There is this prevalent myth that third year is a cakewalk compared to the first two years.  The myth goes something like this: first two years are all schoolwork, and lots of it.  I have provided some evidence on my blog about just how much schoolwork there is in the first two years.  The myth continues by noting that in the third year, you’re out of the classroom.  It would follow that being out of the classroom would mean less “school work” type stuff, i.e. less studying.  While it is fair to say that there is less studying, there is also a lot less time to allot to studying, which pretty much equals out in terms of how stressful it all is.  I was talking with some classmates the other day, and they all said they would rather do second year over again than do third year right now simply because of the scheduling wackiness that comes with third year.  So, I would like to eradicate the Myth of Third Year Simplicity once and for all.  Even though I’m only a month into my third year, I think it’s fair to say that third year is, at the very least, equal in intensity to the first two years, and in it’s own right, it is more challenging.  

Check back soon, now that I’m not on the wards, I’m going to share some of my more resonant third year experiences.

If you wear this in a restaurant, you are part of the problem.

This article just popped up on my RSS reader: What residents and medical students should wear in the hospital | KevinMD.com.

From the article:

5. Scrubs are for the hospital not for home. As a New York Times article pointed out, no one wants to sit next to someone on the subway wearing scrubs, particularly those with uncharacterizable stains on them. Scrubs are there, in part, to keep you from taking hospital germs into the community. It’s also hospital policy. Unless a resident or student is staying overnight or involved with procedures, scrubs are a ‘dressed down’ look. So plan to change from scrubs to regular clothes before you wander around outside the hospital.

This is so true.  I think one of my biggest pet peeves about some of my fellow med students is that so many of them wear scrubs like a badge of honor, as if scrubs are some sort of social signifier that really sets them apart from the rest of humanity.  I can see why a med student who has studied for a billion years to earn the privilege to scrub into surgery might get the impression that scrubs are some special power garment, but the truth is, they just aren’t.  There are people who have a high school diploma (or less) who have access to that same pile of scrubs in the hospital locker room.  They’re nothing special.

Don’t get me wrong, I wear scrubs in the hospital when I’m supposed to, but you can bet your ass I change out of them before I go out in public.  The other night, a friend of mine showed up to a restaurant wearing scrubs.  Here is a person I respect and whose company I enjoy, but the whole time he was sitting there I couldn’t get over the fact that he was “one of those med students” who has no shame about going out in public wearing surgical scrubs.  I’m sorry, but if you’ve been cutting open abdomens all day long, I don’t really think you should be sitting next to me at dinner until you put on normal clothes.  Is that too much to ask?  Who knows what sort of viscera is hiding out in that fabric.  Ugh.

On the other hand, if you have a pair of clean scrubs at your house, they definitely do make a nice pair of PJs, there’s no denying that!

Aside from that, there are a lot of other good pieces of advice in the article.  Having only minimal hospital experience thus far, I can’t think of much to add to the list in the article.  Any thoughts?

Link: What residents and medical students should wear in the hospital | KevinMD.com.

So far third year has been nothing like I had imagined. Right now I’m rotating through a bunch of Internal Medicine subspecialty clinics and basically shadowing doctors for half a day. I had this impression of third year as being a time when I would wake up early, go pre-round on my patients, then round with my attending and his residents and interns. Get pimped, write SOAP notes, that kind of thing. So far, my experience has been nothing like that. So far I’ve had no direct role in patient care. So far the longest I’ve been in the same room as a patient is probably fifteen minutes. So far it has been more like the experience I had when I was an undergrad shadowing doctors than what I thought it would be like to be a medical student. And I’m pretty bored, to be honest.

One day I rotated through a dialysis clinic. In less than two hours, we zipped through, met all the patients there for the morning, talked for a few minutes about how dialysis patients are managed in the most superficial of terms, and then we were done. For the day. In two hours.

