First Day on the Wards: Part 1

Are We Healing People Yet?

So there you are, on the first day of third year about to start your clinical training. Two years of lectures behind you, thousands of facts disintegrating in your brain every day, and you are standing sheepishly in your new short white coat at the nurse’s station about to start your first real day of your new career without a clue as to what exactly is your job and what you should do first.

You’ve had the orientation, of course, where you are told what is expected of you but somehow it doesn’t exactly translate on a Monday morning at 6 AM surrounded by the bustling world of an academic medical center.

Relax. Here’s how a typical ward rotation works.

First thing: By “wards” we mean a rotation dealing with patients who have been admitted to the hospital and who reside there for the duration of their treatment. Some rotations are all “outpatient” (as opposed to wards which are “inpatient”) and you will be seeing patients in a clinic. Family medicine is a good example of an outpatient rotation. We will discuss these rotations in a later post. Just keep in mind that even on an inpatient rotation you may spend some time seeing outpatients in a clinic setting.

As you will find out, third year is divided into short blocks, typically two months long, during which you cover all of the major areas of medicine such as Surgery, Obstetrics and Gynecology (OB-Gyn), Internal Medicine (“Medicine”), Pediatrics, Surgical Subspecialties (such as Urology, Opthamology, and Otolaryngology), Psychiatry, and a few other things depending on the priorities of your school.

These two month blocks are typically further broken down into shorter sections. You might, for example, do one month of General Surgery and one month of Vascular Surgery in a two month surgery rotation. On a two month medicine rotation, as another example, you might do one month of General Internal Medicine, two weeks of Cardiology, and two weeks of Nephrology.

Suppose you start on General Medicine. Let’s flesh out a typical day. Bear in mind that every medical school is different and other’s may have had different experiences.

How early should you show up?

Get to the floor early enough to pre-round on the patients you are assigned to follow. This simply means that you must see the patients, examine them, and make a note of any changes in their condition before morning rounds. You must also follow up on pertinent labs or studies from the day before and be familiar with their treatment plan (including the all-important discharge plan) as well as any pending tests and their current medications. How early you show up depends on the number of patients you are following, your familiarity with them, and how efficiently you work.

Keep in mind that you will be waking most of the patients up to do your exam. (Usually a focused exam dealing only with the presenting complaint. You do not generally need to do a neuro exam for someone being treated for a small bowel obstruction.) While they expect to be disturbed during their stay, 4 AM is a little early to be turning on the lights and poking them in the belly. (Examining a patient in the dark is called “groping” and is a no-no.)

You will probably not be assigned more than two patients when you first get started, Still, as you will be completely unfamiliar with almost everything about the workings of the hospital I’d allow plenty of time. If you show up too early the worst that will happen is that you will be standing around with nothing to do before morning rounds. The converse to this is not having enough time and being asked embarrassing questions about your patients that you can’t answer.

Typically, you will be responsible to make a note in the patients chart before rounds summarizing what you have learned. This is the famous “SOAP” note of which you have probably heard. The SOAP note is easy to grasp but difficult, initially, for most medical students to execute. The usual problem is trying to cram too much into the note. It should be concise, not wordy, and should not recapitulate the admission History and Physical except to remind the reader about the patient. (Believe me, the admission H & P, especially on medicine, is where you can go crazy with detail.)

The parts of a SOAP note are as follows:

Subjective: Who the patient is, a brief summary of the reason for their hospitalization, and what they or the nurses told you about their hospital course overnight.

“Mr. Jones is a 63-year-old man admitted for congestive heart failure exacerbation. The patient reported difficulty breathing and a non-productive cough last night at around nine PM but these resolved after administration of IV lasix. Patient is currently without complaints.”

Objective: Subjective is just that, subjective. It does not cover things that you observed in your exam or were reported by the lab, radiology or other consultants. These things are all objective, that is, facts that do not depend on the patient’s interpretation.

Typically you record the last set vital signs making particular note of anything unusual like a fever overnight or a string of high or low blood pressure readings which were unusual for the patient.

Next you will record the results of your physical exam. Generally, every patient regardless of their complaint deserves at least a cardiovascular exam, a lung exam, and an abdominal exam. Listen to the heart in several locations, listen to the lungs, listen for bowel sounds and palpate the abdomen. You can record this succintly using any number of “boiler-plate” abbreviations such as “lungs CTAB” for “lungs clear to auscultation bilaterally.” Of course you need to note any new findings,

Although opinions vary, on my SOAP notes I like to record pertinent lab values. I know that the results are usually on a computer somewhere but it simplifies the job of the person reading your note. I also give brief summary of any new imaging results or the results of any other tests which were not available for the previous note.

assessment/Plan: This is the list of what is wrong with the patient and the ongoing plan to address these problems. Typically it is also preceded by a brief recapitulation of the patient as in the first line of the note. Is this necessary? Maybe not but since most people jump to the assessment and plan when they read a note, particularly a long one, the recapitulation is always helpful. People will read your notes. might as well make them useful and user friendly.

