Born to be an otolaryngologist: The preclinical years

So far I’ve covered the reasons otolaryngology originally drew me in, and how you can improve your residency application by doing research.  Those are all great and everything, but how about the nuts and bolts stuff of the timeline to match day?  Let’s say you came into medical school knowing you were born  to be an otolaryngologist.  What can you do during the preclinical years to help make that notion a reality?

You know the deal with any competitive specialty and years 1 and 2 of medical school – you have to do well.  Those years can seem supremely important as you are in the midst of them, but having the advantage of hindsight so far removed from them I can say: yes, they are important, but not as important as they feel when you’re progressing through them.  It’s easy to get caught up in the drudgery and intra-class competition as you are barraged with massive amounts of information and exams.  But I would caution you to take pause and keep perspective in the matter.

What do the pre-clinical grades of medical school distill down to?  Really, nothing more than a class rank (or quartile, depending on your school).  Your individual grades in histology and cardiology don’t mean a whole lot (unless you fail and have to remediate).  Will your class rank help you get interviews come application time?  Not likely.  The caveat to this is that if you are in the bottom half of the class, it can be considered a red flag about why there is such a discrepancy between your preclinical grades and beyond.  The preclinical grades (and subsequently, your class rank) are more about supplying a necessary component of your application rather than making yourself stand out.  Otherwise stated: if they are good, that is adequate, and if they aren’t, that is a deficiency in your application you must account for.

So really, focus on yourself and doing as well as you can.  Don’t get caught up in comparing yourself to your classmates – but if you find yourself struggling, address it early.  Your goal should be to be in the top third/quartile of your class.  But ultimately, the main reason to strive to do well on your preclinical classes isn’t necessarily your grades, but rather because preclinical grades are the best correlate for Step 1 success.

Yes, the mighty Step 1, able to slay the medical student with merely a glance.  I would be lying if I didn’t say your Step 1 score is important.  Heck I’d be lying if I didn’t say it was really important.  If there is one aspect of your application that can immediately close doors before they are open, it’s your Step 1 score.  This may not be fair, but from the perspective of the residency program, who is attempting to compare students from schools with a wide variety of grading policies and rubrics, it is reasonable.  Seen here below is the NRMP data for the 2009 match showing Step 1 scores and applicants into ENT:

What can be distilled from this chart?  First of all, if you bomb Step 1, there’s still hope.  Individuals matched into otolaryngology with board scores well below average.  But if you breakdown the segments, the match rate is:  211-220 = 60% match rate. 221-230 = 71% match rate.  231-240 = 81% match rate.  241-250 = 90% match rate. 251+ = 97% match rate.  The rub: adding 10 points to your step 1 score can increase your chance of successfully matching by 10%.  That. Is. Substantial.

There is a gluttony of information and advice about studying for Step 1 on the internet, by word of mouth, and in books.  I’ll gladly defer the nuts and bolts here, but I will say the main keys to success are: (1) know yourself, how you best study and learn, and how quickly your study and learn (2) formulate a very specific and thorough plan/calendar/timeline based on your study qualities (3) start early, work hard.  This is your one shot, so make it count.

Beyond academics, the preclinical years are a great way to get involved outside the classroom.  While extracurriculars are not nearly as emphasized in residency applications as they are in medical school applications, programs like to see applicants that have interests outside the classroom, can hold positions of leadership, and are altruistic.  Find a project or clinic to volunteer with.  Organize an event or help with an interest group.  Attend a conference.  Run for student government.  These are the years of medical school when you have time for these things.  But ultimately, don’t get involved because you need things for your residency application.  Get involved because it makes you a better medical student and a more well-rounded individual.  Stick to projects that you’re invested and interested in, and don’t become overwhelmed.  Remember, in the grand scheme of things, you’re here to learn medicine, so don’t sacrifice academics for extracurriculars because you “need” them on your CV.

But really, that’s all that is required the first two years of medical school.  Do well in your classes, do well on Step 1, get involved in a few things that interest you.  Easy, right?

I know, it’s not easy.  But set small and reasonable goals for yourself along the way, and you can do it.

