An impromptu lesson in the finer details of suturing at the end of a case brought back memories of childhood violin lessons in which my violin teacher would explain the finer mechanisms of producing a spiccato. “Relax your wrist,” he would say while demonstrating. I would go home and practice the same bowing technique hundreds to thousands of times, gradually taking incremental steps towards improving the technique until eventually, it became second nature.
In some ways, it was an odd payoff. I would spend months, equating to thousands of minutes, practicing the same musical piece for a single 10-minute performance at a recital. Yet, there was immense satisfaction at the end. I imagine surgery is much the same. Surgeons too take time to develop, which might explain why there is a sense of order and hierarchy innate to surgery. Experience and effort matters. I find the order and structure calming.
Someone asked me recently whether it was tough making it through a Whipple procedure, a notoriously long surgical procedure used to treat pancreatic cancer. I was somewhat caught off-guard by the question as I had never really considered the issue. The act of actively participating in the case made time pass faster than the clock on the wall would suggest. The field of surgery is not for everyone, but for those who do love it, it has an irresistible draw.
Relaxing after shelf exam at Tomukun Korean BBQ
The third year of medical school is a truly unique experience in which students get to sample a variety of medical specialties. While on service, I often like to ask residents and attendings why they have chosen a certain specialty. It can be incredibly informative. I asked my resident how he knew surgery was the right choice, expecting to hear that he had known from the very start that he wanted to be a surgeon. I was surprised by his answer.
His journey into medicine began innocuously enough, he explained. He had studied economics in college and while completing a summer internship discovered that it was not for him. Coincidentally, his roommates who were both pre-meds recommended shadowing a surgeon. On a whim, he decided to check it out. Even 10 years later, he vividly recalled his first encounter with Dr. X. While he had no idea what the surgery was about, he loved how simple the explanation for the heart worked. I listened enthralled as he described the technical intricacies of fixing a child’s aortic valve. As he talked passionately about how this experience led him to think that at age 40, he wanted to be like Dr. X, and I couldn’t help but to think that in 5 years I wanted to be like him.
Surgery is a paradox in some ways. Despite requiring more years of training and working longer hours than most specialties, I’ve yet to have seen people more passionate about the work they do. If you ask a surgeon about why they chose surgery, they will tell you that there was no other option for them – that nothing else would satisfy them. Perhaps this makes sense. It requires intense study and practice!
“Don’t contaminate the surgical field,” I repeatedly thought to myself as I entered the OR. Over the first 3 weeks of my surgery clerkship, I had made more than a handful of mistakes. The first day, I forgot to take off my watch prior to putting on gloves to place a Foley catheter. The second day, the patient bed brushed the corner of the scrub nurse’s blue sterile table as I was wheeling it out of the OR. The third day, I cut too close to the end of the surgeon’s knot – thus undoing his work. Day 4, I touched the handle of the surgical lights with my sterile gloves and so the list goes on. Throughout the clerkship, I made a list of all the mistakes I’ve made, partly to remind me not to make the same mistake again since as Confucius would say, “a man who has committed a mistake and doesn’t correct it is committing another mistake.” But it also serves to document how far I’ve come within even the year and even a month. On a day to day basis, I am constantly humbled by how much more there is to learn. As with many activities, the more I learn, the less I realize I know.
One of the many corridors in the hospital early in the morning
The smooth confident motion in which I saw the attending and surgery resident swiftly tie the knot with seemingly minimal effort belied the amount of technique that goes into the motion. I quickly learned this when towards the end of the case, my resident handed me a suture.
“Do you know how to tie a subcutaneous stitch?” he asked me. During my first two years, I had attended multiple suturing sessions and had practiced with pig feet. I felt reasonably confident. “Yes,” I concisely told him. I soon learned that there is a skill in doing this.
“Turn your wrist more,” he admonished. I rotated my wrist.
“Pinch less skin with your forceps”, he told me, “that way you’re better able to see where you’re going.”
“You can’t come out where you grab the skin. Grab another piece”.
I struggled to perform these steps correctly. The resident was very nice about it. But it seemed as though I was doing every possible thing wrong. Ironically, I had tied a subcutaneous suture previously with another resident, during which I had received no commentary. Was it that my technique had gotten much worse over the past week? Or that the previous resident was too polite to comment? Or that he simply wanted to quickly finish closing the patient up after a long case? Or maybe it is that the farther we go in our training, the more confident we feel in teaching others. It’s hard to know exactly why.