So far my other assignment has been to shadow a doctor in an outpatient internal medicine clinic. While it was fun to see the doctor/patient relationship at play in this context (compared to the typical context in which I see it–the hospitalized patient) again, I was only very slightly involved. I saw maybe four or five patients over the course of the morning and that was it. For the day. In the past week, I’ve “worked” a total of maybe five or six hours (not counting studying, which I’ve had ample time to do, but no context for whatsoever.)

The point of the rotation that I’m on right now is to expose us to the different possibilities available in Internal Medicine, and to that end, I suppose it’s a valuable experience. However, having it as my first rotation is pretty boring. I suppose that at some point later in the year, it would have been nice to have this rotation as a mini break of sorts, but having it first is kind of torturous. For the last two years I’ve been eager to start getting to be involved in patient care, and here, my third year has started, and I’m going to have to wait another two weeks!

Oh well, at least I didn’t start out on Gyn Onc. I have a few classmates who started out on that rotation who have to be at the hospital at 4:50am and stay until 7:00pm. Not looking forward to that one!

Eventually I arrived, thirty minutes late rather than the fifteen minutes early I had hoped to be. In the end it wasn’t really a big deal because it was a very informal meeting to just fill us in on policies, and the attending was very laid back and didn’t seem mad or anything. That, and there were at least 5 other people who were as late as I was. But seriously, though–my med school has the WORST organizational abilities EVER.

Lesson #1 for third year: check your e-mail. All the time. I guess it’s time to go in on a smartphone that will let me check it at all hours of the day.

I had the opportunity to speak with Dr. Jauhar by phone one afternoon recently.  He is a very warm and friendly man whose deliberately worded responses to my questions reflected the same kind of insight and introspection that initially attracted me to his book.   I asked him about his book, his experiences in residency, and how he decided to become a doctor.  The transcript of our conversation follows.

To hear audio from the audiobook, click here.

Med School Memoir: A lot of my readers are premeds and I think a lot of them aren’t sure if medicine is actually for them.  Could you talk a little bit about why you decided to go into medicine?  Because your path to medicine was unique, so for those who haven’t read the book, could you talk a little bit about why you went into medicine, and if you would do it again?

Dr. Jauhar: Well, I would do it again, because I found a niche that feels comfortable.  But as you probably know from the book, for a long time I struggled with being a medical student and being an intern.  I think that my path was very circuitous and my position was formed by many different motivations and thoughts.  One was that I was in graduate school doing very esoteric work, and for lack of a better word, I started just to feel lonely.  Not only was I doing work that most people didn’t understand—quantum physics—but my lab, the actual physical space, was up in the Berkeley Hills, so I wasn’t really interacting with the sorts of people who I found vibrant and interesting when I was an undergrad, which was people who were interested in arts, literature, and other various pursuits.  I was spending most of my time with physicists, and I liked them a lot, but I felt somewhat limited.  That was one issue.  Then, paired with that, there was a sense that I wasn’t contributing much to the world, or society.  What I was doing was very esoteric, and perhaps it was going to have some applications down the road, but immediately I didn’t see any tangible benefits.  Then, as you probably know from the book, my girlfriend got sick with lupus, and that really was traumatic, because I wanted to help her.  She was sick for quite a while, and she eventually got better with medications, but in the process of helping her and understanding what was going on, I delved into medicine.  I spoke with doctors, I went to medical school libraries, I started talking a lot more to my brother more about medicine, I started reading textbooks, journals, and so on.  I found that medicine had so many unknowns, and there were so many uncertainties in medicine, and that was exciting.  I was drawn to the idea, I think, of traveling a road that so many had traveled before me, as far as joining a community that had a really long tradition.  There were all these different inputs, but in the end, I decided I was going to leave Academic Physics and go to medical school.  Fortunately, I was only 26 when I started medical school, and I completed the premedical requirements when I was 24 or 25, before the end of graduate school.  It all worked out.  A lot of students today are nontraditional like me, and they do bring a lot to medicine, in terms of varied life experiences, and an ability to relate to different kinds of patients.  I think the fact that I was a little bit older, maybe a little more mature than I was when I was 20 or 21 really helped in the end.  I was very ambivalent, but in the end I got a lot more comfortable in my own skin, and now I’m reasonably contented.  You know, life isn’t perfect; it wouldn’t be if I were a lawyer or a Wall-Streeter, or whatever, but that’s more a function of my own biology than medicine.

