Challenges As Opportunities To Grow

I originally wrote this piece for studentdoctor, which is a website for premed and medical students to share their experiences and to learn from others on their road to becoming physicians. I wanted to post this on my personal blog because I think it gives a little more insight to who I am. I also hope to encourage others experiencing any of their own challenges. I hope you find this helpful.

Up until medical school, my life was relatively smoothing sailing. I did not really have too many challenges before this point. Once I got the hang of college, I had good grades, participated in the right extracurricular activities, and worked in a medical research lab. Never did I imagine that the next few years would hold so many obstacles.

I had gotten into my dream medical school. I could not imagine a place I would rather be, but was completely unprepared. I had exceled in undergrad, but now I was surrounded by people smarter and more accomplished than me. Not only were my classmates some of the most impressive people I had ever met, but I was at an institution that I had no idea how to navigate. This became very difficult during my third year clerkships. Up until this point, I had not spent much time in the hospital. I had no idea what I was walking into. I knew this was probably my most important year of medical school aside from taking Step 1.

What caught me by surprise during third year was the amount of interpersonal skill and self-confidence I would need to excel this year. I do not have a very aggressive personality and it takes me awhile to get the hang of things. I struggled during my clerkships and had no one to talk to about it. I did not know where to go to ask for guidance. All my grades suffered during my clerkship year, and I was mediocre at best. I started to doubt if I was built to be a doctor and whether I would get into any residency. I did not have the best letters of recommendation and had no advocates to help call residency programs I was most interested in. My worse fears bore out, and I matched at one of the programs at the bottom of my list.

I arrived at my residency very distraught. I was still holding on to resentment from my medical school experience and was discouraged by my lack of success. I was not emotionally ready for all that intern year required. Intern year was by far my most challenging year of training. I was nowhere near prepared, and this was evident in my work. I got a terrible evaluation on my second rotation. My attending said I was the worst intern he had seen in his 10 years of practice. Shortly after this rotation I worked more hours than I thought possible—up to 120 hours per week because of my complete inefficiency, and I was still not finishing my checklist at the end of the day. Because of my severe duty hour violations I had to meet with my program director, who told me that I would need to shadow another resident for a month and repeat the rotation. I was yanked from my current rotation and remediated. I felt humiliated and did not have the courage to tell people why I was pulled off service. This was my all time low. It took me 4 months to get out of this.

I felt alone and lost. I did not understand how I had gotten here. I went from being at the top of my premed class to now being remediated. I knew no one and had no other people to talk to. I was alone in a new city, and my friends from med school were absorbed in their own internships. I let myself wallow in self-pity and gave up. Then I started to think: I can’t let myself fail here. I will become the best doctor I can be if it is the last thing I do. This is something I have wanted all my life and I can’t give up on it now.

When I finally began to see the positive that came from all of this, it changed my perspective on what had happened. I had focused on all the negative and had not seen the beauty in all of it. Medical school and intern year were the best times for me to be challenged. These were very formative years, and the things I learned at the beginning would help make me the doctor I am today. The things I considered setbacks had actually taught me valuable lessons and have helped to shape me. I previously thought I was perfect. That I could learn everything I needed to without the help of others. As I started to see that there was so much I didn’t know, I took my studies more seriously. I took the feedback others had for me and tried to improve in these weaknesses. I learned to ask for help when I needed it and that medicine is a team effort.

I tackled each comment on my evaluations one at a time. Assertiveness was one of the first things I was told to work on in medical school. I needed to say things with conviction and be able to support my ideas. The conviction I would need to be able to speak up would only come from really believing what I said, but that meant more reading and more learning. I would not be willing to assert my opinion if I had not taken the time to read about it beforehand. I continue to work on this, but because of my new found voice, I have been able to speak up when something does not seem right. It has even given me the courage to start writing.

Next I needed to work on my organization and efficiency. This was a difficult one in residency because I was required to be on top of everything while I was learning how to do it. I knew that these were important skills because they would allow me to take the best care of my patients. Plus, being efficient would allow me to spend less time on documentation and more time with my patients.

Finally, I still struggled with attention to detail. I would miss things buried in charts or glance over important labs. This was detrimental to the care of my patients. I could not miss anything. I needed to know my patients better than anyone else. It is better to take the time to learn every detail than to rush to see more patients. So now I focus on the task at hand and try not let my mind race to the many other things that I still need to do. It does a disservice to the patient I am taking care of at the time and in the end does not really save me much time because I have to go back and relook at things.