Finishing the day, heading home
A view of the hospital on the walk back to my apartment
I have however found that good feedback can be hard to come by. Feedback that is both specific and actionable is rare. This is often due to limitations in time as, understandably, patient care takes priority. Furthermore, giving good feedback can be difficult too in itself. Prior to entering medical school, I had taught as a high school teacher and found while grading chemistry lab reports that it can be incredibly difficult to give constructive feedback. While one can often see that something is wrong, it takes a more thorough understanding of all the finer details of a process to be able to explain not only “what” is wrong, but also “how” and “why” it is wrong. So when a resident, nurse, attending, or even fellow medical students are able to give useful feedback especially things that I’m doing wrong, I am incredibly grateful. I will always bear in mind the feedback and things I’ve learned here as I continue this journey!
Lecture hall at 8:30 a.m.
The idea of attending lectures is becoming more and more of a thing of yesteryear with the advent of technology. Medical faculty often marvel at how rarely one takes notes by hand anymore or how textbooks are now often electronic. On any given lecture day, anywhere from 10 to 30 students are sitting in the lecture hall at 8:30 a.m. (generally less on snowy days or right before long holiday weekends like Labor Day).
UMMS affords students flexibility in deciding how they like to learn lecture material whether in class or online. All class lectures are recorded and are posted only minutes after the lecture, making it easy to watch lecture content from the comfort of one’s home, library, coffee shop, or even bed! Students even have access to prior year’s lectures, making it possible to watch all the lectures before the first day of school (for all the over-achievers out there). I will point out though that on several days of the week, we also have interactive group sessions usually in the afternoons that require attendance and are not recorded (doctoring, paths of excellence, patient presentations, small group discussions, initial clinical experiences).
While certain portions of the curriculum are mandatory attendance, lecture attendance is usually optional. As someone who both streams and attends lecture, there is something to be said for going to class. Here are a few things I like about it:
- You get to see people in your class – with most of the classes being optional in the M2 year and with more individual standardized patient experiences for doctoring rather than whole group discussions, it is possible to be a complete hermit and go weeks without seeing classmates.
- You are forced to watch and hear things at a normal speed – I have a tendency when streaming to want to watch videos at 1.4 or 2x faster only later realizing that I didn’t catch what was being said at all. For example, just last week we learned about PAH (pulmonary arterial hypertension) and PH (pulmonary hypertension), which sound surprisingly alike especially when watching at a faster speed. However, in class, I can just turn around and ask, “What did he just say?”
- You get to laugh at the professor’s humorous remarks along with your class-going friends. Sequences later, you’ll reminisce and say “remember that time professor X said ...” These often just don’t translate as well when listening – especially when watching the video at 2x speeds. Some of my favorite recent comments by professors in class,
- On lecturing: “More glad than usual to be here [lecturing]. I’ve bored myself to death over the last 24 hrs playing Angry Birds and watching South Park episodes after episodes after episodes”
- On streamers: I’ve been talking this whole time to you on the recording. Now I learn that you are watching this like Sunday morning after the football game… So I’m going to stop speaking to you like you’re presently listening.”
- On lecturing for the second hour in a row: “I’m tired of listening to myself so I’m going to get the enthusiasm up here. I’m going to be James Earl Jones, I’m going to be Jim Harbaugh…and we’re going to talk about … lungs.”
- You automatically block off time on your schedule for lectures. With there being so many events and cool things to do in medical school, it is often easy to delay watching lectures and become wrapped up with things like research, shadowing, or extracurricular and with quiz-free weekends, it becomes all the more important to keep up with the material. Going to lecture helps me from getting behind on content.
Nonetheless, I appreciate the flexibility of streaming too. On any given week, I will go to class half the time and stream the other half. Sometimes I even pick and choose which lectures I want to go to. I can’t seem to quite make up my mind on which I like more so, in the meantime, I will just enjoy the freedom of being able to choose!
This week in doctoring, we talk about breaking bad news. How to tell someone that his or her loved one is dying or is dead. We hear heartbreaking stories from parents of dead children, of organ donors, and of heroes. Their sorrow seems so palpable and fresh despite the years that have passed that we can’t help but listen transfixed, rooted in their stories. On the other hand, we also hear uplifting tales from organ recipients, from doctors who are also patients, and from people whose lives have been saved and irrevocably changed. Never has the line between the finality of death and fragility of life seemed so close.
On a Tuesday afternoon, the ER is packed. Our clinical reasoning elective mentor is busy with getting caught up as he is just starting his shift so we ask the attending signing off if there are any cases that would be good to visit. “There’s a burn patient coming in. You should definitely see that,” she tells us. I watch the bustle of the resuscitation bay of the main ER as paramedics cart the patient in.
I don’t know who he is, how old he is, or even what his name is. But his body is covered in burns. Even watching from afar, I see that his skin is an angry red, sloughing off in chunks. I’m no expert, but it looks bad. “His burn surface area is 45%, which we estimate using a 9 by 9 by 9 rule”, an off-duty attending explains to me. I can’t imagine what that must feel like. I hope he’s not awake I think to myself.
