“Professionalism in Medicine” Panel Lecture Series

I recently had the pleasure to be a panelist for the Van Wormer Student Judiciary Committee at AUC. As current AUC students are aware, there are many, MANY questions involving clinical rotations, USMLE Step examinations, and residency applications, accompanied with some confusion about where to find the answers. Below are my questions and answers.

*As a side note, for all of you out there interested in matching into Surgery, Dr. Hernandez is an excellent resource. He can be contacted at ahernandez@aucmed.edu.

 

  1. Can you give an example of when you were in rotations and an alarming or ethical situation arose and how you decided to deal with it?

During my emergency medicine rotation, I had a very ambitious resident that did not quite respect my limitations as a student. There were multiple occasions where he pushed me into a situation or procedure for which I as not adequately trained. One good example were ABGs. I had only done them on mannequins previously while in medical school, and had practiced only a couple times on a live patient. I as not prepared to do them without supervision, because of the potential risk of harming the patient. The resident told me specifically to do an ABG on my own for a patient who had just been admitted. After doing so, I approached him and asked if there was a reason for this conflict and explained my perspective. He reflected for a moment and stated he was overworked and taking his stress out on medical students. We came to an agreement that while I was more than willing to learn and do procedures, until I felt comfortable on my own I would appreciate the supervision while doing so. He thankfully agreed and taught me how to do proper ABGs until I felt confident enough to do them on my own.

 

  1. What clinical sites did you choose to complete your rotations at? Do you recommend changing sites often or utilizing one main hospital?

I did my OBGYN and Surgery rotations at Epsom Hospital in the UK, about 30 minutes south of London. My fiancé, Tylor, came with me and we thoroughly enjoyed our time in England. In addition to learning an entirely different healthcare system, Tylor and I had the opportunity to travel around Europe at a relatively low cost. We never would have seen so many countries or experienced the unique cultures within them if I had chosen to complete all of my rotations in the US.

Afterwards, my remaining clinical rotations were completed in New York between 3 separate hospitals: Flushing Hospital, Nassau University Medical Center (NUMC), and Bronx-Lebanon Medical Center.

Here is what my schedule looked like:

Summary

Tylor and our dog Brutus (@brutesmcpoops if you’re interested in the best doggie instagram ever) were living with me during my clinical rotations. Because of this, I decided to stay in one location the entire time – Queens, NY. I attempted to place our apartment location in the middle of all 3 hospital sites, with a reasonable commute between all of them. It worked out alright, my only complaint was the commute to Bronx Lebanon. 2 Trains, 1 bus, and 1.5-2 hours later I could arrive to the hospital for a 6am shift. To NUMC was about 30-45 minutes (you’re going in the opposite direction of morning and evening traffic which is AMAZING), and about 15-20 minutes to Flushing.

 

  1. What do you think was the most attractive quality about a clinical site where you completed a rotation?

Whether or not the rotation made an effort to incorporate medical students, and how supportive nurses, residents, and attendings were of each other. The worst rotations were those who treated medical students as a nuisance. It was obvious we were there to hinder their work instead of learn from it. Lectures were always over our heads and there were large gaps of time where we couldn’t do anything,

A good support system is also what I’m looking for in a residency program right now. I don’t want to work in a toxic environment, where there is a constant internal struggle between nurses and doctors. Personally, I learned the most from the nursing staff and to see them mistreated fostered an environment of distrust.

 

  1. Did you feel that medical school wholly prepared you for clinicals? What do you think, if anything, would have improved your performance in clinical rotations?

To be honest, the main focus on the first two years of medical school are basic sciences. The majority of your time will be spent in preparation for the Step 1 exam. Once you begin clinical rotations as a 3rd year medical student, there is a distinct transition from the books to the hospital world. The best way to prepare for this is to keep in mind that everything you read about, whether the subject is microbiology, pathology, or physiology, MUST be applied to a patient in a clinical setting. Always visualize a patient presenting with these problems, and it will make the transition smoother. Also, do not learn these subjects “separately.” If you remember that everything is connected and the subjects you learned in basic sciences are intertwined together, you will build a strong differential diagnosis for any patient presentation.

 

  1. Did you feel like other medical students were respectful of you being an IMG? Did you ever feel being an IMG was a problem with a preceptor? Why or why not?

For me, the hospital sites I rotated in had strong representation from not only AUC students, but other Caribbean medical students as well. Because of this, we were united on that front. There were medical students from other schools (like NYCOM at NUMC for example), but for the most part, everyone was respectful of each other. Where you went to medical school came up occasionally in conversation, but confidence/competence as a medical student had a stronger impact.

 

  1. How do international core rotations look on a resume? Do you believe completing some of your core rotations in the UK was beneficial?

