This thing I refer to as My Life

Cross-post: This will likely be my last cross-post from the U. Michigan blog. I will certainly keep blogging here, but they will only be here like in the good old days and they will likely be a bit more personal.

In fact, here's something personal: today I decided to fight against all of the trucks and SUVs that are blinding me at night! I put tint on the side-view mirrors on both cars! It's an idea I got from my old 5-series BMW as it had factory tinted side-view mirrors and it really helped a lot. Putting on the tint myself was certainly a learning experience and I did get better as I went along. (I did the Sebring first and did the driver's side twice since I did not like the first attempt.) The Suby looks great and the Sebring is good enough for jazz. I'll let you know how I like it when I go out at night again. Now I just have to remember to only use soapy water to clean the side-views as ammonia will kill the tint!

Okay, here's the last U. Mich blog cross-post:
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A Dirty Little Rumore!...and more...

05/21/07

I'll start with the...and more part: I don't care what anyone says but graduation is mostly a sad time. Yes, it's great to get a degree and have all of your family around but it is also the day where you are going to lose many of your friends. These are people that you have counted on when the chips were down, when you wanted to go out and have fun, when you did not understand how to deal with a situation. You're saying goodbye to people you've experienced events that you will never experience with another person in the same way. There are ways that we will keep in touch, but, at least with my group of friends, we are going to be scattered across the country. That makes it a sad occasion and while I've experienced it a few times before, it does not seem to get easier: quite the opposite.

Since I did not offer/ask anyone to e-mail me, I have absolutely no idea who or how many people actually read this thing. Well, I know that a few of my friends to read this when they're bored. I have no idea why?! They have to suffer with my stories live-and-in person. I hope it has provided some insight into the more interesting and meaningful events in the process of medical school. Certainly, I left out many days of "the grind" and I hope that was understood. I also left out much of my whining about the process because no one wants to hear it, let alone read it! Those of you who choose this path, I wish you the best. Remember to reflect on the positive days and events and learn from (and then forget) the bad days. Take nothing personally because very few people who will have control over your life will actually take time to get to know you. Those that do, hang on to them. Praise them. Cherish them. Try to become like them.

Enough of the drivel: It's time for Deep House Dish!

This was too hot of an observation to just let it slide. All I will tell you about the source of this observation is that it does not come from a student. The observation has been made to me that AOA-honors are not given to all of the students at UofM medical school who meet the eligibility.

Point-Counterpoint

So, that person that wanted to post an anonymous blog earlier, that never did, finally was inspired to come up with a posting for him-/her-self. This is his/her take on grading:

"post anonymously, please :p

In my experience, I found that clinical grades matter more than the standardized test and other grade-determining assignments. For instance, in Family Medicine, I had all average to slightly above average evaluations, with one subpar evaluation from an attending that I didn't get along with (unfortunately it does happen, and you may find that a good part of your grade can have to do with personality). However, I got the highest grade in my cohort on the standardized exam and a high pass on the case study paper that factored into our grade. My final grade for the clerkship was still a pass - clearly determined by the evaluations and not the objective exam.

Something similar happened fourth year as well, when very average clerkship evaluations combined with a 98 on the final exam to produce a pass. Of course, by that time I had already matched, so I didn't quite care as much...

All that being said of course, now that we've graduated, I can say - grades are kind of ridiculous. Much of it has to do with whether or not your personality meshes with your team and your attendings. Obviously, social skills and human decency are a prerequisite for anything, but as you said in an earlier post, your relationship and experience in a certain field can not only determine your grade, but also what field you decide to pursue. After my not-so-perfect experience on the Family clerkship, I had no plans whatsoever to pursue it as a career, which is somewhat ironic as it perfectly meshes with my interests and personality. So you never really know who or what can help to shape your future. Be nice to those who plan your schedule!

For the final comment regarding grades are ridiculous - they are also very necessary to determine that we know what we need to. After all, in a month, we will be the doctor, not the student, and we will be forced to make the decisions at 3am. Like Elliott, I also stayed late to talk to the patients - because unlike the grades, they are what we truly got into medicine for. As a student, you are the only one on the team with enough time to actually spend just talking with people, not always about medicine, but being a sounding board while they are in a scary place during a very scary time in their lives. If your goal in life is to get the best grade while putting in the miminum effort, you're going into the wrong field. It not only really aggravates your fellow team-members (who do know, they're pretty smart), but you're also fooling yourself because medicine is about putting others first - embrace it, because you're going to spend a lot of time, sleepless nights, and energy making that statement a reality.

And now that I've started rambling, I'll end this. I'm just not as prolific a writer as Elliott. But I have better hair."

Final Dirty Little Secret!

Look for the rumor in a few days...

