Another Test

I'm not actually sure why I continue to torture myself with more tests, but I do. The SSAT, the SAT, the MCAT, the GRE, etc. etc. I might as well just take the LSAT and GMAT, and that way I'm covered for all the graduate schools for the next five years. So today, in order to propitiate the admissions committees at prospective public policy schools, I took the GRE. And although it was painful to study during my "week off" (orientation for the longitudinal program this week!), I did learn a few things. With the goal of taking the positives out of every situation, I can admit that absconding down to Greenville, South Carolina for the afternoon was not time wasted (yes Mother, I did "abscond" - I left Asheville "hurriedly and secretly to avoid detection or arrest"). This is what I learned...

• However ephemeral, I did learn a few words. I used the Kaplan book and memorized the 150 most used words on the GRE. I would say that at least 10 of these were part of questions on my exam (hint hint for anyone out there). There are three types of verbal sections on the "new" GRE: fill-in-the-blank with the appropriate word, fill-in-the-blank with the two most appropriate words that complete the sentence (in an equivalent fashion), and the typical reading comprehension passages + questions. This is wonderful because it means there are no more of those damn analogies... "oxen yoke" is to "North Korea" as "cattle prod" is to... blank. You know, I just don't care. No patient, attending, grocer, financial advisor, or parent has ever asked me a question is this form before. Let's keep it that way.
• I know triangles. Like, I really know them. In the biblical sense. I'm a little rusty, so I probably knew them better in the ninth grade, but damn it feels good to 5-12-13 again. You want me to solve for an angle? Length of the side? How about the area of the space between a circle a triangle inscribed in said circle? One half base times height. BOOM. It is a skill that is literally only useful for standardized tests and for those that sell triangles (maybe architects too... or painters), so who cares? Don't even give me a calculator. Pythagorean Theorem? Pythagorean Theorem-schmearem! And now I will promptly forget it all. As the Dean of Admission of UNC School of Medicine, Dr. Robert Bashford, once famously said, "I learned the Krebs Cycle five times in my life for a total of 17 minutes. That's all." I think the same applies for triangles.
• This blog is not helping my test taking skills. While I am accustomed to the typical weekly opprobrium (actual word that was on my exam) from my mother with regards to my liberal variations of English language words, I did not recognize the damage it's done until now. Generously expanding the meanings of words to fit my own creative insights actually made it difficult to answer the "fill-in-the-blank-with-two-synonyms" practice questions. I prefer to use my imagination and pretend that words can be similar if you just give them the right inflection. My guidebook proved me horribly wrong, and I was appropriately conditioned to black and white definitions. Poo-poo.
• A 4 hour exam is not grueling. While I must forgive Kaplan's chicanery, I'm just not impressed. Step 1, an eight hour exam, is grueling. This was just a drop in the bucket. I'm getting used to the 3-4 hour test length with the Shelves each Block. No, I don't need to do deep breathing, Kaplan!

Sorry to be so laconic this post, but there just isn't much to say about a test that caused me so much capriciousness for the entire week. If there's nothing further, I'll be off to my usual daily nepotism.

The Longitudinal Model

A lot of people have asked me what I mean when I say I'm doing a "longitudinal program" for my third year of medical school. Usually I say that instead of doing all eight clerkships in separate 4-8 week blocks, we do them all at the same time. Plus, we follow "continuity" patients all throughout the year, and we have ethics meetings, and we have half days to explore other areas of medicine, and we do radiology, cardiology, and emergency medicine, plus, we do...

So, bottom-line I'm not drawing a good picture of what I'm doing out here in Asheville (mostly because I'm not totally sure yet!). But we do have Orientation this week, and our schedules have begun to pop up on our Google Calendars, so now I can give you a better idea of what the year is going to be like. We started off in the "traditional" model; I spent 6 weeks in Surgery and 6 weeks on OB/GYN (the other traditional clerkships are Family Medicine, Internal Medicine, Outpatient Medicine, Psychiatry, Pediatrics, and Neurology). Surgery was a wee bit different in that we weren't working with residents, only attendings. Still our first three months were more traditional, but now in October we begin our unique curriculum. So here is a typical week in Asheville, NC...

