MINDFUL OF MEDICINE

To start off my series of clerkship overviews what better clerkship to start with than internal medicine! My hope is that this series will be of use to those of you looking to see what different clerkships are like, including things like hours, study materials, and generally how to be successful. I will also be sharing a few things from my own perspective. If you have any questions that aren't addressed by the post please leave a comment or email me!

This was my first clerkship of third year. I only had a week of vacation in between Step 1 and starting third year, which was both good and bad. The good thing was a lot of material was still fresh and burned into my memory which helps a ton on medicine. The only bad part was that I still hadn't fully recovered from the mental and physical aftermath of step 1, but this would have been the case regardless of which clerkship I started with. Overall I'm extremely grateful to have had medicine first, it really does make a difference going forward and sets a solid foundation for the rest of the shelf exams. I learned so much on medicine and enjoyed applying what I had learned during MS1/2 while settling into my new role as a student doctor.

Clerkship outline:

• 12-weeks, with three 4-week blocks for a total of 8 weeks of inpatient, 4 weeks of outpatient.


• Academic half-day once a week, each week.


• NBME shelf exam

Clerkship work hours:

Inpatient: I had two different inpatient settings. My first was at the university hospital and I arrived at 5:30am for morning sign out and left at 5:30 or 6pm after evening sign out. There was no call since residents are either on day shift or night shift. During my first month of inpatient I also had the opportunity to work on the heme/onc & BMT (bone marrow transplant) inpatient services. The hours here were very nice, usually 7:30am to 4:30pm. My second inpatient block was at the VA and the day always started at 7:00am but with a rotating schedule of call so I would get to go home around 2 pm for pre-call day, 7 or 8pm on long-call, 1pm post-call, 5 pm on day-call. No matter what, I was excused by noon for academic half days once a week, though. All inpatient weeks are 6-day work weeks; the day you get off is usually a post-call day. Or when I didn't have call due to a set 5:30am-6pm schedule, I got to pick one day of the week to have off as long as my senior resident was okay with it.

Outpatient: My outpatient experience consisted of mornings and afternoons at multiple university specialty clinics, often switching clinics at lunch. I requested to work in in heme/onc, BMT, and pulmonolgy and ended up doing most of my clinics in these specialities.. I also had one morning of primary care internal medicine. The hours for outpatient were great, almost always 8-12 for morning clinic and 1-5 for afternoon clinics. About once a week I had a free afternoon or morning, or even a cancelled clinic which was great for studying. I got every weekend off during outpatient.

Daily life:

Inpatient: As a med student your day typically starts with getting overnight updates on your patients and continuing to work with these patients or picking up new ones. Depending on the team I'd have 2-4 patients at a time. Rounds are usually around 9 or 10am so depending on when you get to the hospital you have plenty of time to round on your patients by yourself, discuss your plan with your intern or senior, work on your notes and prepare your presentation for rounds. After rounds the rest of the day is dedicated to helping your interns and residents with whatever they need to make things go smoothly, that can include calling different departments for consults, speaking with the nursing staff, running to ask patients a question, or, if you're lucky, a little studying. One of the nice things about the VA I worked at was that med student notes are valid documentation and can be copied by interns/residents and signed off as the progress note for the day (it's always nice to feel like your hard work is actually making a difference!). Your day will end at the end of your shift or when your resident says you may go home.

Outpatient: Your day will start as soon as the first patient arrives, though you should try to be there a few minutes before 8. My outpatient experience was a little unexpected in that 75% of my clinics were basically just shadowing. In the rest of my clinics I got to see my patients on my own, though. The nice thing about outpatient is that there is always protected lunch time so you have a more regular eating schedule or time to sit, study, or relax - that is unless you're spending your lunch driving to your next clinic, which is entirely possible. Your day ends when the last patient leaves.

Most memorable moments:

My most memorable moment on inpatient medicine was an older gentleman at the VA that had lost his hearing but definitely not his personality! Each time I spoke with him I had to print out a list of pre-written questions in large, bold font so that he could read and respond. Once he got going he wouldn't stop talking and he was hilarious, stubborn, and ultimately added a lot of fun to our morning rounds. Another moment I'll never forget was being on the care team of a very sweet and young patient that was losing their battle with esophageal cancer. I had gotten to know the patient and their spouse during their admission to our heme/onc unit for what we initially thought was an admission for pain control. Just a couple of days later the patient had deteriorated and we had a very difficult, heartbreaking conversation with their family about palliative care and hospice. The realness of the situation hit me hard and I'm grateful that the family allowed me to be a part of their care.

