More Medical School Admission Advice: Addressing the Diversity Puzzle (Real Questions from Real Readers)

(Once again I dig deep into the archives to answer questions about the medical school admissions process-PB)

Dear Panda,

In order to take advantage of affirmative action, I lied about my race. Good move or not?

Sincerely,

Plain Vanilla Pre-med

(Eating a Baloney Sandwich, on White Bread, With Mayonaise, somewhere in Minnesota)

Dear Vanilla,

I also lied about my race. I said I was black. At first my interviewers didn’t want to believe me because not only am I actually Greek but my ancestors are Macedonian Greeks, i.e. the Swiss of the Hellenic world.

So we went around and around. I’d give some proof, they’d refute it. I tried busting a rhyme, they cited Vanilla Ice. I railed against “the Man,” they yawned as every white liberal does this. I even tried a few break dance moves but despite my baggy pants, apparently MC Hammer sold out and is now considered a white man.

Finally, I dropped the big one. Let’s just say that they didn’t call him “Alexander the Great” for nothing.

But generally you need to leave this kind of thing alone unless you can produce the goods.

Sincerely,

P. Bear, MD

No Moussaka, No Peace

Dear Uncle Panda,

During the admission interview I was trying to be conversational and asked my interviewer how their medical school reconciled their primary care rural setting with their research goals. As they also have a homogenous, rural population, I asked how they increase student’s exposure to diverse patient populations. My point was not to be intense or to show intellectual superiority but to ask about genuine issues that the school faces. I think I threw my interviewer for a loop because he ended the interview shortly thereafter. Were these not appropriate questions?

Sincerely,

Trepidatious in Tacoma

Dear Trepidatious,

Sweet smiling baby Jesus. I admit it. I must come from a different planet than a lot of you guys. Who actually thinks like that? Or cares about that kind of crap anyways? Diversity is a totally meaningless concept. I know it has become something of a growth industry and sucks hospital resources from important things like patient care and paying the residents a little more but if there is one thing you are going to learn, despite all of the “Sprit Catches You and You Fall Down,” the diversity seminars, the multi-cultural gestapo, and the linking of hands to sing Kumbayah, efforts to promote diversity only serve to drive a wedge between people, particularly Americans, who should be striving for a little more conformity.

(Ah…Sweet, sweet conformity. What a great society it would be if we all stopped whining about our past and looked to the future. A society where we could put away the emphasis on our differences and strive to live like Americans, embodying as this does our best traits as a people which include enterprise, courage, self-reliance, generosity, and an abhorrence of being perceived by our fellow citizens as a whiner.)

Come on. ‘fess up. If they offer you a spot you’ll still have the freshly opened acceptance envelope in your sweaty hands when you call and say, “Thank you, I will certainly come.” All of that crap you mention above (and it is meaningless, irrelevant crap) won’t matter a bit.

I weep for the youth of today. When I was in my early twenties I did normal things like chase girls, drink too much, and get in minor scrapes here and there. Somebody please tell your Uncle Panda that you kids still know how to do these kinds of things.

Sorrowfully Yours,

P. Bear, MD

Dear Dr. Bear,

I secured an interview at a prestigious Eastern medical school and everything was going fine at the interviews until my interviewer asked me if I had any questions. Now, to be honest, they had done a pretty good job during the tour answering our questions. To be even more honest I really want to attend this school and would accept admission there even if a pre-requisite was having a nest of rabid weasels lighted on fire and packed in my ass. I’m afraid I blurted out the first thing that came to mind which was, “What qualities are important for your graduates to possess?”

Did I blow it?

Respectfully,

Depressed in Dallas

Dear Depressed,

Man. Must everyone be a tool all the time. How do you expect them to answer that?

“Gee, buddy, if we can get them to stop yelling racial epithets and molesting the patients by the time they graduate we put ‘em in the ‘win’ column.”

I repeat, it is not necessary to be a tool all the time. It’s all right to make small talk and perfectly acceptable to ask, “So, how’s the nightlife around here?”

I think you blew your shot at that medical school. Sorry.

Respectfully,

P. Bear, MD

More Medical School Admission Advice: Addressing the Diversity Puzzle (Real Questions from Real Readers)

Navigating the Medical School Admission Obstacle Course. (Real Questions from Real Readers)

(I have received quite a few emails over the past two years asking for advice as well as anwering a lot of questions about the medical school admission process on The Student Doctor Network. I thought I’d publish some of them along with my replies. -PB)

Dear Panda,

I said I spoke Spanish on my AMCAS application when in fact the only Spanish I know is the Taco Bell menu. Was this a bad idea and will it come back to haunt me?

Sincerely,

Nervous in Nebraska

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Dear Nervous,

I also claimed to speak a foreign language. The problem with this is, obviously, that someone who interviews you might actually speak the language and want to bust out with you, his homie, in his native toungue.

So Spanish is definitely out. Although the possibility is remote, I have heard that some members of admission committees (and even some doctors if you can believe it) speak a little Spanish.

I picked “Walloon” as my language and wouldn’t you know it, one of my interviewers was from the Low Countries and started jabbering at me the minute I walked into his office.

That’s when I played my trump card and had a full-blown Grand Mal seizure. They took me to the Emergency Department and I was post-ictal until the end of that particular interview slot. But it’s cool. I had devoted some of my personal statement to how I had fought and overcome epilepsy to achieve my goal of Medical School so I had them in check.

Like I said. You have to think quick and be prepared.

Respectfully,

P. Bear, MD

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Dear Uncle Panda,

In a desperate attempt to make myself more diverse I may have exaggerated some of my extracurricular activities and qualifications. Do medical schools try to verify these things?

Respectfully,

Worried in Wyoming
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Dear Worried in Wyoming,
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They most certainly do check on your qualifications and extracurricular activities. My medical school has an office that does nothing but verify everything you list on your AMCAS application. Fortunately they are kind of short-staffed because of budget cuts so if you play your cards right, delay submitting your application to the last minute, and use a little common sense the odds are that they won’t get around to checking your extracurriculars and qualifications until you are well into first year at which time, possession being nine-tenths of the law, it will be very difficult to dislodge you.

In fact, I listed myself as “Native American” and even described some of the suffering of my people in my personal statement.  I’m not really a Native American except in the sense that I was born here (so technically I am a indeed a native American). One day towards the end of first year I got an irate email from the registrar inviting me to explain to the verification committee how I could possibly make this claim.

