On Having Medical Students

The last few months of residency have been a blur. Second year has been as busy as ever and on top of looking after patients, I have medical students to look after now! After being the senior resident with junior residents and medical students, I’ve gained a new perspective on medical education.

It has been interesting supervising medical students. What a big difference a few years can make, as I compare myself to these new clerkship students. I was in their shoes not too long ago, in fact it was only three years ago! For the most part, I enjoy having medical students on the CTU team, even though they aren’t always that helpful. There’s also such a diversity in terms of knowledge, skills and communication skills amongst them. So I thought I would share some thoughts now that I’m finally on the “other side.”

Medical Students will Take up your Time

In general, medical students slow you down. Most of the time, they don’t know what’s going on and because of that they will ask a lot of questions. If it normally takes 15 minutes to see a patient, it will take new med students twice as long. At their stage everything is new. From taking good histories to performing physical exams you have to factor in their inexperience. Even final year elective students will require your guidance (or at least your signature). The sooner you factor this in, the better you can plan your days.

Medical Students Need Supervision

I probably didn’t receiving enough supervision as a medical student. I could have learned a lot more if someone had looked over more what I did clerkship. I could have saved myself a lot of time spent figuring things out on my own. At the same time, I try not to micromanage or do too many things for my medical students. Although I know it’s much faster for me to do their work, the whole point of clerkship is for them to learn. Currently, I let my medical students see patients and write notes on their own. Afterwards, I review with them their findings, proofread their notes and then we go back to see the patient together. I usually try to go over physical exam manuevres at this time and then I give them a chance to explain the medical plan to the patient. I think this way gives them a sense of patient ownership.

Medical Students have Different Strengths and Weaknesses

Despite having been in the same classes during preclinical, there is such a variability in knowledge, communication styles and work ethics amongst clerkship students. Some are very book smart and the majority have forgotten all their medical knowledge.It doesn’t take long to figure out who are the excellent students and who are the ones that need help. Similarly, it’s easy to spot the hardworking and lazy ones. Some you can trust and others you will have to supervise more closely.

Medical Students want to Learn

Above all, clerkship students are excited to learn. They’ve been waiting four years of undergrad and another two years of medical student for this moment. They are here to see and look after patients! Give them opportunites to learn at an appropriately level.I personally find their enthusiasm contagious. I enjoy having new learners on the team as it helps me look at topics I know in a new light. Teaching them medical knowledge makes each topic and concept clearer for me too, as I try to explain to them in the most basic terms. I also try to teach them non-medical things during the day such as tips and tricks for getting things done in the hospital or how to communicate with families and other disciplines. So far I have gotten a good response to my teaching.

As a senior resident, I think one of the most important things we can do is give specific and timely feedback our learners. Even though medical students will pick up most things by “doing” it, they need to know what they are doing is right or wrong. There is so much inconsistency in their teaching that they often don’t know what they are doing is wrong.If they have a medical concept wrong – the best time to correct them is as soon as possible. If they make a mistake or error in judgement (which they will do, double/triple check everything they do), correct them in private and remind them that you are there to help.

Medical Students Need Feedback

I’m sure my views of medical students will change as I work with more students at different stages of their training. I find students at the start of clerkship are more keen but lack knowledge. End of year students have knowledge and experience but can often be burnt out. Ways medical students can fight these effects is to read more during the beginning of the year and learn to find balance near the end.

Overall, I found teaching and supervising medical students an enjoyable experience. Perhaps there’s still some academia in me left despite my leaning towards community practice.

Lessons Learned from Premed Research

When I started my pre-med coursework, I asked myself a universal question premed students ask: “Do I really need research experience?”

Which, let’s be honest, is not a question that has an easy answer. After all, plenty of students are admitted to medical school each year with little or no research experience. From what I can tell though, those stories are becoming more scarce, suggesting research is becoming an unspoken requirement. Because  I subscribe to the don’t-knock-it-‘til-you-try-it philosophy of life, I made the choice to pursue a research project in order to get some experience.

Now, it would be nice if I went to an enormous, well-funded university hosting a variety of research projects that have direct applications to the field of medicine, but was not the case. Instead, I found myself working on a project examining the effects of population density on mortality and bone ossification in African clawed frogs. Yeah, I know, my paper is never going to be cited in NEJM. What matters was  I could get a research experience, build connections, and figure out whether I wanted to do research work.