MSM: So you think your experiences prior to med school were ultimately beneficial to you as a physician?

Dr. Jauhar: I think so.  Not in any kind of concrete way.  I don’t use my physics training explicitly, but the way I learned to think about problems logically, the fact that I was an older student, the fact that I had been through career and was late to medicine, it made me a little more committed, if for no other reason than I was older, and I didn’t have any more time to change my mind about stuff.  I think in the end it was beneficial for me, and I think that I needed to do what I did.  Eventually I found a niche writing about medicine, and practicing in a way that I believe to be fulfilling.

MSM: Flash forward a little bit from before med school to when you were an intern, since that’s what the book was about.  The entire middle section was really great—the atmosphere when you were on call in the hospital during the evenings, it seems so hectic, but it also seemed kind of exciting.  I’m guessing you don’t really have those stresses in your practice anymore.  Do you ever miss the atmosphere that you encountered as an intern?

Dr. Jauhar: Yes and no.  I don’t miss the anxiety of the sleep deprivation and the fatigue, and the overwhelming sense of responsibility—I don’t miss that!  I do miss the engagement I had with patients and the fact that so much was new.  The learning curve was really steep, and so much of what I was seeing was actually providing a lot of fodder for writing and creative pursuits.  This is a good time to start writing if you have time to write, because everything is new, and at the same time you’re on the front line.  You’re never that close to the bedside, as you are as an intern.  As an attending now, obviously I see patients at the bedside, but so much of what I rely on is what my fellows and my residents tell me.  But yeah, I miss it.  But I also miss the time.  It’s hard to disentangle what was happening in my life at that time.  I was single, no kids, I was sort of a free bird in a lot of ways.  In that sense, I was only thinking about me.  As you get on in life, you have more responsibilities to other people and other things.

MSM: You mentioned how in your residency, the new experiences provided good fodder for you to start writing.  I got a big sense that you were also writing as a way to perhaps change the culture of medicine or something like that…

Dr. Jauhar: Yeah, I initially thought I was going to set on making big changes, but in the end I learned my lesson.  Medicine is just too big of a field to transform, and like a lot of people who join a field, I ended up embracing the culture of it.  I’m probably a bit of an odd bird, still, because I write about medicine, and I practice it, and I maybe think a little bit more about things, or at least in different ways, than the run-of-the-mill doctor.  But I’m a loyal practitioner—I’m like every other doctor bemoaning reimbursement cuts and losses in salary and all those things.  I, of course, support health care reform, unlike a lot of doctors I know, but I feel the pain.

MSM: What do you think it is about the training that squashes that idealistic spirit, because I feel like that’s a common theme with many students?

Dr. Jauhar: Yeah, you see so much, and it’s hard to remain idealistic.  You get beaten down by the experience.  You can only see so much suffering and remain sensitive.  That’s part it.  And also, you’re sleep-deprived, fatigued, and that’s a big part of getting cynical, because your own body is under so much stress.

MSM: One last question, and I’ll let you go, and I appreciate it so much!  For any of my readers who might be about to start their own intern year, are there any pearls that you have for maintaining your sanity or avoiding burnout?

Dr. Jauhar: Keep a diary, and process your experiences.  Think about it, because it’s a very rewarding experience, in the end, but it doesn’t feel that way.  It’s like a boot camp of sorts, because you’re suffering, but maybe you don’t see the reward initially, but it’s there.  So process what you’re doing, think about it, be mindful of the experience, and if you can, write about it a little bit.  Keep a diary, then revisit those old experience when you get older, because it’s very rewarding.  That’s what I did, and I ended up writing a book!

After I dumped out all the boxes I got a shot from above to show the mass, but there was no perspective, and it doesn’t look all that impressive.