As soon as I walked into the registrar’s office I let out a blood-curdling shriek, charged his desk, and touched him with my coup stick…you know…just to establish my tribal cred’.

“We prefer to be called Indians,” I said as I adjusted my loin cloth and sat down, “And I don’t know how those people from Calcutta or Bombay get away with calling themselves Indians either. It’s shameful and I don’t think they’re fooling anybody.”

The registrar politely inquired as to when we they would get my tribal certificate from the Bureau of Indian Affairs who had claimed to have never heard of me.

“I don’t need the white man’s worthless paper,” I replied fixing him with what I hoped was a don’t-give-me-your-small-pox-infected-blanket stare, “Or the white man’s laws, the white man’ unnatural technology, or the white man’s corrupt political system.”

“Hey, is that some of the white man’s coffee? Mind if I get a cup?”

Apparently the North Dakota Sioux in which tribe I may or may not have claimed membership had never heard of me either.

“Did you call my Uncle John Raging Pony? He’s the chief, you know.” Actually my uncle John couldn’t chief his way out of a paper bag. We only call him Raging Pony because he drinks a lot of Malt Liquor. But he lives in North Dakota. In a trailer. With no phone which is not really my problem.

“Oh, and my tribal name is Turgid Ferret.”

The registrar insisted that there was no record as far as they could tell of my belonging to any tribe in the United States.

“Well, there’s yer’ problem Great White Father. Our ancestral homeland straddles the border with Canada. We actually spend most of our time in Alberta. More bison, you understand”

Very pained look from the registrar. I could see he didn’t relish negotiating Canada’s incredibly primitive phone system. Plus he didn’t speak French so talking to the Canadians was going to be a problem. Always pick a third world country for your extracurriculars. It slows the verification process.

“Well, if that’s all I’ll be on way,”I said prying my tomahawk from his desk, “I go now to commune with the spirits of my ancestors over the traditional frothy coffee drink of my people.”

The medical school admission process is tough. You have to be smart and you have to keep your options open.

Glad I could help

Regards,

P. Bear, MD

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Dear Dr. Bear,

What keeps people from making up extracurricular activites?

Respectfully,

Curious in Klamath Falls

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Dear Curious,

What keeps people from making up extracurricular activities?

Nothing. Absolutely nothing.

Yours,

P. Bear MD
Winner, 1998 Noble Prize for Chemistry

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Dr. Panda,

What is the purpose of the essay on the Secondary Application? I mean, I wrote my heart out on the AMCAS personal statement and now I have nothing more to give.

Sincerely,

Perplexed in Paducah

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Dear Perplexed,

The secondary essay gives you a place to explain why you called Mahatma Gandhi a “urine drinking magnificent bastard” in you AMCAS personal statement. It is also a good place to admit that you don’t actually have any kittens and yer’ Grandma who you claimed to have cared for until she “slid gently into a peaceful dream of death” is actually in a third-rate nursing home in the suburbs of Dubuque and you actually haven’t seen her in three years because the smell of “poopy” makes you gag.

They do check these things you know. My medical school had a whole department of “verifiers.”

Glad I could help.

Respects,

P. Bear, MD

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Dear Dr. Bear,

Do medical schools really verify all of the crap we list as extracurricular activities in our AMCAS application? I may have stretched the truth a bit (well, more than a bit) and I am starting to worry.

Respectfully,

Nail-Biting in New York

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Dear Nail Biting,

About six months into fourth year I got called into the Dean of Students office. Apparently they had found out that I hadn’t actually won the Nobel Prize for chemistry.

Thinking quickly, I said, “Nobel prize? Of course I didn’t win the Nobel Prize. I won the Noble Prize. See? Right there. Call my undergraduate institution and ask them about it.”

“Sure, I keep the Harvard registrars phone number in my wallet. Here ya’ go.”

By the time they sorted it out I had graduated.

I didn’t actually go to Harvard, by the way. A few months later I got an angry letter from the Dean of Students saying that there was no record of my having attended Harvard.

“Harvard?” I wrote back, “I didn’t go to Harvard, I went to Harvarads…you know, in St. Croix.” I gave him the phone number of the registrar which was really my cell-phone number. Every call I got for the next three months I always answered (in a thick Jamaican accent), “Hello, Registrars Office, can I help you mon?”

Incidently, if you look closely at my ID badge, between the “M” and the “D” is a tiny “C.” I actually didn’t go to a real undergraduate university but I did attend McDonald’s Hamburger U as an assistant night shift trainee. It said “University of Hamburg” on my AMCAS application so I’m not really lying. Besides, are they really going to call Norway to verify that I went there?

You just have to be smart.

My Best Regards,

Panda Bear, MD

Navigating the Medical School Admission Obstacle Course. (Real Questions from Real Readers)

Don’t Tell the Spartans

(Many of you are about to start third year and are looking forward to it with feelings of both anticipation and dread. You know that it’s going to be the real start of your medical career where you finally get to see what all the fuss is about. At the same time, despite the propaganda, you have the uneasy feeling that third year is going to blow, and blow hard, not for the least of which reasons because, after what in years to come will have seemed like a two-year vacation, you now will be working on a rigid schedule with responsibilities that you can’t casually shirk.

There are two schools of thought about clinical education for medical students. One school believes that your clinical years should be a model for residency complete with long hours, pointless abuse, and call. This is under the theory that it will toughen you up for residency where you will be further toughened up so you can be prepared for the real world where medicine is not practiced at all how it is in residency.

The other school, the Panda School, knows that abuse serves no purpose other than self-justification for the past suffering of the abuser, that you cannot condition yourself to do without sleep, and that clinical training as it is currently structured at most medical schools is actually detrimental to education. Not to mention that since you will get plenty of abuse as an intern, there is no point wearing you out now, especially since, despite what The Man says, you have no responsibility for patients.


I was referred to an interesting discussion on the Student Doctor Network about the mistreatment of medical students by residents and since we have been giving short-shrift to this topic (although Brother Hoover has it covered pretty well) I thought I’d try to address some of the common complaints that medical students have about residents and particularly interns.

I am known to be very easy on medical students, by the way, as some of my medical students who read this blog can probably attest.-PB)

1. It’s my first day on the Service, and my first day of the third year, and the intern is mad that I don’t know anything.

