God complexes and entitlement

So, I took a practice practical and practice written for anatomy yesterday. (The former was organized by the second years, the latter was in Gray's). Barely passed the practical and solidly flunked the written. Methinks today I will memorize the syllabus, which apparently is the key to success is anatomy.

My anatomy prof is a bit of a jerk -- ok, a serious jerk. In lab, there are a few professors who wander around helping us find structures. One of them, as he was digging out the sympathetic chain ganglia for us, gave us a beautiful explanation of the nervous system, which our actual professor can't teach for a million bucks. We asked if he could give a NS lecture to the class, and apparently Dr. Jerk won't let him because "students shouldn't have to seek outside help."

Going along with that, one of my classmates bumped into the doctor who did our radiology lectures, who was surprised to learn that there would be a radiology component to the anatomy exam. She offered to hold office hours Sunday morning for student questions. As I got dressed after the practice practical, I heard some of the other women in my class bitching that Dr. R. was having Sunday office hours. "Sunday morning. I want to sleep."

Well, so do I. I'm sure Dr. R. would rather sleep, or be with her family, or whatever. As far as I can tell, office hours are totally optional for professors here. Unlike in college, where they are required to hold a certain number of office hours (which they are paid for), here they do it on their own time. And so even though I value my rest, I also am incredibly grateful to any lecturer who is willing to reteach the material so that we understand it.

Most of my class is pretty cool. And I know we're all stressed and tired and cranky about these upcoming exams. But ingratitude like that just smacks of entitlement.

First exams are in about ten days. My study group met for the first time this afternoon and we tried to cover three weeks' worth of material in just a few hours. It was rough, but I think it was worthwhile. Much easier to study when there are others to talk through the slides with.

Tomorrow, we are going into the anatomy lab to look at various cadavers and aberrancies. Our anatomy exam is only on the thorax, but it's frightening to think how much material is contained in just that segment.

We start clerkships next week. It's not anything like 3rd year rotations: we just learn to interview patients under the guidance of a clinical care provider. We had a practice session today with patient-actors, and it was incredibly difficult.... Perhaps I was concentrating too hard on my body language, because I had trouble coming up with things to say. Whereas I'm sure that if I met this woman (or character, whatever) in a regular social context, without the white coat, I would find it much easier to establish rapport, etc.

On the fun side of things, I went to a wine tasting last night and learned all about Italian wines. It was sort of my last free night before I buckle down and study.

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Radiographic Anatomy

Here's what I did in lecture today: an artistic representation of a transverse section of the heart screaming, "Help, I'm trapped in the mediastinum!"

Radiology is not hard per se -- all you do is look at films all day -- but they are kind of throwing us into things without any real context. When Dr. R. pointed to haze and said "This is clearly the aortic arch," we all sort of giggled nervously. Even histo's clearer than this.

Other than difficulty with the chest X-rays and CT scans, life and classes are going well. I just got back from a weekend in the Catskills, chaperoning low-income city kids for an enrichment program run out of the children's hospital here. They learned team-building and I re-learned how much I enjoy working with kids and helping them understand the world around them. Around the campfire, I told them all about the stars -- they'd never seen stars before -- and Cassopeia and Orion and slaves running north with only the Big Dipper to guide them. They were fascinated, and I got an incredible rush from telling them something new and exciting. I think I'm going to get more involved with the program as the school year goes on.

Reflections on the first week

Now that my first official week of med school is over, let's look back at my courses.

For 2 hours every morning, we have an integrated basic science class, which thus far is basically one-week crash courses in biochem (last week) and cell bio (this week). I'm very very thankful that I've seen the material before, because it allows me to concentrate on ....