A lot of program directors weren’t aware that I completed my OBGYN and surgery rotations in the UK until I brought it up in an interview, but when it came up it became an interesting talking point. Because of that, I do believe completing some core rotations in the UK was beneficial. You have to remember that these programs are interviewing hundreds of applicants for a handful of positions. Now that you’ve made it past the Step cutoff scores and have been selected to interview, it’s up to you to pull out memorable details from your application that will help you stand out. It’s a good idea to have a list of 5 interesting talking points from your application that you always try to incorporate into the conversation. For me, my time in the UK was one of those talking points. A word of advice: schedule these rotations as early as possible. There are some factors involved with doing rotations in the UK, including taking time to move back to the US. Especially for the September class, you must stick to a strict schedule in order to match on time.

 

  1. How did you schedule your core rotations, or is that pre-selected at your clinical site?

The first rotation you schedule should not be something you’re interested in. That way, you can make a total fool of yourself during that rotation while you get used to the system and it won’t matter. I wasn’t interested in surgery or OBGYN at the time, so I scheduled those 2 first. From the UK, I scheduled the rest of my core rotations in New York. Keep in mind that you want a letter of recommendation from your specialty of choice before you submit your application for The Match on September 15th.

AUC’s Core Clerkship Guide: https://www.aucmed.edu/content/dam/dmi/www_aucmed_edu/PDFs/academics/OCSA-Core-Clerkship-Guide.pdf

Can be used to find programs of interest according to their geographical location. You submit a list of your top 4 program choices to your advisor at coordinators@aucmed.edu and a couple days later, they will send you an email with your updated schedule. For elective rotations, there is an elective request form that can be found on AUC’s website.

*Scheduling rotations must take place AFTER passing Step 1.

 

  1. Did you take any breaks in between your core and elective rotations?

I had a 2 week break in between my core and elective rotations. I would recommend scheduling a 2-4 week break before taking the USMLE Step 2 CK examination.

 

  1. What was your timeline after leaving the island?

Comp Exam: March 23rd, 2016

Left Island: April 19th, 2016

Step 1: June 20th, 2016. Score received July 13th

Arrived in Epsom, UK: September 12th for my first clinical rotation!

 

Smiles 🙂

CG

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The Residency Application Process

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“Freckles” at the AUC adoption fair

Hello everyone! Sorry it’s been awhile since my last blog post. I’ve just started the trek for residency interviews and wanted to write about my current job and what I’ve experienced in the meantime. Eventually, once I have completed my interview journey and submitted my rank order list, I’ll create a separate post and tell you all about what I’ve learned! Stay Tuned for: The Residency Application Trail coming to a blog post near you.

Also, so you’re not taken by surprise, there has been a name change! Tales of the Caribbean has been updated to the “AUC Survival Guide”. Credit goes to my lovely fiance, Tylor for finding a more relevant name 😉

As I’ve expressed before, the September class is faced with a time crunch when it comes to residency applications. USMLE examinations and core rotations (ideally including a family medicine rotation) should be completed before you submit your residency application in mid-September. For everyone matching in 2019, that means the deadline to take USMLE Step 2CS is July 14th 2018, and for Step 2 CK the date should be August 12th 2018. More information about the timeline and the 2019 match can be found in the AUC 2019 Match Handbook.

What clinical medical students will come to realize is that in order to make those USMLE deadlines, you must study and take Step during your rotations, in some cases (the majority of the September class) during core rotations. For example, in July and August I was in my Pediatrics core rotation. Because I am applying to family medicine, I realized I could not squeeze a family medicine elective in on time and obtain a letter of recommendation for my residency application. I did not feel adequately prepared for the Step 2 CK exam and did not want to rush into it without feeling comfortable. A combination of these factors ultimately led to my decision to match in 2019 instead of 2018.

Once that decision was made, now I could move onto freaking out about how to fill my time with something medicine-related. I heard about clinical “fellows” that could teach and do research through AUC while waiting for residency placement. More information about what the job entails can be found at the AUC Careers Page.

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Some “Fellows” and I (Dr. Dabrowski and Dr. Materum) before our 1st Breast Screening Event!

As an introduction to clinical medicine (ICM) fellow, you work with medical students and prepare them for what they’ll see in the clinical world. I’m involved in small groups where we discuss how to build a differential diagnosis, perform a physical exam, and collect a full patient history. Sometimes we learn about various topics/conditions they’ll encounter in the hospital, both common and uncommon. The ICM department holds multiple workshops throughout a semester, including intubation and venipuncture/IV placement. I was recently involved in a venipuncture workshop with my good friend and “fellow fellow” Dr. Hernandez. Obviously the most appropriate time to hold a workshop involving severed arms and blood was on Halloween – scary stuff. I probably should have dressed up.

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Venipuncture workshop with my buddy Dr. Hernandez!