The three things that I got out most from my research as an undergraduate (well, post-baccalaureate) student:

1) You form close relationships with some of the best professors in the world.

Not only has she been an excellent sounding board for my hare-brained ideas, she also got to know me well enough to write me a strong letter of recommendation. Apparently, despite a few broken pieces of glassware and other minor (and sometimes major) lab mishaps, I managed to convince her that I’m actually competent. Maybe she’s not so smart after all.

2) You learn to work in team environments

Because my teammates and I all have full-time professional Look At Me I’m A Grown-Up jobs, we came up with creative ways of addressing the logistical problems of our work when meeting face-to-face was  not feasible. Just like patient handoffs, frog (well, data) handoffs are critical.

3)  You get a real sense of accomplishment

I don’t know about you, but I feel like I come from a culture that de-emphasizes personal accomplishments, which is kind of a bummer. I mean, you work hard, you overcome a challenge, and then you have to shut up about it lest someone respond dismissively. Well, after a year of spent tediously rearing our tadpoles, painstakingly collecting data, staining our specimens so we can visualize their developing skeletons, and cataloging the presence or absence of dozens of bones in hundreds of specimens, we are finally putting together an abstract for submission to a conference. And I am going to buck my culture and say yes, I am happy with what we have accomplished!

Which brings us to this past week. At our last meeting, the three research students were hunched over our laptops, alternately exclaiming “YES!” and “Wait… Noooo!” as we fiddled with our graphs in an effort to discern trends out of noise. We are not at the home stretch yet. Abstracts need to be finished, posters have to be started.

Conclusion

So, with over a year of experience, am I a convert? Does research light my fire? The answer is… I have no idea. Maybe? Probably. Who knows.

There are dozens pf things I enjoyed about my project, yes, and a decent number of them are things that are not project-specific but rather applicable to research as a whole. And there are plenty of aspects of medical research that I might love that are wholly absent from the project I have the most experience with. . All I can tell you for now is that I don’t hate research, and I am not terrible at it, and I might enjoy it a bit more if it was in a subject I found more engaging.

With this in mind, the typical advice of “It doesn’t matter what kind of research you do, just do some research,” may be bad advice for many of us. Maybe we ought to amend it to “Admissions committees don’t care what kind of research you do, but you should pick something that’s either medically relevant or personally interesting.” Too bad that’s not quite as pithy.

What do you think, readers? Did your undergraduate research experiences affirm or destroy your interest in research, or do you just feel mildly uninspired?

(PS: For those of you playing along at home, as of this writing, I’ve received eleven interview invites and three rejections. I’m flying out for the first interview at the end of August and could not be more excited. This is really happening!)

Reconnecting with my Goals

work in progress

Since I normally take classes year-round and have been taking premed prerequisite classes after my bachelor’s degree, July was my first month of no classes in six years! Though I’m still working, this was my first month of completely unstructured time.

Turns out, unstructured time is kryptonite to my productivity.

With the July coming to a close, I realized just how much time I spent parked in front of my computer, decompressing with Netflix and Reddit. And you know what? I am not going to let it get to me. Nope! I’m going to muzzle the part of my brain that wants so badly to be perfect all the time. I was due for a break, and I kept up with my secondaries, and The West Wing is fantastic, so no, I’m not going to agonize over a “wasted” month. At the same time, I need a game plan for August.

Thus, without further ado, I present to you my August resolutions:

Just say no to Netflix. Really great programming available on-demand in nearly infinite quantities – Welcome to the future, kids! Unfortunately, it’s a huge time-suck that I can’t really afford. Now that I’ve finished devouring all seven seasons of The West Wing, I’m done. Exceptions to this rule: Netflix as background noise when cleaning, exercising, or spending time with my boyfriend is fair game. (The fact that my boyfriend and I unwind in front of the television with our cell phones out is another post entirely.)

Practice Spanish. For most of July, I completely neglected my language studies. Now I’m back on the wagon, keeping up with the Pimsleur series in the car and Duolingo on my computer. The problem with language learning is that it is a slowwww process. When I get impatient, I start researching language learning tactics, and before I know it, I’ve spent hours researching instead of practicing. No es bueno. This month, I’m going to make a concerted effort to stick to the systems I already have in place (the aforementioned Pimsleur and Duolingo, plus Anki and Spanish-dubbed Simpsons) instead of wasting time chasing down new leads in an unending search for the ephemeral best language learning system. Just like the best camera is the one you have with you, the best system is the one you actually use.