... Anatomy! Our first lecture, on Tuesday, was three hours long. No breaks to speak of. (I think we had five minutes while he was figuring out how to change powerpoints.) Lots of vocabulary. Thursday's lecture was a little better, because it was (1) coherent and (2) intellectually interesting. However, then we went into lab, which was a little rough. Although several of my older family members have died, I'd never seen a body that close up. Ours doesn't have a first name on her wristband, which means she was probably unclaimed. It's tough to console yourself with thoughts of honoring a person's dying wish, when you know that they are only there on the table by accident. Also, my grandfather, who died just over a year ago, donated his body to the medical school where he used to teach. My reaction to "Alba" (what I have named my group's cadaver) made me wonder about his body. Still, a friend later reminded me of Sydney Carton's last words -- "It is a far, far better thing I do than I have ever done." -- and I felt a bit better. This unknown person might be my most intimate teacher in medical school -- and that reminded me of Eklavya and Dronacharya.

On Thursday, a patient of one of our professors came in to talk to our entire class about her chronic illness, which was very touching. She's been through a great deal of pain and suffering -- it was difficult for her to hold the microphone up -- and yet she was in remarkable spirits. She even joked about some of the doctors who misdiagnosed her and told us that her inner strength comes from her hope that life will be better for the next generation of those with this horribly painful disease. I find that remarkably selfless, and it certainly puts into perspective my whining about having to study.

On Friday, we spent most of the day in our small groups, learning about what to do if someone collapses on the street. The basic gist was "don't do anything, but if you really want to, pretend to be MacGyver and improvise a splint out of the New York Times." It was kind of fun and pretty interactive -- and I did learn a lot about trauma cases -- but I'm not sure how useful it would be "in the field." Still, it wasn't a bad way to spend a Friday.

So far, at least, med school isn't THAT bad. Sure, I have to study 4-5 hours a day, every day, but it's intellectually interesting stuff, which makes all the difference in my opinion. I am also a nerd who doesn't ever go to bars. :) I'm sure it will get tougher as time goes on, but I still think it's the right decision.

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First day!

As first days go, this was among the best.

I woke up early with an adrenaline rush and watched the sun rise (or rather, the reflection of the sunrise; my room faces west). Made myself a proper breakfast and spent the morning running last-minute errands: getting my name pin fixed, picking up my anatomy book and white coat, things like that.

We only had class from 10-12 today, with a five-minute break between the lectures. It wasn't too difficult; they are starting off with college-level biochemistry, which I majored in. Aside from a very few numerical details, I had seen the material before. I guess that's why they say college biochem helps in med school. Granted, in one hour we covered about two weeks' worth of college material, but the familiarity helps get things settled.

In the afternoon I went grocery shopping to a new store. Had to hike through Harlem to get there, through an area that looked like the Jets and the Sharks were just around the corner, snapping their fingers and dancing like the extremely fey gang members they are. Definitely wouldn't want to go there at night, but the selection and cost was worth it.

I also cooked today! I'm very proud of myself, even if it was just and pasta. Cooking makes a nice break from studying. I think I'll be doing a lot of it.

And I just watched a beautiful crimson sunset over the Hudson as lights shone on the George Washington Bridge and a canoe paddled downriver. God, I love this place.

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Orientation Week

As Orientation winds down, I finally have a moment to stop and reflect on the past week. Since I moved in on Sunday, I've had a wonderful time. Can hardly believe I was afraid of this place, because the last week confirms that I did, in fact, make the right decision.

Mostly they've kept us busy exploring the city -- I've been to MoMA and The Lion King, both of which were fantastic -- and they've talked at us a great deal. We had a curriculum overview and an administrative overview and a safety overview and a financial aid overview and just about every other overview you could possibly think of. Also lots of free stuff -- mugs and pens and food. That last is most important, because we have neither a dining hall nor a kitchen.

Yesterday we broke into small groups and discussed the Hippocratic Oath. The version we'll be reading later today at our White Coat Ceremony was revised in 1928, so it's certainly more modern than swearing by Apollo, but it paints a very idealistic picture. (I guess that's kind of the point of the Hippocratic Oath....) The fourth-years who led the discussions told us a little about the reality of seeing patients and how the Oath can be ambiguous.