You might say “Mr. Smith is a 63-year-old man with a history of congestive heart failure, Diabetes, hypertension, and gout admitted on January 3rd for a CHF exacerbation.” Then you make a list, by problem, of the plan to address that problem and how things are either working or not working.

For example:

CHF: Patient diuresed of approximately three liters of fluid over last 24 hours on 60 mg IV lasix every eight hours. Chest xray shows continuing resoution of pulmonary edema. Last ejection fraction was 25 percent by transesophageal echo on January 1st.

Diabetes: Well controlled on sliding scale insulin.

Hypertension: Blood pressure well controlled on Hydralzine etc. etc. etc.

You get the point. Also, you might want to add in your note how the patient is doing towards meeting his discharge criteria. Use accepted abbreviations but try not to get too jiggy with them. Most people have to think a little before they realize that BRBPR stands for “Bright Red Blood Per Rectum.”

Why is a the SOAP note important? Several reasons. However, let’s not kid ourselves into thinking that your attending or your resident is going to rely on your assessment and plan for her treatment decisions. Ain’t going to happen. Sorry. What the note does is provide a framework for your over-worked resident to quickly add her own pertinent comments as an addendum to your note. Sometimes the addendum can be as simple as “Agree with medical student note.” At other times the resident will add her own assessment and plan. Either way it saves her a little bit of time.

For you, the medical student, the big advantage of the SOAP note is that if you copy them and carry them around you will be well-armed when the time comes to present your patient.

More on that in Part 2.

First Day on the Wards: Part 1

What is it Really Like?

Getting Past the Hype

Only one percent of all visits to physicians take place at academic medical centers. And yet, because as medical students and residents we spend all of our time at these institutions our views of the profession are colored accordingly. As I am a resident at a large academic medical center (Duke) you need to take what follows with a grain of salt.

Medicine is not as glamorous as you may be lead to believe by depictions of the profession in the media. I know that you, gentle reader, already know this but I don’t think the typical medical school applicant realizes exactly how much of a grind certain aspects of medicine can be.

First of all, the patients are not all nice looking and don’t all come with compelling stories. Sometimes your patient is going to be an 87-year-old senile lady transferred from a local nursing home on a “soft admit” who’s past medical history runs to two pages and who is taking twenty different medications. She will be demented, diabetic, fluid over-loaded from heart failure and renal failure, a double below knee amputee from diabetes, and she will just lay there making occasional primitive noises.

Name a system and she will have a major problem with it. Dialysis on Moday, Wednesday, and Friday. Ileostomy for total colectomy. History of multiple angioplasy. This is a patient who will be wearing an adult diaper and will be spoon fed by a nurse’s aid if she’s not being fed through an nasogastric tube or a PEG.

And the transfer note will give as a reason for transfer, “Shortness of Breath.”

Duh.

Or you may find yourself in the Emergency Department working up a local gang-banger and you will realize that the typical thug is just not that glamourous. They beat their girlfriends, have the emotional development of twelve-year-olds, and do not have the souls of poets. Not that I don’t enjoy this kind of patient, because I do, but these are not gritty philosophers who have any legitimate things to tell you about your own life except perhaps to reinforce your decision to send your kids to private school.

After you pick up a patient, you will also find that the majority of your interventions and decisions are going to be pretty routine. Many aspects of medicine lend themselves to algorithms which you pretty much follow mechanically for most patients. Someone comes in with chest pain, for example, and you will automatically get an EKG, chest films, cardiac enzymes, and lytes while you start him on oxygen, nitro, and morphine. If his enzymes are elevated or he shows acute EKG changes you will route him to the CCU for thrombolytics or to the cath lab for an emergent cardiac catheterization.

Most chest pain patients, however, do not have dramatic EKG changes and elevated cardiac enzymes and settle down pretty quickly under the onslaught of your algorithm. When you first start your cardiology rotation as an intern you will be terrified when the Nurse pages you with a patient in acute chest pain. By the end of the rotation you will be non-plussed unless they show you the money.

On the other hand you always have to be wary of the patient who will not follow the algorithm.