• Monday - in the mornings I am working in Family Medicine. Basically, as I understand it, I will be working with one of the docs in the clinic seeing patients, or we will be in the hospital if my doc is rounding at Mission. Shadowing is a thing of the past, as I will be taking the history, performing the physical, creating an assessment and plan, and then meeting with my attending to present the patient and my course of action. My plan will be accepted, tweaked, or thrown out, depending on the accuracy of my assessment. As trust builds with each attending, I will be able to take on more and more responsibility for my patients. Certain patients will become part of my "continuity of care" population. I will follow-up on these patients in the clinic, at referrals, at the hospital, and in the emergency department (we will be getting more information on this in the upcoming week, so we're all still a little uncertain as to how this will work). I have a new phone number specifically dedicated to these patients, and will take on the responsibility of being their care provider and advocate. I will work with the same attending all year in order to facilitate my own continuity.
• Tuesday - every other Tuesday afternoon I will be in Cardiology. Cardiology is not actually one of the "traditional" clerkships that most students take, but we are lucky enough to build in time with an outpatient group. No matter what I choose to practice, I will see congestive heart failure, heart attacks, and many other common cardiovascular abnormalities every day. I realized how important this block will be for me when I was describing a heart beat to my intern on OB/GYN as "lub, dub, SQUEAK! lub, dub, SQUEAK!" These hours will be well spent.
• Wednesday - in the mornings I am in outpatient Internal Medicine, and then we will all congregate in the lecture hall for afternoon didactic sessions. We will have lecturers from all the specialties, starting with Internal Medicine, Emergency Medicine, and Pediatrics this October. Other didactics are interspersed throughout the week, sometimes occurring immediately before or after a morning or afternoon clinic day. For example, I know that on Fridays I will be having Psychiatry group learning sessions before my afternoon shift. We also have Radiology lectures on Friday mornings at 7am, and Master Clinician Series teachings once a month. Two weeks out of the year we will drop everything and spend the entire week in Inpatient Medicine. This allows us to see what IM is like in the hospital, and care for patients on the floor and in the ICU.
• Thursday - Pediatrics in the morning and Neurology in the afternoon. Again, these follow a similar teaching style and development of continuity of care. For Pediatrics, I believe we are spending 6 months in a primary care clinic and 3 months in "specialty" Pediatrics (Cardiology, Neurology, etc.). And just like with Internal Medicine, we will take 2 weeks out of our schedule to spend a week in Inpatient Pediatrics, continuing to develop our inpatient skills.
• Friday - I will spend each afternoon in outpatient Psychiatry. As I understand it, the patients are aware that students will be part of their care on Mondays and Fridays. We are also extremely lucky to work in Adolescent Psychiatry later in the year.
• Weekends - about 3x per month we work 5 hour shifts in Emergency Medicine. Typically these are scheduled on the weekends, but a number are scheduled throughout the week. There will be a lot of time dedicated to skills development and emergency management. This year we will get academic credit for our work in the ED, which is a huge bonus because it gives us an extra 4 weeks of flexibility as fourth years.
• Free Blocks - as you may have noticed, there are typically 2-3 free mornings/afternoons a week. These are used to hone our skills in other clinics and to read about our patients. Also, as we begin to pick up continuity of care patients, we will follow them to their other appointments and procedures. We will also be rounding on these patients in the hospital in the mornings if any of them are sick enough to need inpatient care. Otherwise we can use free blocs to beef up our knowledge in other specialties. I am looking forward to spending more time on Trauma Surgery and additional sessions in Radiology, just to start. As I begin to see where my weaknesses are, I can fill in some of the gaps. For example, if I realize that my eye exam knowledge is lacking, I can spend a day in Ophthalmology. So these free blocks will fill up quickly!
• Group Meetings / Ethics Discussions - interspersed throughout the weeks we will continue to have group meetings and discuss ethics cases. As you can see, while there is free time each week, there is also a ton going on. Apparently, past classes have experienced the highest levels of internal stress in October, as they tried to figure out where to be, what to study, and how to start assimilating massive amounts of information. I'm sure our group will be no different.

