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The Texas 2-Step

It seems that summer turned to fall at some point—not quite sure when, but I think it was right around the time that hordes of people began to make their way to Ann Arbor for the start of football season. Personally, I have always been one to get more excited for the approaching field hockey season, and although they are off to a solid 6-4 start, the fans don’t flock to the Phyllis Ocker Field in quite the same numbers (>100,000!) that file into the Big House each Saturday!

It’s been a crazy couple of months, and now being the eve of my sub-internship in Boston in Orthopaedic Surgery, I don’t anticipate things getting any quieter for the next month! I spent the month of August rotating in Emergency Medicine at St. Joseph Mercy Hospital (affectionately known as “St. Joe’s”), a nearby hospital in Ypsilanti that is affiliated with the University of Michigan and is known for offering students a great glimpse into life as an Emergency Medicine physician.

I have to say that I enjoyed ER a lot more than I thought I would, to be honest. One of the things I loved most about it was the sheer variety—I would literally bounce between rooms where the chief complaints ranged from a motorcycle accident to OB/GYN issues to psychotic delusions to a heart attack, all in the course of one eight-hour shift! I also really enjoyed getting to do a variety of procedures–we had a whole session with nurses and technicians dedicated solely to putting IVs into patients’ arms, as well as learning to obtain Arterial Blood Gases, insert nasogastric tubes, put on splints and casts, and obtain EKGs. In addition, I got to be involved with procedures like suturing up lacerations, putting in central lines, reducing dislocated shoulders, performing lumbar punctures, and inserting chest tubes. Most of the shifts flew by, and I really liked the intensity of the ER and the excitement of not knowing what might come through the door at any time.

What I liked less, however, was the lack of continuity of care—except for some occasional “frequent fliers,” an official medical term for those who pay many a visit to the local ER, it was unlikely that we would see any of these patients again after they were discharged. I realized how much I missed getting to know how things turned out for these folks after they left the ER. In addition, I missed being part of a team in which everyone in the room—attendings, residents, and students—are focused on working together to take care of one person at a time. In the ER, residents fly back and forth between patients, discuss their findings and management plans with the attending and possibly confer with one another if they have questions, but for the most part work pretty independently. And then, most importantly, I realized how much I missed the operating room—as much as I enjoyed procedures like placing central lines and sewing up lacerations, it was nothing compared to the excitement of working through a big case in the OR.

After finishing up Emergency Medicine, I started on my month of “Vacation”—I use this term lightly, as I spent most of the month studying for my Step 2 Clinical Knowledge Exam, which I took this past week. The day after taking the exam, I hopped on a plane for Houston, Texas, where I spent the next day taking the 8-hour Clinical Skills Exam before flying back to Michigan and then headed to Boston for my sub-internship out here. As much fun (and by that I mean nerdy) as it sounds to spend one’s month studying for a big exam, I actually had a fantastic month. In a way, it is sort of fun to go through review books and questions and realize how much you’ve learned throughout the year as an M3 and M4. Whereas with Step 1 studying, you are memorizing biochemical pathways and drug mechanisms and in general trying to maintain your sanity, with Step 2 you have often actually taken care of patients who have the diseases described in questions, and you can think back on how your team managed that patient’s case. I found a great coffee shop in a nearby town with some very friendly people (and cheap coffee!) to study from morning to evening, and the process of studying itself became a relatively peaceful journey. The week of the 2 exams itself was not too much fun—although it seemed like a good idea at the time to schedule both exams for one week, it turned out to not exactly be as smooth as I had hoped given all the travel—but it is a relief to know that both of these tests are done as I move into my away rotation and interview season.

The reason this past month was so great was not the “excitement” of studying, however, but rather was mostly due to some exciting things happening outside of the books. First, my father was inducted as a Lieutenant Colonel into the U.S. Army, and I got to fly back to Boston for the event (pictures are forthcoming; not currently available due to some technical difficulties!). It was a really proud moment for him, and after all the events he has come to for me and my siblings, I was so glad to get to be a part of it. A few days later, I competed in an Ultra-Marathon—and actually finished! It was a 50-kilometer (or 31.1-mile) race, and it involved everything from wading through streams to sliding through mud to climbing up hills to consuming obscene amounts of Gu, an energy gel that I would not otherwise recommend as a snack for taste reasons alone. It took several days before my legs felt the desire to try to walk again, and a week after the 50k we undertook a much more modest 5k—although truth be told, even this distance felt somewhat punishing after the previous week’s event.