            Bobby
            aka MedZag

Things I've Learned on the Interview Trail

Long hiatus from blogging. Hard to find time for much on the interview trail when you're constantly switching time zones, packing/repacking the suitcase, and hustling to catch the next flight. I took a true "vacation" over the holidays and checked out from anything academic... first time in over 2 years.

Anyways, with a month spent traveling, thought I'd past along some tips from my own experiences and experiences of classmates and fellow applicants:
1. If at all humanly possible, downsize to only a check on bag
Yes, checked luggage does get lost, and it does happen to medical students. The risk of your luggage going lost increases exponentially if your flight gets delayed, or you have 1+ connections, and the last thing you want is to arrive in a city without your suit. Trust me, it happens every year and it happened to a few people I know this year. So go to the store and get those little 3 oz toiletries, and make it work. If you're having trouble fitting everything, wear your suit on the plane. The peace of mind is worth it.

2. TripIt.com
Interviews can be a logistical nightmare with all the airline flights, hotel confirmations, car rentals, etc. I was lucky I stumbled across this little gem, tripit.com. It allows you to create individual "trips" for each of your interviews and keep track off all your flight information, confirmation codes, addresses of interview dinners, and even gives you maps. They have an iPhone and Droid and you can access it online from any Smartphone or laptop. Plus it syncs so you don't need web access to retrieve your info. It's been a lifesaver as far as keeping everything in one place and being able to pull it up at a moment's notice. Plus it's free.

3. Research your hotels
The "recommended" hotels provided by programs are not all nice places to stay (learned that the hard way), and often are not the cheapest or closest places. Before you book anywhere, google the hotel and read some of the reviews to weed out the stinkers. You also want to make sure you are at a place with an iron (so you aren't crumpled on interview day) and internet access (for checking into flights and for sanity). If you have a rental car or there are limited hotels in the area around your interview, you can often get away with using hotline.com to get a deal as well. At one interview, there was only one hotel by the medical campus, and even with the "medical discount" it was still $100+ a night. I did a hotline search for the area, found the hotel (even though it was hidden, I knew it was the one) and was able to book for $68 a night. These little savings add up in an expensive endeavor.

4. When possible, book extra time in a city when you visit
It's impossible to get a feel for a city when you're around only for your interview day. When possible, I'd try to get in earlier the day before or stay the night after and see the city a bit. Plus, this whole process is supposed to be kind of FUN. It's way more fun when you have time to explore a bit and try out some cool little restaurants or walk around a downtown of a city you've never been in before.

Along the same lines, if you have an opportunity to stay with friends, take it up in a heartbeat. On one trek, I had a 4 day layoff between two interviews and didn't want to fly the 2000 miles home in between, so I made a quick jump up to a city 500 miles north and stayed with a friend I hadn't seen in 7 years. Made the trip much more enjoyable and I saved some money on airfare in the process.

5. If you're going to drink, tread carefully.
Many of the social dinners are open bars, and occasionally the residents and/or faculty will take you out beyond that. Don't be afraid to have fun, but also tread carefully. The last thing you want to be known as is the applicant who was sloppy or did something inappropriate. I have seen this happen at several of the social events. Interviews are exhausting and stressful, so feel free to have a drink or two, but know your limits.

6. Take notes
After a couple of interviews, the places start to blend together. Use the flight out of the city as an excuse to take 30 minutes and go stream-of-consciousness on a tablet of paper. It helps when you're trying to remember your impressions from places weeks later. It gets old, but at the same time I have no idea who I'd make me rank list without it.

7. Exercise and hydrate
When changing time zones a lot, your body gets really confused. When sitting on planes a lot, your muscles atrophy. When eating airport food and drinking airport coffee, you gain weight and get dehydrated. Bring along some running shoes and workout clothes and hit the pavement or the hotel gym when possible. You'll feel better and sleep better. And trust me, you want to be rested for your interview day. I've had two interviews already where I was absolutely exhausted the day of and between the powerpoint presentations and repetitive questions, it was very, very difficult to stay locked in. Do everything you can to help your energy level.