I don’t know of another career where the trainees are berated for not knowing their job on the first day but this is a fact of life for medical students. On the first day you won’t even know how to work the phones much less care for patients and it may take you hours to complete a simple task (such as dictating a brief note) that you will complete in thirty seconds as a resident. This is because you have nothing but jumbled facts bouncing around your brain with no experience in marshalling them into a coherent assessment and plan for your patient. You also have no idea about the logistics of the hospital, where they keep things, and who does what.
I don’t know why this is hard for some residents to understand except that medical school admission committees seem to be selecting for assholes and, although medical school is good for personal growth, these people tend to grow as assholes.

The solution? There isn’t one except the general advice that the hospital is not Thermopylae, the patients are not the Persian hordes, and you are not a Spartan who has to sacrifice himself for the greater glory of a large, bureaucratic machine that if possible, thinks less of you than it does of the residents. Pace yourself. Realize that you don’t know anything, and revel in it. Don’t apologize, and be direct in the face of worthless, spiteful criticism, especially from an intern.

I assure you that interns have very little input into your grade for the rotation and generally speaking, as most residents are decent people, we can see as easily as you which interns are socially dysfunctional. You also have to ask yourself if your grade is more important than your self-respect. If it is, then you will have to suck it up. If not then you should establish the ground rules for how you are going to be treated early. As Dr. Phil says, we teach people how to treat us. If you are firm, forceful, and fair, people will either respect you or they will be intimidated, either one of which is fine. If you are a weak, squirrely biach you are going to be treated as such.

It’s like prison. If you pick a fight with the meanest, baddest prisoner on your first day, win or lose you are going to establish some credibility. I’m not advocating beating your intern but it’s not like this guy is that far removed from you. Hell, it’s July. He’s more scared than you because he has real responsibility. So sometimes, as you learn in the joint, a brother has to shiv’ a motherfucker. Establish early on that you are not a biach and you will do fine.

2. My intern is stealing my work and getting credit for it.

One of your duties will be to see patients and write notes, especially the time-consuming Admission History and Physical. No question about it, medical students write exhaustive H & Ps. You usually have the luxury of time while your intern is perptually under the gun so his may be a little more sparse than yours. While you may turn in a copy of your luxurious History and Physical for a grade, to your intern it is nothing but meaningless paperwork, especially since for 95 percent of patients everything pertinent could be written on a small index card in thick black marker. It’s another obstacle in a day filled with obstacles. He also knows that even in the unlikely event that anybody reads the note, the only thing they are interested in is the assessment and plan and not your detailed description of the patient’s travel history since the Carter administration.

Your intern does not get credit for your History and Physical. There is no such thing as “credit” for this sort of thing. It’s done, the box is checked, and it becomes just another scrap of paper mouldering away down in medical records. I have never heard an attending say, “Hey, that was a cracker-jack History and Physical. Take the rest of the day off.”
So don’t sweat it.

3. My intern is stupid.

Have a heart. You are fresh from two years of intensive lectures and the USMLE Step 1. Your intern spent most of the last six months of fourth year playing video games and catching up on sleep. I am a PGY-2 (second year resident). I once asked a medical student a question and when he went into his pimp-defense mode I said, “Relax, I’m really asking you if you have ever heard of this condition because I sure as hell don’t remember it.

Not to mention that your intern is sleep deprived and under a lot of pressure. It is easy to look and sound stupid if you’re supposed to know what’s going on but don’t which is typical of most interns. It’s not that they’re stupid, it’s just that compared to their upper levels and attendings they seem that way. They’re learning too, just like you but the difference is that they count and you don’t (no offense).

On the other hand since “MD” actually stands for “Minimal Doctor,” it is quite possible that your intern is, in fact, a jibbering moron, at least by medical standards. It is inevitable that somebody is going to slip through the cracks and the “questionable admission” may very well have pulled off yet another snow-job and landed a residency position. Not to mention that there are a few specialties that are known for scraping the bottom of the barrel when it comes to the help.

If he’s a jibbering motard but otherwise a nice fellow you might consider trying to cover his ass. You don’t have to, you understand, and nobody is going fault you or even know if you don’t but good residents look out for each other and you may as well start practicing now. I know, I know. You’ll be helping a guy along who will one day be in the position to hurt patients but decent people don’t think like this. Let his State Board sort it out.

4. My intern tries to get me to do his work, especially on call.

I despise call, probably more than most people. Ever since I started publishing this blog it seems like more and more residents are coming out of the closet in this regard. Certainly when I was a medical student to say you disliked anything about medicine, not just call, was viewed with the same horror by your residents as if you had a large, greasy bowel movement in their Lucky Charms. But they’re not fooling anyone. Call blows. Nobody likes it just like nobody really likes residency training for the most part except that some tolerate it better than others.

So it would be natural for an unscruplous intern to try to either shame you or force you into doing his work for him. Just keep two things in mind. First of all, most medical schools have rules about call for medical students. At some, medical students are to be discharged at some reasonable hour of the night because, wonderous to behold, the school realizes that a medical student’s purpose is to learn, not to be a scut ox who is too tired to study. It is up to you to know the rules and grow a set of gonads about sticking to them. Don’t care for the rotation or the intern? Hey, it’s eleven o’clock buddy and I am outta’ here! All you have to lose is the respect of the intern…but…and stop me if this is obvious…he’s just an intern. His respect his worthless anyways if it comes at the price of your sleep and your health. Stay all night if you want and if you feel like you will learn something but scut work is worthless and you’re not being paid to do it.

The second thing to remember is the French Hooker Rule. No matter what they want, you can only give them what you can give them. It is not your responsibility to clear out the backlog of admissions in the Emergency Department. Most interns wouldn’t even think of giving you this task, not for the least of which reasons that you can’t do it. But sometimes a lazy and unscrupulous intern, on being paged for an admission, will send his medical student to knock out the preliminaries which involves most of the paperwork. Learning is one thing and you need to do some admissions to get the feel for it but you are not cheap labor, the intern is…or didn’t he get the memo?

And I am sick of sports metaphors. It’s not a team. If it were a team everybody would get treated better than they do. It’s more like a salt mine (I mean if we’re going to throw metaphors around). Do your assigned work diligently but don’t be patsy either.