Eat better. Crappy food choices short-circuited any chance I stood at losing weight during July, but at least I didn’t gain any, either. In August, I’m recommitting to tracking what I eat and staying under my calorie goal using MyFitnessPal.

Finish my secondaries, prepare for interviews. It may feel like there’s no end in sight, but the window for secondary applications is drawing to a close. By my count, I have five left to write. I have interviews scheduled for the first weeks of September already so I need to schedule some prep time with one of the more intense professors at my undergrad institution.

Shadow some physicians. While I generally think my application is solid, I have to admit clinical observing is one of my weaker aspects. Which is silly – compared to the other things I’ve done to get to this point, shadowing should be easy! Sure, nobody likes cold-calling doctors, but I’ve been putting it off for long enough. If nothing else, I really need to make some progress in this area before my schedule fills up again.

So there you have it. I do hereby swear, affirm, and pledge to adhere to the above guidelines for all 31 days of the month of August, and to check back in and report my progress (or lack thereof). Full steam ahead.

What about you – What goals have you been working towards? How will you use this month to better prepare for medical school, residency, or whatever life plans you may have planning?

Photo credit – Flickr Blumpy

Residency Subspecialty Shortlist – PGY2

Choices

One of the biggest appeals of internal medicine is that it is such a broad specialty. Even within adult medicine, you can choose to sub-specialize or remain a generalist. In Canada, internal medicine residents go through a second CaRMS process called the Medicine Subspecialty Match during PGY3. In Canada, there are 15 specialty fellowships to choose from.

Lately, I have been thinking a lot about what specialty I would like to do. To help with that decision, I have decided to make another shortlist of subspecialties I am considering. For those who are not familiar, I made similar shortlists during medical school – Year 1, Year 2 and Year 3 – which I found extremely helpful. Last year, I wrote a guide on how to choose a medical subspecialty. I found putting down my thoughts into words helped clarify what I liked and didn’t like about each specialty. It’s my hope that this shortlist will again help guide my career decisions. Since there are only 15 specialties, I will list them all with my current thoughts about each one.

Top 5

  1. Respirology
    I really enjoyed my PGY1 respirology rotation and it was a subject I liked a lot during med school. It appeals to my undergrad physics background with its pressure and volume equations. I also find there’s a good balance of diagnosis and medical treatment. I have always had an interest in airway management even when I was on my anesthesia and thoracic surgery rotations. In resp, there’s a good combination of inpatient and outpatient servuce, young and old patients, and a mix of procedures such as bronchoscopy and thoracocentesis. I would say I’m 70% set on applying to this specialty and have arranged a few more respirology rotations for this year to re-affirm my choice.
  2. Critical Care
    I was first exposed to critical care as a third year medical student and at the time I loved it. It was a key factor that made me apply to internal medicine. Caring for critical care patients was applying physiology concepts in real-time. I loved the comprehensive systems approach to patient care and the  team environment was amazing. ICU nurses are amongst the best to work with! The patients were complex and each required deep thinking to manage properly. There were lots of procedures to do and I found discussing goals of care with family members meaningful. However after doing ICU as a resident, it has come downon my rank list. I found that there were things I missed doing  – talking to patients, evidence-based physical exams, long term follow up. I’ll probably still apply to critical care for CaRMS but I will see what my subsequent ICU rotations are like.
  3. Infectious Diseases (ID)
    What I like about ID is you get to see some really cool presentations of diseases. When you’re on consult service, you see patients on every service in the hospital. In the outpatient setting, you get to see a great breadth of cases from HIV patients to fevers in returning travelers. I worked several summers in a microbiology lab, so infectious diseases has always been something that interested me. However, what I don’t like so far is the I am smarter than you attitude of “why would you prescribe that antibiotic for that bug!” that gets perpetuated. Overall, ID is a really fascinating specialty that requires a broad base of general and specialist knowledge.
  4. Gastroenterology
    I have put GI high on my list without having done a rotation in yet. I’m not sure if it will remain high on my list. What I do like about GI is there’s a variety of organ systems within GI itself. From esophagus to colorectal, there are a plethora of areas to focus on. However, when I’m on team medicine it seems the only reason I call the gastroenterologists are for bleeds and scopes. Maybe my thoughts will change once I finish my GI rotation. Of note, I think hepatology is a really neat subspecialty that is coming out with a lot of big breakthroughs will change things up.
  5. General Medicine
    I enjoyed doing team medicine a lot as a PGY1 resident. You get to be the primary care team for patients, you get to coordinate their care with subspecialists, you take responsibility and I liked that. You also see a large variety of patients, whatever walks through the emergency room was fair game. This year I’ll be the senior resident on team medicine and I will have a different perspective on running a GIM team. One pitfall I do see with GIM is that in the foreseeable future GIM will equate to hospitalist medicine. Finding referrals for an outpatient practice may be challenging. Furthermore, I do think I would prefer to be an expert in one area than a generalist.