8. Relax
90% of my interviews have been very casual and very conversational. Even the more difficult ones have been because of interesting personalities or "behavior-based" questions. Even the curveballs have been fairly soft, so try to relax when the interviews come up. After the first couple interviews, you'll be in a flow and already have a rote response for 90% of the questions that will come your way.

Four interviews left then it's time to create my rank list. CRAZY. 

Leaving on a jetplane

Last night, got to say adios to my plastics "sub-i" and scurry home to pack my belongings.

Today, I embarked on the interview trail that will take me (as of now) to 11 different states and several thousand miles. I won't see another patient until February of 2011 (which is weird to think about... 2 months in medical school without medicine?) Over the next 30 days, I'll spend 18 of them away from home. Then in January another 4 interviews. Whew.

I'm sure there will be some things learned the hard way along the way... I'll be sure to chronicle the foibles and follies here. 

Sid Meier's Hospital

So I'm on Plastic Surgery this month. Excuse me, Plastic & RECONSTRUCTIVE Surgery. Though I think it's fair to say the department here earns that title as they do a fair bit of reconstruction amongst the stripperplasties and wrinkles-be-gonesies. It's strange being back on an academic surgical service after a break of over 3 months, but refreshing at the same time as the duties of the medical student on said services of academia (list updating, prerounding, hastily presenting, obscure pimping) are warm and familiar to me. Like a well worn sweatshirt or something. But the hours still suck.

We had a really interesting person on the census the past while - the whole package, interesting medical case and interesting personality. The guy was tackled by a buddy of his and broke a rib. Being the regular dust-on-the-boots American that he is, he didn't come to the ED but rather was just going to deal with the pain. Problem was, he was a nice guy, and since bad things only happen to nice guys, the rib pierced his pleura and soon enough he was in the hospital whether he liked it or not with a rip roaring empyema. One lobectomy, a lat flap, and a couple chest tubes later, he found himself parked on the floor slowly biding his time until he was given the blessings of the great doctors to go home. The healing was slow and he was nearing 2 months on service when I rotated on.

Of course he felt well enough, and rather than bore himself with watching his chest tube output, every day when we rolled through the room in the clusterfuck that is surgery rounds, he would be clicking away on his laptop, engrossed in a computer game. Now despite my rugged and masculine exterior, I am quite the computer nerd. Growing up in the glory days of DOS, I spent many an hour of my youth tinkering away at the computer keyboard with classics such as X-Wing, Doom, and Mechwarrior. Like like many things of youth, these hobbies have slowly been eroded away by the responsibilities of growing up. So on rounds we were much more focused on said chest tubes than what was on the computer screen.

Finally, after a few days on service, the chief resident glances up from the patient's incision and asks "Are you playing Civilization???"

The junior looks up from the chart to add "Hey, I love Civilization."

Intern: "What version? I haven't played 5 yet."

From my n=1 experience, I can now say that all medical students and residents have played Civilization. I'm not sure what that says about our demographic, but the computer nerd in me grinned internally.

Sure enough, this past weekend we were rounding with the attending on call, and our fearless world leader slash conquerer was getting ready to be discharged home. We roll into the room and there he is, clicking away at his laptop like always. He's excited to go home. We make small talk. Finally, the attending was bent over glancing at the site of the last chest tube, when she comments "Is that Civilization? I love that game!"

Somewhere, Sid Meier is smiling. 

These Healing Hands

It's a reality in medicine that sometimes your patients die, and patients generally do not take exception to this fact if they happen to be cared for by a medical student. Some deaths can be more difficult than others as a student, depending on how well you got to know the patient beforehand or the circumstances of their death. Throughout my third year of medical school, I had several patients who I was caring for pass away while I was on service. Generally, these deaths were of one of two varieties:
(1) A healthy individual crashes and burns, a code is called, and we try our damndest for hours to fight the inevitable tide of death. Eventually the code is called, the team collapses in exhaustion, but there is a certain amount of solace to be taken in knowing that we tried everything.

