than some of the more senior team members can (since they are busy putting out fires that never cease to get started). This was one of those times, and she’s a patient I’ll definitely remember.

The Verdict

I don’t see myself going into OB-GYN. Once again, I enjoyed several aspects of the rotation. It really is a pretty cool mix of surgery, primary care, clinic visits, and inpatient medicine. There’s a lot to do and a lot of very distinct fellowship opportunities. I didn’t think the test was quite as brutal as the Pediatrics final exam – we took an NBME shelf and I felt like the UWorld questions and the Case Files book, along with reading Up-to-Date and various articles throughout the rotation, was sufficient.

One thing that was interesting was just the simple fact that this was the first true “specialty” I rotated in. Pediatrics is a specialty, yes, but it’s essentially medicine for little people, which means it’s a very broad field. OB-GYN, on the other hand, has a definite knowledge set that those who pursue the field become experts in. I think that appeals to a lot of people (not about OB-GYN in particular, but about niche specialties in general), but I’m think I’m the type of person who would rather know a moderate amount of information about a broad range of topics (e.g. internal medicine, emergency medicine, family medicine, some surgical fields, etc.) rather than know a lot of information about a particular slice of medicine. We shall see.

In the meantime, though, I’m thoroughly enjoying a week off with my little family. Our son is almost a year and half now and is getting into all kinds of trouble. It’s awesome to see him figure out who he is and develop his own personality, interests, and sense of humor (like sitting on dad’s face. Apparently that’s the funniest thing in the world…). This Monday, I start psychiatry. The site that I have is known to be a bit of a true crazy house and also has pretty decent hours, from what I’ve heard. Should be a nice change of pace.

Step 1 Aftermath

First off, to the kind soul who tried to leave a lengthy, encouraging comment recently on the “How to Study in Medical School” post and perhaps was wondering why it didn’t show up: I think I accidently deleted it. Sorry. I did see it and appreciated your words, though.

This has nothing to do with this post

As the title suggests, Step 1 is over (!!!) and I’ve started third year. I had planned to write up a “How to Study for Step 1” type post, but I think a post like that would be misleading. There isn’t one best way to study for Step 1, just like there really isn’t one best way to study for medical school. That said, I feel like a “How to Study in Medical School” post (like this one) is a bit more helpful because it’s such a different beast than anything you’ve done before. Step 1 is too, to some degree, but by the end of two years in medical school you should have a fairly good handle on what works for you and what resources you like. 

So there isn’t one prescription for an awesome Step 1 score. That said, as I was planning my study schedule out, I found it helpful to read about what other people did, found helpful, or had success with. Also, even though there isn’t necessarily one way of doing things, there are definitely some common resources and themes that lend to success on what might be one of the most important tests you ever take. With that in mind, I’ll try to give at least of a rough sketch of what I did below.

Laying a Foundation

The first thing I’ll say is that probably one of the most helpful things you can do to get a solid score on Step 1 is lay a good foundation for yourself in the first two years of medical school. Don’t get too caught up in what’s “high yield” or whatever. You just don’t know what matters and what doesn’t, especially in first year and into the beginning of your second year. There were things that showed up during my dedicated study period that I remember seeing in first year and never really thought I’d ever see again. So just do your best to do well in classes. I know some people go to schools where they feel like professors mostly just drone on about their research, but by and large medical education across the U.S. is fairly standardized, at least more or less in terms of essential content.

The Resources

Outside of class material, there are some tools available during your first two years that might prove helpful. I’ve written extensively about using Anki to make flashcards. Some people who like the idea of flashcards but don’t want to make them have liked Firecracker. First Aid is helpful to at least look at along with your classes, just to see what might be particularly important and get familiar with how it’s laid out, but more so in second year. Pathoma for pathology and Sketchy Micro (I guess now it’s called Sketchy Medical) for microbiology (and maybe soon for pharm? That would be sweet) are absolute gold. Some people (I’m one of them) enjoyed listening to Goljan audio during second year and/or during their dedicated Step 1 study period while working out or driving. Some people like doing question banks during second year. I just didn’t have the time.

