Category Archives: Medical School

First Day on the Wards: Part 1

Are We Healing People Yet?

So there you are, on the first day of third year about to start your clinical training. Two years of lectures behind you, thousands of facts disintegrating in your brain every day, and you are standing sheepishly in your new short white coat at the nurse’s station about to start your first real day of your new career without a clue as to what exactly is your job and what you should do first.

You’ve had the orientation, of course, where you are told what is expected of you but somehow it doesn’t exactly translate on a Monday morning at 6 AM surrounded by the bustling world of an academic medical center.

Relax. Here’s how a typical ward rotation works.

First thing: By “wards” we mean a rotation dealing with patients who have been admitted to the hospital and who reside there for the duration of their treatment. Some rotations are all “outpatient” (as opposed to wards which are “inpatient”) and you will be seeing patients in a clinic. Family medicine is a good example of an outpatient rotation. We will discuss these rotations in a later post. Just keep in mind that even on an inpatient rotation you may spend some time seeing outpatients in a clinic setting.

As you will find out, third year is divided into short blocks, typically two months long, during which you cover all of the major areas of medicine such as Surgery, Obstetrics and Gynecology (OB-Gyn), Internal Medicine (“Medicine”), Pediatrics, Surgical Subspecialties (such as Urology, Opthamology, and Otolaryngology), Psychiatry, and a few other things depending on the priorities of your school.

These two month blocks are typically further broken down into shorter sections. You might, for example, do one month of General Surgery and one month of Vascular Surgery in a two month surgery rotation. On a two month medicine rotation, as another example, you might do one month of General Internal Medicine, two weeks of Cardiology, and two weeks of Nephrology.

Suppose you start on General Medicine. Let’s flesh out a typical day. Bear in mind that every medical school is different and other’s may have had different experiences.

How early should you show up?

Get to the floor early enough to pre-round on the patients you are assigned to follow. This simply means that you must see the patients, examine them, and make a note of any changes in their condition before morning rounds. You must also follow up on pertinent labs or studies from the day before and be familiar with their treatment plan (including the all-important discharge plan) as well as any pending tests and their current medications. How early you show up depends on the number of patients you are following, your familiarity with them, and how efficiently you work.

Keep in mind that you will be waking most of the patients up to do your exam. (Usually a focused exam dealing only with the presenting complaint. You do not generally need to do a neuro exam for someone being treated for a small bowel obstruction.) While they expect to be disturbed during their stay, 4 AM is a little early to be turning on the lights and poking them in the belly. (Examining a patient in the dark is called “groping” and is a no-no.)

You will probably not be assigned more than two patients when you first get started, Still, as you will be completely unfamiliar with almost everything about the workings of the hospital I’d allow plenty of time. If you show up too early the worst that will happen is that you will be standing around with nothing to do before morning rounds. The converse to this is not having enough time and being asked embarrassing questions about your patients that you can’t answer.

Typically, you will be responsible to make a note in the patients chart before rounds summarizing what you have learned. This is the famous “SOAP” note of which you have probably heard. The SOAP note is easy to grasp but difficult, initially, for most medical students to execute. The usual problem is trying to cram too much into the note. It should be concise, not wordy, and should not recapitulate the admission History and Physical except to remind the reader about the patient. (Believe me, the admission H & P, especially on medicine, is where you can go crazy with detail.)

The parts of a SOAP note are as follows:

Subjective: Who the patient is, a brief summary of the reason for their hospitalization, and what they or the nurses told you about their hospital course overnight.

“Mr. Jones is a 63-year-old man admitted for congestive heart failure exacerbation. The patient reported difficulty breathing and a non-productive cough last night at around nine PM but these resolved after administration of IV lasix. Patient is currently without complaints.”

Objective: Subjective is just that, subjective. It does not cover things that you observed in your exam or were reported by the lab, radiology or other consultants. These things are all objective, that is, facts that do not depend on the patient’s interpretation.

Typically you record the last set vital signs making particular note of anything unusual like a fever overnight or a string of high or low blood pressure readings which were unusual for the patient.

Next you will record the results of your physical exam. Generally, every patient regardless of their complaint deserves at least a cardiovascular exam, a lung exam, and an abdominal exam. Listen to the heart in several locations, listen to the lungs, listen for bowel sounds and palpate the abdomen. You can record this succintly using any number of “boiler-plate” abbreviations such as “lungs CTAB” for “lungs clear to auscultation bilaterally.” Of course you need to note any new findings,

Although opinions vary, on my SOAP notes I like to record pertinent lab values. I know that the results are usually on a computer somewhere but it simplifies the job of the person reading your note. I also give brief summary of any new imaging results or the results of any other tests which were not available for the previous note.

assessment/Plan: This is the list of what is wrong with the patient and the ongoing plan to address these problems. Typically it is also preceded by a brief recapitulation of the patient as in the first line of the note. Is this necessary? Maybe not but since most people jump to the assessment and plan when they read a note, particularly a long one, the recapitulation is always helpful. People will read your notes. might as well make them useful and user friendly.