(2) An individual with end stage x disease, who has been playing ding-dong-ditch at Death's front door for far to long, finally catches Death as he/she is walking by the front door in a bath robe and passes quietly in the night. News of these deaths comes during the AM handoffs and is generally met with a general sense of "Damn." but part of your psyche had already begun stacking the sandbags, knowing full well that your dying patient was, well, dying.

I had another, unique experience with death while on my neurology rotation. We had been consulted on an elderly woman admitted with altered mental status, in the classic CYA consult "rule/out stroke" that elderly patients with AMS tend to collect as they pass through the ED. I originally went to examine her with my attending in the AM, to find a frail looking woman, eyes open staring directly at the ceiling, unresponsive to anything in the room around her. She was altered (frankly, encephalopathic), but we did a full exam anyways and determined that she most likely did not have a stroke. Her breathing was shallow, raspy, and moist, a death gurgle of sorts as she was having difficulty handling her secretions. Labs would show a CO2 of >150... the likely culprit of her current stuporous state.

We weighed in our opinion and were off to clinic for the day. When the late afternoon rolled around, I decided to check back up on her, anticipating that after the requisite therapy for her COPD exacerbation, she would be doing much better. Luckily, I decided to glance at the chart before entering the room, and found a note from the medicine team "Discussed situation and prognosis with family. Family wishes DNR/DNI, palliative care consult."

I enter to find her much as she was that morning. Eyes open, staring blankly at the ceiling, still unresponsive. The late afternoon tends to be quiet in this wing of the hospital, and it was just her and I and the setting sun through the hospital window. Her raspy breathing penetrated harshly through the serenity of the moment. Like a good medical student, I set to task repeating the neurological exam, looking for any differences from the morning. Dolls eye test. Corneal reflex. Tap on the tendons. Check tone. It is just as I remove her sock to perform a babinski exam that I notice a subtle change in the room. It takes me a moment to realize that the throaty death rattle, my patient's weakened attempts at oxygen exchange... had stopped.

The first thought to race across my mind was "Oh shit!" I don't know how, but I remembered at that moment her do-not-resuscitate status, which fortunately prevented me from running into the hallways like an idiot yelling "Call a code!!!!" I watched as the color rapidly drained from her face, and stepped out of the room to talk to the nurse. "Ms. R just passed away. I don't know the protocol for the hospital, do you need to page the attending? I'm just a medical student." She replies that it is ok, as the patient was on comfort care. "Just go listen to the heart and lungs to confirm."

As a medical student, you are not trusted to do a whole lot. In today's chaotic environment of CYA-medicine and medical malpractice, we mainly pretend we can do things while someone holds our hand, until intern year rolls around. And a task as simple as listening to a patient's heart & lungs and feeling for a pulse should be elementary for a fourth year medical student, who has felt hundreds of pulses and listened to hundreds if not thousands of hearts. Regardless, there was a certain amount of anxiety involved in confirming a patient's death. Placing a finality on a life, even a life known to be near it's end, felt like a heavy responsibility. "I'm just a medical student."

"Time of death 18:21."

There would be no code, no crowd of people in the room, no blood staining the gown from STAT blood draws. Just myself, and my patient - a patient I had never even talked to. This was a different death than what I was used to. Some would say a good death. But the intimacy of the moment, especially considering it happened while I was performing the physical exam, struck me.

I page my neuro attending to tell him the news. He breaks the mood with some levity: "Well don't go see of the other patients now... I thought they were supposed to be healing hands!"

I looked down at those healing hands. 

Onwards and Upwards

Jeesh, I've been really slacking on this blogging thing. Probably because my life has been incredibly uninteresting the past month slaving away in honor to the boards gods. So I successfully (I think) navigated the travails of Step 2 and its assorted clinical vignettes and fake patients. The second romp with the Step exam was not nearly as stressful or interesting as the first go. More a matter of knowing what you have to do, then going and doing it. And yes, Step 2 CS is as big of a joke as everyone makes it out to be.

This month is neurology, which has turned out to be a quite the neurocation. Which means I've replaced qbank and first aid with monday night football and hulu. I'm already starting to feel that 4th year senioritis sink in.