Even though all of these challenges have been a blow to my ego, they have greatly improved the type of physician I am now, and I would never change the chain of events that have gotten me to this point. Don’t be so hard on yourself. Let these experiences shape you and make you a better person.

Perseverance: Don’t Give Up On Your Dreams (How I Almost “Failed” Residency”)

“Persevere: to persist in anything undertaken; maintain a purpose in spite of difficulty, obstacles, or discouragement; continue steadfastly.”

As I went through residency, there were many times I did not think I could make it. I was pushed mentally, physicially, and emotionally.

There were not many supporters in my corner. I had people tell me that I was the worst intern they had ever met. I had someone tell me I should consider something other than cardiology because I just didn’t have the personality to make it.

These were the very same people that were supposed to be my mentors. To encourage me and show me what it meant to be a doctor. Rather I just got day after day that I should give up. In many ways medicine is still an apprenticeship and you learn from those that come before you. It can be very disheartening to hear from those you are learning from that you have wasted your time in the pursuit of this career. A constant reminder of your inadequacy nd stupidity.

It really hurt to keep hearing that I did not have what it takes to pursue the career I had always dreamed of. I had wanted for so long to be a cardiologist. The career offered all the things I always wanted. The heart is both a beautiful and magnificent organ. Something so simple as a pump that keeps us alive, yet so intricate that we have not been able to completely understand it or regenerate it in it’s entirety. Not to mention that heart disease is common and knows no boundaries. It reaches across gender, age, ethnicity, economic boundaries, religious differences, and so much more.

In fact, I viewed my pursuit of cardiology as more than just as a career, but more a calling. I was not going to let anyone tell me I couldn’t do it. The journey during resident was very lonely and difficult at the beginning. I doubted my abilities and if I was cut out to do it, but it made me stronger. I dug deep. Reminded myself constantly my end goal.

There will be people who will try to tear you down. They will tell you that you’re not good enough. Don’t listen to these voices. Drown them out with your own words of encouragement. You are the most important voice of all. No matter what you are pursuing, you need to be your biggest cheerleader. You voice must be heard above the rest. If you do not believe in yourself, how can you expect anyone else to. There will be hurdles in life and you will need to be strong to make it through.

I hope that by sharing my story and showing that my life has not been perfect others can see their dreams can come true too. I am so very happy that I did not give up. I could not imagine doing anything else right now. I still have struggles and I expect there will be many more hurdles, but I now know that I am capable of anything. I know I can handle what comes next. Don’t be afraid to pursue your dreams. You never know what will be waiting for you on the other side.

Physician Burnout: How Does It Happen?

How do type A, high achieving, perfectionist people burnout?

You have trained all your life to be a physician and now you have lost the spark.

You are not alone.

Unfortunately, many physicians experience burnout. How does this happen? Can anything be done to fix the epidemic?

I believe there are common threads that contribute to burnout in physicians. This is by no means an exhaustive list, but some areas that we can try to work on to improve the mental health of physicians.