So I stacked it up next to the biggest textbook I could find, Robbins & Cotran Pathologic Basis of Disease, which is a massive tome that stands ~11 inches tall and weighs about 7 pounds.

As you can plainly see, my mound of flashcards dwarfs Robbins in every dimension.  This is two years worth of med school.

I spent about thirty minutes removing all the binder clips, paperclips, and rubber bands from all my piles of flashcards.

And in the end, it all winds up in the garbage.  Oh well, I won’t be sorry to see it all go.  My study room is far less cluttered now.

Tomorrow I begin my preparation for Step 1.

Pathology–Path was a course that I expected to really like.  I thought I would learn a lot about how diseases affect the body.  Since I have always been interested in disease processes–for instance, in undergrad classes, I was always way more interested in clinical correlations that taught about how the basic sciences we were learning affected human health than by the actual science itself–I figured that I would really enjoy path.  The reality of Pathology class, however, is that you spend about 20% of your time learning about disease processes and the remaining 80% memorizing what Pathology tissue slides look like.  This aspect of the class is basically tantamount to learning how to differentiate between a thousand different kinds of cancer under the microscope, and if you’re not interested in going into Pathology as a career, it doesn’t feel terribly useful.  So, in this regard, the course is basically the beefed up, angry, diseased, sequel to Histology class (which I did not enjoy.)  Nonetheless, that 20% where we actually learned about disease processes was really interesting to me, and I think path might have been my favorite class.

Pharmacology–I was a Chemistry major in undergrad, and so I had a feeling that Pharm would end up being one of my best and most enjoyable classes.  Despite the fact that there were hundreds of drugs to memorize and it could be quite difficult to keep everything straight, the class was, for the most part, straightforward.  So long as you are able to memorize tons of information (as with everything else in med school), this class is not terribly difficult, conceptually speaking.  In many ways it Pharmacology is just applied physiology–if you understand Physiology, Pharmacology shouldn’t be terribly difficult as long as you can keep all the drugs straight.

Microbiology–This was one class that I expected to like, but ended up being a little disappointed in.  I have always been interested in infectious diseases, so I figured that Microbiology would be right up my alley.  However, it turned out that I don’t really care about the virulence factors for bacteria as much as is required to really enjoy this class.  While I think it’s obviously necessary to know all the bugs that cause common illnesses, I found it terribly boring to have to memorize dozens of protein names like M protein, Streptolysin, and Leukocidin, when knowing full well that knowing these protein names will likely not affect the way I practice medicine in the future.  Nontheless, this is the type of thing you have to put up with in med school: learning stuff because it’s there to be learned.  I’m not trying to complain, however, because overall I did enjoy the class more than most of the others.

Behavioral Sciences–I had anticipated that I would enjoy this class.  And to be honest, it was nice to not have 1000 things to memorize every week, as is the case in Path, Pharm, and Micro, but Behavioral Science ended up being a lot less interesting to me than I had anticipated.  Maybe it’s because I felt like it was largely rehashing a lot of stuff I learned a long time ago–I took AP Psychology in high school, and I’d say that there was about a good 50%-70% overlap between that and Behavioral Sciences–but I found the class rather uninteresting most of the time.  I suppose if you’ve never learned about people with Schizophrenia or Bipolar Disorder and all that stuff before, Behavioral Sciences could be very interesting.  I’ve known about it for a long time, so the course felt like old news to me.

Genetics–If you’re like me and you hate memorizing useless trivia, you’ll hate Genetics about as much as I did.  One’s brain can only retain so many chromosomal translocations and gene names before he or she becomes engulfed rage and bloodlust for the sadistic professors who are making him learn the pointless material.

ICM-2–So, this class suffered a lot from poorly written exam questions and a lot of disorganization at my school, so I pretty much hated everything about it except for my preceptorship where I had the opportunity to work closely with an attending physician in the department of Internal Medicine.  That whole experience was great, but it only constituted a very small fraction of the actual class.  Otherwise, ICM is a bit of a misnomer, as there is very little “clinical” about Intro to Clinical Medicine.  A more correct name would be “Intro to the Theoretical Practice of Medicine Wherein You Consider Overly-Simplified Medical Situations and are Judged Harshly and Very Subjectively by Your Superiors, Who Likely Despise You,” AKA “ITPMWYCOSMSJHVSYSWLDY.”  Come to think of it, ICM does roll of the tongue a bit better.