First residency interview invite finally trickled in today. The residents warned me that in ENT things happen late, so while my classmates have been racking in the interviews I've been obsessively checking MyERAS to see "Available, but not yet retrieved" over and over again. After a month of hearing only crickets, it's nice to finally start getting some movement. So it's back to twiddling my thumbs and hitting refresh on my cell phone email every 30 minutes.

Btw, blog crossed 50,000 visitors this week. Pretty freaking surreal if you ask me. Thanks to all who follow this site and pretend to enjoy the content. Never thought when I started this thing it would generate such attention. Y'all are great!

Empathy, Tragedy, and Progress

She was 28 years old when she first noticed the spot on her tongue.

Red and bleeding, it resembled a pinpoint ulcer along the left lateral border. She went to her doctor, with understandable concern. And he reassured her it looked like a small aphthous ulcer. He told her if it did not get better, or got larger, to come back and see him.

Shortly after that, she became pregnant with her third child. And as anyone would in that situation would likely do, concerns of small aphthous ulcers were placed into the back of her mind as her and her husband went about planning the new addition to their family. Months went by, until one day in her third trimester, she was brushing her teeth and noticed blood on the toothbrush. She took a look at her tongue again, only this time to find a large hard mass in place of the small red spot from before.

What followed was more doctors visits, biopsies, referrals, and a diagnosis... squamous cell carcinoma of the left lateral tongue. She was told there would need to be surgery, but not for another few weeks until her baby was safely delivered.

The baby was safely delivered.

It was the morning of her operation when our paths first crossed. I introduced myself to her, and the entirety of her large, supportive family in the pre-op room. I made small talk, and she spoke in articulate words with a slight British accent. I asked if she had any questions, and she shook her head no.

Back in the operating room, it was business as usual. Help transfer the patient to the OR table. SCDs on. Bovie pad on. Extra blanket on. Warm air circulating. She succumbs to the general anesthetic. Intubation successful. Rotate table 180 degrees. I go out to scrub with the attending and resident, yellow iodine dripping down my forearms into the sink. Sterile towel. Sterile gown. Gloves. Spin. Prep the operative field.

We are finally ready to begin, and we finally get a good look at the tumor. It it large, extending from the lateral edge nearly to the tip. Fingers of white parasite extending deeper into the tissue.

Calmly, the operation commences. According to the pre-operative MRI, it looked like the tumor did not creep too deep. The hope was to get in, get clean margins, and close primarily, leaving her enough residual tissue that her speech and swallowing would be largely unaffected. The dissection proceeds around the mass, and finally the bovie tip penetrates out the opposite side. Frozen sections are sent off to pathology, and we breathe a sigh of relief for the moment. We sit and absorb ourselves in the BB King playing from the iPod. We have a discussion about how much we enjoy the blues.

The phone rings, pathology on the other end. "Frozen sections show margin passing through tumor." In the passing 3 hours, more tissue was taken, more sections were sent, more phones ring, and more swear words penetrate the soft, solemn blues of BB King wafting through the air. The partial glossectomy transforms itself into a hemoglossectomy, which creeps towards a near total glossectomy with each positive margin. Finally, margins are clear and we close, folding the thin strip of remaining tongue over onto itself and securing it with the appropriate number of half hitches.

I am reminded on my last question to her before the operation, when she simply shook her head and smiled. What brings me back to that moment is that for the next few days, her sole mode of communication involves those same left-right, upwards-downwards motions. Any pain? Shake no. Comfortable? Shake yes. Ok, more of the same today. Try to get out of the bed. She turns out to be quite lucky in some ways. Her swallowing was intact. And she will eventually speak again, though not without a heavy lisp and not until the burns of the radiation therapy subside and many months of speech therapy are completed.

There were two things that stuck out to me as particularly profound about this case, about this mother of three.