5. My intern berates me in front of the other students.

Berate back. He’s not your mother. There is no penalty for shoving back. You are not contractually obligated to take crap from anyone. On the other hand, no need to be on a hair-trigger, either. Certainly don’t buy into the “Welcome to My Service” speech that some interns like to give. I got one of those as an intern from my twenty-something third-year resident who, among other pearls of wisdom, informed me that my family needed to come second after medicine in my order of priorities. This only sounds good to people who don’t have families, of course. The point is that the intern has different priorities and goals for the rotation than you might have. It may be his specialty and he may be really into it. You may hate the specialty and just want to get through it with the low pass.

The irony of medical school is that you are expected to take abuse from people who are only a few years ahead of you in training and whose ass you would otherwise kick if they treated you half as bad anywhere but the hospital.

Don’t Tell the Spartans

Clinical Evaluations

Actual Evaluation by My Residents and Attendings

(Just for old time’s sake I reviewed my Dean’s letter. Man, those were the days! -PB)

OB/Gyn: Student is on time and does everything asked of him willingly and with good humor but seemed uninterested in assisting in any more vaginal deliveries than were required to pass the rotation. Actually winced, yes winced, when he was sprayed with urine and feces during one particularly rapid delivery. Commented to me that it was “Nothing like the Discovery Channel.”

OB/Gyn: Student Doctor Bear is on time and cheerful but does not fight hard enough to be the first to see patients complaining of vaginal discharge. I don’t think he should fail the rotation but I am giving him low marks for referring to our weekly STD clinic as “Kooter Patrol.” I also caught him rolling his eyes as I lectured a young, single, G5P4004 on the need for greater personal responsibility. I didn’t quite understand what he meant when he invited me to “repeat my advice to the wall and see if there was any difference” but I think he was making fun of me. Student Doctor Bear also showed no interest in standing around doing nothing while I performed a particularly difficult colposcopy.

General Surgery: Student Doctor Bear did everything asked of him but was singularly unenthusiastic about holding a retractor for six hours. He does not seem to enjoy call and never seems to either know or care about the answers to the random trivia question I ask him just to keep him on his toes.

Medicine: Does not seem enthusiastic. Once actually sat down (!) during rounds…and the attending and all of the residents were still standing! Had an insolent, “you people keep talking while I rest my feet,” expression on his face and ignored every frantic hand gesture to stand up before he made the attending mad. When the attending asked, with admirable sarcasm, “Are you tired, Student Doctor Bear?” he said, “Yes,” and persisted in his sitting position until we had moved to the next patient. And then, oh weep thou heavens and hide thine eyes in shame, when the attending suggested that maybe he wasn’t cut out for internal medicine he replied, “You’re probably right about that.”

Medicine: For reasons unknown to me, Student Doctor Bear is uninterested in electrolytes. Even after spending a brief forty-five minutes discussing a patient’s Potassium (Peace Be Upon Its Holy Name) level his only comment was, “So, do you think we need to supplement it?” Supplement it? Is the wind’s name Mariah? Can we began to explore the intricacies of Potassium (PBUIHN) in the brief time we had between five PM and eight PM when the silly rules require us to let our medical students go home to study?

Pediatrics: A good medical student but he has kids of his own so I don’t think he believes us when we say how great working with kids is. Changes diapers like a pro and is not awkward at all when handling the babies.

Heme-Onc: Did not directly observe the medical student. If you tell me he was on the rotation I’ll believe you and I do seem to remember catching a brief glimpse of him hanging way, way back in the team but when I blinked he was gone. I could probably review the hospital surveillance tapes if you really need an evaluation but I suspect finding more than a few seconds of footage will be more difficult than locating Big Foot.

Surgery: Not a good medical student at all. Despite never having been in an operating room, rotated on a surgery team, observed any operations, or completed a surgery residency, Student Doctor Bear displays absolutely no knowledge of how we do things in the OR, where to stand, and what my favorite music is. And this was his his second day of third year, for crying out loud. And he is woefully ignorant of the collateral circulation supplying the anterior two-thirds of the left adrenal gland even though he should have learned this in first year anatomy.

Family Medicine: I detected a lot of resistance from Student Doctor Bear. He seems reluctant to hug the patients and his sympathetic nodding skills are woefully inadequate. His empathy skills also need work. For example, when a patient complains about knee pain Student Doctor Bear needs to refer her to physical therapy, not comment that it is “No wonder because every time you stand up you squat-press a small German car.”

Family Medicine: He’s not buying it. Student Doctor Bear is not ready to board the Primary Care Mother Ship. Maybe we could have tried sleep deprivation and a low protein diet but he we didn’t have the time.

Clinical Evaluations

Barking Mad

Psychiatric Ward

Inpatient psychiatry wasn’t as fun as I thought it would be. The people locked up on the tenth floor of our hospital were just a little too crazy to really be interesting. A little insanity, like a little spice, adds flavor to a patient’s personality. Too much of it and it overpowers everything. After all, a patient can only cut his scrotum open with a razor blade a couple of times before everybody just yawns and moves on to the next sensation.

It’s not that I don’t appreciate odd behavior. I am as mean-spirited as anybody and take the usual guilty pleasure in other people’s misfortunes, particularly when they are the result of some absolutely inexplicable but voluntary lapse of common sense.

It’s like slapstick comedy. We shouldn’t laugh but we do.

The truly insane, however, are directed by impulses so remote from the normal as to be both chilling and profoundly boring at the same time. If you’ve heard one patient explain how the television has commanded him to kill you’ve heard them all. If it’s not the television it’s the lawnmower, the dog, or the dead people next door. Just some variation of minds so out of whack that there isn’t even any guilty fun to be had. We don’t laugh and point at a diabetic. It’s the same with insanity.

Now if someone claimed that his cat was hissing dark commands in his head, instructing him to take night courses at the local community college towards a degree in medical coding, well, that would be unusual. I’d settle for his dead mother screaming at him about the benefits of good dental hygiene, something you almost never see in the insane.

What is your job as a medical student working on the psych ward? In essence, nothing. Oh sure, you will follow patients but except that you may have extraordinary conversational skills, you might as well just sit and stare at each other for all the good it will do. They’re schizophrenic. Their brains hear and see things that are internally generated but perceived as absolute external reality. Maybe they can be talked out of it but it will require someone skilled in the black arts of psychotherapy, not little old you casually rotating through. All the talk in the world probably isn’t going to make a difference anyways. The voices will not listen to reason and have to be silenced with psychiatry’s ever-expanding arsenal of medications.