So this month I’ll be trading in my running shoes and test-taking pencils (not actually true, since all exams are now done on the computer, but you know what I mean) for scrubs and clogs, and headed back for another round of Orthopaedic Surgery. I am nervous—but excited—to see what it’s like to rotate through a hospital outside of Ann Arbor, and another perk is that I get to live at home, complete with free home-cooked meals! I will be missing Ann Arbor, as fall is probably the best time of year in my adopted home city, but I’m excited for what lies ahead.

It’s About Time!

It occurred to me recently when a classmate of mine who is doing a Cardiology rotation in Alaska sent me a not-so-subtle e-mail about the less-than-modest amount of time that has passed since my last update-that perhaps it was in fact time for an update.  And since there is much to be updated, here we go!

With my mother and brother, Brad, in New York City for Brad's law school graduation--and, the next day, the briss of my new cousin, Noah Moses!

First and foremost, I am pretty thrilled to announce that I have made a career decision!  Granted, I was pretty certain coming in to medical school and even after finishing M3 year that my decision was set-I had planned on becoming a General Surgeon.  And so it was to be, or so I thought, until the day I stepped into an Orthopaedic Surgery operating room.

I have heard many of my colleagues as well as current physicians describe their path to making a decision.  Some have said they had that “Aha!” moment in their very first days of rotating on the specialty that they decide upon, whereas others talk about the long thought process-often one of elimination-involved in leading to their eventual selection.  For me, choosing to become an Orthopaedic Surgeon was actually a bit of a circuitous route.  As my friends and family later reminded me, this was the very type of doctor I had aspired to become from the time I even knew I wanted to be a doctor.  I was reminded by more than one person that I had always pointed to the physicians on the sideline of my collegiate field hockey games and commented that I thought they had, and I quote, “The best job in the world.”  Not to mention that for me, besides my father, the original idea in my head of what a great doctor is and can do was based on the two surgeons who performed my knee surgeries (one on each!) in high school.  I did steer away from Ortho for awhile during my first few years of medical school-I had heard that it was one of the most competitive specialties in medicine in terms of applying for residency (which can certainly be a daunting thought), that there was very little medicine involved in patient care, and that I would have to have biceps of steel and bench press twice my weight in order to survive and be able to do what I needed to do.

All these concerns virtually disappeared from the very first day I saw my first orthopaedic procedure.  I do not know for sure if there is such a thing as fate, but I will say that it was quite a coincidence that the very first case I saw happened to be an operation performed on one of my idols in athletics.  I had just come off of 2 months of General Surgery, and while I had found all of the cases interesting and realized during that time that my heart was set on becoming a surgeon, I can’t quite describe the feeling that I had as I watched these orthopods (another term for orthopaedic surgeons, which is a rather long couple of words) reconstruct a shattered bone from what seemed like dozens of tiny fragments with plates and screws, or reconstructed knee ligaments from tendons taken from the opposite hamstrings.  For the first time in all of my clinical experiences, I actually really looked forward to clinic, because I found that people had such interesting stories in describing how they fell or got injured and the impact that it had upon their lives.  (It also didn’t hurt that Sports Medicine clinic at the University of Michigan is located at MedSport, a facility that has a gigantic athletic facility and rehabilitation center connected to the clinic itself.  It reminded me of being right back in college in the training room, only this time I was on the other side of the injury.  I loved every minute of it!)  Whereas different types of diseases are often ascribed to distinct categories of patients, anyone of any age, gender, race, or socioeconomic background can get hurt or develop a problem somewhere in their limbs or back that is bad enough to prevent them from doing what they want to do.  While many patients are older and very sick, often these are otherwise healthy people who are out living their lives and then, in the blink of an eye, get injured.  It is incredibly gratifying to be involved in a case in which something is broken, or torn, or causing a patient great and often debilitating pain, and your team is able to fix it with their hands.  And, not to mention, an array of incredibly cool gadgets such as power drills, large saws, mallets, and nails that are, for lack of a better word, just really fun to use.

During my two months of Orthopaedics rotations, I have gotten to rotate through Sports (mostly knee and shoulder injuries, and surprisingly not actually all related to sports-this clinic sees its fair share of men and women with knee and shoulder injuries who may well not have been engaged in an athletic endeavor since middle school recess!), Trauma, Pediatrics, and even a little bit of a field called Orthopaedic Oncology, consisting of tumors that either arise in or have spread to any region of the musculoskeletal system.  Certainly, not every day is like that first day of my Ortho rotation when I was in the operating room and realized that I had found what I wanted to spend my life doing.  It is very, very hard work-any of the residents and attendings will certainly attest to this.  Being a surgical discipline and thus involving long hours in the operating room, it is less than friendly on the back-and any field hockey player can tell you that years of playing a sport focused on a tiny ball that travels along the ground does not exactly have a therapeutic effect on the lower back.  But I have to say, I can’t remember when I was happier doing anything than spending my day in the OR for these cases or even seeing patients in clinic after their operations.  As I shared with someone a few weeks ago at the end of a long day involving operations on everything from the back to the wrist to the elbow to the ankle, I can really see myself still being excited to do these cases every day for the rest of my life.