First occurred during those nauseating hours in the OR as frozen section after frozen section returned with tumor as we burrowed deeper into tongue tissue. With each subsequent resection, I could not shake the feeling of how horribly I felt for the patient, that we were slowly robbing her of her chance at a normal life. Part of that is good, I think. It means these past four years of medical school have not robbed me of those intimate emotions, of the ability to feel empathy for the person prepped and draped in front of me. But I was also struck by how calmly and confidently the attending surgeon, a man I greatly respect and admire, went back to work with each setback... steadfastly marching with tenacity towards negative margins. He knew the data, but more importantly he had lived the data in his many years of practice. He knew that if we did not get clear margins, this woman in front of us would be robbed of her chance to see her children grow old. So he could bury those emotions in order to do what is necessary. Me, I could not yet detach myself from those feelings of horror, because I was not yet convinced it was necessary. Quite bluntly, I have not seen enough people die to be convinced.

It reminded me how much time and space still yet separate myself, inquisitive pitiful fourth year medical student, from the title of surgeon. Because in that situation, I'm not sure I could have done what was necessary. That was humbling to realize.

The second profound moment came the next week in clinic when the attending, chief resident, and myself saw the name of a 32 year of woman on the schedule for follow-up. She too had developed a tongue cancer noticed after becoming pregnant. She too required an operation and radiation. We got to talking, and the chief resident remembered another young woman from her second year of residency who had a tongue squamous cell. We look at her chart and notice she was pregnant. "Interesting," the attending states, and we go to see our follow-up patient. Somehow the conversation turned to what we were discussing earlier, and the patient states she also knew another young woman in the south part of the state who had tongue squamous cell. The momentum of the conversation between the three of us accelerated throughout the day. By the end of clinic, we had assembled a list of 9 young pregnant women with tongue cancer who had been operated on in the past several years. Questions floated about to the tune of the scientific method. Why pregnancy? Why are we seeing more of these tumors? What's different about these tumors? Are there unique ways of approaching treating them?

And so a hypothesis was born. And a plan. There would be a study. IRB protocols and special stains and information databases and eventually a publication. And hopefully... progress. And I thought that all is not so horrible after all.

Sub-I... Check

Man, time flies when you're having fun, I guess. My four weeks on my otolaryngology sub-i were over in a flash. I have to admit, I was a bit nervous coming into the rotation. I felt like I had a fair amount of exposure to the field of otolaryngology, but any time you're making a decision to enter a field when you haven't spent dedicated time rotating through the specialty, you have to wonder if you'll end up enjoying it as much as you think you will. Luckily, I found a great experience during my rotation that reaffirmed rather than undermined my decision.

That being said, talk about a crash course of an experience. Doing a sub-i in a field that is only peripherally covered by the third year rotations, I found myself having to read quite a bit every night just to stay on top of the topics I may see in the clinic or OR the next day. Luckily, I got to rotate through a different service each week, so I could focus each week on learning one specific aspect of the field, be it head & neck, rhinology, peds, or facial plastics. That being said, I felt like the rotation was much less about showing what I knew and much more about showing my willingness to learn. Definitely a different experience than some of my friends who were doing sub-i's in general surgery, internal medicine, etc where you're expected to have mastered basic principles as a third year and graduated on to more patient management.

That being said, being a sub-i kicks butt compared to being a third year. The attendings know you are entering their field, and are much more willing to tolerate your presence and teach. You're given more hands-on opportunities. You're seen more as part of the team and less as a stranger passing through for a few weeks. Good times abound.

Some highlights from the four weeks:
- First assisting an entire anterior lateral thigh free flap
- Getting to perform a trachesotomy on my own
- Pulling a popcorn kernel out of a 3 year old kiddo's ear
- Draining 350cc's of pus out of a patient's neck who has a post-op infection (I'm afraid to admit... I love I&D's)
- Becoming known as "the PEG man" on service, and being paged specifically to come put one in
- First assisting an entire rhinoplasty with rib cartilage harvest
- First time getting to use the microdebrider
- First time getting to play with the DaVinci robot
- First time getting to shoot the laser

But, all good things must come to an end. My sub-i wrapped up and now I'm off on an away rotation. Living in a different, large city with only a small furniture-less room and a twin sized bed to call home. But still otolaryngology, so I can't complain. Grin.