Study resources:

The internal medicine shelf exam is the most challenging exam of third year. Studying for it felt a lot like studying for step 1 because it encompasses almost everything you can imagine and requires you to go beyond simply recognizing a disease process, but going a step further to determine the best management and course of action. I approached the shelf holisically. I initialy got Step Up 2 Medicine but soon realized that, while it is a comprehensive review of internal medicine, I simply didn't have enough time to sit and study like I had in the past. I barely read a few pages of it before giving up on it entirely. The medicine section of UWorld for Step 2 is, in my opinion,  the ultimate resource for the medicine shelf. With 1400+ questions of high-yield material, it was the best use of my time. I completed about 20% of the medicine questions during the first 9 weeks of medicine, leaving me with another 80% to complete in the last 3 weeks. It was quite the task but I think it helped me be very successful on the self.

By leaving most of the questions until the end I was able to focus on learning from my patients & researching their pathophysiology and management on databases like UpToDate. You'd be surprised how much you learn but mindfully paying attention to how your patient's diseases are managed and being an active part of their care! Those last 3 weeks before my shelf I worked super hard to finish all of the medicine questions on UWorld. I also made a UWorld Journal by annotating key points from questions in a google doc to review before the exam. By doing most of my studying at the end of my clerkship the material was fresh in my mind on exam day. I'm glad I stuck to UWorld because the questions are much harder than the questions on the shelf exam, there are a lot of questions to review and explanations, and I could flip through questions on my phone/iPad while I was on the wards or in clinic which is really convenient when you hardly have time to sit and study.  Two days before the exam I watched the High Yield Internal Medicine presentation by Emma Ramahi which was an AMAZING review of IM and helped solidify the material.

I understand there are a lot of resources for medicine so keep in mind that this advice is simply my own. I would recommend the following resources: 1. UWorld, 2. MedEd Videos, 3. High-Yield Internal Medicine PDF/Video by Emma Holliday Ramahi - all of her reviews are amazingly helpful, definitely check them out!

Resources I would not recommend: MKSAP, CaseFiles, PreTest (too many questions that are too simple and don't add anything that UWorld doesn't already cover).

Things I liked:

1. I liked that medicine was my first rotation after taking step 1 because it gave me a real-life setting in which to use my knowledge in a very tangible way. This rotation also solidified my presentation skills. I was lucky to work with a great mentor during my first two years of med school that expected a lot of my presentation skills and it really paid off during medicine. Beyond showing up and doing your work, the way you show that you're competent and capable as a med student is essentially through your presentation skills - residents and attendings really place a lot of weight on this! Medicine gave me a great venue to practice and perfect my presentation. And hey, getting told you present like at an intern or 4th year level as a third year is pretty darn flattering.

2. Seeing the full spectrum of adult medicine, from treating sepsis secondary to IV drug abuse to discussing engraftment of a bone marrow transplant. It really gave me an appreciation for the immense scope of practice of internal medicine.

3. How brilliant the doctors I worked with are and their passion for the science of internal medicine and the way they genuinely cared for their patients.

Advice:

Internal medicine is long, challenging and your performance in the clerkship is weighted highly for residency, even more so if you're applying to more competitive specialties. My biggest pieces of advice for success in medicine are to be a good team member, do your best during presentations, and study hard for the shelf. It's important to remember than numbers aren't everything in third year. And though a high shelf exam score will help you qualify for high pass or honors, evaluations will make all the difference. Being genuine, helpful and compassionate goes a long way :).

 

Hello! It's been a little bit since I've posted. I feel like peds was even more busy for me than internal medicine, hence the slacking in the blogging department - oops. I'm now on family medicine and I can't believe I've only got 5 weeks left until the first half of MS3 is over!

I've wanted to share a post on being married in med school since it's one of the most frequent questions I get. Every marriage/partnership is unique so I'm not declaring myself an expert on the subject. But these words are from my own perspective and my hope is that they might apply to other couples out there as well! But first, a little background.