Some people in my class had trouble with the implication that we as future physicians are held to a higher moral standard than the rest of society. The Oath says, "my holding myself aloof from wrong, from corruption, from the tempting of others to vice," and one guy called it a "holier-than-thou" attitude. I don't think that's the case. Coming from the University, where Honor is queen (and Jefferson is king), I think that the Oath is just reminding us -- everyone -- that we should live ethically and honorably.

On a lighter note, a bunch of us were playing Taboo last night, and the clue was "When you pee, it comes out of this." My friend L immediately guessed "urethra." The word was "bladder," but we're such nerds.

I think I'm going to like it here.

Pre-moving jitters

A good friend of mine from high school got married this past weekend. At the reception, I met people I haven't talked to since high school graduation (and one guy I went to elementary school with). As recent college graduates, we all asked each other the same question.

"What are your plans for next year?"

I told everyone that I'm moving to New York in mid-August to start medical school and that I was very excited. I mean, it's New York City. It's on every tourist's must-see list; it has all these songs written about it; it's an absolutely unique place to be. No other city has more theaters, publishing houses, and academic institutions, not to mention an amazingly complex subway system that will ferry you hither and thither for just two bucks a ride. I want to be a part of all that. I want to be a New Yorker.

And at the same time, I'm terrified of the City.

I've never lived anywhere but a suburb and a college town. What if I can't stand city life? What if I get mugged? I don't know anyone in New York; what if I get lonely? What if I can't handle being so far from home? What if I fail anatomy, or worse still, realize that doctoring isn't for me? (*mentally adds "hobo" to list of backup plans*)

You know, once I write all those fears down, they seem kind of silly. I'll be ok. It's just a little bit frightening to go through all the stuff in my room -- the books and papers and clothes and trinkets of 22 years -- and decide what I'm taking with me and what stays behind. Except for a week's vacation at Christmas, I won't really be coming back here again. I think that's what scares me the most.

Going off to college was not such a big deal; it was just two hours away and I never really moved out. But towards the end (fourth year, especially), "home" stopped being my parents' lovely house in suburbia and became my little 11 x 13 room with the high ceiling and the two windows. The one night I spent in New York, at a second look weekend, I became incredibly homesick -- for my dorm.

I do insist that I made the right choice. The school where I'll be matriculating in less than a month (ahhh!) was the only place with which I really fell in love. My future classmates seem chill. It'll just be ... different. As Richard Curtis wrote in The Vicar of Dibley, there's good change, and there's bad change. ("There's the Changing of the Guard ... and then there's prawn-flavored crisps!")

I think the moral here is when in doubt, watch something written by Richard Curtis. Truly, the man's a genius.

Agency

Yesterday I read Better: A Surgeon's Notes on Performance, by Atul Gawande. It was an excellent book, especially after The Spirit Catches You and You Fall Down. Both address problems in healthcare, but whereas Spirit is anecdotal and a little touchy-feely, Better provides facts to back up its claims. Most importantly, Better focuses on how doctors and nurses can improve things. Mainly, it seems, by giving themselves agency.

Agency is a funny sort of word. I first heard it in my first semester of college, in a class about Shakespearean comedies. I think it was the lecture about Much Ado about Nothing (great play, fantastic movie starring Kenneth Branagh, Emma Thompson, and Denzel Washington). It refers to the power to effect change. So, Hero ("Leonato's short daughter") has no agency in the events of the play. Instead of, say, Merchant's Portia, who does things like cross-dress as a lawyer, Hero allows things to be done to her.

Literary digressions are fun!

But the main point is that agency, and a belief in one's own agency, is important. It underlies the ethical principle of autonomy. There's a lot of energy focused on the patient's autonomy, as there should be. For example, the Lees in Spirit lost autonomy in part because of their inability to communicate with the physicians. In many ways, the book is as much about their struggle to be subjects as it is about Lia's battle with epilepsy.