What is it Really Like?

So You Want to Go to Medical School

Relax

Several years before I applied to medical school my daughter became ill and had to be admitted to our local teaching hospital. Twice a day, the head of the Pediatrics department would make his rounds followed by an impressive entourage of about a dozen residents and third year medical students rotating through pediatrics. As they stood in my daughter’s room, the head of the department would pepper his followers with questions about my daughter’s condition, prognosis, treatment, and other relevant medical knowledge. Standing in the back of the group was a third year medical student who looked incredibly awkward, especially after he mumbled and stammered incorrect answers to several questions directed at him.

A few years later, I found myself on a third-year pediatric rotation at the same hospital and realized that I was “that guy.” As smart as my mother thinks I am I was in full mental vapor-lock unable to recall the simplest item of medical knowledge.

It is a popular misconception reinforced by inaccurate stereotypical descriptions of medical students in the popular culture and wildly inaccurate medical school guide books that medical school is incredibly difficult and can only be successfully undertaken by a student with a photographic memory, the stamina to study sixteen hours a day, and a robotic obsession with medical knowledge. While it is true that medical schools are full of students who fit that description, there are an equal or greater number who are just slightly-smarter-then average regular people.

My purpose in writing this blog is to share some of my experiences and observations about life in medical school and residency from the perspective of a guy who is not at the top of his class and likes to keep stress to a minimum. I also hope that when you arrive at medical school you will have a fairly good idea of what to expect and how things really work. I want to show you that while you must study, if you are efficient and disciplined you can get by without studying long into the night on a regular basis. (But by no means am I going to give you easy study tips or a fool-proof studying system.)

I also want to pass on some essential information about third and fourth year which will not eliminate all of your stress or the awkwardness you will feel the first time you show your face on the wards but will at least give you an idea of what you are supposed to do.

Additionally, I want to make you aware of some of the potential pitfalls of the residency match so you will not make some of the mistakes I made.

Let’s get a few things straight, however. First, you will have to study in medical school. Someone who spends his undergraduate years trying to get into medical school and then blows off studying is a fool and will find himself as one of the tiny elite who are kicked out of medical school for bad grades. (It happens but not as often as you think.)

Second, you should know that many residency programs in highly selective specialties almost always require excellent grades and high class rank. If you want to do Dermatology or Ophthalmology as a specialty then I wish you luck but maybe you need to be reading a different blog.

Keep watching this blog for updates.

So You Want to Go to Medical School

Anatomy Lab

Don’t Get Carried Away

Exactly how much anatomy do you need to know and how much time should you spend in gross lab? Opinions vary. Some people love lab and eat it up (figuratively speaking) maintaining that there is no way to learn anatomy other than to spend hundreds of hours elbow deep in a cadaver. These are the folks who come in on the weekends to poke around a little for that one little nerve that they can’t seem to find.

Others spend the least amount of time in lab required by decorum and school policy.

How much anatomy do you need to know?

A lot, no question about it. I’m not convinced, however, that gross lab is the place to do it.

While you need to go to lab and poke around a little to get the feel for things, it is much more efficient to get a Rohan’s Photographic Atlas and use this as your non-smelly, non-gooey, portable anatomy lab.

Understand that most schools test you on gross anatomy by holding what is called a “practical.” In this test, you circulate around the lab from tank to tank (as if in some unholy buffet ) and are given a certain amount of time at each cadaver to identify a tagged item. The tagged item is usually well dissected and does not require any digging on your part.

Since there are usually anywhere from twenty to fifty cadavers in the lab (depending on the size of your class) most of the tagged items will be on cadavers with which you are unfamiliar. With this being the case, you might as well use a photographic atlas which usually shows structures unambiguously dissected in several views from which you generalize to any cadaver, not just the one that you have butchered.

The Rohan’s atlas has the legend on the side or under the photograph with numbered leaders to the structures. It is practically tailor made for quizzing yourself.

You will find that most of your lab time is spent dissecting rather than learning. By this I mean that you will spend hours picking through what looks like leftover thanksgiving turkey looking for an obscure nerve or blood vessel which you could have identified in your photographic atlas in three different views in thirty seconds.

I’m not saying that you don’t need to study anatomy, only that you need to do it efficiently.

Anatomy Lab

Things You Should Know

Things that Suck About Medicine

1. People who don’t wash. Come on, folks. Soap is cheap. If I ran the hospital every patient, before being allowed to enter, would have to wash his feet, wash his crotch, and wipe his ass. Oh, and tooth-brushing, that’s important too.

