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  • I'm back!

    Andrea Knittel
    AMSA Member
    7th Year MSTP/M3
    University of Michigan

    Post #8 of the  "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

    Yesterday marked the start of my outpatient pediatrics rotation, the first of my third year of medical school, and the end of this series of posts on my transition from doctoral work in the School of Public Health to my third year clerkships. As I interacted with my M3 colleagues during general orientation last week, and pediatrics orientation yesterday morning, I was struck by the overall high level of anxiety. In spite of my perception that everyone (except maybe the other returning MD/PhD students) should be calmer than me because of their more recent completion of things like clinical competency assessments and Step 1 of the USMLE, all of us were talking nervously about seeing real patients, presenting histories and physicals in the inpatient and outpatient setting. Many of us noted with some trepidation that we don’t do any pediatric exams during our first two years of medical school. While I still believe that many of my colleagues were much more prepared than they believed themselves to be, orientation was nonetheless an important reminder that no matter how large or small the period of time between the pre-clinical and the clinical years of medical school, the jump in expectations (both self-imposed and outlined in the ever present learning objectives for each rotation) is daunting. None of us felt truly ready for the challenges that Monday afternoon would bring.

    Despite all this, Monday afternoon was great. I can only speak for myself, as I haven’t had much time to debrief with other students, but although I didn’t have all of the answers at my patients’ well-child exams, or ask all of the questions I needed to at sick visits, I made it through and presented what I did know to an understanding and friendly attending. I tried not to hesitate to ask questions and highlight the gaps in my own knowledge. In some ways, I think that doctoral work was great preparation for the wards. Who better, after all, than a PhD student to give a succinct outline of what is known, highlight the gaps, and attempt to make a conclusion anyway? At the same time, I felt myself struggling as I dusted off my medical vocabulary, only to find it a little rusty and perhaps a bit smaller than last time I trotted it out, and I often came up blank as I tried to expand my differential diagnosis.

    Looking forward, I see a lot of reading and asking of clarifying questions as my rotation progresses. Just in the past few days I have absorbed a great deal in clinic, and am recognizing the value of applied and practical learning structured around the patients I see. I think my time away will ultimately make me a better doctor, but first, I’ve got to get to studying!

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  • One small step for a current student, one giant leap for me

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #7 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

    On Monday and Tuesday of this week, an incredibly gracious current M3 let me shadow him on the first two days of his inpatient pediatrics rotation. I would highly recommend this before returning from an extended absence, as it not only gives you a better sense of what will happen in the months to come, but gives the more advanced student a unique opportunity to demonstrate everything he/she has learned and to teach a newer student.

    The logistics: The MD/PhD program identified a willing volunteer who was on an inpatient pediatrics rotation this month, which is what I’ll be doing in either May or June, and put me in touch with him. I decided not to go to orientation, as I knew I’d get my own orientation soon enough, but met up with him following orientation before rounds started for the day. I only spent a few hours with the team on Monday, but I got a good sense of how the team works in the hospital, and when I showed up for pre-rounding on Tuesday, I got a real sense of what medical students do with patients who’ve already been in the hospital for a while. I went on rounds again, saw the med students present, and helped with the tasks that followed.

    The lessons: Do this! No amount of shadowing can prepare anyone completely for anything, but it can substantially decrease anxiety. I learned that even after eleven months of clinical rotations, there are still new things to learn and different approaches to adapt to on each service. I saw some great medical students in action, and learned that even folks who haven’t taken a break are constantly learning new things. I also learned that interns, residents, and even attendings are not scary (which should not have been surprising, as many of them were my med school classmates!), and are nice and helpful and willing to teach if you work hard, try new things, and aren’t afraid to ask questions. I also learned that “work hard” includes spending long hours at the hospital. I had a good sense before that this was the case, but spending just two half days in the hospital drove it home.

    The bottom line: I need to start believing folks that this will all be fine! There will be long hours, and lots of work, but nothing insurmountable. I’m certain that as crazy as next month may be, at the end of it, I’ll join the chorus reassuring you that you too, will be fine.

