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Surgery

A few months back I had this dream. Nothing but water all around– I was walking on a rickety boardwalk, wearing my light blue surgery scrubs. I could taste the sea. The ocean spray on my face. My body was haggard. It was with my last ounce of strength that I moved my legs. I lifted my hands, they floated there for a moment, the breeze kissing my fingertips. I felt free. 

I imagined finishing 8 weeks of surgery would feel just like that–a release perfectly timed with my last bit of strength. So many mornings waking up at 5 am I cursed the path I had chosen. Cranky that I could not crawl back into my warm bed (it would sit empty for another 18 hours) instead I was off to the hospital. When you are in the thick of it–that release is all you can think of. Now that I made it–mostly what I feel is nostalgia.  It is funny how quickly you forget the tired mornings and late nights. All I remember now are the exhilarating highs.

Surgery was the most fun I’ve had in medical school.

I will not be a surgeon. I am going into Emergency Medicine and knowing that this rotation will likely be the only time that I’ll be spending in the OR, made it that much more exciting. I transformed from a clueless 3rd year med student, hands shaky, stupidly holding my needle driver like scissors…to a confident, somewhat less-clueless surgical student. By the end of two months I was able to read ventilator settings, remove chest tubes, tie knots, close a surgical wound nice enough to have the ultimate of critics–the scrub nurse–utter the words “beautiful.” I could prepare for rounds in 30 minutes flat, knowing every lab, urine output, nutritional status, vital sign and Flowtrack indicator for my patients. This training came at an incredible price. I stayed late. Studied even later. And walked around for 8 weeks sore as hell.

I will never forget the cases I came across. Terrible calamities. Now part of my training forever. A stabbing in the middle of the night. Gun shot wounds. Flesh eating bacteria. Total body burns. Fulminant sepsis. Amputations. Tumor in the heart. Every day I felt lucky to have the privilege of being in that OR.

Of all the specialties surgery will always have a special place in my heart. It was the only one that gave me pause. Ultimately, it is not right for me, but this rotation will be one I won’t soon forget.

 

 

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My Life as a Heart Surgeon

Ever wondered what it’s like to be a heart surgeon? Since my last blog post, I’ve gotten a chance to find out. I am doing my surgical rotation on the Cardiothoracic service. I haven’t settled on how I feel about it. Over the last two weeks I’ve gone from absolutely dreading it…to pure enjoyment.

My team is small. Just myself, my resident (R3) and our attending–the only cardiothoracic surgeon at our institution. Partly out of necessity since my  first morning I’ve been pushed into the role of “acting” sub-I/junior resident. At first having such high expectations thrust upon a meager 3rd year med student was terrifying. I felt as if I was failing at every step (and I was). My confidence crumbled as my inadequacies were brilliantly pointed out every morning. This was my first introduction to intensive care medicine. I knew nothing about management of drains, chest tubes, cardiac output monitors, ventilation settings, etc. I stared wide-eyed during am rounds as I had never even heard of most of the things my resident asked me to do. She pushed me at every opportunity. She knew exactly how uncomfortable she was making me. And she did it with just that purpose. Here was a person who was interested in seeing me grow. She was dedicated to my education.

So often as medical students we are given an easy pass…don’t know something, well that’s ok, you are “just” a med student. Not on this team. Every time I didn’t know something, I looked it up, wrote it down in my handy mini moleskin notebook and burned it into my brain. The embarrassment alone was enough not to let me forget it. Nothing was ever overtly said, but not knowing the answer to something is unacceptable to me (I put a lot of pressure on myself to be the best I can). I feel so lucky to have my resident on our team. She pushed me out of my comfort zone–in the process, I face-planted. Only to get up feeling like I actually can be a resident next year. Every day, I am starting to feel more comfortable about the non-theoretical medicine stuff. Like what meds we actually use to replete mag, how much do you give? When is it time to take out a blake? What CVP are you comfortable with? What are extubation criteria? How to remove a chest tube without giving your patient a pneumothorax. Nitty gritty medicine, you don’t want to waste time intern year having to look-up. After a 6-7 hour open operation our patients are fragile; their kidneys do funny things, their hearts get funny rhythms and there are a million reasons why we manage them in the ICU. With each passing day I’ve grown less terrified about how it all works.