 

In addition to teaching, the ICM fellows are also involved in research. Dr. Chobanyan, our director, placed me in charge of her breast abnormalities/cancer research project, where we’re assessing the prevalence of breast abnormalities in women on St. Maarten. It’s actually a really neat project, because guidelines and protocols do not exist for this population, and we hope our project will fix that problem. We’ve held 3 screening events so far; where the women of St. Maarten can be assessed for risk factors of breast cancer, receive an education component, and a clinical breast exam from Dr. Chobanyan. Once enough information is gathered, it will be sent to the Ministry of Health on St. Maarten to be properly documented, cataloged, and used in the future to build breast-screening protocols.

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Our 2nd Breast Screening Event with the Minister of Health, Mr. Emil Lee

All in all, it’s a neat position to have and so far my residency interviewers have expressed a lot of interest in it. However, building these differential diagnoses and teaching medical students is making me ITCH to start residency. I want to apply what I’ve learned to MY OWN PATIENTS darn it!

 

TIME TO GET SERIOUS ____________________________________________________________________________________________

Now, before applying for residency, there is some terminology you should be aware of. There are 2 matching services AUC students usually deal with: ERAS/NRMP/ACGME and CaRMS. My US friends will be dealing with ERAS, my Canadian friends with CaRMS. Personally, I’m a US citizen and obviously more familiar with ERAS, so that is what I’ll be talking about here.

 

ERAS: Electronic Residency Application Service

NRMP: National Resident Matching Program or THE MATCH

ECFMG: Educational Commission for Foreign Medical Graduates

 

As mentioned in the 2019 Residency Match Handbook from AUC (link above), you will need to:

  1. Research residency programs
  • FREIDA (https://freida.ama-assn.org/Freida/#/programs) is a fantastic way to start. You can sort programs by specialty and location. There is useful information for each program listed, including the percentage of IMGs accepted and minimum USMLE cutoff scores.
  • AUC Residency Match placements (https://www.aucmed.edu/about/residency-placements/2018-residency-placements.html) This is another good resource. You can see where other AUC graduates have matched in the past all the way from 2014. Additionally there is an excel sheet floating around somewhere with residency placements from AUC, St. George, and Ross over several years separated by specialty. Last time I checked it was on Facebook and will likely be updated with the match results from 2018 soon.
  • Basically, you can increase your chances of matching into residency by applying to programs that take a large percentage of IMGs, or programs that have accepted Caribbean grads in the past, especially from AUC. An important thing to remember with this process – NEVER apply to a program you don’t want to go to. Although it is important to match, you don’t want to be miserable the entire time. If you’re an average applicant with no red flags, you will have multiple interviews.

 

  1. Write a personal statement that can be modified for each residency program application
  • The personal statement must be specific to each specialty if you’re applying to more than one, like internal medicine and family medicine for example. However, the personal statement should also be tailored to the geographical location you want to match in. For example, residency programs in Hawaii require a personal statement that answers the question: Why Hawaii? Keep that in mind while you’re writing!

 

  1. Update your CV
  • There’s not much to say about this, except to be aware that interviewers can ask you ANYTHING off your resume dating back to the dawn of time. It would be best to review everything listed on your CV and be able to talk about each tidbit in detail.

 

  1. Request Letters of Recommendation (LORs) from your attendings, preceptors, program directors, and chairs.
  • Although title is important, it is always best to request a LOR from an attending who knows you well over someone with a distinguished title who will write a generic letter. My interviewers told me they rarely receive a bad letter of recommendation, but they do receive generic ones, and are constantly on the hunt of “key words” that indicate a subpar performance in clinical rotations. Do not ask for a LOR unless you have a good relationship with that person. How I usually approached a potential writer was with the question: Do you feel you can write me a strong letter of recommendation? This gives them an opportunity to say “no”. If they hesitate, walk away!
  • The LOR writers must submit their letters to ERAS themselves. Once you register with ERAS and receive your token, you can email them a copy of instructions on how to submit their letter using your provided token number. These take the longest amount of time and unfortunately, its out of your control. The only thing you can do to accelerate the process is to remind them of when your letter is actually due. I usually sent an annoyance email out to my letter writers every couple weeks. They were all submitted early/on time.

 

  1. Register with ECFMG (upload information, including photo to OASIS)
  • From the ECFMG Website, go to “Online Services” then “OASIS – Online applicant status and information system.” Here you can upload basic information including your residency photograph and transmit all information into ERAS. Once everything is loaded into ERAS you won’t be using this much. I took my residency picture with JCPenney. They almost always have a deal happening.

 

  1. Apply to ERAS
  • A token must be purchased through ECFMG. You use this token in the MyERAS Once you’ve registered, go through and submit your supporting documents (application, letters of recommendation, programs applying to). This site will be the most frequented site in your history. Programs usually communicate with you, (i.e. send you interview invitations!) through the MyERAS messaging inbox.

 

  1. Register for NRMP
  • This usually opens September 15th. After you register and receive your number, you must go back into your ERAS application and update it.