You might say “Mr. Smith is a 63-year-old man with a history of congestive heart failure, Diabetes, hypertension, and gout admitted on January 3rd for a CHF exacerbation.” Then you make a list, by problem, of the plan to address that problem and how things are either working or not working.

For example:

CHF: Patient diuresed of approximately three liters of fluid over last 24 hours on 60 mg IV lasix every eight hours. Chest xray shows continuing resoution of pulmonary edema. Last ejection fraction was 25 percent by transesophageal echo on January 1st.

Diabetes: Well controlled on sliding scale insulin.

Hypertension: Blood pressure well controlled on Hydralzine etc. etc. etc.

You get the point. Also, you might want to add in your note how the patient is doing towards meeting his discharge criteria. Use accepted abbreviations but try not to get too jiggy with them. Most people have to think a little before they realize that BRBPR stands for “Bright Red Blood Per Rectum.”

Why is a the SOAP note important? Several reasons. However, let’s not kid ourselves into thinking that your attending or your resident is going to rely on your assessment and plan for her treatment decisions. Ain’t going to happen. Sorry. What the note does is provide a framework for your over-worked resident to quickly add her own pertinent comments as an addendum to your note. Sometimes the addendum can be as simple as “Agree with medical student note.” At other times the resident will add her own assessment and plan. Either way it saves her a little bit of time.

For you, the medical student, the big advantage of the SOAP note is that if you copy them and carry them around you will be well-armed when the time comes to present your patient.

More on that in Part 2.

Anatomy Lab

Don’t Get Carried Away

Exactly how much anatomy do you need to know and how much time should you spend in gross lab? Opinions vary. Some people love lab and eat it up (figuratively speaking) maintaining that there is no way to learn anatomy other than to spend hundreds of hours elbow deep in a cadaver. These are the folks who come in on the weekends to poke around a little for that one little nerve that they can’t seem to find.

Others spend the least amount of time in lab required by decorum and school policy.

How much anatomy do you need to know?

A lot, no question about it. I’m not convinced, however, that gross lab is the place to do it.

While you need to go to lab and poke around a little to get the feel for things, it is much more efficient to get a Rohan’s Photographic Atlas and use this as your non-smelly, non-gooey, portable anatomy lab.

Understand that most schools test you on gross anatomy by holding what is called a “practical.” In this test, you circulate around the lab from tank to tank (as if in some unholy buffet ) and are given a certain amount of time at each cadaver to identify a tagged item. The tagged item is usually well dissected and does not require any digging on your part.

Since there are usually anywhere from twenty to fifty cadavers in the lab (depending on the size of your class) most of the tagged items will be on cadavers with which you are unfamiliar. With this being the case, you might as well use a photographic atlas which usually shows structures unambiguously dissected in several views from which you generalize to any cadaver, not just the one that you have butchered.

The Rohan’s atlas has the legend on the side or under the photograph with numbered leaders to the structures. It is practically tailor made for quizzing yourself.

You will find that most of your lab time is spent dissecting rather than learning. By this I mean that you will spend hours picking through what looks like leftover thanksgiving turkey looking for an obscure nerve or blood vessel which you could have identified in your photographic atlas in three different views in thirty seconds.

I’m not saying that you don’t need to study anatomy, only that you need to do it efficiently.

So You Want to Go to Medical School


Several years before I applied to medical school my daughter became ill and had to be admitted to our local teaching hospital. Twice a day, the head of the Pediatrics department would make his rounds followed by an impressive entourage of about a dozen residents and third year medical students rotating through pediatrics. As they stood in my daughter’s room, the head of the department would pepper his followers with questions about my daughter’s condition, prognosis, treatment, and other relevant medical knowledge. Standing in the back of the group was a third year medical student who looked incredibly awkward, especially after he mumbled and stammered incorrect answers to several questions directed at him.

A few years later, I found myself on a third-year pediatric rotation at the same hospital and realized that I was “that guy.” As smart as my mother thinks I am I was in full mental vapor-lock unable to recall the simplest item of medical knowledge.

It is a popular misconception reinforced by inaccurate stereotypical descriptions of medical students in the popular culture and wildly inaccurate medical school guide books that medical school is incredibly difficult and can only be successfully undertaken by a student with a photographic memory, the stamina to study sixteen hours a day, and a robotic obsession with medical knowledge. While it is true that medical schools are full of students who fit that description, there are an equal or greater number who are just slightly-smarter-then average regular people.