But there is also the autonomy of the physician. This seems to be gaining ground nowadays, with physician discontent with the insurance system in this country and with government/administrator involvement in how their practices are to be run. Better's kind of unique in that it addresses the autonomy of physicians, surgeons, and nurses to make choices about their practice of medicine. One chapter, which I personally found the most fascinating, deals with medical practitioners assisting in lethal execution, and their ethical and personal dilemmas about how far to go.

It's a great book, even better than Complications, his first. Go read it.

More on The Spirit Catches You

I finished reading The Spirit Catches You and You Fall Down a few days ago. First off, I mistakenly called the family Cambodian in my earlier post; they are Hmong. I didn't really know a whole lot about the Hmong before reading this book, and I still don't know a lot about them. Interspersed within the medical narrative were histories of the Hmong, who have faced persecution just about everywhere because of their refusal (stubborn or courageous, depending on your point of view) to assimilate into the mainstream culture. Anne Fadiman characterizes them as "scrappy."

But I begin to see why people on SDN are so frustrated with the way the parents behaved. They took the epilepsy meds and pretty much made up their own medication regimen, without informing the doctors. The kid kept seizing, and the result was painful.

What I don't understand is this: why did the parents, who were very mistrustful of Western-style evidence-based medicine, keep bringing Lia back to the doctors? In general, it seemed as though they loved the kid to distraction, but they were so ambivalent about her treatment: medicating her whenever they felt like it, skipping days, overdosing her. For a long time, this was not communicated to the doctors, either willfully or because of faulty (or non-existent) interpretation.

Some bleeding hearts might say it's politically incorrect to suggest that the parents purposely withheld information. But no. Politically (and factually) incorrect would be saying something like "All Hmong are dirty liars," which is just ludicrous. Don't confuse personal accountability with group stereotypes. In fact, the only criticism I have of this book is that Fadiman treats the Hmong like porcelain figurines. The doctors are very realistic -- some efficient and some effusive -- but the Hmong are long-suffering victims to the last man; no criticisms allowed. Although she devotes a lot of time to what the doctors could have done to facilitate communication, she seems almost afraid to point out that compromise is a two-way street and that the parents' confused stubbornness is just as much to blame as the physician's insistence on a biomedical treatment.

In the end, I found myself sympathizing with the parents but empathizing with the doctors. Lack of compromise can have terrible results.

The Scrivener's Guide to Applications

(or, how to retain some semblance of sanity and financial solvency)

Let's get one thing clear: the medical school admissions process is designed to encourage neuroses. If you subject a group of intelligent, hardworking people to a process shrouded in secrecy and with terrible odds (half of those who apply will be rejected from all schools), you're bound to incur some paranoia.

That being said, you, too, can get into medical school if you follow these easy tips. What makes me qualified to give you advice? I applied to 12 allopathic schools for Fall 2007 (including one Canadian school), got 9 interviews, and ended up with 7 acceptances. All told, applications cost me about $2000 (3000 if you include the MCAT fee, my two suits, and Second Look weekends). Plus, I just like giving away free advice. This particular post comes via a suggestion from my friend K, who is applying for Fall 2008. As I told him, if you know what you're doing, this process is not a crapshoot.

Tip #1 is to be normal. I really can't stress this enough. A friend of mine had a stellar academic record, but she was so obsessed with getting into med school that she ended up shooting herself in the foot and not doing as well as one would have thought. Myself, I was so nervous at my first interview that I babbled and gushed about how great medicine was and ended up waitlisted and then rejected. Maintain an interest in something outside academics/work and applications, because otherwise, sure as the sun rises in the east, you will go crazy. Watch some TV; read a book; hike a mountain—anything.