Experiment with what’s out there. There is a lot. By the middle of your second year or so, start nailing down what resources you are likely to use for your dedicated period. Don’t try and do too much. I feel that it’s better to have a handful of resources down pat than to stretch yourself too thin.

Personally, I ended up using First Aid, Pathoma, Sketchy Medical, and UWorld during my dedicated study period. I had used all of these except for UWorld throughout second year. During the year, I tried to make Anki cards with most of First Aid content and Pathoma along with some class stuff, and had watched most of the Pathoma videos at least twice by the time the dedicated study period began. I decided not to keep using Anki through my Step 1 period. It had served its purpose, and I felt like I wouldn’t have enough time (and that turned out to be true). I also used a website called Cramfighter to plug in my resources and spit out a study schedule for each day – it was pretty awesome, and I highly recommend it.

A Day in the Life

My dedicated study period was five weeks. I felt like four was a bit too short, but six weeks was long and I wanted to maximize my vacation time afterwards. Five weeks ended up being perfect for me. Before second year ended, my school provided everyone with an NBME practice exam (Form 12), and I scored 215.

Our last final was on a Thursday, we had a long weekend, and then I got to it on the next Monday. For the first four weeks, my goal was to get through everything once. My day started typically around 6 am. I’d exercise while listening to Goljan audio, shower, eat breakfast, and get started with UWorld questions around 8 am. This would take the bulk of the day. I’d do two blocks of 46 questions (until they changed the max to 44 to match the new change in Step 1) on random timed. One note about that: some people like doing questions by subject or in tutor mode. It doesn’t matter. Pick what you like and what you think will serve you best. I liked random timed because 1) that’s how the test is and 2) by this point you should have at least seen everything in the first two years, so it’s not like you’ll being seeing stuff that you’ve never seen before (for the most part). Also, it let me see things several times over throughout the study period – that repetition is important for me.

I’d do the two blocks, which would usually take about an hour and half or so. The next 4-5 hours would be spent reviewing all of the questions, reading all of the explanations (read at least the educational objective for each question, even the ones you got right. For most questions, I’d also read at least the expanded explanation. If you’re feeling frisky, read the explanations for each of the answer choices). For questions I missed or concepts I wanted to see again, I’d keep a running list for each test in OneNote where I would put explanations, pictures, graphs, etc. This was probably one of the more important things I did. I’ll talk a little more about it later. I kept First Aid nearby while reviewing, and made myself physically turn to the page that dealt with whatever question I was on, regardless of whether I got it right or wrong (if you have an electronic copy, word searching for the page you need makes this a lot faster). Repetition is the mother of learning.

After I finally finished UWorld stuff for the day (usually between 1:30-3 pm), I would read First Aid. It was usually about 30 pages a day, and I took my time getting through it. First Aid is not a thorough text. It’s more of an outline. If you didn’t lay a decent foundation during the first two years, it will seem like gibberish. If you did, though, you’ll be able to read through it and be reminded of things you learned before. This is when I also watched Pathoma videos.

Around 6 pm, I’d call it quits for a couple of hours and hang out with my wife and son, eat dinner, put my son down, etc. Some nights I’d take a bit more time off, but most every night I had some stuff to finish up. I usually watched at least a half hour of Sketchy Medical videos (probably the easiest, most efficient learning you will do) and attempted to get through some Lange pharm cards (I ended up abandoning this halfway through the deck).