So you will round on your patients and write your notes. Unlike, say, a surgery rotation where you can state proudly on your progress note that the patient “has had a bowel movement and is tolerating a soft diet on post-op day three of his bowel resection,” in psychiatry progress is hard to measure and most of your notes might as well conclude that “The patient is still as crazy as a shithouse rat…but we’re going to discharge him today because he is not a threat to himself or others…for now.”

About all you can do is be a little familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, the fourth and current edition) which is the Bible, Koran, and Vedic Texts of psychiatry rolled into one hard to digest bolus. When I say to become familiar with the DSM-IV I mean to get a review book, preferably one that will fit in your pocket. The DSM-IV is a large reference text and therefore highly unreadable except on the idiot savant level.

The DSM was developed to standardize the language of psychiatry between different mental health professionals in different countries and psychiatric traditions. This was necessary because as you can imagine, psychiatry is one of the most subjective medical specialties and has previously been very flexible even in the objective description of psychiatric pathology. The DSM also sets forth criteria for the diagnosis of discrete disorders as well as providing a framework for completely describing a patient for the purposes of psychiatric diagnosis and treatment by the use of five categories or “Axis.”

Axis I, for example, describes major disorders like schizophrenia or bipolar.

Axis II is for underlying or pervasive personality disorders or things like mental retardation.

Axis III is a “gimme” or a “freebie” for most medical students and residents who are not interested in psychiatry because while it is technically a description of other medical conditions that may contribute to the disorder, in practice it is the non-psychiatric past medical history. It gives you something to grab a hold of on an otherwise mystifying patient. Here, at last, are conditions that we can treat definitively, or at least definitively know we can’t treat.

Axis IV describes psychosocial factors, things like homelessness, unemployment, or poor family support. Axis V is the Global Assessment of Function (GAF) and is a numeric score from 0 to 100. Most of us function at around 90 to 100 which is considered normal. Someone lower than 60 probably needs to be committed except our society has unfortunately moved away from institutionalizing the mentally ill. That’s a subject for a different day but it would freeze your blood if you knew some of the truly unhinged characters standing in line with you at Wal Mart.

If you know a handful of common psychiatric presentations and can fit them into the five axis you will do all right.

Your psych ward patients will be a mixed bag (of nuts), ranging from the homeless guy claiming suicidal intentions for “three hots and a cot” to the raving but mostly non-violent schizophrenic. It is unlikely that you will rotate, as a medical student, on a ward for the criminally insane which would definitely kick things up a notch in the fear department. Students are occasionally attacked but this is not as common as you imagine. Just make sure to never let the patient get between you and the door, never wear a tie, and don’t get into a pissing contest with a lunatic. With a little common sense you will be fine.

My favorite patients are the bums who have the system figured out. They typically draw a disability check every month and use most of it for booze and drugs. By good economy and thrift they may manage to get almost to the end of the month at which point, malnourished, hung over, withdrawing, and cold they present to the Emergency Department, the 24-hour representative of “The Man” and claim they want to kill themselves. This buys them a stay in the psych ward where they can get a shower, hot food, and some rest in the bosom of the system. The only price to pay is being interviewed every day by an earnest medical student trying to cure them. Most of them actually have underlying psychiatric disorders that contribute to their situation but this disorder by itself is usually not serious enough to warrant inpatient care.

The bipolar patients are probably the most interesting. They will talk for hours in response to one question when they are manic. Even their medications can’t completely suppress this. I’d hate to be friends with a person like that but if you’ve got nothing better to do (and you won’t) you might as well listen to somebody who has everything figured out all the time. Beginners try to faithfully record everything the patient says in their progress note, often scribbling away furiously as the patient talks. Eventually you realize that it doesn’t really matter what the patient says and you condense your description of thirty minutes of frenzied speech to “Expansive mood, inflated self-esteem, and grandiosity.”

When they’re depressed, and you can sometimes follow the same patient long enough to see both sides of the disease, they can be almost catatonic and you will miss your chatty buddy from the previous week.

Will you like inpatient psychiatry? It is an easy rotation. You don’t really do anything but talk and there are no procedural or physical exam skills to learn. The hours are generally pretty good. You see your patients, present them, and maybe sit in a group therapy session and listen to the patients try to one-up each other. It can be frustrating, on the other hand, to write notes that nobody even reads, see patients for whom you don’t even have the usual medical student pretend-responsibility, and get the same tired story from the same patient day after day after day until somebody decides that, mirabile dictu, they are well enough to be discharged.

Barking Mad

Hell on Earth

Problem Based Learning

Lecture is a pleasant, drowsy picnic where you nod in and out of sleep while listening to the far-away drone of bees and the faint ringing of goat-bells as the local peasant girls herd them to the high alpine pastures.

Problem Based Learning is like being sodomized in prison by a big sweaty guy named Ronaldo who has bad breath and hands the size of dinner plates.

Problem Based Learning (PBL) is a system of medical education where instead of following a rational curriculum that lays out the subjects in which you should be proficient in an organized manner and instructing you accordingly, the lunatics are put in charge of the asylum and it is up to them to figure it all out. Of course it sounds good in theory. Its proponents use phrases like “self directed learning” and “team based approach” to disguise the fact that it was implemented primarily to spare professors the onerous burden of teaching poorly attended lectures.

How does PBL work? Well, first let’s imagine a traditional lecture-based curriculum. In this system, during first and second year you attend lectures Monday through Friday which are organized into discrete subjects like Pathology, Microbiology, Biochemistry, and the various other big medical school topics. Some medical schools mix the order a bit by having their lectures “systems based.” In this scheme the lectures of the standard medical subjects are tailored to the particular organ system that you are studying.

If you are on the cardiology block, for example, you might have lectures on heart pathology or heart-specific medications and their properties. I rather like this system, by the way, even if there are some subjects that need to be taught en bloc and not broken up between different systems.

Microbiology comes to mind.

Whatever the case, in a lecture-based curriculum you will usually have a syllabus with concrete learning objectives stating what you need to know to master the material. The fact that lectures are often poorly attended speaks to a strength of this system, namely that you know what you need to learn and can dispense with the inefficiency of listening to somebody else talk about it when you can read about it on your own.