 

  1. Submit Transcript and Medical Student Performance Evaluation (MSPE) requests to AUC

There is a link for both the transcript and MSPE request on AUC’s website, under OSPD forms and resources. The deadline to request these is September 10th and September 16th respectively. The MSPE letter is a document outlining every piece of feedback you’ve received from your clinical rotations. Initially, on September 15th your application will be submitted from ERAS to every program you’ve selected without your MSPE letter. Many programs wait until your MSPE letter is released by AUC on October 1st before sending you an interview invitation. MAKE SURE TO REVIEW your MSPE letter for any inaccurate information. Errors do happen, but the school does give you an opportunity to review before they send it.

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My stunning mutt Brutus in all his glory at Mullet Bay Beach

 

As of now, that’s really all I can tell you about the application process. If you have any other questions, feel free to post them and I’ll answer as quickly as I can. The further I progress into the residency application cycle, the more information I’ll be able to provide for you. I know it sounds like a complicated process, and you’ll always feel like you’re missing something, but once you make an account with ECFMG and ERAS you will see exactly which documents you need. In addition, a basic schedule outlining when to take each USMLE examination and when to submit all other documentation is outlined in the AUC 2019 Match Handbook. I referenced this sucker all the time. In the end, YOU GOT THIS. Work hard, impress everyone, and do well on Step. Interviews will come.

 

Smiles,

CG

 

 

 

 

 

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An Island In Recovery

Today marks the 1 year anniversary since Hurricane Irma ravaged the little island of St. Maarten. I’ve taken some progress pics of St. Maarten during my brief time here so far, and there are many more to come. For now, here is Cupecoy, Porto Cupecoy, Philipsburg, Maho, and Marigot.

 

 

Smiles 🙂

CG

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Call me Golding, Dr. Golding

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It’s official!

 

Well, I’ve officially finished medical school. I’ve been thinking about what I could possibly write to mark the end of this crazy train, and then I thought, I’ll just write about everything! What follows will be my most significant summarized chapters from start to finish of the insane, stressful, rewarding journey of being a medical student at the American University of the Caribbean SOM.

 

Pre Island Jitters

Before Tylor and I began this grand adventure, we were living together in our first apartment in Manchester Center, Vermont. I had graduated from Castleton University over a year ago with a Bachelor of Science degree and was working as an Emergency Department Scribe, gaining experience for my next pursuit: medical school. I had filled out all of the applications, taken the MCAT, and received rejection letters from everywhere I applied to, except for AUC and SGU.

Obviously I knew about the stigmas associated with Caribbean medical schools, and a lot of research went into my decision. I found that AUC was one of the “top 4” Caribbean medical schools to attend. All have impressive residency attainment rates, and because of student success, federal loans are available. AUC’s residency match rate fluctuates between 80-90 percent. I knew with those odds, I could push myself to achieve my dream of becoming a physician. Of course, my opinion might change if I don’t actually match into a residency, but we’ll cross that bridge when we come to it.

Anyway, AUC and SGU had both offered interviews, but because AUC offered smaller class sizes and I preferred St. Maarten’s living conditions vs. Grenada, I chose AUC. Living conditions may seem like a trivial thing to a lot of people, but where I studied medicine for the next two years had a huge influence on me. I wanted paradise, and St. Maarten was ultimately the perfect choice. After a brief interview in NYC and an acceptance letter 2 weeks later, Tylor and I prepared to leave behind everything and everyone we had come to know and love to move to a foreign country.

 

Arriving to St. Maarten

As I’ve mentioned in previous blog posts, I do NOT like change. I prefer a strict daily and longitudinal schedule, and variation from that schedule creates anxiety. Well, lets just say leaving the state I was raised in and moving to a foreign country with a different climate and culture was not exactly my cup of tea. Tylor, on the other hand, is always up for adventure. Granted he had some hesitation leaving Vermont, but after a few Google searches of St. Maarten he threw himself whole-heartedly into an “early retirement plan”.

When we first arrived, I was convinced we made a mistake. I walked out of the airport and was hit with a wave of humidity (something I would grow to love by the way) and the hustle and bustle of local taxi drivers. Like shark drawn to chum, they were frantic to stuff as many tourists into their mini-vans as possible before the next flight arrived. As a result, the drive to our new apartment in Arbor Estates was NOT smooth. The mantra from Dodgeball comes to mind – Dodge, Duck, Dip, Dive, and Dodge – an entirely accurate statement considering I almost threw up in the backseat. Finally, green in the face and accompanied by an unsympathetic Tylor laughing hysterically, we arrived to our new Caribbean home for the next 2 years.

Arbor Estates is a gated community about 3-4 minutes walking distance from AUC. We paid $1250 per month for a 1-bedroom apartment. Looking back, I probably would not have rented an apartment on the ground floor, because mosquitoes were a huge issue. Every time you opened the door, a swarm hovering nearby would be swept into the apartment by the draft and proceed to keep you up at night sucking sweetly off your blood. They didn’t like Tylor much, but hot damn did they like me. I tried everything from spraying myself with Off! multiple times per night to duct-taping probable holes in the screen door, to buying an indoor mosquito device that drew them in using UV light. Nothing worked. Would not recommend. Other than the mosquitos, Arbor Estates was a decent place to be. It was close to the school and Mullet Beach and that was all I needed. A tall gate surrounded the entire community and there was a security guard present 24/7.