To take a quick rabbit trail: for those that have significant others, the dedicated study period can be a difficult time. There’s really no way around it. You have a very finite amount of time to prepare for what is probably the most important test you will take, and endless amounts of information to memorize. This is probably the most time you will ever spend studying in your life. Still, though, it’s important to pay attention to those around you and their needs. Communication, as always, is key. Way ahead of the start time of your dedicated period, be sure that you are talking with your significant other about what’s coming up and what it might look like. Err on the side of overestimating the time Step 1 will require from you here, at least to some degree, so that if you end up having more time, it will be a pleasant surprise for both of you since you were both prepared for the worst. Make sure that you take at least a couple hours each day to spend with your significant other, and at least one day off each week. And it’s OK to count down the days. It’s always important that you and your SO aren’t resentful for any reason towards each other, and that’s especially true during this time. Talk with each other, and understand that even though you are exhausted at the end of each day, this is difficult for them too and the world doesn’t revolve around you. This period will end, Step 1 will be over someday soon, and normality will resume.

Back to an outline of a typical day. The last thing I would usually do each day is review my running list of wrong questions, both for that day and all of the previous tests that week. Once a week, I would go back to the previous week and review all of those (so on week 3 I would review all of the missed stuff from week 2). This was probably the most helpful thing that I did in terms of making my weak areas my strengths. I usually finished my day by 11 pm or so.

So that went on for four weeks, six days a week. I took Sundays off and just hung out with my family. By the Monday of the fifth week, I had made it through Pathoma, UWorld, and First Aid once.

Tuesday of the fifth week, I took another school-provided practice test (NBME 17) and scored 245. I took two practice tests in total. I know some people have this idea that they need to take every test possible on the off chance a question shows up on the actual test, but my feeling is that the tests are best used for assessment purposes to see how things are going. You really aren’t learning much by taking them, and in the dedicated period your time is best spend learning from your chosen resources. But do what works for you. The only thing that might be worthwhile is taking two tests back to back a week out just to get an idea of how exhausting the real thing is.

Wednesday through Saturday of that last week was spent making a mad dash through First Aid and Pathoma. I had already finished my “take my sweet time to learn stuff” pass through the material – this was just to see everything again closer to the test. Each day, I also went through a week’s worth of missed questions on my running list. I took Sunday off, and the test was the next day.

Game Day

The morning of the test, I made sure that I was up early enough to eat breakfast (while reading through the rapid review section of First Aid) and get to the testing center in plenty of time. I sat in the parking lot for about a half hour finishing up the rapid review section (I definitely remember seeing stuff on the test that made me glad I reviewed some of those last-minute details) before it was time to go in.

The test itself is a marathon. I took at least a short break between each block to collect my thoughts (or at least zone out for a bit), although the breaks got longer as the day progressed. I did bring some earplugs, which was helpful. And keep in mind that you have to go through the whole fingerprint/search/sign in or out process each time you enter or exit the test room, which takes at least a couple of minutes. I thought the test itself was harder than the practice exams, but sort of easier than UWorld – at least in the sense that there were more first and second order questions and less third and fourth order ones.

I walked out fairly certain that I at least passed, but otherwise had no idea how things went. It was hard, and I felt like it was harder as it went along (although it’s probably just because I was pretty fatigued in the last few blocks). As the days went on, I became less sure that I passed, but for the most part didn’t think about it at all for the next few weeks (which is partly why this post is a bit later than I had intended).

The Aftermath

My final score ended up being between 250 and 255. That’s a little vague, I know. I’m sort of trying to preserve the few shreds of anonymity that I have left, but I also know that’s frustrating to read through an entire Step 1 experience just to get to the end and have no idea how it turned out for the person. Also, since I’ve talked so much about studying in medical school, it would be sort of anticlimactic if I didn’t at least give an idea of how things turned out.

So that’s my Step 1 experience. This post has turned out to be a bit longer than I anticipated. Feel free to email me or leave comments below with any questions. Good luck. 

Half MD

Well, second year is officially over. I just finished my last couple of finals on Thursday and now have a three day weekend of glorious freedom to spend with my family and celebrate our son’s first birthday before Step 1 studying starts.