1. Too much work. Not enough time. You are asked to see more and more patients without more time given to accomplish this. You have your set 15 minutes for a return visit and 30 minutes for a new patient if you’re lucky. You want to be able to see and take care of everyone, but there just isn’t enough time in the day. It takes time to get to know patients and as people age, healthcare becomes more complex and patients come in with more co-morbidities that need to be managed. Not only is there a lot of time that goes into learning about patients, but charting is another challenge. Each clinic visit has accompanying documentation that can take just as much time or even more. A recent paper in JAMA estimated that for every hour spent seeing patients another two hours are spent documenting (1). You feel like you can never catch up with your work and often have to take work home. You become both a physician and administrator. You’re exhausted and always feel like you’re running from one patient to the next with no time to think, eat, or rest and you’re still behind.
2. Limited time with patients. You became a physician to take care of patients, but now you have no time to spend with them. You are given a 15 minute slot to see the patient, order labs/tests, and document. There is no way this can be done in such a short period of time without a significant sacrifice. Often this means less time talking to the patient. It is estimated that after just a very brief amount of time the doctor will start talking after the patient has come into the room and very little time is given for the patient to explain what their questions and concerns are. You become disheartened by the degradation of the patient-doctor relationship and can make it hard to remain connected to medicine. You may feel like you have lost your purpose in medicine and this can really tear at your self esteem and commitment to what you are doing.
3. Not enough time outside of work. No work-life balance. As mentioned earlier, because there is so much work that needs to get done you often have to bring work home. This can make it difficult to maintain a personal life. Your life becomes consumed by your work and your family and friends suffer. You trade time with family for documentation. Even if you are not working at home, you may be at work for long periods of time. Clinic runs long, call is busy, or a colleague needs you to cover procedures. What little time you have for yourself can be taken away as fast as a blink of the eye. You knew you were always going to be busy and work more hours than the typical 40 hour work week, but you did not know it was going to come at the cost of everything else in your life.
4. Compensation not always commensurate to amount of workload. This can be especially true for nonspecialists. General practitioners  are often the first point of contact for many patients and often manage large patient panels with very complex co-morbidities. The reimbursement for primary care physicians is not always equal to the amount of work they do. This can be very trying to feel that your efforts are not as valued as specialists and could be contributing to why there is such a need for primary care physicians. When you don’t feel appreciated for all the work you do this can fracture your love of what you are doing. You want other people to believe in what you do just as much as you do.
5. Highly competitive. Medicine attracts highly motivated and ambitious individuals. This fierce inner compass continues late into a physician’s career and can make it difficult for a community to be formed. We need to let our guard down and ask for help. There is a taboo in medicine to ask for help. People can feel shame or even disappointment in not living up to expectations and this can lead many to remain silent. We may feel like we have always been high achievers and able to complete any task put before us. Why are we “failing” now? It may not be a matter of failing, but learning to realign your goals and aspirations. Take a moment to pause. Your world won’t fall apart because you took time to nurture your mind and soul. Physicians are human too and there is no shame in saying that we need to take care of ourselves as much as we care for our patients. It will only make us better doctors.

 

1. West, Colin. “Addressing Physician Burnout The Way Forward”. JAMA. 2017;317(9):901-902.

Mentorship

I really believe that I would not be where I am without the mentors I have had along the way. I cannot emphasize the importance of finding the right mentor. You can have several mentors, each serving different roles at different stages of training. There could be a mentor for career development, one for personal growth, and another for success as a minority. I found mentors that were personable and wanted to see me succeed. Advocates are key! Mentors help you network and can get you to the next step. You should meet with your mentor often. Show interest. Let them know you hard working and ready to commit the time and effort to complete any task set before you. You should always be giving a 110%. It does not have to be the most famous researcher on campus or the most number of papers published, but it needs to be someone who will give you work to do and give you credit for your contributions. Don’t get me wrong, who you work with will become more important as you advance in your career, but first you should start out with a supportive mentor above all else.

While in undergrad, I had the to privilege to work in a lab run by an MD. He was able to give me perspective working as an MD both in the clinical and research world. He also shared his personal experiences as a medical student. I was fortunate to want to go to the same medical school he attended and he was willing to write a letter of recommendation for me. I think it helped that I had someone who had attended the university as a letter writer. He was a wonderful mentor and really wanted to help me along my journey. He was continuously supportive and encouraged me even when I was most stressed about my classes. I felt comfortable enough to ask him questions when things were not going perfectly. I even had a college mentor that was not even a physician. She stood by my side through it all. She helped me not feel alone or overwhelmed. She believed in my abilities and was there to provide resources and encouragement along the way. In fact, she was my breath of fresh air. She reminded me that I was not defined by my grades or research projects.

I continued to seek good mentors even after my undergrad time, as I had such a positive experience with my prior mentor. In medical school I had a mentor that showed me how to do clinical research and really imprinted the amount of dedication it takes to be successful in clinical research. This was again my experience in residency. Do not get me wrong. Not all of my mentors have been good ones. I have had personality clashes with some of my mentors or realized that our goals do not align. I try to talk about expectations early, because this can lead to a source of disagreement if not explained early. I had a PI who wanted me in the lab many more hours than I could be there with my workload from classes.

All that being said, my advice to you is don’t be discouraged. Not all mentor-mentee relationships work. They are are like relationships in any other part of life. Some work and some don’t. It doesn’t mean that there was something on your part that you did wrong. It’s just a matter of “chemistry”. There is someone out there that will work and it takes the time and perseverance to find the right one. When you do find it, do not let it go. It is invaluable. Maintain the relationships you make. You never know when roads will cross again or worlds will collide. As you will see medicine is a very small world.

How to pay for medical school

Medical school can be the most expensive endeavor that you take on. It is important to have a plan for how you will pay for it. USNews reports that the median debt for medical students is as high as $175,000. You need to decide early how much you are willing to pay for medical school as this will affect the type of schools you apply for. State schools with in state tuition are generally cheaper than private schools. Although you may not have a lot of choices what schools you are accepted at, you can start to think about the programs you want to apply to and would be willing to pay for.