2. Manual disimpaction. Enough said.

3. Overnight call.

4. Dumb, lazy, ignorant, irresponsible patients who will spend several hundred dollars per month on booze and smokes but can’t spare $15 for their Dilantin.

5. Nebulous, non-specific chief complaints like “my back hurts” or “headaches” which remain nebulous even after a meticulous review of systems and physical exam. You know, the kind of thing where when you are done spending half an hour with the patient you can only conclude, “Yes, you have a headache.”

6. Patients who think that medical students and residents make “six figures.”

7. Really, really fat patients. three-to-five hundred pounders. What’s the use? Can’t hear their heart through all the padding. Can’t palpate squat. They have every friggin’ complaint from OSA to knee pain. Their real problem is their weight so every treatment regimine we put them on is just an attempt to distract the Grim Reaper. Not to mention pelvic exams.

I bet nobody asks you, when you interview, how you will like being in a small exam room with a patient who hasen’t bathed since the Clinton Administration, is covered with his own urine, and is threatening to blow chunks or crap himself or both.

Things You Should Know

A Subversive Thought

Can You Be a Pro-Life Physician?

You all might as well know that I am very pro-life. Without arguing the merits of the position, I want to dispel a common misconception among medical students and physicians, namely that even if a physician is pro-life he must still refer a patient to an abortion providor even if, because of religious or moral principles, he objects to the practice and does not want to become an accomplice to what he considers a crime.

Nothing could be more removed from the truth. Almost all of the states have laws on the books which explicitly protect a physician from legal jeopardy for refusing to take any part in the practice of abortion. This includes referral.

These laws, collectively known as “Conscience Clauses,” are the best kept secret in the medical profession. In fact, when I was a medical student the faculty wanted to discipline me for taking this position. They called me for a meeting and were all set to chastise me severely when I calmly pulled out a copy of the pertinent law and, figuratively speaking, rolled it into a tube and deposited it in that place where the sun doesn’t shine.

Just for good measure I also showed them the law which prohibits abortions or the discussion of abortions at the public hospitals in my state (Louisiana) of which my medical school was one. And then, just to add insult to their injury I produced the official hospital policy which pretty much followed state law.

I have seldom been so right, from a legal point of view, in my entire life.

Now, the AMA and various quasi-official bodies will make a big deal about their “guidelines” and “standards of practice.” The AMA is blatantly pro-abortion. Just keep in mind that the AMA is a lobbying organization and has no power over any physician. Only state and federal legislatures can enact laws and these can only be implemented, as it applies to the practice of medicine, through duly constituted State Medical Boards.

The AMA can rage and howl, can puff themselves up into paroxysms of self-righteous indignation but I ain’t a friggin’ member of their club so I don’t give a rat’s ass. On this matter I am directed by a higher authority. And the law, not to put too fine a point on it, is the law.

Here is the applicable North Carolina law: (Italics mine)

North Carolina General Statutes:

§ 14‑45.1. When abortion not unlawful.

(a) Notwithstanding any of the provisions of G.S. 14‑44 and 14‑45, it shall not be unlawful, during the first 20 weeks of a woman’s pregnancy, to advise, procure, or cause a miscarriage or abortion when the procedure is performed by a physician licensed to practice medicine in North Carolina in a hospital or clinic certified by the Department of Health and Human Services to be a suitable facility for the performance of abortions.

(b) Notwithstanding any of the provisions of G.S. 14‑44 and 14‑45, it shall not be unlawful, after the twentieth week of a woman’s pregnancy, to advise, procure or cause a miscarriage or abortion when the procedure is performed by a physician licensed to practice medicine in North Carolina in a hospital licensed by the Department of Health and Human Services, if there is substantial risk that continuance of the pregnancy would threaten the life or gravely impair the health of the woman.

(c) The Department of Health and Human Services shall prescribe and collect on an annual basis, from hospitals or clinics where abortions are performed, such representative samplings of statistical summary reports concerning the medical and demographic characteristics of the abortions provided for in this section as it shall deem to be in the public interest. Hospitals or clinics where abortions are performed shall be responsible for providing these statistical summary reports to the Department of Health and Human Services. The reports shall be for statistical purposes only and the confidentiality of the patient relationship shall be protected.

(d) The requirements of G.S. 130‑43 are not applicable to abortions performed pursuant to this section.

(e) Nothing in this section shall require a physician licensed to practice medicine in North Carolina or any nurse who shall state an objection to abortion on moral, ethical, or religious grounds, to perform or participate in medical procedures which result in an abortion. The refusal of such physician to perform or participate in these medical procedures shall not be a basis for damages for such refusal, or for any disciplinary or any other recriminatory action against such physician.