Let me bring up something I see as a system problem within this and across many other fine medical institutions: grading. The current system is totally ass-backwards and it just needs to be fixed!

I have seen this in other aspects of medicine where the community takes a disease that exists on a spectrum and tries to give it discrete cut-off's, such as high blood pressure, and visa-versa. Medical school grading has, unfortunately, fallen victim to these same problems.

The first two years of medical school are much like another educational experience. You are provided with lectures and reading material and you are periodically given exams to assess your level of familiarity and competence with the material. The exams are reasonable objective and lend themselves well to object grading. However! The administration has decided to grade these years as pass/fail to help reduce some of the stress that students tend to self-impose through competition. I am not so sure that I really care one way or the other and I do not think it really makes any difference to the students. They still know how many and which questions they answered incorrectly and so they are still going to pursue higher grades either by challenging the questions and/or reviewing the material. In general I think the mistake is to assume that the competition is between students. I think it is more likely that the competition is within the student him or herself and there is no way to change that without hiding the answer key. Which, I think, would be a bad idea.

However, what you find here is that the clinical years (M3 and M4) are still graded: honors, high pass, pass and fail. The dirty little secrete (or lie, as I like to call it) is that your clinical years are graded mostly on your clinical performance: how you work as a team, how well you take care of your patients and a small portion of your grade is based on that rotation's shelf exam (or paper or oral exam). Since these years are like an apprenticeship, you also receive clinical comments on your performance. But, that's not exactly how it works.

As far as grades go, your clinical comments do almost nothing to help elevate your grade. It, unfortunately, does not matter toward your grade how much time you spend taking care of patients nor how many "good" things you do on the floor and for the team. If you completely mess up, however, I believe that your clinical performance can bring your grade down. As it turns out, most of your grade is determined by the self exam and not by your clinical performance at all. So, it behooves one to do the minimum clinical work to get average/normal comments and make your team satisfied and study every moment you can for the self exam.

Now, if the administration really wanted to step up to the plate, here is how I think it "should" be done: Grade the first two years, or not. It doesn't matter! The students will not significantly change their behavior. The third and fourth years (the clinical years) should be Pass/Fail and significantly more emphasis should be placed on the clinical comments. This does not mean do away with the shelf/oral exams, but rather just make passing the test part of the requirement for passing the rotation! In this paradigm, the students will have the incentive to do what needs to be done in these two years: learning to work as part of a team and providing excellent patient care. With respect to these goals, the current system is broken and no amount of patching is going to make it better. M3 and M4 are very subject years, so stop trying to place objective grades onto them and keep it purely subjective! (And, for the people that are responsible for assigning AOA: I say you will have to "Read, Read, Read!" those clinical comments and make your judgment based on that.)

But, if you want to get higher grades during your clinical years in the current system, here's what you want to do: 1) Do as many rotations at other hospitals as you can! UM attendings are notorious for giving their students lower grades and often for considerably more work and less teaching than the students that go to other hospitals.

2) Do not take medicine, surgery, pediatrics or OB as your first rotation. These are the core rotations and these grades are most important. More over, at least one attending I came across in medicine stated to us that she "does not ever recommend a student for honors in the first month because it is just too hard to tell." (I cannot even begin to tell you what is wrong with that statement because there are just not enough characters in the alphabet to deal with it!) Cut your teeth on one of the other "lesser" rotations. (No, I don't like saying "lesser" and I don't believe it should be that way, but this is how it works right now.)

3) Be enthusiastic when on the wards but don't do anything extra if it is not "visible" to the senior or attending; but do not piss off the interns. For instances, when there was down time during my medicine rotation (which I did first), I would go and check-up on my patients. I'd see how they were doing and if they needed anything and check up on their lab results. This, however, was invisible to the senior and attending and, since the interns don't grade the students (although they should because they have the most interactions with them!!), it did not help my grade. (Here, I was able to really fine-tune my patient interaction skills and I get nothing but praise from my patients, but that is not important to getting into a residency.) I should have been studying for the shelf exam. I should have been sitting in the conference room studying for the shelf so I could have receive a much higher score on an exam which is only supposed to be 10% of my grade but fully determines the grade in reality. Do enough work on the wards to get by and study the rest of the time, but study in front of someone if you are supposed to be in the hospital. That, unfortunately, is how to get the high grade. Pretty asinine, don't you think? (And, anyone that doesn't believe me is fooling themselves because having a superior become emotionally involved (if not more) with a student does occasionally happen! And they do not necessarily bow out of the grading process.)

4) Don't ask too many questions. Some doctors take questions better than others, but if you ask a question to someone that takes it as though you are attacking their knowledgebase you will be shooting yourself in the foot. And, after all, the more questions you ask the less time you will have to study for the shelf.