J and I met back when I was a sophomore in undergrad in February 2011. After just a couple of weeks of talking (we were long distance) we knew we wanted to spend our lives together. But, more importantly, we wanted to build a life together from the bottom up. He knew my vision, I knew his and soon they became one. That summer that followed we were married religiously (also known as a katb kitaab) at his parent's house in beautiful North Lebanon. A year later, we had our wedding and we moved in together right before I started med school and he started his masters program. I guess I'm sharing all this to give some background and to give an example that a marriage isn't built overnight, and that it takes years to achieve things; whether that's finally getting to be together after years spent half a world apart, or goals like higher education, career building, and even surviving med school.

As a couple, we are each other's best friend / support system / biggest fan / you name it. We are equal partners in life and have always tried to approach challenges and blessings in this way. Our approach to medical school has been no different. Since starting my first semester of med school, J has always encouraged me to do my best while going out of his way to help me find time to study. To be honest, he's a super competitive person (and pretty brilliant I might add!) so he's often more intense than I am, lol. First and second year were pretty relaxed in terms of time commitments, though I did have to study a lot. Still though, I made my own schedule (should have enjoyed it more when I had the chance!) leaving us with plenty of free time for ourselves. Then came Step 1, also known as a the most mentally brutal and intellectually challenging time of my life. J did his best to ensure that I had time to study and less things to worry about like cooking, cleaning, and running errands. And now I'm almost 6 months into my third year which has been a totally new dynamic for us. Third year entails a lot of hours, on good weeks that means 40 hours. That has forced us to accommodate two work schedules while keeping up with our other responsibilities. There's also less time for ourselves, which makes "us" time more special. Considering that my days of passively learning in a classroom are over, I'd say learning to juggle demanding schedules while maintaining balance has been valuable and will continue to be so for the rest of our careers. Through these years I've learned a few things about being married in med school, and so I'd like to share a few key thoughts.

- Foundation. A strong foundation is the basis to any relationship and even more so in a marriage. I think that it's crucial to talk about your goals early on and how you plan on getting there even if you don't have an exact plan. Even more important, however, is having common goals in the first place. Communication is absolutely vital in this area. Establishing yourselves as a strong duo early on is the most important thing about married in medical school. There will be hard days, weeks, and months but being there for one another no matter what is a beautiful thing. For some of us med students, medical school is the most challenging thing we've ever gone through. Having someone who makes it easier on you by supporting you, cheering you on, and helping you out is priceless.

- Priorities. This is something that will depend on your personal beliefs and desires in life. For me, second only to our faith, my little family is my highest priority. That means that just as I set aside time to study or figure out my rotation / study schedule I also make sure that there is "us" time set aside. It honestly keeps me grounded and is my happy place. I think it's important to discuss priorities early on so there are no surprises.  As a woman in medicine, the idea of priorities is a deeply complex and challenging concept. There are already so many expectations placed on women that adding the responsibility of a medical career may seem daunting. A supportive partner can make all the difference. Another issue that may arise in the realm of "priorities" is that of whose career is more important at any given time. This can be especially challenging when a couple has two high-powered careers. I think it's important to respect and admire each others accomplishments and make space for them. While medicine is a life-long commitment, so are other careers and they are no less important to those in them than medicine is to us.

- Balance. Medicine can be consuming; it may take more than you would expect from your mind, body, and soul. Going through something like that can be taxing, but it doesn't always have to be. That being said, the stress and difficulties you experience as a med student will inevitably be shared with your partner. Expressing how you feel and getting through it together is not only cathartic, but makes you stronger as a couple. Do not feel that you must give 100% of yourself to medicine, your partner, your responsibilities, your children, etc at all times because it is simply not possible; and while the areas you are focusing on thrive, others will suffer. Your focus and energy will often be shared among many things but remember that you have the power to choose which parts get the most of you. Self-care is often forsaken in medicine, but how can we heal others if we ourselves are withering? Taking care of yourself is so important, and will help keep your relationship healthy.

- Reward. How special is it to become a doctor alongside the person you love? It is a privilege and should be treated as such. Being able to tell my husband about all the cool and fascinating stuff I learn, the memorable patients I meet and my ever-changing specialty interests is pretty special. Med school is hard, but it is temporary. And, as in life, there are hard times. But try to appreciate them,  they often teach us more than the easy ones and let us learn new things about ourselves and our partners. Celebrate your successes with your partner, recover from your failures together and appreciate the little rewards along the way, there are many.

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I've learned so much in these last few years in med school that goes beyond facts and clinical pearls and I'm grateful to go through every step alongside my husband. In the end, a partner should make the hard things in life easier. Med school is a big feat, but it's not the impossible mountain for relationships that some make it out to be.