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  • It really does start to come back

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #6 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

    It’s hard to believe I’m already at post #6 in this series. I’ve been averaging about one each month, which means that almost half a year has gone by. In that time I’ve done a lot of things to prepare me for my return to the medical school! I’ve scheduled a dissertation defense, written a dissertation (only edits and formatting left…), and worked with two different internal medicine attendings to try to remember how to be a medical student. Believe it or not, I think that the last item on that list has been the most anxiety provoking. Something I can tell you for sure, however, is that it really does come back. Something else I can tell you is that apparently anything can feel normal after you try it a few times. If you had told me just a few weeks ago that I would casually walk up to one of the nursing stations in University Hospital, have someone help me identify a patient, and then take a reasonably competent history and perform a slow and imperfect, but adequate physical exam, I would have laughed at you. If you had said that I would attempt to present this information to an attending I would have cried. So take heart, whether you are simply making the transition from the pre-clinical years to working on the wards, or you are working to regain the skills you had before a break, because it all really does come back.

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  • Hello history taking

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #5 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

     

    Last week I saw a real patient by myself for the first time. Granted, my actions had absolutely no bearing on his care as I was only seeing him as part of my program's official reentry clinical experiences, but nonetheless, I saw a patient by myself. It was profoundly different from every other experience I’d had conducting a history and physical examination. Unlike practicing with a friend or a standardized patient, this patient wasn’t directly evaluating my skills.  There would be no debriefing with him at the end of the afternoon to discuss whether or not he thought I had adequately checked for organomegaly on the abdominal exam (aka, enlarged liver or spleen), or how I might have more carefully guided him through a recounting of his past medical history. Unlike previous sessions where I was observed directly by an attending physician, there was no doctor present. There was no instructor correcting my percussion technique or reminding me to ask about medication allergies, or noting carefully that I should have been more diligent about screening for domestic violence. Unlike clinical examinations, and unlike many of my clinical experiences to come, there was no time limit. I had as much time as necessary to meander through a history and struggle through a physical exam. All of these differences did make the whole experience less stressful, but highlighted for me the value of having patients who are either truly performing (as my colleagues and standardized patients had done), or those who recognize that they are being watched by a doctor as part of a clinical exercise and put on their best helpful patient facade. Instead, I got a friendly and talkative gentleman (carefully selected for me by the charge nurse) who assumed I was a nurse and wound his way through a baffling series of events that proved to comprise his entire life history, occasionally touching on episodes related to his medical condition.

    As a student training in public health, I firmly believe that the social determinants of health are as important as any explicitly medical issue. You’ll note that in the previous sentence, however, that I place those two things on equal grounding, indicating that a good history has to lead to a good understanding of what medical issues and interventions led the patient to the current state, as well as the social issues and interventions along the way. At this point, I can safely say that I am not a good history taker. I am excellent at establishing rapport with the patient, am careful not to interrupt too soon, aware that data suggest that responding too soon to the first things a patient says can lead the history taker astray (possibly missing more urgent problems further along in the patient’s story), and generally leave the interaction with a vast knowledge of the patient’s children, eating habits, and hospital preferences.  I am not yet excellent at knowing when to redirect a conversation in a more productive direction (say, to illuminate some aspect of the past medical history), or how to suggest that a topic of conversation may be inappropriate (for example, the patient’s perception that an outside hospital is inferior and begins listing examples). Striking the balance between empathic confidante and authoritative information-seeker is difficult, and I’m convinced that this is not made easier by small stature, female sex, and clinical inexperience, none of which is easily disguised on the wards. So what is the rusty and inexperienced clinician (dare I even call myself that at this point) to do? Fortunately, interactions with those further along in this process suggest that ultimately, clinical experience overcomes most additional barriers, and that it becomes easier to matter-of-factly state, “No, I am the medical student/doctor.” This, fortunately or unfortunately, depending on how you look at it, leaves me with only one option, and only one recommendation for you, dear readers, should you find yourselves in a similar position: practice. That’s right. As in all things, I can only hope that if I try and try again, eventually I’ll succeed.

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  • Changing great expectations

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #4 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations. 