My purpose in writing this blog is to share some of my experiences and observations about life in medical school and residency from the perspective of a guy who is not at the top of his class and likes to keep stress to a minimum. I also hope that when you arrive at medical school you will have a fairly good idea of what to expect and how things really work. I want to show you that while you must study, if you are efficient and disciplined you can get by without studying long into the night on a regular basis. (But by no means am I going to give you easy study tips or a fool-proof studying system.)

I also want to pass on some essential information about third and fourth year which will not eliminate all of your stress or the awkwardness you will feel the first time you show your face on the wards but will at least give you an idea of what you are supposed to do.

Additionally, I want to make you aware of some of the potential pitfalls of the residency match so you will not make some of the mistakes I made.

Let’s get a few things straight, however. First, you will have to study in medical school. Someone who spends his undergraduate years trying to get into medical school and then blows off studying is a fool and will find himself as one of the tiny elite who are kicked out of medical school for bad grades. (It happens but not as often as you think.)

Second, you should know that many residency programs in highly selective specialties almost always require excellent grades and high class rank. If you want to do Dermatology or Ophthalmology as a specialty then I wish you luck but maybe you need to be reading a different blog.

Keep watching this blog for updates.

More Random Advice

More Random Advice for Medical Students

1. Don’t lick your fingers after a digital rectal exam…and for pete’s sake don’t linger. There’s not that much up there that you can’t feel in three minutes.

2. Brain: It only looks tasty.

3. Yell at the nurses. Tell them that when you’re an intern, there will be hell to pay if you don’t get some respect like right now.

4. Even though you feel bad about turning on a patient’s light at five AM, examining a patient in the dark is technically considered “groping.”

5. Sometimes you have to splint the speculum. You’ll know when it’s time.

6. Childbirth is only a beautiful experience if you enjoy watching fat ladies passing stool. Sorry.

7. When you’re milking the prostate of a prisoner, his shoulder is not a good place to put your free hand.

8. Give a man a couple of narcotic pain pills, he’ll get high for a day. Teach him to write his own prescriptions on stolen prescription pads and he’ll get high for a lifetime.

9. Both the foot and the penis have dorsal veins. Know how to differentiate them.

10. The days when nurses looked like porn stars are long gone. Deal with it.

11. Your disdain for a good salary which peaks as you interview for medical school will decline to the point where by the middle of third year you will swear that if there wasn’t the big bucks at the end of the tunnel you’d quit and go to law school.

Urban Myth

Don’t Freak Out

The requirement to do pelvics, DREs and other invasive exams on classmates is an urban myth. You will not have to stick a speculum or your finger in anybody in your class, period.

To learn how to do a pelvic, for example, on your OB-Gyn rotation you will probably observe your resident do a few at which time he will let you try your hand. Believe it or not it is a rare patient at a teaching hospital who will object to even this.

As for Digitial Rectal Exams, when you do surgery or medicine your resident will just tell you to go do one. The first one you do will fell kind of akward but after a few it will be nothing, just another skill.

It is true that you may do a few “surface anatomy” exercises with your classmates but you will not touch anybody’s breasts, genitals or any other spot which would make anybody uncomfortable. We did practice drawing blood once from each other but that was it. Occasionally the professor will ask for a volunteer to demonstrate some exam skill but this is voluntary. If you don’t want to be touched by your professor or classmates this is perfectly acceptable.

Because you are expected not to be squeamish about other people’s bodies does not mean you are expected to discard your own modesty. When you examine a naked patient you do not strip nude yourself to make him feel more comfortable.

Some Random Advice

1. The Medical Profession is not a cult. I get flamed for saying this. You do not have to sacrifice your sanity, health, and physical fitness to its service, especially not in first and second year. It is just a profession. Treat it as a demanding job to which you expect to devote sixty hours a week and you will do fine.

It is also all right to dislike certain aspects of it or to be bored by certain subjects. You are not offending some rigid order if you do. Many people, for example, have unashamedly discovered that they despise pediatrics. I am one of them. I would rather flip burgers than be a pediatrician. Some people, on the other hand, love it.

2. Don’t get obsessed with the minutia of first semseter lectures. Of course you have to learn it, of course you will be tested on it, but around spring-break of first year you will realize that you don’t remember any of the little details of biochemistry that seemed so important in the fall. This is normal. Most first semester stuff is trivia, absolutely useless to a clinician except as part of his deep background of knowledge. You will have two days of lectures, for example, on proteoglycans, the important and (more importantly) Step 1 testable portion of which could fit on a small index card even though the professor who is an expert in the subject will deliver six hours of lectures.

It’s his area of expertise, after all, a subject to which he has devoted his life.

3. As you progress, you will develop a knack for knowing what is important and what is trivia. Even though you cover more material in second year, you will probably only study a third as much as you did in first year for the same grades.