1. School scholarships: Many schools offer scholarships for their students. Here are lists of schools that offer the most scholarships: Public schools that award the most financial aid; http://grad-schools.usnews.rankingsandreviews.com/best-graduate-schools/top-medical-schools/private-financial-aid-rankings?int=96e308
2. Outside scholarships: Achievement Rewards for College Scientists, National Medical Fellowships, American Medical Association’s Physicians of Tomorrow, Paul and Daisy Soros Fellowship for New Americans (there are many more)
3. Loans: look for loans with low interest – usually government and school loans have lower interest than private loans
4. Student loan forgiveness: there are programs specifically for primary care providers that provide loan forgiveness for after a certain number of years of service at a pre-specified clinic – usually in an underserved area. There is also the 10 year repayment program through the government if you pay for 10 consecutive years while working for a hospital or clinic that qualifies as a not-for-profit.

One other thing that I learned was the less I spent for undergrad, the more I would have for medical school. This can seem counter-intuitive because you may expect that you need to go to the best college to be able to get into medical school, but really it is about making the most of whatever place you are at. I ended up having very little debt from undergrad and allowed me to go into medical school without a lot hanging over my head. I also worked in undergrad and that allowed me to save some money to pay for med school applications and textbooks.

Personal Statement

The personal statement is a crucial essay in each step of the way. But then that dreaded question comes up. What should you write about? This can be a difficult question to answer. Many are confronted with writer’s block or find that it is difficult to articulate their experiences into a cohort story. The first thing you have to do is write! You will never get anywhere just talking in your head. You have to put words on paper. You will go through many drafts, but that is how you develop your story. You realize there was a part of “you” that didn’t make it the first time and you need to add it to the next one. I got some great advice when writing my personal statements. The one that I remember the most was the one for medical school. I had dreamed for so long about getting into medical school and this was my first chance to express my hopes and dreams to others who had never met me. I was so nervous and wanted it to be just right and it took a long time and a lot of drafts, but I finally wrote something that sounded like me. Here is what I learned along the way…

1. Be genuine. This will come across in the essay. Be honest with yourself about why you want to do medicine. People can tell when you are not being honest. People want to get to know you. Transparency makes you trustworthy. People know when it is forced or you are lying. It comes across as fake and can be unattractive to schools and programs.
2. Tie it all together. There should be a theme that ties your experience together. Is there something that can be found in each step of the way. Stories aren’t nicely packaged and wrapped in a bow, but there is usually something that defines your journey and accompanies you along the way. Sometimes it can help to even talk to other people that know you well and try to see what others have noticed about your development.
3. Personal story. Can you recall a story that triggered it all for you? Don’t force it. It’s ok if there wasn’t one single moment that started it all. Maybe it was something as small as a conversation you had with someone that changed your life or a volunteer experience that opened your eyes to a whole new world. The story has to be be true to you. No need to glamorize or exaggerate.
4. Highlight your strengths and weaknesses. Don’t be shy. Let people know who you are. No one is perfect and the goal is not find the perfect person, but rather the right person. Everyone has a story and your journey has just begun. I have been surprised what others have seen in me that I did not even know about myself. You may offer special gifts that you are yet to discover.
5. Get feedback. Have as many people as possible read your personal statement. CRITQUE is vital. It helps you grow.

Medical Student Personalities/Traits

You may have wondered what kind of people get into medical school. I would like to argue that many different personalities can thrive in medical school, but I believe there are key qualities that are shared among medical schools there are key traits that lead to excellent performance in medical school and beyond.

1. Hard-working: you need to have resilience in medical school because you will be bombarded with constant information and work. The training process is a marathon and to be honest it does not really stop once you are an attending and practicing on your own. Medical students are selected based on evidence that they are hardworking. This is why grades and MCAT scores are so important. They are objective measures of how hard you will work to do well on classes and standardized exams and to some extent intelligence.
2. Passion and compassion: you care about what you are doing. You are willing to put the guts, sweat, and tears into your work. It will not come easy and you need to feel there is a reason for why you are doing all of it. Ultimately the lives of others will be in your hands.
3. Communication: you are good with people. You enjoy working with patients and teaching people about their health. This does not end up being true for everyone as some people end up being doctors involved in the diagnostic section, such as pathology and radiology, but you still need to be able to communicate well. You need to be able to talk with other physicians with your test results in a clear and well organized fashion.
4. Intelligence: it goes without saying that you have to have the intellectual capacity to understand the intricacy of the human body and mind. You never know, you could be on the verge of the next scientific breakthrough that could change science as we know it.
5. Curiosity: you will never know everything about the human body, but you have to have the hunger to keep reading and learning.
6. Strength in character/determination: you need to have a strong sense of self and not let other people’s opinion of you try to knock you down. There will be nay sayers, but as as long as you remember who you are and why you’re doing this no one can take that from you. Strength comes from within.
7. Confidence: you have to believe in yourself. You are your biggest fan

Myer Briggs personality test can be fun way to get to know your strengths.