In a PBL curriculum, you are broken into small groups and the learning happens, so they tell me, through interaction and self-exploration.

I remember my first PBL session (My school had a smattering of it). The facilitator started us off by presenting a case and then asking us for a differential diagnosis.

Blank looks from the group.

Beuller…Beuller…Anyobdy?

You have to understand that at this point, two weeks into first year, the only medical experience most people have is the month they spent working at a homeless shelter passing out condoms, free needles, and empathy. It was at this time that most of us probably realized everything we did or claimed to have done on our AMCAS application wasn’t going to help us a bit.

“Um…I think my grandmother had that,” said one of the more adventurous students, “They said it was her heart valve…or something.”

This comment died a silly, embarrassing death in the general silence that followed.

And that’s how it went until the facilitator, clearly relieved to be absolved of facilitating, started to lecture us on the relevant aspects of the case. I suppose this was better than listening to the crickets chirping but much of what we were told in this and many other PBL sessions was presented without the necessary background in medical science which you’re supposed to learn before getting jiggy with medicine. It’s like asking a group of people who have lived on Ramen noodles since high school to whip up a gourmet meal by consensus. The spirit yearns for Beef Wellington but the mind only knows noodles.

Eventually, I suppose, you get the hang of it. You learn to do a quick google search a couple of hours before the session so you can drop a few buzz words and pretend you care. Or you learn how to surrepititiously surf the internet on your laptop while pretending to be feverishly taking notes.

I also suppose that eventually you can learn a lot in a PBL session but it is so damned inefficient.

First of all, I hate studying in a group. It’s bad enough that a good portion of medical knowledge is incredibly boring without having to suffer through your classmates, all of who have different studying styles, trying to get a handle on it. It’s all I could do to read about some things. Listening to an amateur droning about them made me yearn for an ice pick to the brain. Teamwork is perfectly fine, of course, and I understand that “team” is a talismanic word that invokes all kinds of goodness to it’s believer. But not everything has to be a team effort. I brush my teeth and dress myself almost completely without assistance every morning. I even have been known to read the paper in silence without calling all of my friends to tell me what they think.

Second, because people like to hear themselves talk, the alpha-students will quickly eastablish their dominance and you will eventually here something you probably haven’t heard since third grade:

“That’s true, Jane, but how about letting one of the other students answer?”

But that’s actually all right with me. I was always content to zone out and let the titans fight it out among themselves. Either that or I surreptitiously studied my class notes from which were a lot higher yield.

Some medical schools are all PBL. This must be a living hell. You can’t even skip and study on your own because your absence from a small group will be missed. Some are a mix of PBL and lecture. Some are mostly lecture but like a malignant cancer, PBL (like empathy training) has metastasized to the entire body of medical education.

Hell on Earth

No Solution

It Sucks to be You

My post on my first day of third year seems to have struck a nerve and a few of you have asked some variation of the question, “What can we do to end the abuses which are so much a part of medical training?”

The short answer is, “nothing.”

As long as there is a steady stream of people willing to sell their mothers to get into medical school it will always be a seller’s market and there will be no incentive to change anything. On top of that, too many people look at medicine as a religious calling which means that, like any Pharisee, they will defend their beloved orthodoxy against attack from reformers.

Not to mention the operation of human nature which ordains that many who have been made to suffer feel it is their duty to inflict pain on others. This explains the sanctimonious old-school attending who defends the abuse of medical students because he had it much worse in his day.

So on an institutional level change is going to come very slowly. The increasing numbers of non-traditional medical students who are less willing to put up with the usual chickenshit is an encouraging development. A twenty-something medical student who has gone straight through from high school to college to medical school without seeing how the rest of the world works is a lot more inclined to accept the status quo as normal than somebody who has worked outside of medicine. Additionally, a resident or attending who knows nothing other than the life of academic medicine is inclined to believe that nobody else works as hard as he does and this makes him more than a little self-righteous.

In reality, other people work hard, often for much less money and prestige than doctors. As a Marine, for example, I endured hardships that would make the Chief of Surgery’s blood run cold. But you don’t see me running around abusing people because I humped a 120-pound pack up and down the mountains during arctic warfare training or spent week after week sweating in a central-American jungle.

About the only thing we (you) can do is to stand up for yourself. There is no rule in medical school that forces us to be pussies. Let’s say you don’t know the answer to a pimp question, instead of getting flustered and embarrassed as we usually do, why not try saying, “I don’t know.” And then just look at the guy like he’s some kind of idiot for pressing you on something which you have just told him you don’t know.

“I said I don’t know, Bob. What part of that don’t you understand?”

If enough people take a stand against abuse by not tolerating it the whole sorry house of cards built by the insecure to protect their fragile egos will come down. The worst thing that can happen, as long as you are reasonably respectful, is that you might get a bad evaluation here or there. The days are long gone when your attendings had the kind of absolute power over you that they once had. There is nobody at your hospital who can stand in front of a review board and explain how he has the right to mistreat his subordinates.

Still, you need to go through medical school with good humor. Most of your attendings and residents are decent people and their knowledge and accompishments should command respect. They have a duty to instruct you and this involves criticism. You need to be able to take legitimate criticism even if it is sometimes delivered with a little well-deserved sarcasm.

I can, however, tell the difference between criticism and plain old bad manners.

No Solution

How Do You Like It So Far?

It’s Going to Get Worse Before It Gets Better

Many of you have just started medical school and I want to congratulate you and remind you that no matter how bleak it looks during the first few months of first year, the time will pass and one day you will look back and wonder where the four years went.

That doesn’t mean, however, that it’s going to be a bed of roses and that you will come to enjoy every precious minute of your adventure. In fact, it is going to get worse, much worse, before it gets better. And then it will get worse again but after that I don’t know because I haven’t got there yet.

I enjoyed the first two years of medical school. I studied, of course, and as you faithful readers of my humble blog know I probably should have studied harder. Still, after the initial shock of the first couple of months of first year things weren’t really that bad. Unless you are at a school that does a lot of the so-called “Problem Based Learning” (or PBL) where you pretty much have to show up every day because your absence from your small group will be missed, you are on autopilot during first and second year. With the exception of anatomy lab and a few other mandatory functions, you can pretty much come and go as you please and only show up for the tests.