Whew. Basically we were told by last year's group to check our Google calendar every morning so we know where we are supposed to be. Things can change on a moment's notice. So, actually I think my initial explanation of the longitudinal model was indeed correct. Instead of doing all eight clerkships in separate 4-8 week blocks, we do them all together at the same time. Plus...


For a video presentation on the program, see our YouTube video here!

Oral Boards and Night Float

Every clerkship has something "special" to look forward to... and by "special" I mean something scary. It's those little things that the prior classes tell stories about; infamous tales of medical student drudgery and potential maltreatment. Some are true, more are not. For Surgery it is the tales of the long hours and the perpetual berating by attendings...

Hey, medical student. What is the difference between dog crap and a medical student?
I don't know.
You don't go out of your way to step on dog crap... (insert hearty laughter). Also, dog crap does not say "thank you" after you step on it.
Wow, I am having a great time here! Thank you! I wish you would tell me that joke 4 to 5 times per day.

No, that wasn't from an actual encounter, but these jokes make for good YouTube videos (Med Student vs. General Surgery). I personally didn't hear any crass jabs thrown my way, but I certainly wish I would have. And why not? My parents tell me they walked to school barefoot in the snow as children, uphill both ways. I have to at least be able to tell my kids that I got a little hazing down the road.

Obstetrics and Gynecology is no different. I heard plenty about the torturous hours on Gyn-Onc and spillage of bodily fluids (although no one fully warned me about the placenta...). But for us here in Asheville, we had two new gauntlets to look forward to: the oral boards and a week of night float.

First, the oral exam. Standardized tests you can BS. You can study how the questions are asked, and sometimes even know exactly which questions are going to be asked. Two or three answers can generally be eliminated before even fully looking at the question stem. It is possible to do very well on these exams, even with a knowledge base that is just so-so. Not the case with an oral test. This is where the attending truly finds out if you know what you're talking about. You can't "recognize" the answer from five choices in front of you. You either know it or you don't. That's why I have to respect this type of test. No bullshitting.

The one thing I was warned about before the exam began was that my preceptor has a perfect poker face. Whether you're right or wrong, you're gonna get nothing from her. So be confident, and keep answering questions until you can't anymore. And eventually that will happen, and that's the point. Every trail of questioning will lead to something you can't answer. That's why everyone thinks they do poorly on the exam, because you only remember the wrong choices you make, not the right ones. So when we got to the review portion of the exam, I thought I had been toasted... although we all did just fine.

Second tribulation, night float. One of the weeks on OB/GYN is completely nocturnal. Starting from Sunday night at 5:45pm, we worked 5 straight 14 hour night shifts. Rounding with the AM team first, we then picked up the patients for the evening through early morn. The service seemed to be a bit quieter, especially since there were fewer staff and no scheduled surgeries, but anything can happen at night. Anything. The random patient that was told to go to the hospital at 1400 for labor will show up at two in the morning, water broken and baby halfway out. As an added bonus, our last night (or "day") finished with 4 hours of lecture from 8am to 12pm. The only positive from this is that it kept me awake long enough so I could flip back to a "normal" human schedule. Even then, I went to bed at 3pm, woke up at midnight, and started reading for my 12 hour day shift that Saturday. It's like switching time zones. This is what I signed up for though, so I better get used to it.

A couple keys to surviving this... first, black out the room. Per Blake Pemberton's suggestion, I taped multiple black garbage bags to the windows to make my bedroom pitch black. It was a cave. There was no way to tell the sun was shining so brightly just outside. I also changed my clock so the "AM/PM" button didn't light up. That way when I went to bed at around 9am, I thought it could have been 9pm. When I woke up at 5pm, I might as well have been waking up at 5am like I did on Gyn-Onc or Labor and Delivery. Tricking your mind is crucial. Blake even suggested that sunglasses should be worn each morning on your drive home. Don't let your eyes see the light!