As in most surgical specialties the days can be long. Really, really long. My record was starting the day at 4:30 am and not getting home until midnight after two long open heart surgeries. At the end of that day my feet felt like I just climbed Kilimanjaro. (Hint: I ordered compression stockings for rush delivery that night). I am in awe of our CT surgeon who is a mythical creature. He works like a machine. Never needing to use the bathroom. Barely eating and always up for adding on an additional heart case no matter how late in the afternoon the consult is. Heart surgery requires such a person. I have convinced myself that for 4 weeks I can assume the role of a machine, but not a day longer than that.

The surgeries themselves are amazing. Who doesn’t want to spend the day staring at a human heart. Stopping it. Then bringing it back to life again. Heart surgery is surprisingly formulaic and now having done 7 or so surgeries I can start to anticipate the next move. I know where to suction, how close to cut the suture, when to retract, when it’s my turn to step in and help with opening the thoracic cavity or what closure suture to use. Now that I know what I am doing, I enjoy the OR very much.

I didn’t know what to expect starting this rotation. I have been pleasantly surprised at how much it has challenged me. My resident is an amazing mentor. She’s found the exact style of learning that will take me to the next level of my training. A combination of uncomfortable pressure with the generous reward and satisfaction of knowing something I failed at before. If I can make it through this, who knows what else I’ll be able to accomplish.

Sometimes you have have to fail at something to learn.

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Turning 30

As the youngest in the family it feels strange hitting the big 3-0. My entire life I always wanted to be older. I wanted to be able to do the things my sister, who is 5 1/2 years my senior was doing. It all began when I was 4, she knew how to read, so I decided I would need to know how to do that too. When I was 10, she was going on dates, so naturally, I needed to tag along on those too. And when I was in college, she was out making her own money, so I definitely needed a real job. I raced through my twenties.

Never satisfied, I crammed as much as I could into the last 10 years and looking back–that really wasn’t such a bad idea. All in all, it was a great decade. By 23, I had finished graduate school and was working as a program manager, which meant getting to travel around the world, keeping my wanderlust at bay.  By 21, I had met and started dating the man I would marry. The kind of guy who watched Titanic and wondered when he would meet the Rose to his Jack. A perfect match to my zany nature, who wasn’t phased (or too impressed) by my endless need to do more–which is exactly what I need to keep doing more. By 25, I had moved 3,000 miles to start our lives on the West Coast and by 27, I was embarking on my first year of medical school. Now at 29 and 362 days, I own my first house and I am months away from starting my final year of med school.

My twenties meant growing as a person. Luckily, my husband and I grew along side each other. Evolving into two people who deep down really just like each other. Our dreams have evolved from dreaming of a wonderful wedding day, medical school acceptance, great job offer, awesome apartment, awesome house…to now one day, a healthy baby and retirement in a Mountain cabin…or Mexico.

My life is still just as hectic as it’s always been. I am continually searching for the next challenge (enter my Surgery rotation which starts on Monday) but I do feel more stable. Perhaps because of medicine I am more logical, concrete–less emotional. I am exactly where I wanted to be by 30: to have a passion I work for every day and a partner to share it with.

As you age, your perception of what’s “old” seems to continue inching forward–a self-preservation mechanism, I guess. I’m still the youngest, which also helps. And so true to form, being 30 just really doesn’t feel that old. I still love staying up late (maybe not at a crowded, late night happy hour) but Netflix marathons are totally things I’ll lose sleep for. I still work-out (ok, so the last time I ran a marathon was 2005) but I am still the same weight I was in high school! I love hanging out with my girlfriends (yes, we recently spent exactly 6 seconds in a college bar before hailing a ride to the ritzy wine bar in the posh financial district) but at least we are still doing girl-talk over cocktails and I can still wear the hell out of my suede pumps. Sure, things may look a bit more refined. But that is just what happens with age.

The best part of entering my 3rd decade–you don’t have to waste any more time figuring out who you are and what you want–because you are already there (that’s what my 20s were for and all those random life de-tours). Knowing exactly what you want is half the battle. And that is probably what excites me the most about my 30s. The “go after it” decade.