“We found him rolled up in a blanket and he was covered in burns,” the paramedic explains. “There was a bonfire outside. It smelled like kerosene.” The room is crowded with lots of people in multi-colored scrubs. Everyone is talking. Space is limited. Who is in charge I wonder? And even more people come in.
I watch the screens beep as the patient’s HR increases. The resident is intubating the patient to secure the airway. The screen then beeps with alarms and I feel as though time has stopped as the patient’s heart rate drops to asystole. The resident immediately starts chest compressions. It happens so quickly that I barely have time to blink. Someone else (maybe an attending?) switches over to do compressions too. Perhaps it is only then that I realize that death is a possibility. “We need more people to do chest compressions – med students.” All of a sudden, I am no longer just a spectator.
Empty room in the ER
“I have a pulse,” the resident calls out before we can even find gloves, which are difficult to find when you actually need them. I don’t think I’ve ever been as relieved. He’ll be okay, won’t he?
It’s strange I know, but I always think of death occurring elsewhere. The patient with ovarian cancer or the patient with heart failure who is at the end of line treatments. Yes I’ve met them, but they’re alive when I see them you see.
Eventually I imagine I will have to face death and perhaps my own limitations. It is a frightening concept, but a very real and universal part of doctoring – or so I’m told. But, at least not today. I don’t know what his end outcome will be. No doubt his path to recovery will not be easy. Life and death are held in a delicate balance.
Nonetheless, he’s alive. And for that I’m thankful.
*** The details mentioned in this post have been modified to protect patient confidentiality.***
I’ve been in medical school for 11 months and 15 days. For the past couple of months, I’ve found fewer and fewer things shock me. I’d like to think it’s a good thing—I’ve become acclimated to the medical community and a quarter of a way closer to becoming a physician. But mainly it seems as if I’ve just become more desensitized.
During the first few months of medical school, everything seems novel and eye-opening. It’s not about the practice of medicine per say – everyone probably has done a fair amount of shadowing prior to entering medical school. It’s more about the fact that you’re embarking on a journey in which you become responsible for the lives of someone else. There’s something magical in that.
As such, many things take on new meaning when I started medical school. When talking to a patient, I wasn’t just talking to a patient, but to someone who could someday be someone like my patient. A HPI became not just a series of meaningless random questions, but a systemic process that would help me reach a diagnosis. Patient panels were more riveting than an episode of Game of Thrones. And then of course, there was anatomy.
Admiring peonies in bloom at Nichols Arboretum
There are few things as defining about medical school as anatomy. It seemed like all along the interview trail, medical schools were showing anatomy labs as part of their campus tours – although I never really understood why. But looking back over the year, even though I’ve long forgotten what happened during our 2 weeks of orientation or details of our doctoring sessions, I still distinctly remember the first time we walked into the anatomy lab and looked at the face of our donor.
As I made the first cut into the back of our cadaver, there was a deep sense of awe and also a bit of fear too. What we were doing did not seem natural – it felt as if I was breaking some unspoken rule of the universe – I couldn’t help but see a face to my donor. Even though the feeling faded over time, I still remember feeling a faint sense of unease throughout the first half of the year. But somewhere along the way, instead of being novel, a lot of things became the new normal.
It isn’t the first time for me where things once novel became “normal” or part of a routine. After I graduated college, I joined Teach For America (TFA). My first few months teaching were utter chaos – I had students throwing water bottles at each other and totally ignoring me during the lesson. It was dark outside when I got up and equally dark when I got back to write my lesson plans for the next day. While I didn’t necessarily mind the long hours, the sense of feeling completely out of my comfort zone and that I was making little difference was difficult. But as the weeks went by, even the utter chaos that was my classroom became normal in that I could almost no longer perceive the destructive patterns. Sometimes looking back, I wonder how something so crazy could have ever become “normal”?
Perhaps it is a coping mechanism that allows us to see things once shocking as normal – at least that is what we often thought in TFA. It could be also why we are able to dissect the face at the end of the year in anatomy when even looking at the cadaver in the beginning of the year fazed so many of us.
Enjoying a relaxing Saturday morning at Juicy Kitchen
But what do you do when the “newness” of something wears off? Is the feeling of things being “normal” even justified? For me, in teaching, it was clearly a no. It was wrong that I had come to see a dysfunctional classroom as typical. But it took me the summer when I finally had time to take a seat back and contemplate the year as a whole to figure that out. When I started my second year of teaching while I might not have been as green or untried as I was in my first year, I was still just as ready for an adventure and able to recapture some of the feeling of novelty to teaching that had seemed to fade towards the end of my first year. While I think some amount of acclimation and acceptance is helpful – it helps me do things I would otherwise be too paralyzed in fear to do, some amount of everlasting feeling of newness is needed too to keep me on my toes. I’d like to take this summer to recapture some of the magic so to say.