Medical Student Presentations

History and Physical

One liner: Age + sex + past medical history + duration of symptoms + presenting symptoms.

HPI: most important part of the medical student know. You should know more about the patient than anyone else. All the details of what led to the presentation. Should be a history that will eventually support what you think the diagnosis is. I usually like to include review of systems in this part. Usually pertinent positives and negatives.

Past Medical History: most should have been mentioned in the one liner, but is more inclusive.

Past Surgical History: any past surgeries.

Family History: pertinent family history – if there for cardiac issues should emphasize cardiac family history rather than malignancy and vice versa.

Social History: Tob, alcohol, and ilicits.

Physical Exam: Vitals. PE.

Data: CXR. ECG. Chemistries. CBC.

Assessment: one liner to summarize what you think is going on.

Plan: what you want to do to work up the diagnosis and treat the problem. Should be a problem based plan. In the intensive care unit will like be systems based as that is a way to ensure nothing is missed.

Daily Progress Notes

S: subjective – how has the patient been over the last 24hrs. Any reports from nursing or significant events over the last 24hrs.

O: Vital signs. Physical Exam (focused on the part of interest – example, if there with chest pain should have a good cardiac and pulmonary exam).

A: Summary of what you think is going on. Example: chest pain likely secondary to acute coronary syndrome. Less likely pulmonary embolus or MSK.

P: Plan of what you want to do to either work up diagnosis or treat ailment.

Excel during 3rd year

Some enter third year afraid of what this time will bring. I will admit, it was my most stressful year in medical school. I did not know how to step out of my shell and always felt like I was second guessing myself. Now I have had time to reflect on this period of my life and wanted to talk about the things I wish I knew at the time.

1. Solid presentations. Watch good interns present and learn from them. There is an art in presentation. Balance conveying a story with facts while being concise without being bogged down in details and losing the forest for the trees.
2. SPEAK UP. Don’t be shy. Let your voice be heard. The team won’t know what you know if you don’t tell them. This was the hardest thing for me to do as I am naturally very shy and have a hard time with new interactions. Some may say that I am a little awkward.
3. Know your patients. You have the most time on the team and the fewest number of patients. You should know everything from vitals, labs, studies, and whether the outside records have come in.
4. Read up on your patients. Be able to talk about what is going on with the patients. Learn the pathology. Rather than ask how to diagnose meninigitis read what your differential would be based on the CSF fluid findings and what your plan will be.
5. Be present! Don’t be late. Show interest. Interact with the entire team.
6. Help to get outside records.
7. Take initiative. Ask if you can help call consults or recheck orthostatic blood pressures.
8. Have supplies on you. Especially helpful when you are on surgical rotations – dressings, gauze, tape, and scissors.

Most Competitive Medical Schools

I found this USNews article interesting. They have listed the top 10 medical schools that accept the fewest number of applicants. What is interesting is that these are not considered the same top 10 ranked medical schools. Why then are these schools so competitive. I can understand California schools being competitive as many people want to move there given location and that does not include all the applicants that come from California and want to stay local, but why then is UCSF not on the list. I still do not have a clear answer for this, but wanted to pose this to others. What makes some schools so selective in who they accept regardless of school rank?

USNews 10 Medical Schools with low acceptance rates

1. Mayo Medical School
2. Florida State University
3. Stanford University
4. George Washington University
5. Brown University
6. Georgetown University
7. University of California-Davis
8. Wake Forest University
9. University of California-Los Angeles
10. University of California-San Diego

This list is more like a warning of what you may be getting into when you apply for medical school. I think it’s really important to have a mix of schools when applying. You should have safety schools and reach schools, even though to be honest when it comes to medical schools there are really no safeties. This list at least gives you a sense of medical schools that are difficult to get into, even if you hadn’t expected it. That does not mean you should not apply to them, but like anything else you should know your chances of actually being able to get in.