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Psych Rotation, how my own well-being improved and why that speaks to the medical profession

Third year of med school can be a grind: Long, relentless hours. No time to study, let alone take care of yourself. Rotations that just keep coming with nothing but a “golden”, rotation-free weekend in between. That is, until you get to your psychiatry rotation. Some have even called it psych-cation. So is the psychiatry rotation the vacation of 3rd year?

The answer is…not quite, but close. In comparison to inpatient medicine and my neurology clerkships, psych has been a welcome change of pace. My hours are 8 am to 5 pm, with a workload that can include maybe 2 or 3 new patients a day. I am currently on psych consult service, meaning I get called when a psychiatric patient comes through the ED doors or a hospitalized patient requires a psychiatric evaluation. As you can imagine, patient loads can ebb and flow. For unknown reasons, psych patients rarely show up at 7am to the Emergency Department, but combine a full-moon, a pleasant Friday night and our service can get pretty busy.

Being able to sleep 8 hours at night and come home around 5pm with enough energy to go on a nice jog has done wonders for my mood and my marriage. Because we have lulls throughout the day I can get my studying in while I am on service and that leaves my evenings free to do something I haven’t done since 3rd year began…relax. My husband is shocked to suddenly have me hanging around the house with free time. I’ve been so busy previously, his go-to answer anytime our friends call was “Maja is at the hospital.” Now, here I am asking if he’s up for a movie or binge watching TV shows–on a Tuesday night!

On a personal level, having this extra time to re-connect, even if for just a few hours a night is super important. I find us laughing more, talking about meaningful things (you know, going beyond the logistics of who is making dinner) and waking up smiling. So without trying, my psych rotation is improving my marriage and mental and physical health.

The hours of 3rd year had began taking their toll on my health by making me too tired to work-out. It turns out walking around the hospital and eating free cookies do not make a healthy routine. And de-conditioning is pretty much the worst thing you can do for POTS. Sorry folks, nothing can replace the heart benefits of a good cardio work-out. Luckily, I am back at it, logging some miles with my running shoes.

It wasn’t until I had time to slow down that I looked back to notice the unsustainable pace I was moving at. Of course when you have the time it’s easy to say here’s all the things I need to be doing to stay healthy– it’s when you are in the thick of it, sleeping 5 hours, feeling overworked and burnt out that your focus turns simply to surviving–who has time for the other stuff? So therein lies the dilemma.

My hope is that all the healthy choices I’ve been making in the last 2 weeks will continue as I move into my Ob/gyn rotation…at least those are my intentions. This slow down in my schedule has got me thinking a lot about how exhausting the other weeks felt at times. As a medical student we are lucky in the sense that those hours are fleeting and we can move on to more humane rotations (enter Psych). But as a resident those hours– the daily grind– it becomes your life.

For decades medicine has asked of us to become super-humans. The humans who need only a few hours of sleep, who can see the worst in people, who can face death and tragedy, who look in the face of hopeless situations and “fix them”, who can continue to log work hours when others are at home with their family….all with a smile and understanding heart. Thankfully my generation is seeing the ridiculousness of the above, no one can be that superhuman indefinitely–not without a cost. I won’t go into the depressing statistics of physician depression and suicide, or the abysmally low satisfaction rates. All I know is that a culture shift is way over due.

I don’t have the answer but I do hope that we can incorporate more balance into our profession. After all, physicians who are healthy and happy are more empathetic, productive and innovative, and more likely to stay in the field (just look at this wonderful research Stanford is doing). Somehow we must find a way to sustain the enthusiasm and dedication seen in medical students throughout our careers. The future of our field depends on it.

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For those who asked: My Step 1 Study Methods

Now that I have my results back I feel more comfortable blogging about the methods I used to study for the exam. Major disclaimer: this is a sample size of 1 person and in the end you really have to do what works best for you personally. I wouldn’t go out and try some new study techniques you have never used before. Stick to what you know works well for YOU. That being said, here is what I did. In the end I scored above average and was happy with my performance.

My test day: May 4th

My first official day studying: March 13th

I really didn’t study much specifically for Step 1 before March. I focused on my MS2 classes and did well on all the shelves leading up to the end of the year which got me honors in all my classes except for one and also laid a solid foundation for Step 1. I did use the UWorld question bank to study for shelves so I had already gone through about 40% of the Q bank.