(f) Nothing in this section shall require a hospital or other health care institution to perform an abortion or to provide abortion services.
(1967, c. 367, s. 2; 1971, c. 383, ss. 1, 11/2; 1973, c. 139; c. 476, s. 128; c. 711; 1997‑443, s. 11A.118(a).)

A Subversive Thought

Just Some Advice on Medical School, Matching, and Residency

How to Get Into Medical School

Every year about 40,000 students apply for about 20,000 spots in the 125-or-so medical schools in the United States. Because I am a “glass half full” kind of guy I call these pretty good odds. But make no mistake, medical school admission is fairly competitive and the trend has not been in your favor over the last few years.

Here, in a nutshell, is the typical sequence of medical school application for a “traditional” student:

1. Decide on a major in your freshman or sophomore year but whatever your major start taking the standard prerequisites for medical school admission.

2. Start gaining some kind of medical experience as soon as possible as this is almost an unwritten prerequisite for medical school admissions.

3. Take the MCAT in April of you junior year of college.

4. Complete and submit the standard application used by almost all medical schools as soon as possible in the summer of your junior year.

5. Complete the “secondary” applications from schools which have looked at your MCAT scores, grades, and standard application and decided that you meet the most minimal requirements to be considered for an interview.

6. Wait for offers to interview at programs to which you have applied. Interviews are usually offered from late October to early April of your senior year.

7. Interview. Check the mailbox several times a day for as many months as it takes for you to be either accepted or rejected by every school where you interviewed.

8. If you are lucky enough to have been accepted to more then one school, as a courtesy to others you need to make up your mind where you will go by the middle of May. (This frees up the wait list at the schools you reject.)

9. Graduate from college without letting your post-acceptance grades slide too far. I have never heard of it happening but they tell of accepted students who are “de-accepted” after their post-acceptance grades show a precipitous drop.

Pre-med

Let me sum it up for all of you prospective pre-med students: Don’t wear scrubs to class. You are not in medical school yet. Don’t be a poseur.

Except at a handful of schools, “pre-med” has no official meaning. You do not major in “pre-med.” If you are the quiet type you can spend your entire four years as a pre-med and nobody will know that you are applying to medical school. (Assuming you are not wearing scrubs to class, I mean.) What you actually do is select a major just like everybody else but structure your schedule to take certain medical school pre-requisite courses. Although the pre-requisites vary slightly for different medical schools, they generally include a couple of semesters of General Chemistry, Organic Chemistry, Biological Sciences, as well as a smattering of math and Physics.

In what should you major?

The answer is simple. Major in anything you want to provided you can stay interested in it long enough to get good grades. Naturally, if you major in Biochemistry you will hit all of the pre-requisites automatically as most of them are also required for your major. If you major in Art History, on the other hand, not only will you take the full course load for Art History but you will also have to schedule the additional forty credits of the medical school pre-requisites.

So you should major in Biochemistry to avoid the extra classes, right?

Not so fast. Although college administrators don’t like to admit it, some majors are inherently more difficult then others. An Electrical Engineering Major, for example, works considerably harder then a Psychology major. Sorry. This is why the psychology department at most universities is huge while the electrical engineering department is relatively small. Everybody starts college thinking they’ll be “pre-med” or an engineer but as the reality of studying sinks in many will naturally gravitate towards the less intellectually stimulating majors which grant degrees without interfering too much with the serious business of partying.

It seems to me that most of our universities are “diploma mills” which for the sake of tuition revenue have developed many non-rigorous degrees to ensure that anybody with a couple of firing synapses can get some kind of expensive degree. This is the topic for another post, of course.

The point is that it is better to get extremely good grades in an easy major then mediocre grades in a difficult one. On some level, medical school admission committees must know that Biochemistry is more difficult then Art History but since medical schools look for reasons not to admit you before anything else, a 4.0 in art history just looks better then a 3.4 in biochemistry. In other words, although a good percentage of medical students majored in science-heavy fields, not everybody does and it is not required that you do. In fact, the trend today is to admit applicants who are more “well-rounded.”

The key is to ace all of the pre-med prerequisites whatever your major. You need to do this for several reasons. First, because the common medical school application used by almost all medical schools breaks down your GPA into several categories beyond the standard “cumulative GPA.” The most important is your BPCM GPA (or Biology, Physics, Chemistry, and Math).

