A New Kind of Hard – 3rd Year

I’m finishing my last week of psychiatry rotation. Like whaa?! I know. I’m a 3rd year. It’s surreal. The challenges of 2nd year and Step 1 is all behind me now, and there’s no turning back.

Ooo, is that my name?! Hehe…umm…do I really know what I’m doing?!

If I could sum up my 3rd year experiences so far in one word, I would say it is “moving.” Definitions (per Google, not in particular order):

  1. Producing strong emotion, especially sadness or sympathy.
  2. Influence or prompt (someone) to do something.
  3. In motion.
  4. Change the place or position of.
  5. Make progress; develop in a particular manner or direction.

Interacting with patients, reinforcing knowledge, and working with a multi-disciplinary team…they all present a new kind of challenge. It’s the kind that drives me to tears not because I got a low score or fear the next set of exams. It drives me to tears because I realize medicine can only go so far. No matter how well the anti-depressants or anti-anxiety meds we prescribe work, we can’t erase childhood abuse or violence in the home. Although we have great plans to transfer patients to a board and care facility for further care, we can’t keep them off the streets if they choose to leave or if they cannot afford it.

I realize, too, the necessary humility physicians must possess to show love and care to patients who may insult us, ignore us, and distrust us. Humility is also needed to admit when we’re wrong, to respond to constructive feedback, to ask for help when we don’t know the answers, and to respectfully listen to people who strongly disagree with us.

Lastly, I learn every day about my own personal limitations. How many emotions from the day can I manage without feeling completely drained by 5 p.m.? How do I keep a healthy boundary between empathy for the patient and my own health? What is the best way to organize all the things – the papers, the emails, the assignments, the sign-offs?!

In the end, I’m human. I make mistakes, I feel hurt when I’m threatened or not appreciated, I feel frustrated when the same patient keeps coming back to the hospital for the same reason, I want to go back to sleep when the alarm clock goes off. But knowing I’m human and knowing that my patients are human too helps me to connect with them in moving ways. Knowing the impact that I can make on someone’s life –  knowing that my hard work is making a difference – makes this new kind of hard totally worth it.

My Hidden Curriculum

Ryan, Third Year Medical Student

So here’s the problem with 3rd year: I suddenly have so many stories to tell, but not nearly enough time to tell them! That said, the type of “busyness” that 3rd year has been providing is so, SO much better than what I experienced in the preclinical years.  Check this out, one of my patients turned out to be a widely published author; she gifted me one of her books:

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Pretty cool! I’ll probably reemphasize this notion throughout the year, but simply studying medicine is nothing compared to seeing it all come together in the clinic.  These experiences are all part of a “hidden curriculum” of sorts.  While tests still need to be taken and papers still need to be written in order to obtain a license, it’s the unofficial learning objectives I feel shape us med students into the doctors we are to become.  They may not be listed anywhere, but they are just as important.

Let me illustrate this with a short story.  After finishing my medicine rotation, I moved on to psychiatry.  Most psychiatric medical conditions are cared for in an outpatient setting, meaning the patient won’t stay overnight in a treatment facility.  However, when someone is sick enough to require hospitalization for a psychiatric emergency, this means that they are acutely a danger to themselves or to others. My rotation site was solely an inpatient setting, so all the patients I helped take care of fell into that second category of “danger to themselves” or “danger to others.”

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My Home for the Last 6 Weeks

While working on the adolescent unit in the Loma Linda University Behavioral Medical Center (LLU BMC), I found myself quickly growing frustrated at some of the situations I would encounter.  Not frustrated in an “I’m going to lose sleep over this” kind of way, but frustrated in the way I feel most doctors get when they wish they could change something, but know that it exceeds limits of how they could help.

Now, I realize that kids who have grown well in to their teens are fully capable of making their own decisions. But the thing that frustrated me about most of the patients I encountered is that most of the time, his or her psychiatric hospitalization was due to something beyond control. I’m not just talking about “bad genetics,” as is the case with patients who develop things like cancer or diabetes; I’m talking about things like poor decisions made by parents or abuse from peers.

So there I was, on the fourth day of my psychiatry rotation, when I met Craig*.  At first glance, he looked like your everyday average 14-year-old, but to the trained eye, one would have noticed his small sized head, flattened cheek bones, smooth upper lip, and other subtle facial abnormalities. Police had brought in Craig to the BMC after he had punched a family member multiple times for “annoying him.”  As a medical student, it was my job to talk to Craig and try to figure out why he needed a stay at the BMC and how we could help him.  This is done through the traditional process of interviewing to hear a patient’s story.