It’s crazy how fast our son is growing up. He is definitely becoming his own little person, and I get the impression he knows more about what’s going on around him than he lets on at times. This has actually been a really fun stage – he was cute to look at when he was a few months old, but now he likes to play in blanket forts, be chased around, roughhouse, roll balls back and forth on the ground, read books, press weird key combinations on my computer while I’m studying that change the screen orientation, and generally stir up mischief around the house. Even though school is busy, you just can’t beat coming home at the end of a day to a smiling four-toothed little rascal who wants to backwash in your water and then get chased around the living room.

I haven’t written much over the past few months. That’s partly been because second year has been increasingly hectic, but also because it’s really fairly boring and monotonous. Don’t get me wrong – I've been enjoying it, and honestly the last few months (with the exception of these past couple of weeks that we've had various finals) have actually been quite pleasant – once you hit your stride with regards to studying, everything becomes pretty manageable (hint – weekly to-do lists are a must!). That being said, though, each day isn't too different from the last. Wake up, listen to lectures, maybe work out, study those lectures, make Anki cards, review Anki cards, tackle any random other projects that have to be taken care of, maybe go into school for a few hours depending on the day, call it quits around 6 pm, rinse and repeat the next day. And the next day. And the next day. So there really hasn’t been much to write about, honestly. That will change come third year, I’m sure (although time will become even more of an issue, probably. Ah well).

But for now, we have the long weekend. So far, it’s been a glorious reprieve. The fun starts back up again on Monday, though. My test is in June, so I’ll have five weeks to study. I’ll probably write another post later about my study strategy, etc., once it’s all said and done. For now, though, I’m basically planning on going through UWorld, First Aid, Pathoma, SketchyMicro, and the Lange pharm cards. Our school provided a practice test a couple of weeks ago to give us a baseline of where we are at, which went pretty well. They’ll give us another one later on, which I’ll probably take about a week out from the real thing. I know some people are really into taking as many tests as possible, but my personal feeling is that they are best used for assessing where you are at rather than wasting time (and money! They are expensive – about $50 a pop) answering questions that, when you are done, you don’t even really get much feedback about. Anyway. I could be way off base, but I’ll write more about that stuff later.

That’s all I've got for now. I may try and get a few short posts in over the next couple of weeks. Or not. We’ll see how things go. In any event… see you on the other side. 

Breaking Radio Silence and Career Conjectures

Hello there, internet people. It’s been a while.

Second year has obviously been kicking my butt. In between trying to not fall too behind in school (harder than you might think) and spend as much time as I can with my long-suffering wife and our rapidly-developing eight month old son, life has been particularly hectic these past few months.

We just finished our first week back from winter break (which was excellent; albeit too short. One more week would have been awesome…), and school has started back up in full force. It didn’t help that a few lectures were reshuffled thanks to the wonderful Chicago weather (it has literally been colder than Mars as of late), which made for a couple of particularly busy days.

We’ve finished up with cardiac, pulmonary, and renal path before break and now are starting gastrointestinal pathology this week, with neuropath after that. In PCM, we’ve been learning EKG interpretation and just started chest x-ray stuff a little before break, which has been interesting.

I also registered for Step 1 last semester, which was a bit sobering. As of right now, I’ll be taking it in early June. I’m planning on taking five weeks to study for it – six seemed a little long (and it would be nice to have some more time off afterwards before third year starts) and four seemed a bit short for a test that plays a large role in determining your future. In terms of preparation/studying, I’ve been doing Pathoma throughout second year – before we start a block, I’ll watch the relevant videos so I get the “big picture” and an idea of what’s important. Then, as I go through the lectures, I’m making Anki cards out of the relevant Pathoma and First Aid sections, plus random material from lecture that isn’t in those sources but seems important. In my dedicated period, I’m planning on going through Pathoma and First Aid again along with the UWorld question bank, but that’s still somewhat fluid – I’ll update with more about that as the time gets closer.