    When I started medical school, there was substantial debate swirling about changing residency work hours, particularly for interns who were putting in untold hours at the hospital clearly to the detriment of their personal wellbeing, and potentially to the detriment of patient care.  These arguments sparked discussions of the best way to train physicians to work independently, how to maintain continuity of care without endless work hours, and even how to measure progress on these issues.  Ultimately, resident work hours were limited to 80 hours per week and shifts limited to 30 hours.  AMSA helped to draft the legislation that implemented these first changes, and continues to advocate for better conditions for residents and students. 

    As I’m preparing to return to the wards, the controversy has flared again, though this time regulations have already passed.  The 80 hour work week remains in place, but first year residents (interns) may only work 16 consecutive hours.  (In addition, as detailed in news articles here and here, stricter rules for how residents should be supervised were added, and other regulations to improve patient care and resident safety were also included.)  On the whole, I’m happy to see medicine becoming a safer and more user-friendly profession, and hope that reduced physician burn-out will be a additional consequence of these regulations. 

    In spite of these hopes, I nonetheless struggle with what a friend recently termed “competitive suffering.”  We’ve all experienced it before.  It’s what happens when you moan that you didn’t get enough sleep because you were writing a paper or studying for a test, and a colleague counters that he/she hasn’t slept in a week because of all of the work that needed to be finished.  Similarly, it occurs when one med student complains about an overnight shift on an OB/GYN rotation, and someone immediately pipes up that their transplant surgery rotation has required an unendingly flexible schedule and many sleepless nights.  Lately, I’ve noticed that it also happens when I express trepidation at the nights of call and night float I’ll be expected to work as a medical student, and my friends remind me that when they were in medical school, they were frequently in the hospital overnight, and that call expectations for medical students were much greater.  This often follows with exclamations of how much they learned at night because no one else was there, or of how amazing the patient was that they admitted in the morning and followed for a full 24 hours.  How is a returning student to deal with this, as medical student expectations are shifted with those of residents?  Certainly stepping back and saying “Wow, you had a rough go of it.  They sure do things differently now!” rarely feels like the right option, but most of the time, I think it is.  I try to remind myself that I learn more when I’m awake, and that my retention is laughable when I haven’t been able to sleep.  If that’s not enough, I think about the friends I’ve been lucky enough not to lose to drowsy driving accidents, or patients they’ve been lucky enough not to lose because of a sleepless error, and remind myself that these regulations mean that I’ll need to rely a little less on luck.

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  • Looking forward by looking past

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #3 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

    As I contemplate returning to the medical school and starting my clinical rotations, I’ve come up with a few strategies along the way to calm myself down and turn my anxiety into anticipation.  These include reminding myself of how much support I will have over the next few months to regain my clinical skills, evaluating potential sequences of rotations to maximize early learning but minimize early embarrassment in front of future colleagues (by choosing to start with a field I don’t plan to call my career), and spending time with my resident/doctor friends, who all assure me that I will be fine and that no one will remember my first few awkward weeks/months on the wards.  The strategy I’ve been using most during the last few weeks, however, is looking forward by looking past.  I’ve been motivating myself to gear up for the third year of medical school by contemplating potential away rotations, research experiences, and vacations I would like to take during my fourth year of medical school.  Although I have come up with a volume that would not fit into another four years of medical school, much less a single year, the process of thinking about what comes after the exhausting, but hopefully rewarding ordeal of third year makes thinking about that exhausting ordeal a little bit easier.

    I really embraced this strategy at the American Public health Association Annual Meeting in Denver earlier this month.  As I prepared for my own presentation, I worked hard to attend the presentations of other scholars in my field, to introduce myself afterward, and to a few with interesting research or clinical connections, suggest the possibility of an away rotation in a unique clinic or a scholarly collaboration on a project that would extend my dissertation research.  Honestly, until I was at the conference and sitting in a particularly inspiring session, I hadn’t thought much about the next big transition after PhD-years to MD-years: school to the “real world.”  As scary as it might seem to think about finally leaving the happy bubble of Ann Arbor and my alma mater, it was exciting to think about what is coming next.  I think that holding on to the exciting possibilities beyond my clinical rotations just may get me through the worst of it.

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  • Who will be there?