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Preparing to Take a History

Craig seemed like a nice enough boy, but shortly into the interview, I could tell something was not right.  He acted very embarrassed by the incident, claiming that it was “no big deal” and that he just wanted to go home.  When I carefully explained that he would not be able to leave until we were sure he was doing ok, he asked if he could instead visit with his girlfriend, who just happened to be living on the girl’s side of the same psychiatric unit. Surprised, I probed for more details about this girlfriend, but Craig suddenly changed subjects to talk about his 8-month-old daughter, who was already walking around and speaking in full sentences. He went on to tell me about his career as a rap star, how he was the captain and star running back of his school’s football team, even how he managed to single handedly subdue a drug dealer at gun-point.

After listening to Craig’s stories for about a ½ hour, I knew I would need to call his family for more information.  We ended the interview on a pleasant note, and I walked away trying to make sense of it all.  Though there’s always the slight possibility a patient is telling the truth when sharing elaborate stories such as these, there’s a good chance he or she is confabulating, and so extra information must be obtained from family (a process known as obtaining collateral). Confabulation refers to when a patient makes up memories or experiences, without intentionally trying to deceive. If you try to point out inconsistencies in these stories, the patient often becomes frustrated or defiant, insisting he or she is in the right.

I called up Craig’s primary caretaker, who turned out to be his first cousin.  The conversation began with Craig’s cousin answering various questions about his history, but quickly turned into a venting session as her own concern and frustration began to flow.  She explained that Craig’s behavior had always been highly unpredictable, and as he had grown bigger and stronger, this behavior had become increasingly disturbing and violent.  She listed some fairly horrific examples, including torture of animals, destruction of property, bullying other kids at school, and being a general terror around her home.

These examples made me instantly think of a diagnosis known as “conduct disorder,” but when I asked about Craig’s parents, a diagnosis didn’t seem as concrete. According to his cousin, Craig was the unwanted outcome of a one-night stand.  His mother used drugs heavily during her pregnancy, a pregnancy which was complicated by poor prenatal care and an improper delivery outside of a hospital.  The cousin said that after Craig’s birth, his mother wanted nothing to do with the child, so he was given up to his biological uncle, a man trying to raise 9 other children on a poor income. She explained that to help her uncle care for Craig, she watched over him during the school year.

At this point, I could tell Craig’s cousin was becoming tearful as the full gravity of her situation bore down on her. I attempted to provide some consoling words while reassuring her we would do everything we could to help Craig, ending the call. I took a deep breath as I tried to make sense of everything I had just heard, removing my glasses to rub the confusion out of my eyes. How could this have happened? What exactly was going on?

It was at that moment, my attending physician walked into our small workroom. Almost forgetting to say hello, I launched right into Craig’s story, hoping she could provide some insight.  She listened patiently as I recited back my presentation, glancing down at Craig’s chart every so often.

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Me with my Residents and Attending

“Well Ryan,” she began as I finished up, “this is an example of what happens when someone uses drugs during pregnancy.” She went on to explain how the frontal lobe of Craig’s brain, the area of the brain responsible for a person’s impulse control and personality, was likely severely under developed. Due to his exposure to drugs while he grew inside his mother’s womb, he couldn’t develop as in a normal pregnancy. This lack of impulse control lead him to do whatever tiny idea crept inside his head, set off by any kind of stimuli. If someone annoys him, he punches him or her. If a cat meows too loudly, he’ll throw it across the room. If he wants to plant a big sloppy kiss on a girl he passes at school, he’ll do it. “He lacks the basic control that you and I take for granted,” my attending said, finishing up her explanation, “he’ll struggle to live a normal life.”

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Brain Lobes!

As we discussed potential treatment options to help Craig control his impulses, I couldn’t help but feel so frustrated with the whole situation.  How is this fair? It’s not fair that Craig’s brain didn’t have the same chance to develop like mine did, it’s not fair that Craig’s cousin has had to live in fear of her own cousin’s impulses… it’s just not fair! And I don’t know the story of his biological mother, but what if she is the continuation of generations of drug abuse and abandonment? How is that fair to her?