You can have all A’s all the time in your Mickey Mouse degree program but a low BPCM GPA will be the kiss of death. It shows the medical school admissions committee that you can’t handle difficult coursework. On the other hand, you can have all A’s in your basket weaving major but have a 4.0 BPCM GPA indicating to the admission committee that you are a smart person, capable of handling the coursework, who happens to have a commendable interest in baskets.

The second important reason to master the material of the pre-med prerequisites is that whatever your major, you will have to take that great equalizer, the MCAT, in your junior year. Your background for this test might only come from the pre-requisites if your major is Art History.

But more on the MCAT later.

I suppose that some of you think a third reason might be that these basic science pre-requisites will help you later in medical school. I suppose so, but the utility of these courses is somewhat over-rated. Take organic chemistry, for example.

Organic chemistry, as taught in college, emphasizes a completely different knowledge set then that stressed in your first year medical school biochemistry course. Memorizing chemical structures and the movements of electrons in chemical reactions which is the basis of undergraduate organic chemistry is relatively unimportant in medical school biochemistry which tends to focus on the big picture.

Actually, very little in the way of a science background is required on your first day of medical school other then a reasonable grasp of high school level chemistry and biology. You pretty much start from scratch.

On the subject of majors, you also have to prepare for three possibilities which are unthinkable to the young pre-med freshman just starting college. The first possibility is that you might not be smart enough to get into medical school. Or, you might be smart enough but you lack the discipline to get good grades. Whatever the case, it is very hard to recover from a string of Cs and Ds in the medical school pre-requisites.

The third possibility is that you may realize that you don’t want to be a doctor. Maybe your volunteer experience in the local emergency room has revealed your absolute intolerance for other people’s bodily fluid. Maybe you are too immature.

With this in mind, make sure to select a major which offers you an alternate career path. Trust me: you will never really know if you like medicine until you do it. It is not uncommon for medical students, and not always the ones from the bottom of the class either, to quit in the middle because they find they just don’t like it as much as they thought. Sure, popular culture makes the job of a physician look glamorous and exciting, and it has its moments, but the hours can be brutal and the many aspects of it are frankly disgusting and would turn the stomach of anybody who isn’t dedicated.

The next important step as a pre-med is to obtain a pre-med advisor. This is a faculty member who will guide you through the complicated process of matriculating into medical school. But beware. As a class, pre-med advisors can be a mixed bag. First of all, they are not (except in the rarest of circumstances) medical doctors. Ideally they have contacts with medical school admissions departments and have a good idea of the requirements but this is not always the case.

Second, they are not always as gung-ho as you are about your chances for admission. This is not a bad thing in itself because a sober, unvarnished appraisal of your qualifications is essential. On the other hand you don’t necessarily want to be told, as I was, that my aspirations towards a career in medicine were at best a crap-shoot.

Snowballs and hell were also mentioned.

Shop around. I ended up with an excellent pre-med advisor from my university’s mechanical engineering department. Don’t settle for the first one you are assigned.

The other not-so-obvious reason to get a good pre-med advisor is that he will be your link to your schools pre-medical advisory committee. This committee (which goes by different names at different schools) will evaluate you in your junior year and write an important letter of recommendation. You will need to get other letters, of course, but this is the first one the admissions committee is likely to read.

Extracurricular Activities

It is a sad commentary on our society that it is not enough to express a desire to be a physician and get good grades but you must also take part in extra-curricular activities to prove your worthiness and dedication. The theory is that a little bit of exposure to the world of medicine will somehow make you a better applicant although I wish somebody would explain exactly how.

Honestly, no medical knowledge whatsoever is required on the first day of medical school. It doesn’t matter if you spent the last five summers running an inner-city STD clinic or flipping burgers, you are all going to start at the same level and learn the same information.
With this being the case, and with the credo to “never fight city hall” firmly in our minds let’s discuss a few common extracurricular activities along with their potential pitfalls and benefits.

It’s axiomatic that you will get out of an extracurricular activity what you put into it. Some are shameless exercises in self-aggrandizement. Others are worthwhile in and of themselves.

First consider the “Pre-Med Club.” Not to generalize too much but this club is generally the domain of the pre-med gunner. Nothing much of use is discussed at meetings that you can’t get from skimming any number of medical school advice books. Occasionally members of local medical school admissions committees will come and speak to you about admission, always telling you exactly what you already know and never quite getting around to telling you their criteria for selecting applicants. I would rate this a one on the ten point scale. I suppose if you have nothing better to put on your application you might mention your involvement. Maybe you were the President although I don’t think it makes a dime’s worth of difference. Avoid the “Pre-Med” club or anything of its type if for no other reason then it will probably demoralize you to be surrounded by so many type-A personalities “gunning” for your spot in medical school.

