I am going to cut right to the chase and let you know that if you took Step 1 and felt so bad about the potential outcome you questioned your entire existence and the last 2-6 years of your life….RELAX. It will actually be OK. I don’t think anyone could have felt worse after their exam than I did. There were tears, PTSD, depression and three weeks of sleepless nights. In the end, I actually did better than any of my NBME practice exams and scored exactly my goal score. So there you go. I think the post-exam depression is just part of the deal. Every single one of the classmates I spoke with felt exactly the same and in the end, here we are, we made it to the other side and now we are 3rd year med students!
The last week has been a blur. Back to the hectic pace of medicine. I was on for 6 days straight and have not gotten out of the hospital before 7:30 pm. The best part is–I don’t even mind it. Here’s a break down of what my new life in Inpatient Medicine looks like:
5:20 am: Wake up and race to get ready. I am one of those people who would rather sleep an extra 10 minutes than waste time in the morning. My beauty routine is a bun/pony tail and some mascara to make my eyes look less sleepy. Alright, I also need some blush because my face hasn’t seen the sun in a week.
6:10 am: Arrive at the hospital. I am on a giant medical campus so walking to my building will take another 5-6 minutes.
6:15 am: Log onto my computer and check any overnight labs that came in on my patients. I might also get lucky and see some notes from the overnight nurse (these are notoriously input later in the day).
6:30 am: Get hand-off from the overnight team and learn if anything happened to my patients over night.
6:35-7:55am: This is the only time I have in the morning to see my patients and talk to them about how they are feeling. I find out if they have any new symptoms or if their condition is getting better or worse. I also do an abbreviated physical exam. Right now I have 2-3 patients at a time, so this amount of time is perfect to do my initial checking in. I also check on various lab work and notes in the computer. After I do my information gathering I have to start thinking about a new plan for the day. This is by far the hardest part for a 3rd year medical student because we haven’t been trained in the nitty gritty of treatment plans. This is also the best part as learning what the protocol is for various conditions is why we are here.
8:00 am-9:00 am: Go to morning report. This is a time when the attendings, residents and medical students come together to go through a case. For example, someone might share an actual patient that came through our ward with his/her presenting symptoms, the labs and work-up that was done and we’ll just discuss the various differentials (things that could be wrong with them). This is kind of like a House episode. You imagine that patient in your head and as a team talk through what was wrong with them and how to fix it.
9:15 am: Morning Rounds. This is when the attending physician (the person ultimately signing off and overseeing the residents and medical students) comes in and we present our patients and assessments and plans. Because this is such a pivotal part of inpatient medicine I’ll spend a little time explaining the process.
For most medical students, this is the most anxiety provoking time of the day as this is our chance to shine in front of the attending (who is evaluating you). Even if you don’t know what you are talking about, if you can present well you can come off seemingly brilliant. In medicine, there is an art to presenting your patient. The presentation has to follow a specific format but despite its rigid guidelines it should still tell a natural story and you don’t want to sound like a robot who is spitting off facts. The best presentations keep your listener engaged, are clear, concise and to the point.
The trouble most 3rd year medical students have is knowing what is actually pertinent to your patient’s condition. You need to know EVERYTHING about your patient. Including their mother’s medical history, the surgery they had 30 years ago, the medications they took last week, their vital signs for the past week and the random phosphate lab that just came in–the skill is knowing which of those facts (which took you 45 minutes to gather) should be included in your 5 minute presentation. I found that if I focus on the true reason the patient is there– say it is heart failure– this helps to guide me in not including too many things that may be wrong with them (maybe a 10 year history of diabetes) but that is better handled outpatient and is not a priority for their current hospitalization. In any case, during Morning Rounds the attending will listen to you present your patient and will then ask you questions (known colloquially as PIMP’ING or putting you in your place) in order to see if you know anything about medicine. Most of the time you get lucky and the questions may be basic but there are often details which you learned 8 months ago and haven’t thought of since. Rounding is a grueling process that usually takes 4-5 hours, although there are stories of rounds lasting from 9 am to 6 pm!
12-1pm: Noon conference. This is when the medical students, residents and attendings meet again to listen to a noon lecture (it can be anything from Hepatitis C, Ebola to how to read an EKG). The best part is you get free food.
1pm-3pm: If you didn’t finish rounding you continue to do that. Some attendings will want to do physical exam rounds at this time, which means you go with the attending to see your patient and perform a physical exam. When you see your patient with an attending 1 of 4 scenarios is almost guaranteed to happen:
1. Your patient’s condition will have changed and everything you told your attending is no longer accurate. Result: you look like you don’t know your patient but it’s not your fault because the circumstance was out of your control.
2. The attending performs a physical exam and finds a physical exam finding that you missed. Result: You are reminded you are a third year medical student and have not yet perfected your heart auscultation skills to the point of detecting a 2/6 heart murmur.
3. Your patient suddenly remembers a new fact or completely changes their mind about their medical history because someone new with a longer white coat is now asking them. Result: You look like an idiot that doesn’t know your patient. Luckily, most people understand that being hospitalized is a high stress situation and people may remember things differently every time they are asked.
4. Your patient is excited to see you, you have a great rapport with them, which is easily noticed by your attending. Your physical exam findings and history for the patient exactly match the situation that is seen by the physician and you are able to truly help your patient get better. Result: You feel like a rock star and mentally high-five yourself. This is the rare situation we work towards!
3 pm-6 pm: This is the time you have to complete your to-do list for your patient. This is also when you chart. For each of my patients I am required to put in a progress note or a full history of present illness note if it’s a new admit. As always, there is a very specific format for how things should be written. Again, the hardest part is the Assessment and Plan, in which you synthesize the facts into a problem list for each patient. For each of their main problems (let’s say 1. Chest pain, 2. Hypothyroid, 3. Low calcium levels) you develop a strategy of what you plan to do to treat them. During this time you may also get a new admit from the Emergency Department. If someone is getting admitted that will now be my new patient, I will go down to the ER and do my initial evaluation. I then have to come back and write a History of Present Illness note and talk with my resident about the orders we think are appropriate.
6 pm-8 pm: Depending on when you get your last admit you may be staying late to finish up. If your shift is ending at 5:30pm, the rules of the universe will guarantee a new admit at 5:20pm and you will be there til 7:30pm writing notes and orders. Despite these long hours the process is the most fun I’ve ever had in my life. Time flies by.
9 pm: Shower. Debate if I have the energy to do some practice questions (yes, we have a big final shelf exam at the end of the rotation) and typically decide it’s better to spend 45 minutes watching tv with my husband before I do it all over again.
So that’s my new life! I wake up each morning excited for the day to come. I don’t get a minute to myself. My day is constantly challenging me and making me feel like I have volumes of knowledge still missing but it is the happiest I have been in a very long time. Guess I made the right choice 🙂