Monday, April 11, 2016

Thoughts on Being in Medical School

I've been in contact with two medical students over the past few years.  Recently received a note from one wondering if perhaps the student had made a mistake.  Below is the reply.

Received your e-mail yesterday.  Much to say about your questioning and self-doubt.  

Every medical student on earth has felt what you are feeling at some point during his or her time in school, particularly the latter stages.  The following quote is near the end of the Temple Medical class of 1975 yearbook The Skull.   "Remember feeling depressed with too much work to do and no end in sight to the hassle?  One could always feel better by walking by the Dean's office and seeing the applicants waiting for an admissions interview.  They were trying desperately to be as miserable as we were."  It was funny but also summarized the reality of those four years that were mercifully at an end.  

There is something important to recall during school.  I call them  'The Three F's' of Medical School."  Fatigue.  Frustration.  Fear.  

Fatigue is the most self-evident.  This is particularly true during the final two years when it seems that one is balancing a full-time job and life as a full-time student, reading, researching, and writing in addition to the hours at the hospital.  However, even during the first two years with the demands for study, memorizing, more study, and weekends that were breaks only in the theoretical sense, i.e. not having to go to class, turned life into a grind.  Computers have made life a little easier in that you don't have to go to the library to access the index medicus (a lot of students have no idea what that is) to research a topic.  You can research from home or just about any place else at any time of day.  However, there is so much to learn and so little time to learn it that intellectual, emotional, spiritual, and physical fatigue are more or less constants.  It is almost impossible to describe the life change that happens upon beginning medical school.  Friends get real jobs, marry, have kids, buy cars, and other perks (if they find a job) while we are grinding away at the books  every night and most weekends.  Oftentimes we lose touch with those friends because our lives have no common points any longer.  The change in one's self-understanding will have to be the topic of another e-mail.

Once night call enters the equation you learn a whole new meaning of fatigue.  You also learn that it can be overcome at least temporarily.  Alas, even when that adrenaline surge hits during an emergency there is a price of physical exhaustion to pay afterwards.  It may be difficult to feel rested.  Sometimes it seems that from the standpoint of feeling rested medical school is a mild case of the flu that lasts for four years.  

Frustration.  This one is tough.  It gets a lot better during internship, residency and the rest of life.  A medical student has no job description.  The student is expected to do what needs to be done, when told to do it, and in the way it is supposed to be done.  The problem, particularly in junior year, is that rarely does the student know what needs to be done, is often times told to do it without a lot of instruction, and has no clue, for the most part, how it is to be done.  I think that is one of the reasons I hated surgery.  I could sort of figure out internal medicine but surgery meant that my ignorance was exposed in the OR.  I never had a clue. 

The frustration is compounded by the instability of rotations.   Just as you are figuring out what needs to be done and how to do it four weeks into a six week rotation, you get ready move to another rotation.  The six basic rotations we had (I am assuming they are the same) of medicine (twice), surgery, OB-Gyn, peds, psychiatry might as well be different solar systems from the med student's point of view.  It becomes an completely different game with each move from one to the other: new attendings, nurses, hospitals, rules, regulations and expectations on everyone's part, including yours.   Having to figure out a new parking lot, new route to the hospital and so on does not help the situation.  On one memorable away rotation at the beginning of senior year I had a 9 x 9 room over the morgue.  It was very quiet. 

You can't really appreciate how off-balance you are/were during med school until you have the chance to look back from a point of relative stability.  I don't think I fully realized this until I became a Jesuit novice.  The same sense of being off-balance and geographic mobility--we were never in Boston for more than four months at a time--reemerged.  That sense of being off balance as a novice wasn't pleasant until I figured out what it was.  Then I realized that after med school the Society of Jesus could not throw one curve in my direction that I couldn't hit out of the park

The questions of making a difference and helping others bears attention.  You do make a difference.   You make a difference though neither you, nor the patient, nor the people with whom you work are aware of that difference.  Most of the time, even when others and perhaps you yourself, are aware, there is no formal thanks or feedback or dissection of how you helped the other (or how the other helped you, something you must never forget).  Being calm at the bedside while an attending was giving bad news, a reassuring hand on the shoulder, and visit after rounds, may make a world of difference that goes unappreciated at the time.  As you progress through training you will become more secure in the kind of difference you make be it resuscitating someone during a cardiac arrest outside of hospital, putting the fears of a concerned parent to rest, or intervening in a way that relieves the pain or cures the illness.  But it is too early for that.  You are not allowed to do anything independently (a change from my day when we would make decisions to catheterize bladders and other things without supervision or discussion) or without guidance.  At times you know the answer to a patient's question but prudence dictates that you not act on what you know. 