This was one of the most memorable thoughts that Dean Woolliscroft, our dean here at the University of Michigan Medical School, had left us with during a lecture several months ago as we prepared to make our career decisions- years from now, are these the things that will still be exciting to you and get you out of bed in the morning (or, as the case may be, in the middle of the night)?  He, along with Dean Petty, encouraged us to really be honest with ourselves.  I guess I had never really paused to think about what that meant until the past few months.  It all kind of hit me a few months ago on my Ortho rotation during a late-night fracture repair, when I saw one of the surgical techs whom I had worked with quite a bit on my General Surgery rotation.  “Lauren, is that you?  I didn’t even recognize you!  You just seem so happy!”  I realized that she was right-I was really happy, and I felt like myself again.  I loved being around these residents, attendings, and patients.  And once I made my decision and announced it to my friends, family, and loved ones, I have to say that it was pretty gratifying to hear all of them say, “Yeah-we sort of always knew that this is what you were born to do.  We just wanted to give you the chance to figure it out on your own!”  (There may, however, be one exception to this-I think my father always held out a covert hope that I would join him as a plastic surgeon, but he has taken the news very well!)

I am off to get back to work on my residency applications and Emergency Room shifts-I will see you, I promise, in less than (insert however many months it has been since I last wrote-hopefully in the single digits)!

Moving Four-ward

So, apparently it is now the month of May, I have completed two months of Surgery and thus my third year of medical school, and it is now the beginning of my fourth and final year of medical school.  These events provoke many questions–how/when did this all happen?  Am I still alive?  What has become of this blog for the past two months?

Posing with the Dune Buggy ride in Saugatuck, Michigan, where I spent a couple of days after finishing up M3 year. Would highly recommend wearing a seatbelt to future riders.

Hopefully I can get to at least some of these questions in the course of this long-delayed update, but first I just have to take a step back to say…Wow.  It has been quite a year.  This thought really hit home a couple weeks ago as I stood up in front of a panel of wide-eyed, brand new M3s during their orientation to address the elusive question of “How to be an M3.”  It was mindboggling to realize that exactly one year ago, I had been sitting in that auditorium, fresh off my boards, about to begin my Obstetrics and Gynecology rotation without being 100% sure which part of this clerkship title meant the delivering of babies and which involved the rest of the aspects of taking care of women.  Since that time, I have completed not only the OB/GYN rotation (and decoded the meaning of these words) but have also been an amateur psychiatrist, cardiologist, general internist, neurologist, family medicine-ist (unclear if this is a word, but it can be so for now), pediatrician, and surgeon for anywhere from 1 to 2 months at a time.  I have, at times, slept less than I ever thought humanly possible, gone to bed earlier than I have since I was in third grade, awoken earlier than I believe most roosters begin to stir, eaten the majority of my meals in the hospital cafeteria, gotten to know the best call rooms and which ones to avoid at all costs, taken care of men, women, and children who have passed away, met patients I am certain I will never forget, and had many a moment that I would certainly like to forget.  Dropping the code pager into the toilet on my first night on call would probably rank quite highly within this last category.  As would my infamous spraying with a not-insignificant amount of blood of no less than three doctors while attempting to remove the placenta from a woman’s pelvis after a C-section.  The anesthesiology resident involved in this case still heckles me for this each time I see him, but it has finally become funny rather than mortifying after a year.  Well, almost.

Upon completing Pediatrics, I entered into a world of 4 AM wake-ups, 4-to-8 hours of standing at a time, lightning-fast rounds, intimate familiarity with retractors, and the reliance upon two hands (not my own, which were busy with the retractors) to remove cancer, relieve bowel obstructions, and perform other such incredible feats with such grace and speed that they seem to have a mind of their own.  For me, it was comparable to watching a great field hockey player with superior stick handling skills at work: years and years of training resulting in knowing exactly what to do without having to so much as think about it.