Ethics–Wow, I was really, really wrong about this class.  I thought it would be thought provoking.  With a few exceptions, it was just a giant waste of time, considering that it was the only class that had mandatory attendance all year long.  There’s nothing more sadistic than taking ~150 people who are all stressed and in need of studying, and forcing them to congregate in a room two days before a giant test to listen to a lecture on the ethics of intersexual gender identity from a guy who is so boring he actually yawns at his own lecture.

Overall–The second year of medical school has a bad reputation for being difficult.  And I feel the reputation is well-earned.  I remember at the end of the first year, someone told me that second year was going to be even more difficult than first year was.  I thought they had to be crazy or just plain wrong.  I mean, the first year had Gross Anatomy, which is hard, and obnoxious as hell–surely second year had nothing that could be so bad.

And that is true.  Sort of.

No single class in second year is actually all that bad.  It’s the sum of all the classes combined that makes it so difficult.  The classes come at you so fast, and throw so much information at you all at once that it is very easy to get overwhelmed.  I witnessed several of my classmates who excelled during first year having a difficult time keeping up with the grueling pace of second year.  Second year is tough.  I’m glad it’s over.  But on the upside, it was, to me at least, infinitely more interesting than first year.  While first year was basically just a bunch of science classes telling you about the human body, second year is when you start knowing doctor-like things.

I’m still a long way from being a competent physician, but I know so much more about it now than I did a year ago.  I can thank second year for that.  I remember volunteering at a free clinic last year and knowing essentially nothing about how to treat a common disease like gout or hypertension.  The physician I was working with just looked at me like “why are you even here?”  I felt useless.  Flash forward to a year later–now when I volunteer there, I get mistaken for someone who actually knows what they’re doing.  It’s a big difference, and it wouldn’t have been possible without the difficulties of second year.

Second year is a lot of work, but in the end, there is a reward.  During second year, you work hard to convert information on a page into knowledge that you own.  The reward is that in third year, you can finally use all that knowledge you spent so long learning.  To some people, that may not sound like much of a reward, but to me, well, I’m actually quite excited to put my knowledge to use.

Up next, Step One.  More to come on that shortly.

My next final is behavioral science, which is tomorrow. Then just one more after that. Then… I’m gonna try and take a week off before starting on STEP 1 preparation.

Reviewing pathology yesterday, I had one of those moments where I panicked and thought there was no way I could retain all the information.  The thing about Path that makes it difficult for me is all the little details that must be remembered.  If you want to pass the class, it’s enough to remember that Burkitt’s Lymphoma is a form of lymphoma that commonly invades the jaw or the ileo-cecal area.  If you want to do well in the class, you have to also remember that it’s associated with c-myc translocation which puts it next to the IGH gene.  The most common translocation is t(8;14)(q24;q32).  You’d be well advised to also remember the lesser translocations if you can.  (I can’t.)  Finally, you also have to remember that the endemic and sporadic forms are associated with the Epstein-Barr virus, whereas the immunodeficiency form is associated with HIV.  If it were just one disease process that you had to worry about, it wouldn’t be that tough.  But there are hundreds of diseases to be familiar with.  For some reason, I am actually really good at understanding how diseases work from a systemic perspective, and I usually have no trouble remembering what a disease does.  Where I have trouble is remembering the tons of genetic minutiae to be memorized, the never-ending supply of trivia that goes with each disease.

Long story short, I had a “firehose” moment yesterday.  They always say med school is like drinking from a firehose.  I always thought that was an exaggeration, but I definitely felt that way yesterday.  Perhaps, then, it’s no surprise that when I woke up this morning, one of the first things I thought about was this video clip from the old but great UHF.