Tip #2 Let it go. Three days after I took the MCAT, I woke up in a cold sweat because I suddenly remembered that I had confused the Lyman and Paschen series in the physical sciences section. This was a bad idea. Once the proctors call “time,” once you mail off your secondary (with sizable check), once you shake your interviewer's hand and walk out, it's over. There isn't a lot more you can do, short of sending a letter of intent (which is legally binding, so think carefully before you write it). Move on with your life. Hike that mountain I mentioned in Tip #1.

After those two rather philosophical tips, #3 is a bit more practical. Get a copy of the MSAR. The Medical School Admissions Requirements book is a must-have when you start the application process. I don't recommend buying—you'll only use it for a week or two, and since an updated one comes out every year, the resale value is almost nil—but borrow from an older friend or check it out from the library. The MSAR is basically an alphabetical listing of all the medical schools in the US and Canada, with a page-long description of each along with average GPA and MCAT. The rule of thumb is GPA*10 + MCAT; your score should be within one point of the school's score. That means you're a good match numerically, but doesn't take into account your state residency, minority status (Native American, black, or Hispanic; sorry, Asians!), or other personal circumstances. Once you have a list from the MSAR, go to individual schools' websites to narrow it down to 15 or so.

Interlude for personal gripe! AMCAS really sucks. The centralized application service is very poorly-designed. For instance, you have to painstakingly enter each college course (including high school APs and IBs) exactly as listed on your transcript. Not in a table; no, that would be too easy. Nope, each course has an individual HTML form, and once you hit “add course,” it's almost impossible to go back and fix mistakes. And then you send them an official transcript so that they can verify all the information you told them, a process that can take several weeks (see below). AMCAS may be streamlined for the schools, but for applicants, it's an exercise in following directions.

Tip #4: Apply early. SDN would have you believe that several thousand premeds hit “submit” on AMCAS at midnight on June 1, the day the whole thing opens. Like most things on SDN, that's an exaggeration, but do try to get your AMCAS in by the end of June. Verification gets more and more backlogged as the summer goes on, and since most schools have rolling admissions, it's best to be at the front of the pack. Turn your secondaries around fast, too; two or three weeks is the norm. If you're still in college, try to get them all in before classes start. Nothing sucks more than having to write a convincing essay (show, don't tell!) about how empathic and diverse you are after taking a three-hour biochem exam.

Tip #5: Don't splurge on a suit. Before buying from Ann Taylor or Jos. A. Bank, go to outlet stores and mid-range department stores. Look for lightweight wool in conservative colors (dark blue, brown, dark gray—avoid black if you can). Try things on. Women, get a three-piece wardrober (jacket, pants, and skirt). Keep an eye out for sales. No one really knows or cares that you are wearing last season's lapels. You shouldn't have to spend more than $75 on a good-quality suit. And get really comfortable shoes. At one school, the girl next to me was wearing those pointy-toed witch shoes. She slipped them off while she was waiting for her interviewer, and her feet had actually molded to squeeze into that unnatural shape. No fashion is worth that price.

Tip #6: Interviews are fun! I know this seems counter-intuitive, since they are so subjective and all, but the vast majority of my interviews were low-key and conversational. At one, we talked for about fifteen minutes about Harry Potter. But be prepared to explain any weakness in your file: a low semester GPA, a red flag in a letter of recommendation. Interviews are also cool because you get to check out the school and the area in person. My opinion of several schools changed a lot after the interview.

Tip #7: Don't take rejection personally, and don't get cocky over an acceptance. Like I said, this process, while certainly difficult, isn't a crapshoot. That's why rejections hurt so much—some school thought that your best wasn't good enough. Take a deep breath and follow Tip #2. (Keeping a stash of chocolate on hand is highly recommended.) Sometimes, the school is willing to look over your file again and tell you what went wrong so you can fix it. No matter what, don't let a rejection affect your performance at other schools. Similarly, celebrate your acceptance, but don't get arrogant about it. All it means is that you managed to convince someone that you might make a good doctor. The real work is still ahead of you.

There you go; the Scrivener's seven certified tips for getting into med school. Apply away!