 

Medical School

Once medical school classes started, there wasn’t much time to get used to my new surroundings. I soon found myself fully immersed in material and trying not to drown. The first month of medical school was basically figuring out whether I was cut out for this gig. I walked in with so much confidence and was immediately torn down. I studied my butt off, and after the first round of examinations, I knew I had a chance to excel.

Here’s the general outline of courses for Semesters 1-5

1st Semester

  • Anatomy
    • Anatomy Lab
  • Molecular Cell Biology I
  • Histology

2nd Semester

  • Molecular Cell Biology II
  • Physiology I
  • Immunology
  • Biostatistics

3rd Semester

  • Physiology II
  • Microbiology
  • Pathology I

4th Semester

  • Pathology II
  • Neurology
  • Pharmacology

5th Semester

  • Introduction to Clinical Medicine
  • Behavioral Sciences

 

Each semester had trials and tribulations. Whether a student found a class easier or harder was entirely up to personal preference. Everyone seemed to struggle with different material. The important part was finding the perseverance to keep pushing even after a subpar grade. As Tylor can attest, I had a few meltdowns. My lowest test score was a 52% in physiology II. I couldn’t believe it. I went home, turned on my shower, and curled up in a fetal position in the tub, convincing myself beyond all reasonable doubt that I would fail. Tylor joined me and comforted me for several minutes telling me everything would be ok. I didn’t believe him at the time, but after working my booty off and focusing on my weak areas in Physiology, I walked away from that class with an 80%.

I definitely wasn’t the smartest student there, and it was incredibly frustrating to study so hard for the block exams while others put in a fraction of the time and aced every test. You must learn early to let go of the habit of comparing yourself to others; it’s not good for your mental wellbeing. There will always be someone who will academically out-perform you in medical school, that’s just the nature of the beast. After all was said and done, I ended up with an 84%, placing me somewhere in the top 1/3 of the class.

5th semester is a relatively light schedule because of all the time necessary to prepare for the comprehensive or “comp” exam. Students must pass AUC’s comprehensive exam with at least a 69% (when I was there) to take the USMLE Step 1 exam. The comp exam is through Becker, where the questions are notoriously more difficult than those on the Step 1 exam. If you don’t pass the comp exam, students must take a pathology and a physiology examination, and pass both. If you do not pass pathology and physiology, AUC sends you to a Step 1 review course in Texas to prepare you adequately for Step 1. Luckily for me, I passed comp on the first attempt and had 3 weeks to explore and enjoy the island.

 

Extracurricular activities

There are many wonderful activities to do on St. Maarten when you come across some rare but precious downtime.

First of all, the area is loaded with restaurants serving cuisine from all over the world. For such a small island, it really does have some good food. If you’re in the mood for something, more than likely you’ll be able to find it. Close to campus is Barcode, a popular and convenient place for students to have a sit down meal. BBs is also a very popular and cheaper option, especially if you’re trying to just pick up food and go back to studying. Now that I’ve returned to the island, many more restaurants have sprung up around campus. I have my work cut out for me!

Tylor basically became a beach bum while we were there, complete with growing his curly hair down to his shoulders. He spent his days lounging on the beach working on his nonexistent tan, swimming, and eventually spearfishing. Be careful though! Larger tropical fish bio-accumulate ciguatoxins, which can result in Ciguatera fish poisoning when consumed. Ciguatera fish poisoning can cause nausea, vomiting, and diarrhea, and is often followed by some neurological issues as well. Not a very fun thing to have, which is why I just flat out refused Tylor’s catch of the day, much to his dismay.

It was a sad day when we left, especially after spending 3 weeks with no medical school classes, just roaming and exploring our island together. There was so much that I hadn’t seen, and still after all of our adventures I missed so much more. But, life goes on and it was time to begin learning about the clinical aspect of medical school. Thus, we planned the next chapter of our lives in England.

 

Clinical Rotations

The United Kingdom

 I decided to do my OBGYN and Surgery clinical rotations in Epsom, UK because:

  1. I wanted exposure to another healthcare system
  2. I knew I wasn’t applying to OBGYN or surgery, so doing those rotations in the US wasn’t necessary
  3. The UK has a ton of hands on experience for medical students compared to the US, and I wanted to involved as much as possible!

 

Tylor and I found a cozy place in Epsom Downs, UK. It was a 10-minute bus ride to the hospital, or if you’re up for it, a 10-minute bike ride down a beautiful little trail. Epsom hospital was quaint and old, like everything else in England, but I had a great experience there.