4. Be aware of the honor code. It is a pesky little thing that most people don’t think about but which can whip around when you least expect it and sink its fangs into your ass. I have never had any trouble but some people in my class, and I will not name names or get more specific out of respect for them, were involved in what seemed like an innocuous action which resulted in some pretty severe punishments which were just short of expulsion.

If you knew how trivial the offense was you’d laugh.

Not trying to scare you. Just want to make you aware. Do I even have to say to steer clear of the obvious honor code violations like cheating?

5. Exercise. Nothing demoralizes most people like sitting around trying to study while they feel themselves turning into lardish library potatos. If you can’t make an hour a day to run or lift weights, especially if you are single, then you are doing someting wrong and need to examine your study habits.I don’t know if it’s scientific but I study better if I am in shape.

6. Studying: Quality over quantity although you do need to do a lot of it. Many of the people who claim to study twelve hours per day are probably in front of their books or at the library 12 hours per day but a lot of what passes for study time is not technically studying. Internet surfing, for example, can suck vast quantities of your study time as can socializing, daydreaming, or studying material you have a good handle on because it is easy.

I got by in first year on four hours per day of good quality studying. I didn’t surf the internet, I didn’t socialize, and I didn’t take breaks. When I was done with my four hours I quit and didn’t worry about it. Of course you should study like crazy at least for the first couple of tests to see how you do. If you are happy with your grades you can start to back off a little.

You will probably be amazed to discover that the amount of studying you do does not always directly correlate with your grade. Unfortunantly at many schools you will not have access to old test questions from the so this avenue of low effort, high yield study is closed to you.

7. When you are done with a course, move on. As long as you passed you can put it in the “win” column. This applies to everybody but those of you planing on matching in highly cometative specialties. Unfortunantly you will have to obsess about grades. Sorry.

Still, there is no point crying about a grade. Move on. Most of us are used to getting good grades in our undergraduate years with minimal effort. You can work like a dog and still get Cs in medical school. Don’t let it bother you.

8. You do not, repeat not, have to get in a study group. They will issue dire warnings about this during orientation but I can assure you that studying alone is best for most people. Your head will not explode.

9. Your milestones are the following:

Step 1: Must pass. End of Second year. You will usually have five or six weeks off between second and third year to study for it or for vacation or any combination. Fail it once and you will have to take your third year vacation month to study and retake it. Fail it twice and you have to sit out the rest of the year and come back with the lower class. Fail it three times and you are done.

Step 2 Clinical Knowledge: Any time in fouth year before April but realistically you want to take it early both to get it out of the way and to have scores for your residency applications.

Step 2 CLinical Skills: Any time in fourth year before April.

ERAS: Electronic Residency Application Service. Start getting your letters of reccomendation early in fourth year. You should have an idea of what you want to specialize in. Submit common applications as early as September.

Interviews:Most usually in November, December, and January.

NRMP:Submit Rank Order List by end of February. Last year the deadline was the 23rd.

Match Day:Third Thursday in March of fourth year.

Graduation: Late May.

A Word About Gross Anatomy Lab

Get a Cheap Pair of Sneakers

Get a cheap pair of sneakers and a couple of pairs of cheap scrubs for anatomy lab. The smell gets everywhere. I’d even consider showering and changing in the Student Exercise Room before going home. Also, you and your tank partners should invest in one Dissector (the book which describes the dissection procedure) and one Atlas to use in the anatomy lab. You do not want anything that was in the lab laying on a cadaver or splashed with juice anywhere near your locker or your home.

You certainly do not want to study in the library or your kitchen with a contaminated atlas. Talk about gross. Some people kept them in a plastic bag in the tank with their cadaver.

Oh, and get a turkey baster. Trust me. It will come in handy draining body cavities.I can’t give you any good advice about lab other than that.

I hated gross lab and was something of a slacker. Since attendance at lab was not enforced let’s just say that I never spent more time in lab then I had to and stopped going completely in October of second year. (Since our curriculum was organ system based, we had a brief introductory course in first semester and then have a couple of days in the lab for every organ system for first and second year.)

Some people have a lot of anxiety over gross lab. For most of us, this is the first time that we are not only exposed to death but are intimate with it. I think everybody worries about how they will respond, whether they will be able to control their revulsion. Don’t sweat it. I had the same feelings. After five minutes with your cadaver the novelty will wear off and it will feel perfectly normal. After about half an hour you will probably start getting hungry because, like most people on their first day of lab, you may have decided to skip breakfast.

After a few days of lab you will find yourself carrying on perfectly normal conversations while casually leaning on the dead body or absent-mindedly picking at some exposed muscle. Eventually you will dread lab, not from some fear of the dead but because it can be dreadfully boring. The only thing that bothered me even a little was sawing the skull in half for the neuroscience course. That was kind of wierd. Oh and looking at the sludge that collects under the body. The funny thing is that after a while, your cadaver will look like old, crow-eaten road kill. I kid you not.