Resources I used and my opinion on them:

Uworld Question bank: Absolutely the best resource you will use. Start using the questions as soon as possible and repeat questions many many many times.

Kaplan: I purchased their review course and stopped using this about mid-way through my dedicated studying. Not sure if it was that helpful. Just another way to see the same information. If you like Kaplan, use it, but nothing new that helped me on the exam came ONLY from Kaplan.

Pathoma: This is why I honored Path. I continued to re-read my Pathoma and watch some videos during dedicated studying. It is essential for pathology.

First Aid: Whether you like it or not this book has ALMOST everything you need to score incredibly well on the exam. If you can focus on anything just make sure you know everything in this book. I had only a handful of questions on the exam that could not have been answered by looking up First Aid but otherwise it was pretty spot on.

Behavioral Science Review Book: Probably worth going through a quick review book like BRS. You will notice once you start taking the NBME practice exams that you are getting really easy BS questions wrong simply because you don’t know how Step 1 wants you to answer them. These will be easy points so prepare for them! Don’t ignore Behavioral Science or the statistics stuff. Also, go over things like the stages of clinical trials.

SketchyMicro: This is why I honored Micro. A really fun and easy way to remember microbiology stuff.

NBME practice exams: These are ESSENTIAL. I took 4 NBME exams and 2 UWorld practice exams. My 2nd UWorld practice exam was about 10 points higher than my actual score, which is what I have heard from a couple of people. The best predictor, in my own experience were the NBMEs. I scored 2 points higher than my best one and almost 20 points higher than my first NBME practice exam that I took 2 weeks into studying. When you buy them spend the extra $10 and get the version that lets you see which questions you got wrong.

My Daily Schedule:

Before you begin studying it is essential that you make a plan for yourself. For me, I did my review by organ system so I would review all the pharm, path and physio within each of those. I gave myself between 3-4 days for each organ. In that time I completed every UWorld question for that topic and read that specific section in First Aid at least once or twice.

AM: I would start with 1 or 2 question blocks in UWorld. If it was day 1 of a new organ system I did tutor mode and would just spend time reading the answers. Otherwise I would do the questions then go through and read each answer at the end. I took notes on things that I had forgotten and then reviewed those notes every couple days.

PM: I read First Aid. I read Pathoma. I did more question blocks.

There is no magic secret to Step 1 studying. Literally just spend 10 hours a day either doing questions or reading First Aid and you will be fine. Periodically (I did every Saturday) take a practice exam to make sure your score is continuing to go up. Remember to review information you have already gone over. Do this by doing random question blocks, question blocks with missed questions. question blocks with marked questions and re-read your notes as much as you can. The key is repetition.

A few things I wish I had done differently:

-Probably not wasted my time with Kaplan, I would have done just fine with out it

-Started UWorld questions even earlier

-Reviewed my notes more often

-Been more relaxed in general; my anxiety was through the roof and that was not conducive to studying

-Made sure I really knew the biochem pathways: THEY WILL COME UP!

-Been conscious of trying to eliminate stupid mistakes- these will be what brings your score down from your absolute possible maximum. I know I made MANY stupid mistakes. Not sure if you can avoid them, but try!

-Don’t use too many resources. If you give yourself too much to do or cover this will backfire. Pick 3 or 4 (max) essentials and stick to those. You have to use First Aid and Uworld- KNOW THESE WELL. Other than that, you can pick 1 or 2 more things that will help you in your weaker areas.

-Enjoy it! This is your time to put everything together. Somewhere mid-way through everything will come together and things will just click. It’s really awesome when that happens and you may actually enjoy this nice time you have to learn medicine.

Good luck!!!

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My Step 1 Experience

I’ve hesitated writing about Step 1 mainly because I didn’t want to think about it. It’s over now. What’s done is done. I wish I could say that after 7 weeks of dutiful studying, thousands and thousands of practice questions, multiple practice exams and nothing else in my life– I conquered it. What I feel happened was just the opposite. I walked out feeling like someone just punched me in the stomach.

Over the last two months I’ve had a singular purpose driving me–to do incredibly well on this exam. There wasn’t a single moment when I slacked off, gave up or strayed from my self-prescribed study schedule. I knew this material. I did nothing but study. Over time, as my knowledge base grew I improved my practice exam scores from a 223 to a 252. In terms of studying, I don’t think there is anything I could have done differently. The problem, it turned out, was something I completely failed to prepare for-I was my own worst enemy.

