Third Year (Part Uno): The BIG One

This is the year you have been waiting for.  It is The. Big. One.  Regardless of what you thought you wanted to do coming into medical school, this is the deciding year.  By the end, you will figure out what kind of doctor you will become.  The hours stink and you will be exhausted.  You will have to work all day and study most nights.  However, you will be doing REAL medicine (while under the close observation of actual doctors). 

Regardless of how well prepared you think you are, you can expect to look completely stupid at least a handful of times during third year.  There is a steep learning curve as you discover how to apply all that information you gathered during the first two years of medical school.  However, somehow by the end of it you come out ready to be a doctor.

Surgery:

Surgery is about survival.  It doesn’t matter if it is a routine procedure or life-saving operation.  Patients are never more vulnerable than when they are on the operating table.  During moments in the OR, their lives are truly in the hands of another person.  Even though it was only for 12 weeks, it was absolutely amazing to see a surgeon at work… most often from the far end of a retractor. The patient comes in broken, and if everything goes right he or she leaves fixed. There is no other area of medicine with more instant gratification.

From the side of the medical student, it is also very much about survival.  For anyone who likes sleep, surgery is not for the faint of heart.  You can’t fully prepare yourself for that kind of sleep deprivation.  Before the rotation, I could not fathom the incredible effort it takes to write a patient note after being awake for 30+ hours and not fall face first into my coffee.  I quickly learned that surgery is not for me.  The time in the OR is amazing, but you have to sacrifice an incredible amount of time and energy to get to those brief moments in the surgical spotlights.  The training is grueling and life as an attending often requires similar sacrifices.

Most of my surgery months truly were a blur, as I shuffled through in my sleep-deprived haze. However, here are some of my surgery moments

- Living on crumbled chewy bars from my white coat pocket

- Trying to cram factoids from the “Surgical Recall” handbook into my head 2 minutes before heading into the OR to be “pimped” (drilled with questions) by my attending

- Learning to write the shortest patient notes known to man

- Telling a mother her son is alive

- Successfully inserting a foley catheter (designed to drain urine from the bladder)

- Gowning up in under 10 seconds for trauma calls

- Learning second-hand it is never a good idea to insert a chest tube through a stab wound

- Being first assist on an emergency thoracotomy (procedure where an incision is made through the chest to gain access to the lungs and heart)

- Mastering the art of sleeping while standing up

- Always carry steri strips, gauze, a suture-removal kit, and scissors in my pocket

- Learning that going to the call room (a place where physicians try to sleep between calls) is just asking to get paged

- A good idea while drunk is a great way to end up in the ER (and possibly OR)

- Seeing the many ways you can be injured while riding horse, motorcycle, four-wheeler, or Jet Ski… and wondering if I will ever get on any of these again

- NEVER stand directly behind the patient when giving an enema

- Always be nice to the nurses!  You can learn a lot about drawing blood, taking samples, and finding things in the crowded supply rooms if you are considerate and thankful

- The simplest things, like applying pressure to a bleeding wound, can save a person’s life

Family Medicine:

When people hear the word “doctor,” many immediately think of the family doc.  I remember going to my family practitioner with my mom as a kid.  My visits to that office were my first exposure to medicine.  When I came to medical school, I wanted to be a family doc.  Family physicians are able to work with patients in all stages of life.  And, they have the privilege of watching their patients grow and change, providing them support for whatever life brings.  They have to know a little bit about everything.

My family medicine rotation was divided between inpatient (hospital) care and outpatient.  It was my first real opportunity in medical school to have ownership over a group of patients.  On inpatient, I enjoyed speaking with the same patients each day, writing notes on their progress, and knowing that I was contributing to the team.  During outpatient, I could see patients daily and write notes before the doctor came in.

Some memorable moments included:

- Managing a patient with an MI (heart attack) successfully from start to finish, and watching him leave with his family by the end.

- Helping a family to transition their loved one into Hospice care

- Learning to read ABG’s, CBC’s, and CMP’s (lab results) in under a minute

- Hearing a baby’s heartbeat for the first time through a pregnant belly

-  Managing an 80-year-old’s blood pressure one minute and then performing a physical on an infant in the next

- Learning wine tours are a great way to get acute pancreatitis

- Following patients in the hospital and later seeing them in the office

- Meeting a couple that has been married for 55 years sitting together and holding hands.  Each knew more about their spouse’s medical conditions than their own

- Learning how to quickly and accurately do physicals on 4 squirmy children… at once

- Realizing that sometimes patients just need someone to talk to

Internal Medicine:

Internists are some of the smartest doctors I know.  It is not necessarily because they were the most talented in medical school or that they earned the top grades.  It is because the training pushes these doctors to gain an in-depth understanding of the diagnosis and treatment of the broad range of illnesses affecting the adult population.

Unlike Family Medicine, Internists have wider opportunities for fellowship training.  In internal medicine, you can choose to be a general practitioner, working as a hospitalist or primary care doc, or you can select a specialty.  Opportunities for specialty training exist in 18 different areas including hematology, cardiovascular disease, gastroenterology, rheumatology, and nephrology.

During my 12-week internal medicine rotation, I again had inpatient (hospital) weeks and outpatient weeks.  Here are some of the lessons I took away and moments I remember.

- It is incredibly difficult to balance 10+ medical problems and 20+ medications in a single patient

- Unfortunately, patients can have more than one cancer at once

- Discovering how to quickly read CT scans and chest x-rays

- Being in the hospital can sometimes be the most dangerous place for a patient.  Bacteria are some of the deadliest killers known to man.

- Always make time for family meetings.  You often need to treat the family, not just the patient.

- Learning is a constant process.  You always can be reading more articles and textbooks or attending more lectures.

- My crowning moment as a medical student: diagnosing a patient with pheochromocytoma who had been seen by multiple doctors and had been misdiagnosed for months.

- Medicine is a constantly changing field.  What is the most current treatment today may be completely done away with tomorrow.

- Ordering more tests can sometimes confuse the picture, not make it better.  Only do what you need to for the patient.  Less can be better

- One disease I never want to get: necrotizing fasciitis. 

- Take pride in the little things.  Sometimes it is a huge accomplishment to simply get a person to eat a meal, sit up in bed, or go to the bathroom

- Always get your vaccinations!  A couple seconds of pain beats a couple weeks or months in the hospital  

**** Blog post part 2 of third year coming shortly