The rotations themselves were pretty relaxed. You were responsible for your own learning, which I believe is how it should be. No one was there to document your attendance and you weren’t expected to adhere to a strict schedule.

At the beginning of my OBGYN rotation, I was given a handbook with the entire schedule for the month. I was able to pick and choose which events I wanted to attend, and tailor my schedule according to my interests. Turns out, I’m a huge fan of C-sections, and because they are scheduled, it was easier to plan my attendance compared to a spontaneous vaginal delivery. During the C-sections, the residents and attendings allowed me to scrub in and actively participate. They were great teachers and big fans of “pimping” the medical students. I learned and did a ton during my time there. I have no interest whatsoever in Surgery, so my time in that rotation seemed to drag on. I did see many interesting cases, but those were LONG days of just standing there observing.

Living in the UK for 6 months provided Tylor and I the opportunity to travel anywhere for cheap. Tylor visited about 15 countries while he was there. London is a fantastic (and cheap!) hub for travel. Ryanair often had flights for 30 dollars, and with hostels to stay in we barely spent anything while traveling. We spent about 1500 dollars total during a 15 day trip to Paris, Prague, Rome, Venice, and Barcelona and it was one of the greatest adventures of my life.

 

New York

With a fiancé and dog in tow, I decided to settle down in Queens, NY at Moda Apartments with reasonable access to 3 different hospitals: Bronx Lebanon, NUMC, and Flushing. This way we could sign a 1-year lease at a pet-friendly apartment (so difficult to find in NYC!) and have some measure of consistency for a while. Now that Tylor was able to work, he found a great job serving tables at District Social in Manhattan. With a little more financial security we were finally able to enjoy ourselves a little more and ease up on the penny pushing.

Although only 15 miles from Bronx Lebanon hospital, it took me nearly 2 hours to get there in the morning for a 6am shift. The commute definitely had a negative impact on how I viewed the rotation, but overall, it was a rewarding experience and further reinforced my interest in Family Medicine. The surrounding community is very diverse and many of their patients do not have access to health insurance. The family medicine team didn’t turn anyone away because of lack of insurance, so I saw a variety of ailments during my time in both an inpatient and outpatient setting.

The majority of my rotations were spent at NUMC, including psychiatry, pediatrics, developmental pediatrics, emergency medicine, infectious disease, rheumatology, internal medicine sub-internship, and radiology. I love the hospital, the surrounding area, and the staff. With each rotation, I learned something vital that shaped my perspective as a medical student. I became competent in many procedures during emergency medicine. My knowledge in pharmacology was reinforced (and reinforced again) during infectious disease. I gained a firm understanding of autism and ADHD in children during developmental pediatrics.

My last rotation was Radiology (I saved the best for last!) and on my last day it was very surreal walking out of the hospital completely finished with everything. I had completed 2 years of basic sciences on St. Maarten, taken Step 1, Step 2 CK, and Step 2 CS USMLE examinations, and finished 2 years of clinical rotations spanning over the UK and the US. Now all that’s left is to apply for residency and wait the day I match into my future program.

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Last day in our New York apartment! Brutie looks so confused.

Preparing for Residency

 At the moment I’m preparing my residency application through ERAS and waiting for the interview season to begin. I’m applying to family medicine programs mainly because I’m in love with all fields of medicine and I simply can’t choose just one! I’m a big procedure person and particularly like OBGYN and Emergency Medicine, so I’m looking for programs with an emphasis in those fields. Also, any programs with Global Health electives are a plus, because the majority of my family is still in the Philippines and it would be great to set up a healthcare outreach program.

August 1st – 4th was the Annual Family Medicine Conference hosted by AAFP (American Academy of Family Physicians) in Kansas City, Missouri. I presented my case report there and spent many hours in the EXPO hall, where almost 400 family medicine residency programs complete with program directors and current residents were in attendance. It was a great place to network with potential residency programs, but make sure to come with a game plan! Otherwise, the whole experience can be very overwhelming.

In the meantime, I’m back in St. Maarten all set to work as an introduction to clinical medicine (ICM) fellow during interview season. It’s a pretty sweet gig and Tylor and I were both anxious to get back to island life. I wanted to do something productive with the 10 months I have until residency begins, and the Caribbean is the perfect place to spend them. It’s a great opportunity for both teaching and research, and the program is flexible enough to let me travel for interviews. AUC provides fellows with a 1-bedroom apartment as part of the contract, and Tylor and I have been living it up in Jordan Village for the last 3 weeks. Once I start I’ll be able to explain what I’m actually doing a little better, so stay tuned!

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Our new home in St. Maarten!

 

Smiles 🙂

CG

 

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AAFP National Conference

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August 1st -4th was the annual American Academy of Family Physicians National Conference in Kansas City, MO. During my infectious disease rotation at NUMC, I encountered a couple patients with multiple necrotic ulcers secondary to Krokodil use. They consented to be a part of my case report, and fortunately that case report was one of the few presented at the AAFP conference this year.