Middle 5

  1. Cardiology
    I think cardiology is really cool. From managing STEMIs, arrhythmias, coding patients to outpatient secondary prevention, I think every internist needs to know cardiology well. And although I like the day-to-day activities of a cardiologist – taking good histories, listening to heart murmurs, interpreting ECGs and echos and implementing solid evidence based treatments – I don’t think I will be pursuing it too seriously. After three months of cardiology as a medical student and resident, I don’t think I love cardiology enough. Becoming a cardiologist requires an extra long training and an adjustment in lifestyle compared to other specialties. Regardless, I’m still excited for my CCU rotation this year because I feel as if you can never have enough cardiology knowledge.
  2. Geriatrics
    I genuinely like looking after elderly patients, it’s one of the big reasons I went into internal medicine. What I like about geriatrics is its holistic care. It’s medicine practiced the right way. Instead of looking after just medical disease, you look after psychological health, emotional well being and social supports. It’s a combination of internal medicine, family medicine and psychiatry. The downside is geriatrics can be draining for the same reasons that it can be rewarding. The lack of acuity is also something that I don’t find that appealing. And I feel like I will see geriatrics patients in any specialty I choose, so I don’t feel like I would be missing too much if I didn’t choose it.
  3. Hematology
    This was a hidden gem for me and I didn’t expect to like hematology as much as I did when I rotated through it. The patient population is diverse and the diseases are quite interesting. From simple anemia workups to treating heme-malignancies, I found hematology a cool specialty. It’s also one of the few specialties that can practice bench to bedside care. Diagnoses made under the microscope can translate to clinical decision making and it was something I never really appreciated.
  4. Nephrology
    Kidney doctors are true internists. They are detail oriented, comprehensive and care for some of the sickest patients. I learned a lot of key concepts during my nephrology rotation that I will use throughout my career. Unfortunately, I wasn’t too fond of dialysis and chronic kidney disease and unfortunately that is the bulk of a nephrologist’s work.
  5. Rheumatology
    I don’t really know much about rheumatology other than (1) it’s an area of knowledge I need to work on and (2) it’s got a good lifestyle. I’m looking forward to my rheum rotation. I think I’ll learn a lot but I don’t expect it to move too much on my list.

Bottom 5

  1. Endocrinology
    Sugars, sugars, sugars, hormones and more sugar. Endocrinology is synonymous with diabetes management. Occasionally there are other hormones affected. I’m ok with treating diabetic patients but I don’t think I could spend so much time on just one disease.
  2. Medical Oncology
    Cancer treatment is one of the fastest evolving fields right. New treatments continue to come out and outcomes are getting better and better. Despite that, I still feel awful every time I break bad news about cancer. It’s heartbreaking. I think I would be really sad if everyone I looked after had cancer. Overall, I think it’s a really promising specialty with a good balance of new therapies, comfortable lifestyle and deep relationships with patients, but it’s not the specialty for me.
  3. Immunology and Allergy
    Unclear about this one… I don’t know much about it… but I can’t see why I would choose it.
  4. Clinical Pharmacology
    I was never really that interested in pharmacology. This might be a neat specialty to do an elective rotation in but I can’t imagine doing it as a career.
  5. Occupational Medicine
    I often wonder why this specialty is under internal medicine. I question whether someone had to rotate through the cardiac care unit, intensive care unit and every other subspecialty to end up doing occupational health. I understand workplace ergonomics and hygiene are important but I wonder what it has to do with internal medicine. I feel as if public health or physiatry would be better entry programs.

Wrap Up

I’ll try to make a shortlist next year around this time just before I apply. I found writing this shortlist was useful not only for identifying specialties to consider but it helped me understand what I liked about each specialty. I hope it will give me some guidance during my subsequent rotations this year.

If you are having trouble deciding on what specialty you would like to do, I encourage you to make your own shortlist and write down your thoughts about each specialty.

(Photo credit –  Flickr Caese)