Second year has been difficult. It’s not so much that the content is difficult or that I’m struggling grade-wise. It’s more that the sheer amount of constant effort required to stay afloat in the face of a constant barrage of new material (while also balancing school with family and life in general) can be draining after a while. I’ve still been trying to take weekends and evenings mostly off to spend time with my family, other than reviewing any Anki cards that come due and with the exception of the weekends right before tests, but that makes the weekdays pretty cram-packed. If you haven’t seen the “Pancakes Every Day” video put out a while back by the students at St. Louis University’s medical school, it’s worth a watch. It describes pretty well the volume of medical school – and how quickly you can get buried if you don’t keep up.

That said, I’m still enjoying medical school – the material itself is really satisfying and learning more clinically relevant things like exam maneuvers, EKGs, CXRs, etc., keeps things interesting. I’m also incredibly thankful to have my wife and son – they are both an incredible support system (though my son might not know it yet!) and I’m thankful for my wife’s patience and encouragement, particularly on those days that are rougher than others.

Since this blog doubles as a bit of a journal for me – it’s interesting even now to look back and read posts from a few years ago (including my somewhat cringe-inducing personal statement for medical school) – I wanted to mention that I’m still trying to decide what I want to be when I grow up. I came into medical school thinking that I would go in to Emergency Medicine, and to be honest that’s likely where I’ll end up. I have been trying to explore different specialties, but nothing really seems to fit quite as well as EM does. I’m looking forward to getting better exposure to some of the other specialties in third year.

One thing about Emergency Medicine that concerns me is the potential for burn out, which can stem from a variety of factors. I think people used to say that EM physicians burned out because, as a young specialty, those who were practicing it weren’t necessarily doing what they thought they would be doing – and to be successful in the specialty, you really do need to have a certain type of personality. And to some extent, that might have been true.

But it’s still happening. It’s still a concern for physicians today – residency-trained physicians who thought from the get-go that this is what they wanted. I think it is multifactorial – certainly, the shift-work aspect, which is often considered to be a benefit of the specialty (and can be, to be sure), can become a curse when you are 50-plus years old and still working on Christmas day or are unable to bounce back from night shifts as well as you used to. Obviously things vary from group-to-group in terms of how the practice structure is set up and how you progress through the ranks, but there are no guarantees. Also, something that’s somewhat unique to EM is the fact that, while some small groups or the rare larger corporation might provide some satisfaction in terms of how you can take part in influencing the group’s future or practice, all too often some physicians find themselves as cogs in a wheel for large corporations that care more about their bottom line, door-to-doctor times, patient satisfaction scores, and the like than they do about the physicians in their employ or even good patient care. That can understandably be frustrating for physicians.

There are a lot of great things about emergency medicine. It is appealing to me to be a jack-of-all trades and yet a master of acute medical care. The shift work, despite its negatives, is also nice – I’d rather work 3-4 busy shifts a week and go home than spend 80 hours in the hospital or be on call. The environment suits me well, and it pays pretty nicely to boot.

That said, I’m also considering a fellowship to give myself an “escape hatch” if needed, or at least to mix things up and hopefully keep things interesting. EM physicians recently became eligible to take part in a one-year pain medicine fellowship, which would allow them to work in an office-based settings (read: more predictable hours) in a stable group of physicians and use a variety of procedures and medications to, well, relieve pain. That sounds like a perfect yang to emergency medicine’s yin.

It can be difficult to get a fellowship spot as an EM physician and I’m not sure how the week-to-week practice of both specialties would play out (maybe 3 days/week of EM + 1 day part time in clinic? Perhaps locum tenens EM as desired + a couple of days in clinic? Who knows…), but it seems like it would provide a nice balance as well as a sustainable option that I could switch over to if I ever desire more predictability and more of an office-hour type job. We shall see.

Who knows what the future will look like? In the meantime, the week is over and the weekend is here. I’m looking forward to a bit of rest with my wife and son, and we’re all already looking forward to the next break!