Craig’s story is just one of many. I saw kids who were considering ending their own life because their parents called them “worthless” and “stupid.” I saw kids with terrible eating disorders because they were being bullied at school. I saw orphaned kids with no parents to teach them right and wrong, already so addicted to drugs it seemed like sobriety would only ever be a fantasy. And I saw kids who were terrified of other human beings because a family member abused them both sexually and physically. How is this fair?

As a Christian, I believe that sin runs rampant throughout the world, and that doesn’t seem very fair at all.  But I also believe there is a reason for this: God could have created us as mindless drones who loved Him by design, but instead, He gave us the gift of choice, something that makes our ability to love genuine, but something that has also resulted in consequences.

Whether you are religious or not, I believe that humans have a tremendous ability to love and care for those less fortunate.  There’s going to be a lot we see in life that “isn’t fair,” and we have to be able to accept this, showing compassion in spite of the circumstances.  And I’m not just talking about health care professionals; this applies to everyone!

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Fellow Classmates, Working Hard…

Rotating through the adolescent unit at the BMC has helped show me how to deal with these kinds of emotions, struggling with my natural inclination to defend the defenseless, yet show my concern in a professional and empathetic way.  As I mentioned at the beginning, this kind of training isn’t necessarily listed in a curriculum somewhere, but it’s experiences like these that provide the best teaching.  It’s definitely one of the things I’ll remember as I continue my education, hoping to touch the lives of others in a positive way.

Well, my psych rotation is ending this week, and even though it seems I was just there, I’m headed back to Kettering, OH for another short three weeks to complete my neurology rotation.  I was hoping to catch a Cincinnati Reds playoff game or two, but unfortunately for my poor team, they got eliminated in the first round (for the 3rd time in 4 years!).  I’m looking forward to seeing my family again, and maybe I’ll get to see the Bengals play instead haha. Until next time! (I feel like I need a catchy sign off phrase, any ideas?)

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My Wife & I in Oak Glen Over the Weekend

*Names have been changed to protect privacy.

Catching Up……

I’m starting to feel like every time I blog I look back and realize it has been much longer between posts than I always think or intend.  I guess that’s just a reality of the craziness of my life and the demands of medical school.  Of course everyone feels overwhelmed by medical school and all the information to learn/tasks to complete, so I’m definitely not complaining :).

SO….let me attempt to give an update on what I’ve been up to since my last post 70+ days ago……..First:  I found out I passed Step 1!! YAY!  This seems like it happened SO LONG AGO, but it’s really only been a few months :).  So, all the hard work payed off and I was able to settle into being a third year (for me, it was hard to officially call myself a third year medical student until I actually physically had my Step 1 score and knew I could look forward to the next step in my medical education).

The next big thing was making it through my first rotation––psychiatry.  The mention of psychiatry brings mixed emotions for most medical students––some look forward to it with enthusiasm, some dread it.  I went into the rotation mostly just excited to be out in the clinic/hospital learning in a more hands-on environment.

For the first two weeks I was working with a fantastic doctor in an adolescent/child partial program where patients come in for the day but are allowed to return home to their families at night––a transition from in-patient psych ward to an outpatient clinic setting.  I greatly enjoyed learning from my attending and resident, and the team of medical students I was with was awesome as well––basically I had a great time on this rotation (and it didn’t hurt that I was home most days before noon!).

For week 3, everyone was placed at either the VAH (Veterans hospital) or LLUMC for an addictions rotation.  I was at the VAH, and spent the week learning about all the treatment options available for veterans struggling with the realities of drug/alcohol addictions.  It was an eye-opening experience (with time spent attending group therapy, AA meetings, NA meetings, Al-Anon meetings, etc.), and I feel much more prepared to help direct my future patients to places they can get the help they need.

The final three weeks of the clerkship I was assigned to the Behavioral Health Intake Program (BHIP) clinic at the VAH.  This clinic is used to guide patients into various doctors/services available at the hospital.  I saw a lot of interesting cases and had several experiences I will probably never forget––I had patients yell at me, cry, run out of the hospital, etc.

So, psych was an overall good experience––certainly better than I had expected, but I’ll be honest, it’s not exactly what I’m looking to do long term.  I am, however, thankful that I had psych as my first rotation for a couple of reasons:  first, it helped ease me into 3rd year with the easier work hours and lighter academic demands, and second, because I believe it will help me relate to my patients and be much more understanding on a more human/relational level––something that really can’t be taught but must be experienced.