Because I was kicked out of college in the early eighties, in part because I never went to class, I have something of a fetish about attendance. On the other hand, I knew that if I was late or just didn’t feel like going it it was no big deal. I skipped a day, for example, to pick up my puppy Daphne from the animal shelter and get her settled at the house.

As you are no doubt discovering, most of your professors give you acess to their Powerpoints, notes, and even videos of the lecture. Not to mention detailed syllabi and even, at most schools, a student-run note-taking services. It is easy to skip class, especially since most schools do not have mandatory attendance.

My point? Don’t freak out over first and second year. While there is a lot of material, if you play your cards right you can treat medical school like a regular job and avoid the stress that will turn many of your peers into jittery freaks. During first and second year we got every federal and state holiday, a long Christmas and Spring break, and eight weeks of vacation between first and second year. Additionally, you can show up to class in pajamas (because medical students often wear scrubs even if they have no clinical need for them) at whatever time you please and also depart at your leisure. If you were only to chill out a little and not obsess over how hard you have it, you will find that there are plenty of hours in the day for study, exercise, recreation, or whatever your taste in procrastinating.

You just have to have a little self-discipline. Maybe we can call it “slacking with a purpose.” In other words, you have just got to prioritize. If attending seven hours of lecture a day and then studying into the night is burning you out, then stop going to lecture but have the self-discipline to spend that free time studying. First and second year are self-study anyways. You will have the notes, you will have the syllabus. You will, God forbid, have the textbooks if your taste runs in that direction.

I was fortunate to go to a medical school that was lecture-based but had cut the number of lectures down to a more reasonable day. It was unusual to be in class past two and this gave me plenty of time to study before going home. I spent more time with my wife and family during first and second year than at any other time in my life. My wife used to say, “Hey, I thought you were in medical school.”

So when does it get worse?

Third year.

After two years of keeping your own hours suddenly you will find yourself stuck places. Stuck in clinic. Stuck with your team as you round for hours and hours. Stuck attending conferences where your absence is not tolerated. Stuck on call. Stuck looking like an idiot on numerous occasions or worse yet, stuck in the role of fifth wheel

I have worked my whole life and first and second year seemed like a vacation. Third year was like going back to work. I liked it but I’d be lying if I said I was thrilled to death on the first day of third year in my spanking-new short white coat opening the door to my very first real patient’s room with only a vague idea of what I was supposed to do.

So enjoy first and second year. Here is some random study advice. Remember who’s giving it to you. I didn’t exactly cover myself in academic glory. On the other hand I think even the most cynical and vindicative will see the logic to my method.

After I recovered from the initital shock of the first test of first year, I adopted a more disciplined approach to studying which included the self-discipline to stop studying at the designated time. You can cover a lot of ground in four or five hours if you avoid distractions. If you read Powerpoint notes then you can probably read a whole week’s worth in two hours. Additionally, BRS and other review books are made to be read quckly.

I favor repetition over trying to get something down the first time. I despise brute-force memorization and refuse to do it.

Let me reiterate my test-taking theory for all of you new people: Most tests are multiple choice. At most schools, every lecture accounts for three or four questions on the test. Most tests (at my school anyways) were around two-hundred questions which means you can miss 60 questions and still pass. Suppose you have a lecture on the Krebb’s Cycle in which the professor has warned you to memorize every intermediate reaction and every product or suffer dire consequences. Suppose most of the other lectures are concept oriented and not as nit-picky.You, my friend, now have a choice. You can devote hours and hours of finite study time memorizing boring and unimportant details which you will forget five minutes after the test or you can completely blow off that lecture and devote your time to other topics which are not as difficult.

At the very worst you will sacrifice three or four questions on the test. Probably less because you can probably make an educated guess or two. My point is that you can always select four or five of the worst lectures to completely blow off.

This is hard to do. Our instinct is to fight and claw for every point but sometimes this is counterproductive. I dreaded studying some subjects because they were extremely boring. I felt a lot better about studying once I admitted this to myself and stopped trying to fight it.

How Do You Like It So Far?

Welcome Aboard

What to Expect Now that You’re Accepted

One of the greatest days of my life was when I was accepted to medical school. It ranks up there with my marriage to my lovely wife, the birth of our children, the day I graduated Marine Corps boot camp and the day I was honorably discharged.

I’m not ashamed to say it. It was one of those days where the future opens up. When I was discharged from the Marines, for example, it was a beautiful April day in North Carolina. I had money in my pocket, an absolutely beautiful girlfriend who I would marry a year later, and nothing much to do until classes started in June. You feel like you can do anything at a moment like that.

Same with getting into medical school. So it is my fondest hope that those of you who have gained acceptance relish this time because the road ahead is long and you will probably have some dark moments. I also hope that those of you who will not get in this year continue to persevere, especially if you are young. Maybe I wouldn’t advise an older applicant to keep beating his head against the admission process but if you are in your mid-twenties, why on earth would you even contemplate giving up so easily after only one or two tries?

So good luck. Stand by. And here is some more unsolicited advice from your Uncle Panda.

First of all, you really don’t need to do anything to prepare. As I have said earlier, there are really no pre-requisites for medical school. I suppose it’s good that we take all of that organic chemistry and biology but I can’t really identify any area in my undergraduate education that was of any use. If you’re the kind of person that remembers everything from your sophmore biochemistry course then you probably will remember everything from your medical school biochemistry course. If you don’t even remember taking biochemistry as an undergrad then why worry about it? You will be exposed to it soon enough, you will remember it long enough, and by the end of fourth year you won’t remember enough of it to matter.

The point is you need to relax and take it easy between now and the middle of August when most of you will start. You cannot possibly cram everything you need to know between now and then. You can try, of course, but it is equally likely that absent any structured guidance you are going beat your head against subjects which will be breezed over in one lecture and never seen again. There’s just no point to cramming. Better to finish your coursework without totally dropping the ball and then take a well-deserved vacation, maybe the last time in your life that you are completely free of responsibility.

Those of you who are non-traditional or have families, would it kill you to quit your job a little early to take it easy for a while? Four years from now when you are a quarter million dollars in debt the couple of thousand bucks you wrested from your crappy job by sticking with it to the bitter end will not seem like that much money.

I was fortunate that I worked for myself and could wrap up my affairs well before my start date.