Night float was actually quite a bit of fun though. I got to do more at night than any regular shift (and I got my first birth! See The Miracle of Life). And every morning after breakfast we watched the sun slowly rise above the Asheville skyline during rounds...

Which makes it all worth it.

The Miracle of Life

9:51pm. It all started with a high-five. I would have preferred the classic 8 mile Eminem opening scene: I can hear the crowd in the other room as I retch over the bathroom sink; I look up at myself in the dirty mirror, breathing heavy and wiping the vomitus off my chapped lips. Lose yourself in the moment, you own it... However, beggars can't be choosers, and this is my first baby. Well, not mine, obviously. This is my first delivery. Legs spread across stirrups; baby crowning in front of my eyes. I had practiced over and over on the "fake baby, fake pelvis" at the rounding table. Left hand, perineal support. Right hand, two fingers on baby's occiput. Control the head. Pushing slows. Use both hands to guide the head, fingers point in the direction of the baby's mouth. Check for a nuchal. Birth the anterior shoulder. Grab the neck with superior hand and control. Pull up and out to deliver posterior shoulder, supporting the arms from arbitrary extension. Deliver the lower extremities. CATCH and HOLD. Untangle the cord. Turn. Present to mother. Clamp the cord. I knew the progression; I just hoped the birth would be easy and slow. These multiparous women can pop out an infant quick. Perineal support. Two fingers on occiput. Control the... "Robert! Let's go birth a baby. You can do this (insert noise of proverbial high-five slap here); I'll coach you through." We enter 391 quickly, disinfecting our hands in stride, pushing through the wide swinging door. This will all go just fine, as long as I don't drop the baby...

9:52pm. Knock, knock. "Robert, go ahead and gown up. What's your glove size?" I put on the face shield first, careful to make sure the clear plastic is miles from my face. Can't birth a baby if you diaphorese (is that a word?), or sweat all over your view. Gown next, then gloves. This is where I put on a show for everyone in the room. Ever seen a med student try to put on a pair of latex in the usual sterile fashion? It's like watching your seven year old kid try to ride a bike for the first time. Do you just let her fall over and over again? It's like putting socks over your hands and then trying to put on a pair of mittens in minus 40 degree weather, barefoot. Cut me some slack. It doesn't help that I have a mother screaming on the other side of the room as I continue my awkward display of incompetence. The little one waited 38 weeks; it can wait another minute and a half. I say a little prayer. Please God, whatever happens, don't let me drop this baby. That's what happened to me, and see how I turned out?

9:53pm. I'm still fumbling with these damn gloves. Where's the scrub tech when you need him?! "Robert! Hurry up!" Just a minute dammit. I'm going to need my gloves on if I'm going to keep from dropping this baby!

9:54pm. By now I'm standing in front of the mom. She's got her legs in the stirrups, and her pelvis is at my knee level. Ergonomically, at 6'5", this is a problem, but I'm used to it. The med student doesn't make the rules, nor does he or she set the table height. So if I D.F.O. ("done fall out"), then I get to blame it on back spasms. I lean over the introitus and begin the progression. Left hand gives perineal support, right index and middle finger control the baby's head. My coach "J" is on my right; Chief stands approvingly at stage left. It's my first birth; anything and everything can go wrong. We already know that the baby is head down via ultrasound, but the rest is completely unpredictable. Who knows, maybe the baby is reaching for the light and a hand will pop out first. Maybe the baby was doing crunches to work on its abs in utero, and the feet will present next after the head. What if the umbilical cord is wrapped five times around the baby's neck? What if there are twins? Or triplets?? And what if I drop this damn baby on its head?!