I may have written elsewhere on the blog but when it comes to long, important standardized exams my brain very consistently decides to turn on me. In the comfort of my house, with absolutely nothing to lose, I am able to answer questions with such ease. But being in the exam, everything changed. I let my nerves and the exhausting process leading up to the exam get the best of me. I just didn’t feel sharp. Anxiety is obviously no excuse to not perform to your true potential, so I feel incredibly disappointed in myself and all the work I put in. Instead of eliminating the handful of stupid mistakes I was making on practice exams, I multiplied them. I keep having flashbacks, like some kind of PTSD, of questions I answered incorrectly. Easy questions that my brain has known the answer to for months. Of course, when it counts, like some kind of zombie I picked the exact opposite of the correct one.

I know that feeling like you failed Step 1 is what everybody feels. It’s natural that after 8 hours of questions your brain will focus only on the ones you were unsure of and remember the questions you blanked on, omitting the easy ones you breezed right through. So yeah, that makes me feel a little better. But I also know that my question count of incorrect items is getting high, it seems I am constantly remembering questions and wanting to kick myself for what I put. I have no idea what to expect.

The only thing I know is that no matter what happened with this exam, it was just one moment in time. It doesn’t erase any of the successes I’ve had in medical school up to now or have any bearing on how I’ll do in clerkships. It feels like I had a bad day, but in the end I won’t know anything until I get my score back. I am already looking forward to everything I will learn once rotations start. I am just trying not to lose sight of why I am here. These last 7 weeks I’ve learned so much and created a truly solid foundation of medical knowledge for myself. Whether my exam score shows that or not, I am not sure. What I am sure of is how much I love learning and how that has been consistently shown in my performance in the last 2 years, and hopefully will translate to success on the wards.

3rd year here I come!

Also, I know that several of my readers would love to have a detailed break-down of the study schedule I used and tips and tricks. I’ve jotted down some notes and will get this information out to you once I’ve processed this whole ordeal. It has been so stressful not only on me, but on my husband and family. I think the most frustrating thing of all is feeling like I just wasted so much potential. I definitely need a good week or two to recover. Thankfully, I have family visiting and an exciting trip planned with my husband to help me put this exam behind me.

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Update #2

Time for another update: First, I wanted to thank all my wonderful blog readers for the encouragement and comments. I was in a pretty low place last week and hearing how other people felt similarly during their Step 1 prep helped tremendously. Sometimes all a girl needs is a little commiseration.

It has been 18 days and I am pretty amazed at how much material I have been able to cover. I’ve reviewed Biochem, Biostats, Respiratory, Cardiology, Neurology, Immunology and half of Reproductive. Within those I’ve covered the relevant pharm, physio, micro, anatomy and embryology. I’ve also done 2,080 practice questions (yes, I keep a spreadsheet and I kind of can’t believe that is the total so far). I took my first Step 1 self assessment this weekend…and with 34 days before my exam date….it was actually a reasonable score. That took so much pressure off me. I could have done a cartwheel if I was more flexible.

Taking that practice exam was a real turning point because it allowed the release of a giant amount of anxiety. Mainly from the unknown. Up until then I had no idea if the 12-14 hours I was spending per day studying was doing anything. Having that small cushion of comfort has transformed the whole experience for me. I am working my ass off but now I think it may just work. I found something crucial I was missing last week–confidence. Now that I believe in my own methods, I am actually having fun.

Doing practice questions and getting them right–is fun. So much more fun when you know the material. Reading First Aid and saying, yes, I remember that–is fun. I started by tackling my worst topics: neuro, biochem, cardio. At first, the process was frustrating and exhausting because there was so much I needed to review. But once you get through it and a foundational layer of information forms you can actually begin to enjoy the information. It is medicine after all! And if you know anything about me, you know that I am obsessed with medicine. I was so far in the weeds I forgot that I actually like learning this stuff.

Update #2 is much more upbeat. Hooray, I am no longer despondent! I still have a hell of a lot of work ahead of me, but knowing that if I just keep at it, I can do this, is enough to get me through the day. My very long, long day.

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