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Welcome to the second installment in a series on returning to the wards after several years as a MSTP doctoral student in public health.  You can find my first (and introductory) post here.  (You can find all of these posts by looking for the tag "Back To The Wards".)  This particular post was motivated by a series of events that have prompted me to think about who I’ll be working with next year.

    As it sinks in that I'll really be going back, I've thought a lot about the class I’ll be joining.  It will be made up of a few individuals I've worked with or made friends with, former students and folks who know me from lectures I've given, people I've never met, and some returning MSTP classmates.  Apart from the medical students I'll be rotating with, however, I'll be working with 4th year medical students, interns, residents, and attendings, as well as medical assistants, nurses, techs, physicians assistants and a variety of other healthcare personnel .  Of these, I'm likely to have met a few of them in my previous 6 years at UMMS or in the university at large.  I anticipate running into my former boss at the Women’s Health Resource Center at various points, perhaps encountering nurses and administrators who have been involved with the UMMS Pride Network, and seeing physicians who have worked with other student organizations I've been involved with.  I also expect to see instructors I've taught for and worked with in other capacities.  These interactions promise to be somewhat straightforward, however, with normal rules of etiquette covering all that I need.  Though there will likely be a few "how should I address this person" moments, I'm looking forward to showing these colleagues that I've made it and am finally back on the wards.

    The interactions I've described above are not the ones I've been thinking most about, however.  Instead I've been considering the friends and medical school classmates who will be 4th years, interns, residents, and even potentially attending when I start my rotations.  Do you call your friend Dr. So-and-so when you've been calling her by her first name for the past 6 years?  Are the expectations higher or lower or can they possibly be the same if your supervisor or evaluator knows you in a context outside of medicine?  These questions are not unique to returning MD/PhD students, but apply to many medical students who worked in the same healthcare setting where they are now in school.  I suppose I'll have to pin down a few folks over the next few months and grill them about their experiences and the etiquette they used to get through them…

    Finally, I've been thinking a lot about friends and colleagues who won't be there when I go back.  Last week the world lost an incredible individual when Sujal Parikh died after a motorcycle accident.  He was an inspiration with his dedication to global health, HIV/AIDS research, responsible global exchange, and the huge range of student organizations he joined and led (including AMSA).  He would have come back to finish his 4th year next year, and I would have had a chance to work with him as a sub-I or on exciting extracurricular things.  Though Suj is the most recent and striking example, there are others who won't be there on the wards next year because of illness or untimely passing, or to care for a loved one.  It's hard not to feel powerless in the face of these losses, and wonder whether every day will bring some reminder, but I'll be keeping those colleagues in my thoughts and if I can, working just a little bit harder in their memory. 

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  • Thinking about going back

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Every dual degree student I've ever spoken with has expressed extreme trepidation at the prospect of returning to clinical duties.  This includes friends who've taken off time between 2nd and 3rd year, 3rd year and 4th year, and 4th year and internship, as well as those who took off a couple of months in the middle of any part of their training to train outside of clinical medicine.  This includes friends who completed a 1 year MPH, MBA, MPP or another condensed masters degree, friends who spent a year working outside clinical medicine in some sort of global health setting, as well as my steadfast colleagues in dual MD/PhD programs who take anywhere from 3-5 years to immerse themselves in the writing a dissertation before starting their clinical rotations.  Finally, this includes everyone from the most confident and well-prepared re-entering medical student to those whose confidence has been shaken by more extended periods away or less structured programs helping them to go back.  In spite of these gigantic psychological barriers, however, most of us make it back.  Most of us successfully return to clinical medicine and learn to be doctors, and those that don't usually have a really good reason unrelated to clinical incompetence. 

    This post is the first in what will be a long (-ish, depending on your point of view) series about my imminent return to my third year of medical school after four years of doctoral work in public health.  I am a 6th year in the Medical Scientist Training Program (MSTP) at the University of Michigan Medical School, and I was in the entering class of 2005.  I took Step 1 of my USMLE in 2007 and started my doctoral work at the University of Michigan School of Public Health that fall.  Now, just over 3 years later, I'm starting to think about going back.  These posts will talk about the experiences I have through this process.  You can follow me through my experiences with a low-key clinical preceptorship, re-entry.

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