On four clerkships (or Third Year: a post-mortem)

Third year, what a trip.

When I finished Step One, I had no idea what laid ahead. The first two years of medical school kept me stuck in powerpoints and flashcards. The shooting provided great focus and perspective on what we might see in the hospital. On the other side of this clerkship crucible, I’m thankful for such a brutally stark introduction to life as a physician.

Internal Medicine

A strong start

I remember how the Step 2 CK board questions at the beginning of the year overwhelmed me. So many details, so difficult to sift through the huge paragraphs quickly, and it felt impossible to pick the right answer. Exactly how Internal Medicine felt.

So many labs and co-morbidities to manage in our Assessment & Plan. When one patient would get discharged home, we’d have to pick up another one and that felt like such a monumental task. Reading through the chart to find out what has been done in the past, interviewing the patient for pertinent information, physically examining them for signs of trouble, and then attempting to collate all this data into a single note and presentation for the attending and residents.

I grew so much as a clinician during these twelve weeks. I realized how little I learned in the first two years of medical school. I thought I had learned the basics of the language, when in fact I had only been introduced to the alphabet. I didn’t know the grammar to form a coherent differential or the colloquialisms that form the basis of inter-clinician communication.

Now, I might not be fluent, but at least I can pick up the gist.

A few highlights


A small glimpse into my future

“Can I endure a four year residency of this?”

I repeated this to myself, over and over again during these twelve weeks. I might not like certain aspects of current psychiatric practice or the culture surrounding the inpatient psych unit, but that wasn’t the point of this clerkship to me. I don’t have to like it, I just need to survive a residency so that I can practice the medicine to which I will devote my life.

Neurology posed a tempting mistress. I met some preceptors that gave me a small dose of responsibility and I liked the physical examination required to diagnose effectively as a neurologist. But would I want to complete a residency in it, and would I want to practice as a neurologist? The answer was no.

Psychiatrists and neurologists are a funny bunch. Very cerebral in different ways. With psychiatrists, I felt like I was always being analyzed. For what? I could not say. The magnifying glass never seemed to go away. From oddly deadpan humor to very reserved affects, my future colleagues will keep me on my toes.

A few highlights

Women’s Health/Pediatrics

Parental practice

This rotation terrified me.

From conception to birth, and from birth to adulthood, the path is fraught with peril. I now know how much can go wrong and exactly how wrong things can go. There are no guarantees and now my defense is to hold tight to the present and be thankful for what I have now.

The labor floor is an odd place. I remember once when three women gave birth within minutes of each other. There’s a power and magic in birth. I smile when I imagine my partner in one of those beds and myself standing awkwardly to the side as she struggles, holding her hand and offering encouragement. So much of the birth experience is universal, the image of the mother, father, and child together for the first time.

I also saw so many sniffly children. I met many frazzled parents. I realized that no one has parenthood figured out, that everyone is learning as they go and making up the rest. This gives me hope as a burgeoning father.

My time on the inpatient pediatric service was long and difficult. The hours sucked the life out of me. However, I did have many enriching experiences on the floor. I connected with some patients. I stepped up to responsibility and felt the time fly by as I helped manage the floor. Perhaps this was my best preview for residency.

A few highlights


A final hurdle

I remember during orientation to third year, the surgical clerkship director told us very directly that “we will see some crazy shit.”

He was correct.

I saw a complicated robotic surgery converted to open during the final moments as a tool malfunctioned. I saw brain surgery to remove a large tumor. I learned how to suture and a retired plastic surgeon complimented my hands.

So much of this clerkship served as a final checkbox. I’ll likely never step foot in an operating room again. I hope to never see another trauma alert. I’ll never again assist with a laparoscopic surgery.

I wanted to see more… but this feeling came from a voyeuristic tendency.

I wanted to see the gunshot wounds, the amputated limbs, the full-body burns. I didn’t want these things to happen to people. I just wanted to see the cases, devoid of the human toll. That’s the cost of a great surgical education: you take the information on someone else’s debit.

And maybe if I did see these things, I might feel differently about wanting to see them.

A few highlights

Looking back, I try to imagine what I would tell Eugene from one year ago, after the shooting but before that first day in clinic.

How could I have prepared him for the onslaught of information and emotions ahead? How could I tell him about the days where you wake up before dawn, walk into the hospital before sunrise, leave after sunset, go home to eat, shower, sleep, and repeat? How can you know until you endure these shifts for weeks on end?

Some of the rotations are easier than others. Sometimes you get home before 3p. Sometimes you can skip clinic because no one knows who you are or where you are supposed to be. Enjoy these lapses while you can.

The hard days don’t get easier, you just get better.

You’ll learn so much.

Some of that learning will be in the hospital. You’ll learn about diseases and differentials. You’ll learn how to navigate grouchy residents and irritable scrub nurses. You’ll figure out what attendings want from you and the next day you’ll guess wrong. You’ll catch something in the history or the physical exam that the rest of the team didn’t notice and you’ll feel on top of the world. And then you’ll be terrified to realize that no one else noticed and that medicine is made up of humans trying their best when they are hungry and stressed.

The rest of that learning will be out of the hospital, away from patients. You’ll cry and not want to leave your bed in the morning. You’ll call out sick when all you really need is some of mom’s cooking. You’ll find yourself having fun on a weekend and then feel a wave of guilt as you think about studying. You’ll miss plans with friends who want to see you.

And sometimes, you’ll feel like it is all worth it.

Long Form Sundays

On Death Podcast

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