9:55pm. This is when all hell breaks loose and the shit hits the fan (NB: although defecation is a common occurrence during delivery, no "shit" hit the fan during this delivery). I have my two fingers controlling the head, and then out of nowhere the baby starts shooting out of the mom's vagina. Doesn't it know this is my first time?! Four hands come flying in. I try to get my hands in place to grab the neck, but I had forgotten to check for a nuchal. My coach gets her fingers in first. The umbilical cord isn't wrapped around the baby's neck, but I have no time to switch my hands to deliver the anterior shoulder. "STOP PUSHING!" Any more pushing and this baby is going by using my chest as a backboard. Bank shot! At least thirty fingers are now controlling its progression. I finally get my right hand firmly around the nape of its neck, my left arm rigid beneath this miracle of life. Okay, so this delivery has not been perfect so far, but I WILL NOT DROP THIS BABY. In any case, there are now two pairs of mitts lurking underneath mine, spotting expectantly. All are ready to catch if the med student turns into Mr. Butterfingers. Abdomen, thighs, knees, toes: the entire lower half of this kid slips out in half a second. And there I am in my moment of glory, the moment of truth. The baby has left its warm, comfortable habitat, and entered the real world in majestic fashion: through the vagina and into the arms of a novice, as nature intended. My eyes narrow because I realize now is the time for utmost concentration. If this baby gets dropped, now is when that would happen.

9:56pm. The cord is untangled, and I'm ready to present the infant to its mother. "NOO! HOLD ON!!" I am a little over-exuberant I guess. The cord isn't long enough yet, so my coach leans in to gently lengthen it in order to prevent avulsion from its owner. "Now, you're ready. Go ahead." I spin the baby carefully in my arms and rest its body on mom. Smiles and grins all around. "It was worth all that work, huh?" Internally, I think this question should be directed to mom and me both, but I realize attention has shifted to the new addition to the room. The cord is clamped and cut; the baby cries as fluid is sunctioned from its newly opened lungs. All is right in the world. I rest in my moment of satisfaction. Mainly because I didn't drop the baby!

9:57pm. I stand and watch. At least one minute is dedicated to joy of birth instead of the science of delivery.

9:58pm. "Alright, Robert. Go ahead and deliver the placenta." My reflection is cut short as I realize that after the birth is the afterbirth. I start at the beginning with a gentle fundal massage. A familiar thought creeps into my consciousness... whatever you do, Robert. Don't drop the placenta.

Ode to the Placenta

Placenta, oh Placenta! Why are you so vile?
I cannot believe you follow the birth of a child.
It's the miracle of life, a baby is born!
And then you too must pass, from uterus torn.
It's such a wondrous event, as child enters the world,
Mothers weep, fathers cheer! for their new boy or girl.
Yet when baby breathes its first breath in the hospital ward,
It is still not rid of you, attached firmly by cord.

I stand in front of mother, offering a hand of support,
I checked in every 2 hours, building a strong rapport.
Then when the time came, I put on my gown and my glove,
A mask on my face to protect from splashes of love.
Push! we yell to mom as the contractions come quicker,
Push! Push! through the crowning, the head's getting bigger!
I put an arm underneath, and secure the nape of his neck,
While dad passes out and mom's screaming like heck.

Oh my God! It's a boy! Congrats all around!
The baby is out of his sac and on solid ground.
The family rejoices, they've waited 9 months for a son,
But while they cheer on, I am nowhere near done.
Even after the baby is out, and the cord has been cut,
I stand between her legs, til the placenta's unstuck.
I tug and I tug, gently pull and then twist,
Throw it all in a bucket, unless membranes persist.

And as you lie there amorphous in a bucket of steel,
A little sick to my stomach is how you make me feel.
An organ of tissue, all gooey and gross,
All grimy and oozy, all slippery and morose.
In some cultures you're eaten, in others you're buried,
For me it's bad enough that in my hands you are carried.
I'm usually not squeamish, but I loathe you and your stroma,
I think the only thing worser is the mature teratoma (yuck!).

So Placenta, Oh Placenta! You're so gross that just maybe,
Next time I'll quickly unscrub, status post birth of the baby...