Of course a source of frustration related to the above is that you don't know much and may be uncertain about the things you do know.  It takes time to feel secure in one's knowledge.  I can now joke, though at the time  it wasn't a joke, that the first time I sent a patient home from the ER with the diagnosis of non-cardiac chest pain (my first day as an intern 24 June 1975), the patient slept better than the intern.  It is the nature of the beast.  The learning curve in medicine is steep.  But any med student worth his or her salt is capable of traveling that curve.

Fear.  Walking into a patient's room the first time with bad news.  Being asked "Doc, am I dying?" Starting your first IV or drawing your first blood gas.  Fear in its purest form.  You may not be able to define specifically what it is that you fear.  That is not a surprise as it is a fear that is not univocal.  Living in a constant state of the Three F's while in med school is exhausting.  

Once school and residency are over much of the fatigue (well, perhaps less than the other two) frustration and fear abate, though it is a slow process.  The transition from book knowledge and boards to the bedside is a tough one.  It is also prolonged.  The first two to three years out of training are difficult in their own way but eventually things settle into a rhythm.  

You wrote a bit ago about your frustration with routine.  Some of us are happy with routine, not just in medicine, but in life. I remember a column written by a man who was considering becoming a Trappist monk.  He lost that desire when he was working with a monk who had been at the monastery for over 35 years.  They were packing eggs.  The aspirant was getting bored.  The Trappist noted that he had been doing this same job daily for 25 years and loved it.   He saw it as the best job in the monastery.

The 'Dig and diuretics' (do you even use digitalis anymore?) of the primary care internist was a drag.  How many times do I want to educate an old lady about regularity?  How many times do I want to assure a man that his prostate is fine.  But then there is the day that the hypochondriac comes in and you realize her voice is much deeper.  And it isn't a cold.  And after a few more questions you realize that her thyroid has become profoundly hypoactive since you last saw her two months ago.  WHAT THE HELL?  Yes, that did happen to me with one of the my most demanding and my favorite hypochondriacs ever, a total of forty-one years and counting. 

The difference between you and all the others, nurse clinicians, practitioners, assistants and so on is that you are preparing to become a physician. You will notice the little things that the others may miss or, worse, be unable to explain.  You know the physiology better, you are much more familiar with the anatomy underlying things, and you know a whole lot more about pharmacology than anyone except a pharmacist.  That is a gift.  Alas, you can't quite use that gift to its greatest extent because you are still a student.  

There is the question of being an example to others, particularly kids who may be thinking of going to med school.  Sometimes it is the encounter with a young physician that sends them in the same direction.  You wrote of the physicians who influenced you while you were still discerning med school.  We rarely, if ever, know how our example influences a younger man or woman to follow into the same career.  Yes, it is wonderful to be told but it is rare.  But these things have to wait.  At the moment you are getting hammered with the realities of medical school.  

On the matter of satisfaction.  The daily examen is important.  Ask yourself, when did I cooperate with God's grace in my daily work?  Where did I resist that grace?  What gave me the most satisfaction?  What was too frustrating to tolerate?  What do I need for tomorrow?   And yes, making the examen while in bed (we called it the examen supine) is OK.

I am going to include a prayer here as a sign off.  It was written by Pierre Teilhard de Chardin, SJ.  He did not write it as a prayer but rather in a letter to a female cousin with whom he was very close, more akin to a sibling than a cousin.  She was struggling with her vocational discernment. She did not feel as if she was making any progress with her life.  Read this often.  

Patient Trust

Above all, trust in the slow work of God
We are quite naturally impatient in everything
   to reach the end without delay.
We should like to skip the intermediate stages. 
We are impatient of being on the way to something
   unknown, something new. 
And yet it is the law of all progress
   that it is made by passing through
   some stages of instability—
   and that it may take a very long time. 

And so I think it is with you. 
   your ideas mature gradually—let them grow,
   let them shape themselves, without undue haste. 
Don't try to force them on, 
   as though you could be today what time
   (that is to say, grace and circumstances
   acting on your own good will)
   will make of you tomorrow. 

Only God could say what this new spirit
   gradually forming within you will be. 
Give Our Lord the benefit of believing
   that his hand is leading you, 
and accept the anxiety of feeling yourself 

   in suspense and incomplete. 

Some black and white photos from Ljubljana.  Eager to go back.  

+ Fr. Jack, SJ, MD

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