Now, do I believe the above advice makes you a better doctor? Heck no! That's why, once I figured it out I did not do buy into it. But, that also means I did not receive as high grades as I could have and I potentially limited my career. Of course, half of the year had gone by before I received my first M3 grade and I did not have anyone to enlighten me in this way so the cat was out of the bad, as it were.

Yippy!

Graduation is tomorrow!

No White Coat

Okay, here's another dirty little secret. I stopped wearing my short white coat fairly early on in my fourth year. It happened by accident one day but I noticed something: when I was not wearing it, everyone was nicer to me! (Well, save the couple of people mentioned in the story above.) I received about twice as many "hello's" in the elevators and people (I did not know) would ask me how my day was going. I don't think anyone did it intentionally; rather just that hospital employees would assume that I was "part of the team." Or, maybe it has to do with the stupid hierarchical system that seems to be pervasive in medicine. (By the way, I don't do hierarchy well, which may also play into that story above.)

Aside: That observation about hierarchy brings back a memory from my M3 cardiology. There was a patient who was a Ph.D. prof at the university and was making some requests to the residents. To be honest, I do not recall what the requests were about but I remember the attending talking about how "entitled" the patient was behaving. I, however, do not think many M.D.'s have any room to speak: Especially the one that was making this comment. Although, I suppose it takes one to know one. And that includes me!

Now, the interesting next step of the short white coat experience is to see if something similarly happens with long white coats. And, before anyone starts to say, "Well the length of the coat lets people and patients know who the doctor is!" I say that is a bunch of crap. I cannot even COUNT how many times I have been standing next to a younger female resident while talking to a patient and have all of the patients' responses addressed to me and the patient referring to the resident as the nurse! (Let me tell you, that is not a fun moment in a student's life!) I always introduce myself including my title to my patients and more of the nurses learn my name that way instead of just calling me "the student."

What do almost graduated medical students do when they have nothing else to do? They help me wash and wax my cars! Wow! Who could ask for a better friend? The best line was, "Oh. This isn't the kind of wax you just rinse off is it? I've never waxed a car this way before." To which I replied, Well then, you're really going to hate me very soon! Good thing you're are moving in a few weeks!"

Here are the pics of both cars freshly washed and waxed. Oh! And just after the Suby was done, a bird pooped on it. Good thing it was easy to clean off!

I decided that there are only two more dirty little secrets (well, outside of the admissions process), one important experience and one important rumor. I'll spread it out over a couple of days.

The reason the "important experience" is not a DLS is because it is mentioned at the start of the clinical years. I suppose I just did not believe exactly how large of an impact it can have: Your attitude about a specific area of medicine can be greatly influenced by the residents around you. During my M3 year, there was one rotation that I particularly enjoyed. In fact, the observation has been made by my spouse that it was my happiest month during my M3 year. I was surrounded by a great group of residents and the attendings were some of my favorites. They loved fielding questions, so long as the abdomen was not filling with blood, and they never took offence to my inquisitive nature--I cannot say that for many of the other clinical rotations. I really considered it as a career, but for a handful of personal reasons, I decided that it was not a realistic option. But, it is a nice place to visit so I decided to do one of my Sub-I's on the transplant surgery service. What I discovered was there were some significant personality conflicts with some of the residents and, what impressed me most, was just how much that affected the tenor of the month for me. If I were to take the second transplant rotation in isolation, I do not think I would have ever considered the field. Of course, the attendings were still great but I had less contact with them because I was "working the floor" with the interns. Now, to be clear, this was a two-way-street. There were things that I did that upset the residents (such as not wearing my short white coat--more on that in a moment) and situations they could have handled better (like telling me directly they were upset that I was not wearing said coat) as well as trying to make the residents understand that my job as a M4 Sub-I was different from their expectations of an M3 student. All of that mess aside, what was impressive was how much I was not "turned on" the second time around and I think that can and does happen to everyone. And, what is possibly worse is having a positive experience in a field and making the decision to go into that field, but never experiencing that positive environment again. That must be devastating. I think something similarly happened to me during my pediatrics month: the in-patient month was so intense and my first team was so negative and worn-out that it wiped out all of the positive experiences I had on my out-patient month. So take this experience to heart, if there is a field that you are really interested in pursing, make sure you get multiple exposures to it over several months with different people so as to not cloud your judgment. And, before anyone in the surgery department gets worried about the nature of this publicity, fear not! The surgery department as a whole (from my experiences) is a fine place and there will always be a part of me that is a transplant-surgeon-wannabe who actually enjoys being paged at 2 AM for a 3:30 AM liver transplant followed by a full day of elective kidney transplants only to have a procurement in the evening and a transplant the following night. There is no other experience like it! But, also, not a three day series I want to repeat for the rest of my life.

Labels: Part Deux