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In addition to the many workshops and procedural skills courses, the AAFP national conference played host to about 400 different residency programs! Within a huge EXPO hall were rows and rows of booths lined with residency programs from all 50 states. It was truly an amazing opportunity for medical students to interact with program directors and residents from potential residency programs.

Honestly, if you’re planning to attend this beast of an event, come up with a game plan ahead of time! It will be overwhelming if you don’t. My best advice would be to have a list of residency programs where AUC students have matched in the past, and line them up with the programs present. It is impossible to visit every booth. You’ll be able to find a list of all programs in attendance before you leave, or through the AAFP Events Mobile App (https://www.aafp.org/events/national-conference/about/app.html).

This is an excellent opportunity for networking, and if you have ANY interest in family medicine, it’s a must-see event. You’ll never again get a chance to talk with so many programs under one roof, and you meet some really neat people along the way. When you stop at a booth, the programs will “scan” your badge and be able to see that you were interested in their residency come application time, so you’ll already have your foot in the door!

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Smiles 🙂

CG

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In the Meantime..

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I’m not sure if it’s the 2-3 month waiting period or just because so much rides on me passing the USMLE Step 2 CS exam, but I’ve never had so much anxiety over a test before. My friends tell me that the CS is nothing to worry about and they’re “sure I did fine”, but as each day passes I can’t help but remember new mistakes I made during the exam. Seriously I’m developing an anxiety disorder over here.

I really don’t mean to come off as such a downer, but it’s difficult to think about anything else right now. I have a suspicion my overly neurotic state is because the CS is my last USMLE Step exam, and the other 2 “more difficult” USMLE exams are officially passed and out of the way. Failing the CS could put a serious damper on my future plans at the moment, affecting my graduation in August, my ICM fellow job in St. Maarten, and the many residency programs that require a first pass CS score. Although I’m nervous about this exam, I can’t think of any obvious reason that would cause me to fail. I made sure to emphasize with my patients, my diagnoses were reasonable, and I’m a native English speaker.

The earliest date my CS exam can be reported is June 20th, the latest July 18th. The ICM program director expects me to start in St. Maarten in July. There are many huge life events culminating at the end of June and no way to really prepare for them other than keeping my fingers crossed, my breathing slow, and my heart rate stable. Once my Step 2 CS score is reported (WITH A PASS), there is the stress of once again, moving to another country. Thank god I have Tylor with me to help me through all of this. He’s the more emotionally stable one by far. This time, my four-legged fur baby will be involved in the moving process. That’s right, my Brutes McGutes wil be returning to his home island along with Tylor and I! I need all the cuddles I can get after all!

The paperwork involved with importing an animal into St. Maarten opens up a whole new can of hurdles.

For complete details, visit this site: https://www.aphis.usda.gov/pet-travel/health-certificates/non-eu/st-maarten-dog-cat.pdf

Other than stressing about what the future may hold, Tylor and I are doing pretty well. He’s been working as a server here in Manhattan (thank god someone is making money), and recently submitted his notice in preparation for our grand move. Our apartment building allowed us to stay for an additional 4 months outside of our original 1-year contract. Our move out date is June 30th! We’ll definitely miss NYC. Especially compared to the vast emptiness of Vermont, there’s always something to do here. This really is “The City that Never Sleeps”. I think I’ll miss the late night food deliveries most of all.

At the moment, we do not know for sure where we are going after June or if we should even keep our apartment furniture. It’s still a little early to start selling off possessions. This whole process is always chaotic, but Tylor and I are pros at dealing with uncertainties by now. Considering I’m the type of person who likes to have things planned far in advance, this took some getting used to.

For now, the plan is to move out of our apartment at the end of June and stay with family in Vermont for a few days while we get our affairs in order. Hopefully they’ll take us back!

Otherwise, school has been consistent. I just finished my Internal Medicine Sub-Internship at NUMC – TEAM MAGENTA, WOOO – and I start Radiology (MY LAST ROTATION) on Monday. Now that I’m not studying for a life changing USMLE exam, I’m focusing on making my residency resume look good.

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Proud Presenters

Recently, I attended the AUC Global Health symposium for a chance to see what my colleagues have achieved in healthcare all over the world. AUC was very well represented that day, with projects ranging from cervical cancer in developing countries to Zika prevention and public education on St. Maarten that is still going strong.

Dr. Majid Sadigh, a director of global health from my homestate of Vermont, moderated a panel of physicians concerning ethical dilemmas in AUC’s global health electives. During lunch, we had the opportunity to sit with physicians from special interest groups (like family medicine) and pepper them with questions about their field of choice.

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Go Zika Prevention!! 

All in all, attending this conference was a very valuable experience. I’m looking forward to also attending the annual family medicine conference in Kansas City this August. I recently learned that my Krokodil case report was chosen as one of the student presentations! There are many family medicine programs I would love to interact with there. Considering there are 100s of family medicine residencies, it will definitely be a busy couple of days.