Second, and I know I am repeating myself here, do not buy anything on your school’s list of required books and equipment unless you don’t care about money. If you show up on the first day of orientation with a pen and a little piece of scrap paper to take notes you will be all right. Heck, eschew the scrap paper as you wil get reams of handouts. Besides most of what you will learn at orientation is pleasant to listen to but of no value at all once the proverbial excrement hits the fan. No need to take notes.

You see, at orientation they will fill your heads with visions of sugerplums which will dance in your head until the first day of actual class when you find that all of the happy talk and kumbayah won’t help you one bit as first year is just a grind, a pathetic slog through trivia.

Ah, orientation. It was a week of emotional masturbation during which we were told six hundred times that we were special, we were going to be empathetic, and gosh darn it, people liked us! Then classes started and people went from feeling warm and fuzzy to stressed, tired, and wound to the breaking point. Oh the bullshit they fed us, everything from “if you don’t study in a group you’re going to fail” to “get the textbooks because there will be required reading.” Har har.

So don’t believe the hype. Smile, enjoy the week (or however long your school allots for orientation) but prepare to get on it once real classes start. If you study, you will pass. If you study all the time, you may get good grades but then again you may only do a few points better than your slacker friend who studies one fifth as much as you. (Sometimes there seems to be no correlations between the amount of time you put in studying and your grade.) Study hard, keep up with the material, listen to good advice from your upper-classmen and try not to get to caught up in the touchy-feely stuff. You’ve got a long road ahead. No sooner will you start feeling like you’re in command of medical school when you will start third year and feel like the biggest superfluous, ignorant, non-essential piece of baggage to ever break the plane of the pelvic outlet.

Let me repeat one piece of good advice that one of the fourth years gave us during orientation. Be macho. No matter what happens just shrug it off as just another day. Big test coming up? No big deal. First day of General Surgery? Just another day. Step 1? Nothing to it.

Good luck.

Welcome Aboard

Things You May or May Not Need: Part 2

The Two Week Rule

Eventually you will fill all of the pockets of your white coat with various pocket reference books, tools, and pens the wieght of which will suprise you. These things will accumulate on you like barnacles on a whale and you will be reluctant to scrape them off against the possibility that you might need one of the items and not have it.

A good rule of thumb is that if you have not used something in two weeks you probably don’t need it and it is safe to leave it home.

The advent of the PDA has gone a long way towards reducing the load carried by interns and medical students. The contents of Harrison’s Textbook of Medicine, which in print weighs ten pounds, fits easily onto a small corner of my PDA’s memory so you can see that with a decent PDA you can carry around a complete library of reference books.

Which you’ll never use, of course. The best applications for the PDA are the electronic equivalents of the pocket reference books. The best, in my opinion, is Eprocrates.

Epocrates is the “killer app” for medical handheld computing and does for PDA what the spreadsheet did for the personal computer and what porn did for the internet. The current version includes a drug reference handbook, a concise medical texbook, a catalogue of lab tests and their interpretation, a medical calculator, and a few more goodies. All of them are cross-referenced and formatted to be read easily on the typical PDA screen.

Epocrates got it’s start as a drug reference and in this it is superior to any other product on the market. You can search its database by drug class or name. It gives you dosages for adults and children, contraindications, mechanism of action, and even price.

Epocrates also has a rapid clinical reference database which I mentioned earlier. Let’s suppose you are treating a Sickle Cell patient. With a couple of taps you can pull up everything you really need to know about the condition including its pathophysiology, treatment, prognosis, and even what labs and studies to order on your patient. Now, to be honest the detail isn’t quite as good as a medicine textbook but it is surely good enough for rounds and will keep you safe in case you are pimped.

On a similar note the “Five Minute Clinical Consult” series is pretty good. They are written for practically every specialty and now that you can load them into your PDA you don’t have to carry around a huge book.

A “Sanford Guide to Anti-Microbial Therapy” is another one of those essential little books (which you can also get for the PDA). It is a good place to look when starting an antibiotic regimine on a patient, especially if you are considering “empiric” therapy, that is, before cultures and sensitivities come back from the lab.

Most medical centers also publish their own small infectious disease manual which lists characteristics of the microbes specific to the medical center.

The trend now is to tie wireless devices into the hospital database. At Duke this works pretty well and you can easily access lab results and other improtant rounding data on your PDA. Some schools are years away from this. Wireless connectivity is a nice plus but not essential and sometimes more trouble than it’s worth unless your school has implemented the technology to make it seamless for the user.

I despise mucking around with computers. All I want is to turn them on and use them,

Good PDAs can be pretty expensive. Many schools make their purchase manatory (along with a laptop computer) and this just adds to your student loan debt. If I could, I’d hold off getting one until third year because you will not need it for first and second year and any PDA you buy as a first year will be pushing obselecnce by the time you start third year. Either that or the prices will come down.

It should go without saying that you will need comfortable shoes. Whether you are in the OR or rounding on a medicine service, you will spend much of the day on your feet. Your dogs will be barking for not the least of which reason as that during first and second year you spent most of your day sitting down. Clogs are very fashionable for men and women and you will see the surgeons wearing them. I think they look kind of silly but then I prefer a more conservative look.

Whatever your preference in fashion, a pair of shoes that are comfortable, cool, and easy to slip on and off will make your long hours on the wards more enjoyable. If you can slip them on and off this will let you really rest your feet if you have a moment to sit down as well as making it easier for you to get moving when you are on call and are startled awake by your beeper.

Would it kill you to buy more than one white coat? Presumably you should change the oil on your coat every three or four thousand miles. Still, you will see medical students and residents rounding with white coats which are almost gray from use. I know it is just me being superficial and that many of the folks I see skulking around in greasy, off-brown white coats are ten times the physician I will ever be but that’s no excuse to look like an ass-bag.

Buy three. Wear one for a few days then wash the the stupid thing. Hit it with an iron too, if you are to cheap to buy the polyester blend.

Oh, and get your wife, girlfriend, or same-sex spousal equivalent (as we say at Duke) to sew a few extra pockets on the inside to carry your gear. A pocket with a velcro or button closure is nice for your PDA. Most scrubs don’t have very good pockets and the minute you break into a trot when the code pager goes off your PDA will slide right out onto the floor.

Trust me.

Things You May or May Not Need: Part 2