Friday, June 26, 2009

Explaining Medicine

It’s hard to explain medical school to other people, but I’m going to try. Trust me, I realize that what I say below is not going to sound like much. But bear with me here.

First Year:
During the first couple of weeks, you are just excited to be there. You are that brand-new 2 month old puppy that gets so excited that they piddle all over the rug while jumping up and down. Everything is new, everything is exciting, everything is rosy. You went to college, you studied hard there – what’s the big deal?
You study “hard” for the first round of tests. You take the tests, feel worried, but get over it. The scores come out and you cry hysterically for the entire weekend wondering where you went so wrong. You’ve never received less than an 88% on ANYTHING before – and an 88% made you pretty darn upset. Where in the hell did this 69 come from? You pass the tests, barely, and wonder what you need to do to make it better. So you wake up every morning at 6:00am and quickly preview your notes before lectures begin at 8:00am sharp. You sit in lecture from 8:00-3:00pm, and then enjoy some sort of laboratory or group session from 3:00-5:00pm. When 5:00pm comes around, you run back to whatever hole you crawled out of earlier that morning. Armed with your books, your notes, and your highlighters, you find a quiet place and study until 11:00pm. You take a quick shower and go to bed, where you stare at the ceiling for at least an hour, wondering what information you missed. The weekends come and go – and the only reason you get excited about them is because it means you can sleep in until 9:00am and can get in at least 10 hours of uninterrupted studying each day. Test week comes roughly once a month. There are usually no fewer than 4 tests, and upwards of 6 (if you count lab practicals as well) for the week. Sometimes there are multiple tests each day. There is so much information to know, so much information to forget. The human body is so incredibly complex. Every minute is spent studying because, for once in your life, everything you are learning is relevant – is useful – and it you don’t learn something, it could make you a poor doctor later on. 11:00pm becomes ridiculously early to go to bed when there is so much to know. Anatomy, physiology, evidence-based medicine, physical diagnosis, biochemistry, histology…it all blurs together. You find yourself alone in a study room at 12:30 am with your microscope and set of study slides and feel like you’ve finally “arrived” when you can draw a slide from the set at random, place it on the stage, and know exactly what you are looking at. It’s like Christmas, only better, when you realize that you might not fail your histology practical after all. Medicine has lost its sheen. There is no rosy glow. You just want to get through. If you entered medical school in a long-term (and likely, long-distance relationship), it ends. You’ll watch married classmates get divorced. You learn to be careful with your relationships – if a person is really, really important to you, don’t get into a relationship with them – nothing kills important relationships quite like medicine.
The academic year ends. You get a 6 week vacation. {Or, in my case, I got bilateral foot surgery during vacation and could not walk. I spent my 6 weeks of freedom watching marathons of “The Flavor of Love” in a chair in the living room}.

Second Year:
A new year starts, and you are not excited about it. You watch the new, incoming first year medical students and almost laugh out loud at their enthusiasm. You wonder how long it will take before they break. You go back to the daily grind of studying, only the courses are slightly different: more biochemistry, pathology, biostatistics, preventive medicine, pharmacology/toxicology, microbiology, neuroscience, etc fills your mind. You keep the same fast-paced hours of studying, but feel more pressure because you understand that at the end of this year, the game changes. You are required to take Step 1 of the United States Medical Licensing Exam (USMLE). The test will test you on everything you did (or didn’t) learn from years 1 and 2. It is a big deal. The score you get on your Step 1 will, in part, determine what kind of residency you are eligible to apply for in the coming years. If you don’t want to get relegated to family medicine, you’d better study and you’d better study hard**. The courses are harder, things begin to integrate in ways you could never have imagined, and you worry that you will forget everything when it really matters. You study for your academic tests but also have to review your 1st year material for Step 1. You become a sleep-walking zombie in the spring. You look forward to the beginning of your 3rd year because it means clerkships – you’ll work in the hospital. You’ll have more free time! Life will be better!
The year ends. You take Step 1. You enjoy 2 weeks of summer vacation before starting the next year. **Disclaimer: There are many people who choose to go into Family Medicine and had exemplary scores. But if you want to be an ENT surgeon and score poorly on the Step 1, you may be in big trouble.