And now I am just over two weeks into my internal medicine rotation.  Internal medicine is one of the tougher rotations during third year because it is time intensive and because it encompasses so much information.  I’ve been blessed to start the clerkship at an outpatient clinic at the VAH working with a team of doctors that are absolutely amazing.  The main attending I am working with is extremely helpful––she quizzes me about patient care but is also more than happy to teach me the things I don’t know well.  Seeing patients in the clinic setting has helped solidify that what I really want to be doing in medicine is working in a clinic!  I love seeing several patients with different symptoms, and I love spending time getting to know each one of them.  Don’t get me wrong––it’s terrifying to simply be handed a patient’s chart and told to do the initial evaluation on my own…but this is what I’ve spent the first two years preparing for and I feel as prepared as I possibly could be.  I know eventually the nerves will settle down and I will be able to simply enjoy the process (without the added increase in heart rate 🙂 ).  The weeks ahead are definitely going to become more challenging (as I transition from outpatient to inpatient care) but I am greatly looking forward to the challenges and all the learning I know I will do.

On one last note, some about the life that I do still have outside of medical school 🙂 :

1.  My husband and I enjoyed a quick but delightful trip home to visit our families in IL a couple weeks ago.

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My cousins and I around my grandparents as we celebrated my Grandpa’s 70th birthday!

 

2. We continue to work on our goal of making it to all the professional baseball fields in the U.S. …..in August we saw the Dodgers play our Chicago Cubs at Dodger Stadium in LA and this weekend we got to see the Angels play in Anaheim :)!

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Reflections

Laura, Third Year Medical StudentIn eight short weeks, my third year of medical school will be over. I cannot believe how fast this year has flown and how memorable it has been! Here are some reflections from each rotation:

1. Obstetrics & Gynecology

Delivering a baby was by far the most thrilling experience from this rotation. I enjoyed having the privilege of sharing such a precious moment with several families. It will not be soon forgotten. On a lighter note, I was reminded of just how “green” I was on this rotation when a baby was out of mom in a crash c-section before I could even get my second glove on. Oh well, practice makes perfect right?

2. Family Medicine

What a broad field! I truly enjoyed seeing a diverse population of patients everyday I went in to work. From 3 week old babies to elderly individuals with every medical problem in-between, it was all there. My favorite part of this rotation was the personal relationships formed. Family docs have the unique opportunity to oversee all of an individual’s care, not just one condition. I felt that this led to a closer relationship between doctor and patient, what an awesome benefit!

3. Internal Medicine

Wow, what an experience! Many medical students consider this to be the “meat & potatoes” rotation during third year where the most information is learned. I found this to be true. Although busy, the rotation was also quite fun for me both from working with great teams and from the patients I had the opportunity to follow. One patient in particular, Mr. C, was 98 years old and had served in WWI! Serving such individuals made both this rotation and the year as a whole worthwhile and reminded me of just how blessed I am to be in this profession.

4. Neurology

For this rotation I decided to have a change in pace and fly across the country to Kettering, OH. I am very glad I did! Kettering is not only a lovely city but the hospital there was also wonderful to work at. I also felt that it was a very good experience for me to branch out and see how other hospitals are run. The most memorable patient encounter from this rotation was getting to see Anton’s syndrome, a condition in which damage from a stroke renders an individual blind but having them still believe they can see. Although very sad such diseases remind me of just how intricate our bodies are made & of just how well we are at compensating after damage has occurred.

5. Psychiatry

Spending one week on the addictions unit and three weeks working with individuals battling eating disorders was by far the most memorable in this rotation. Although they may appear to be quite different I found both of these areas to be similar with the issue of “control” at their center. It was interesting to listen to the stories and to see just how much these problems can consume an individuals life. After completing this rotation I have a new respect for people fighting these diseases.

6. Surgery

Phew! This was by far the most difficult rotation for me. After completing it I can honestly say that I am not cut out for long hours in the operating room. I have a high respect for surgeons; they do amazing work. That being said, I will happily refer my patients in need of an operation to them during my medical career.

7. Pediatrics

The kids are adorable & they have such resilience! They are the best part of being on the pediatric rotation and I find that I am constantly smiling with them around me. I can’t wait to see what the rest of this rotation has in store for me.

This year has had its ups and downs but overall I am truly thankful that I am here in medical school and look forward to the opportunities that await me in the time to come.