Let’s talk about research. Research is the lifeblood of academic medical centers. Not only is it the vehicle by which medical knowledge is incrementally advanced but it brings vast sums of money into the institution. Every one of your basic science and clinical instructors in medical school will be involved in research. With this in mind, meaningful undergraduate research activities are bound to look good on your application and if you are that type, then God love you.

The ideal situation is to take such an active role in a research project that you get mentioned as an author. (Look in any medical or academic journal and you will see that many articles have a list of authors.) This explains the section on the medical school application form for “publications.”

But what about the rest of us? For my part, I quit graduate school because I didn’t like research. In fact, the last meaningful research I ever did was a little paper entitled “Our Friend the Badger” in the third grade. Clearly, research is not for everybody and you will be relieved to know that a majority of medical students didn’t do any either.

Having no research experience will certainly hurt your chances of getting into Harvard or another ultra-prestigious medical school but most medical schools are not ultra-prestigious. If you are a solid student with a decent MCAT score and a few good extracurricular activities there is a place for you in medical school and you will do fine.

Bottom line: Research is a great and looks good on your application. But realistically it is not feasible for many students either from a lack of interest of a lack of opportunity. Don’t sweat it.
As I have mentioned your goal in any extra-curricular activity should be to demonstrate to the admission committees a genuine interest in the medical profession. Some of you may already have medical experience as nurses, ER techs, or the like. You are in good shape and can dedicate more of your time to getting good grades.

Just Some Advice on Medical School, Matching, and Residency

A Word About Gross Anatomy Lab

Get a Cheap Pair of Sneakers

Get a cheap pair of sneakers and a couple of pairs of cheap scrubs for anatomy lab. The smell gets everywhere. I’d even consider showering and changing in the Student Exercise Room before going home. Also, you and your tank partners should invest in one Dissector (the book which describes the dissection procedure) and one Atlas to use in the anatomy lab. You do not want anything that was in the lab laying on a cadaver or splashed with juice anywhere near your locker or your home.

You certainly do not want to study in the library or your kitchen with a contaminated atlas. Talk about gross. Some people kept them in a plastic bag in the tank with their cadaver.

Oh, and get a turkey baster. Trust me. It will come in handy draining body cavities.I can’t give you any good advice about lab other than that.

I hated gross lab and was something of a slacker. Since attendance at lab was not enforced let’s just say that I never spent more time in lab then I had to and stopped going completely in October of second year. (Since our curriculum was organ system based, we had a brief introductory course in first semester and then have a couple of days in the lab for every organ system for first and second year.)

Some people have a lot of anxiety over gross lab. For most of us, this is the first time that we are not only exposed to death but are intimate with it. I think everybody worries about how they will respond, whether they will be able to control their revulsion. Don’t sweat it. I had the same feelings. After five minutes with your cadaver the novelty will wear off and it will feel perfectly normal. After about half an hour you will probably start getting hungry because, like most people on their first day of lab, you may have decided to skip breakfast.

After a few days of lab you will find yourself carrying on perfectly normal conversations while casually leaning on the dead body or absent-mindedly picking at some exposed muscle. Eventually you will dread lab, not from some fear of the dead but because it can be dreadfully boring. The only thing that bothered me even a little was sawing the skull in half for the neuroscience course. That was kind of wierd. Oh and looking at the sludge that collects under the body. The funny thing is that after a while, your cadaver will look like old, crow-eaten road kill. I kid you not.

A Word About Gross Anatomy Lab

Some Random Advice

1. The Medical Profession is not a cult. I get flamed for saying this. You do not have to sacrifice your sanity, health, and physical fitness to its service, especially not in first and second year. It is just a profession. Treat it as a demanding job to which you expect to devote sixty hours a week and you will do fine.

It is also all right to dislike certain aspects of it or to be bored by certain subjects. You are not offending some rigid order if you do. Many people, for example, have unashamedly discovered that they despise pediatrics. I am one of them. I would rather flip burgers than be a pediatrician. Some people, on the other hand, love it.

2. Don’t get obsessed with the minutia of first semseter lectures. Of course you have to learn it, of course you will be tested on it, but around spring-break of first year you will realize that you don’t remember any of the little details of biochemistry that seemed so important in the fall. This is normal. Most first semester stuff is trivia, absolutely useless to a clinician except as part of his deep background of knowledge. You will have two days of lectures, for example, on proteoglycans, the important and (more importantly) Step 1 testable portion of which could fit on a small index card even though the professor who is an expert in the subject will deliver six hours of lectures.