Year 3:
Clerkships are finally here. From now on, you will be placed with a selected group of your classmates that are on the same rotation schedule as you. You will not see much of the classmates that are not on your selected rotation track. In varying orders, you will spend months on OB/GYN, psychiatry, surgery (general and subspecialty), family medicine, neurology, pediatrics, and internal medicine. You enter a world of waking up before the sun rises and going to bed long after the sun has set. You violate the 80 hour work week policy over and over again – but shh! If you tell anyone, it’s YOU (and not the system) that will be in trouble – and if you have to log your hours every week, it will only add more work for you. Your short white coat grows grubby and ink-stained and there is no amount of Chlorox that can take the stains away. The pockets in your coat begin to tear from the weight of all your pocket books and papers and pens and pagers. In fact, you want desperately to burn the stupid white coat because it’s a symbol of your incompetence and imprisonment. You’d also like to throw your pager into the depths of the ocean where its ear-piercing screams will never again wake you. You learn that it is entirely possible to live on a 1 hour power nap while you are on call – and that you can, indeed, nap comfortably on the floor in the student lounge when all of the available gurneys in the call rooms are occupied. You learn the subtle nuances of disease and you learn how to treat the patient AND their disease. You find that not all patients are grateful. In fact, the grateful patient is a distinct and vanishing minority. You find that your male patients will grope you and make lewd, sexist remarks while you are bending over and listening through your stethoscope. You will find that pediatric patients have distinct tells that warn you to get out of the way before they turn their head – if you don’t, you will find vomit dripping down your already dirty white coat and onto your favorite pair of comfortable shoes. Of course, you learn this AFTER the fact. You also learn that no amount of hand hygiene and face mask wearing will prevent your pediatric patients from giving you pink eye, viral colds, and bacterial pneumonia. You also learn that you CAN work while in the throes of pneumonia. You learn that there are certain specialties where the male attendings and residents remain quite sexist, and they cut you out of good learning opportunities because they believe that you should be raising children instead of learning medicine. You will have residents who tell you wrong information so that you look stupid and they look good when questioned by the attending – and over time, you become good at ferreting out the lies that people (patients and otherwise) tell you. Nurses will yell at you for no better reason than that you are lower on the food chain than they are, and everyone knows that shit flows downstream. You have some attendings that live to make you cry – and you will, at some point, spend time in the floor bathroom crying helplessly at 3:00am. You will help save lives and you will watch, helplessly, as lives are permanently changed or ended. You will hold hands and learn what it means to make the hard decisions that nobody ever wants to make. You still take tests at the end of every rotation and are still scored against your classmates. And, oh yes, you take the USMLE Step 2 (which covers everything you were supposed to learn from every rotation you completed) before being promoted to the 4th and final year of medical school. Step 2 scores are almost equally important for residency. Again, you don’t want to screw it up.

Year 4:
Somewhat the same as year 3, only in different ways. You spend more time in elective rotations, doing the things that YOU want to be doing – often geared more toward the kind of specialty that you are hoping to enter. [I spent 12 blissful weeks in pathology]. Your schedule eases, because you have the opportunity to take easier rotations (like child psychiatry, which you take not out of interest but more because you’ll only have to work from 8:00-11:00am). You get a couple months worth of vacation time to spend exactly as you want it (I chose to use it for residency interviewing purposes). You choose and apply for a residency specialty (like pathology!). You spend weeks criss-crossing the country interviewing. You grow to hate ALL airlines, although you score some serious frequent flier miles. You loathe your interview suit. You smile until your cheeks hurt and answer the same questions all day. You eat horrible airplane food, horrible airport food, and horrible hotel food. You want nothing more than to just sleep at home in your own bed – after awhile, even the Hilton turns sour. You spent thousands of dollars that you don’t really have - some people will wind up taking out an additional personal loan to cover interviewing expenses. Depending on your specialty, you make need upwards of 15 interviews to secure a spot. It’s a costly, time-consuming, exhausting process. At the end, you rank all the places you interviewed in order of how much you want to go there, and all the places that you interviewed rank you against all the other people they interviewed. You send in your lists, and your fate hands in the hands of a computer algorithm that “matches” you. Hopefully. There are people that do not match, and then have to scramble for a position, ANY position [it’s not uncommon to find a hopeful ENT surgery candidate scramble into a pediatrics slot]. You wait for over a month to find out your fate…not only IF you matched to a program, but WHERE you matched. If you’re lucky, you’ll get one of your top 3 choices. If you are unlucky, you might get your last choice. It’s a crap-shoot. After match, it’s all downhill. You finish your rotations and find yourself in the middle of the pomp and circumstance of graduation. Suddenly, the graduation tent on the lawn is for YO. It’s YOUR name in the program and on the degree and YOUR turn to walk that stage. You enter the stage as a medical student and in the span of the 30 seconds it takes you to cross the stage, you exit a doctor. Seconds ago, you had no responsibility and incompetence was the expected medium – and now, things matter. A lot. It’s overwhelming. The game has changed.

Medical school is hard. It’s hard in ways that nothing can adequately convey. There are a lot of sleepless nights. There is a lot of crying and frustration. It is four years feeling utterly inadequate, helpless, and miserable. You will make decisions and question them later. There are many times where the end-product of medicine is not worth the sacrifice. You lose time, sleep, tears, and relationships in pursuit of the elusive M.D. And once you’ve finally arrived, once you have those little letters after your name, it’s hard to balance life and medicine. You spend more time trying to integrate your life into medicine when in reality, you should be integrating medicine into your life. Medicine is frustrating because people are frustrating. People can be belligerent, ignorant, cruel, unappreciative, selfish, intolerant, and unrealistic – they often are. But people can also be grateful and humbling and once in awhile, they help you remember why you got into the business in the first place. Medicine is all consuming, because it has to be. It’s hard because it has to be. But once in awhile, when you realize that something you did has made a difference, it’s hard not to be humbled and awed by what those sleepless, tear filled nights helped you to achieve.