This world of Surgery began for me in early March, when I started on the Endocrine Surgery service.  The vast majority of our patients were having their thyroid or parathyroid glands removed, although I did get to see some adrenal gland (the glands that sit above the kidneys and produce lots of hormones) cases as well.  I also got to see a ton of bread-and-butter General Surgery this month, including hemorrhoid removals, hernia repairs, and the removal of various lumps and bumps from very diverse parts of the human body.  The endocrine cases were in many ways very satisfying, as they were relatively short procedures with small, subtle scars and, according to the patients I saw in clinic after their operations, almost immediate relief of the sometimes debilitating symptoms that these tiny (or, in the case of some of the gigantic thyroids, not-so-tiny) glands had bestowed upon them.  I was surprised by how much medicine was involved in General Surgery: the discussions about patient diseases, diagnosis, and treatment were similar to those I had participated in during my Internal Medicine rotation, but they were much quicker, occurred earlier in the morning, and were followed by a full day in the Operating Room.

The necessity of knowing the pathophysiology, diagnosis, and management of the diseases we were treating surgically became particularly apparent inside the walls of the OR, where from the first incision some attending surgeons would ask me everything from, “What were this patient’s presenting symptoms?” to “What is the work-up for an adrenal mass found incidentally on MRI?” to “So Lauren, how exactly does the Bovie function?”  I can tell you that the OR can be a warm place, between scrubs and gowns and masks and overhead lights–and it can quickly become a very hot place when you are asked a series of questions with the whole room listening while simultaneously trying to hold two retractors completely still.

Prior to starting my surgery rotation, I had completed all of the other M3 clerkships and was feeling pretty confident that I had started to figure out this much-talked about, much-anxiety producing M3 year.  I would quickly learn, however, that surgery was a whole new ballgame.  One of the biggest factors in this is the abrupt change in your schedule.  I had gotten up early throughout the year (although “early” can mean very different things–on psychiatry, we were told never to come in earlier than 8 AM, and on medicine I would usually arrive at around 6 AM), but getting up earlier than 5 AM and going to sleep around 9 or 10 was definitely a shock to the system at first.  More importantly, there was so little time between arriving home for a long day in the OR and needing to get to bed in preparation for the next day, and so many things to do in that period of time–i.e. make dinner, eat dinner, study for the oral and shelf exams, prepare for the next day’s cases, and, ideally, bathe–that exercise took a back seat for me.  Or more like a position somewhere in the trunk of this metaphorical car.  My uncle once told me something like, “Lauren, I’m not a doctor, but I do know that when you’re an athlete and you don’t work out, something in your brain–some chemicals or something–just aren’t right, and you just don’t feel like yourself.”  I found this to be extremely true.  I would only run once or twice a week, and my favorite pastimes like reading, playing guitar, seeing movies, seeing my friends, talking to my family, following sports teams, etc. were put aside.

So yes, these major changes in my schedule and exposure to this outside world were difficult to adapt to, and there was certainly a great deal of relief when my classmates and I put down our pencils from the Surgery Oral and Shelf Exams (which occurred on the same day–more on these events in another post) and were free for a week having then “graduated” from M3 year.  On the other hand, there were definitely some unforgettable moments on this rotation.  It is incredibly rewarding, for example, to see a patient to come in to the hospital in an extraordinary amount of pain and to take him to the OR, identify the bowel adhesions causing his pain, release or resect them, and then watch the small intestine go from a dismal blue to this bright pink color within seconds and, thereafter, see the patient’s condition improve rapidly.  It is also a tremendous privilege to get to take care of extremely sick patients whose families entrust their loved one’s life to the surgery team.  As I grew up witnessing firsthand through my father, surgeons are a remarkable group of people who sacrifice an extraordinary amount of time, sleep, and energy on a daily basis for many years in order to take care of the sickest of the sick.  I also have to say that I have a whole new appreciation for my father and the training he went through to become a surgeon, all while still attending all of my embarrassing dance recitals, viola concerts (yes, I just admitted to that), and sports games.  In addition, in seeing how hard the residents work, I can now appreciate how difficult it must have been for my mother to take care of me and my brother while getting through law school as my father completed a residency back when residents took call every other night and worked 120+ hours per week.  As I have mentioned, I found it hard enough to maintain basic standards of hygiene and nutrition while getting through this year at times, and I really admire my classmates who have spouses and children and still made it through this challenging year.

I’m thinking that I’ve gone on long enough for now, and I promise to update soon about my adventures on my first rotation of M4  year¿Orthopaedic Surgery!  Until then, enjoy the spring and, as always, I would love to answer any questions about Michigan, M3 year, the viola, or various other topics at