It’s his area of expertise, after all, a subject to which he has devoted his life.

3. As you progress, you will develop a knack for knowing what is important and what is trivia. Even though you cover more material in second year, you will probably only study a third as much as you did in first year for the same grades.

4. Be aware of the honor code. It is a pesky little thing that most people don’t think about but which can whip around when you least expect it and sink its fangs into your ass. I have never had any trouble but some people in my class, and I will not name names or get more specific out of respect for them, were involved in what seemed like an innocuous action which resulted in some pretty severe punishments which were just short of expulsion.

If you knew how trivial the offense was you’d laugh.

Not trying to scare you. Just want to make you aware. Do I even have to say to steer clear of the obvious honor code violations like cheating?

5. Exercise. Nothing demoralizes most people like sitting around trying to study while they feel themselves turning into lardish library potatos. If you can’t make an hour a day to run or lift weights, especially if you are single, then you are doing someting wrong and need to examine your study habits.I don’t know if it’s scientific but I study better if I am in shape.

6. Studying: Quality over quantity although you do need to do a lot of it. Many of the people who claim to study twelve hours per day are probably in front of their books or at the library 12 hours per day but a lot of what passes for study time is not technically studying. Internet surfing, for example, can suck vast quantities of your study time as can socializing, daydreaming, or studying material you have a good handle on because it is easy.

I got by in first year on four hours per day of good quality studying. I didn’t surf the internet, I didn’t socialize, and I didn’t take breaks. When I was done with my four hours I quit and didn’t worry about it. Of course you should study like crazy at least for the first couple of tests to see how you do. If you are happy with your grades you can start to back off a little.

You will probably be amazed to discover that the amount of studying you do does not always directly correlate with your grade. Unfortunantly at many schools you will not have access to old test questions from the so this avenue of low effort, high yield study is closed to you.

7. When you are done with a course, move on. As long as you passed you can put it in the “win” column. This applies to everybody but those of you planing on matching in highly cometative specialties. Unfortunantly you will have to obsess about grades. Sorry.

Still, there is no point crying about a grade. Move on. Most of us are used to getting good grades in our undergraduate years with minimal effort. You can work like a dog and still get Cs in medical school. Don’t let it bother you.

8. You do not, repeat not, have to get in a study group. They will issue dire warnings about this during orientation but I can assure you that studying alone is best for most people. Your head will not explode.

9. Your milestones are the following:

Step 1: Must pass. End of Second year. You will usually have five or six weeks off between second and third year to study for it or for vacation or any combination. Fail it once and you will have to take your third year vacation month to study and retake it. Fail it twice and you have to sit out the rest of the year and come back with the lower class. Fail it three times and you are done.

Step 2 Clinical Knowledge: Any time in fouth year before April but realistically you want to take it early both to get it out of the way and to have scores for your residency applications.

Step 2 CLinical Skills: Any time in fourth year before April.

ERAS: Electronic Residency Application Service. Start getting your letters of reccomendation early in fourth year. You should have an idea of what you want to specialize in. Submit common applications as early as September.

Interviews:Most usually in November, December, and January.

NRMP:Submit Rank Order List by end of February. Last year the deadline was the 23rd.

Match Day:Third Thursday in March of fourth year.

Graduation: Late May.

Some Random Advice

Urban Myth

Don’t Freak Out

The requirement to do pelvics, DREs and other invasive exams on classmates is an urban myth. You will not have to stick a speculum or your finger in anybody in your class, period.

To learn how to do a pelvic, for example, on your OB-Gyn rotation you will probably observe your resident do a few at which time he will let you try your hand. Believe it or not it is a rare patient at a teaching hospital who will object to even this.

As for Digitial Rectal Exams, when you do surgery or medicine your resident will just tell you to go do one. The first one you do will fell kind of akward but after a few it will be nothing, just another skill.

It is true that you may do a few “surface anatomy” exercises with your classmates but you will not touch anybody’s breasts, genitals or any other spot which would make anybody uncomfortable. We did practice drawing blood once from each other but that was it. Occasionally the professor will ask for a volunteer to demonstrate some exam skill but this is voluntary. If you don’t want to be touched by your professor or classmates this is perfectly acceptable.

Because you are expected not to be squeamish about other people’s bodies does not mean you are expected to discard your own modesty. When you examine a naked patient you do not strip nude yourself to make him feel more comfortable.

Urban Myth