Many of my friends graduated recently in Miami, Florida. I wish I was among them, but my time will come soon!! There were rumors that all future graduation ceremonies will be held in Miami instead of St. Maarten. Tylor will be BUMMED if that happens, but considering we’ll likely spend the next year in St. Maarten, hopefully he can suck it up.

CONGRATULATIONS again to all of my beautiful friends who have graduated as MEDICAL FREAKING DOCTORS and attained their spectacular residencies. The future is so bright for you guys, you should be very, very proud.

Smiles 🙂

CG

UPDATE: I PASSED CS!!!

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Rheumatology at NUMC

Rheumatology was unique among all other elective rotations. It involves the diagnosis and treatment of autoimmune conditions (Rheumatoid Arthritis, Lupus, Ankylosing Spondylitis) that can affect the joints, muscles, and ligaments. Before this rotation, I had not seen many cases of rheumatologic disorders, and in the cases I had seen, the patients had already been diagnosed with the condition. Now, I was witnessing how undiagnosed patients initially present and the pertinent questions the Rheumatology team asked to point them towards the correct diagnosis.

 

Of course, many of these patients had no idea what an “autoimmune condition” was. It was not a fun conversation to tell a patient that their body was literally attacking itself. There were many questions of “Why is this happening?” and “What’s the treatment?” Unfortunately, Rheumatic diseases are not like broken bones; you cannot simply set a cast and walk away. Treatment is a process of trial and error. These medications are meant to dampen the patient’s overzealous immune system and treat any symptoms that have arisen as a consequence. Effectiveness of a treatment varies on a case-by-case basis, and patients must be on a life-long regimen. Still, these regimens only slow the progression of the disorder, not halt it completely.

 

The Rheumatology elective is a 4-week rotation with relatively flexible hours. Although there are Internal Medicine residents present, the medical students typically work with the Rheumatology fellows. These are physicians who have chosen the field of Rheumatology as their career, and as such have much more knowledge about the disorders compared to residents. Sorry residents! Because the fellows are split between 2 hospital sites (NUMC and Winthrop) their schedules vary, but they’re good at communicating when they’ll actually be on site. The 2 days of Rheumatology clinic remain constant week to week. Clinic takes place on Tuesday and Wednesday from 8:30 – 12. All other days are consult based, and these patients are usually seen sometime in the afternoon with Dr. Anand, IM residents on the Rheumatology rotation, and the fellow. Dr. Anand is the program director for Internal Medicine, and a complete gem. She is one of the kindest attendings I’ve had the pleasure of working with, loves to teach, and values the input of MEDICAL STUDENTS – a quality that is (unfortunately) rare the “higher up” you climb.

 

Overall, this rotation was terrific for learning about presentation, diagnosis, and management of each rheumatic disorder. Clinic was a great platform to learn how the patients were reacting to each regimen, side effects of the medications, and how to alter management. Now that I’m studying for Step 2 CS, many of the same questions asked during my rheumatology rotation are appearing again. Asking a patient about cold intolerance is key for hypothyroidism. Fingers turning blue or white in the cold are a big indicator for Raynaud’s phenomenon, and possibly lupus. I learned a lot in a short amount of time, and I’m looking forward to using my rheumatology thinking cap in the future!

 

Smiles 🙂

CG

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USMLE Step 2 CS Exam

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Study Partner Furever

Hello everyone and welcome back to my blog! I’m sorry I haven’t updated in awhile, but I’ve had the month off to fill with CS studying which is pretty boring to write about. However, that’s just what I’m going to do, so enjoy (or not).

The USMLE Step 2 CS (Clinical Skills) exam is something every medical student needs to take before they graduate. It happens to be my very last USMLE, so I’m extremely excited for this to be over with. I know as a medical physician, I’ll be studying and testing for the rest of my career, but passing all 3 USMLE exams and finally graduating is a huge stepping-stone I’ve been working toward for a long time.

Step 2 CS “assesses the ability of examinees to apply medical knowledge, skills, and understanding of clinical science” (http://www.usmle.org/step-2-cs/), which basically means it can test anything you’ve learned during your time in medical school, particularly during clinical training. It’s typically seen as the easiest of the 3 USMLE examinations, but it is definitely not to be underestimated. There are still a small percentage of students who fail this every year. I would say this exam is the most important one to pass. Many residency programs require a first pass attempt for the USMLE Step 2 CS, but allow multiple attempts on Step 1 and CK. The total examination length is 8 hours with 2 breaks (30 minutes; 15 minutes) and 12 patient encounters (10 are scored). The length of each patient encounter is 15 minutes, and then you are allowed 10 minutes to write the note.

Many students break up the patient encounter into 3 segments:

7 minutes to collect a history (History of present illness, Review of systems, Past medical history, Allergies, Medications, Hospitalizations, Illnesses, Trauma, Surgeries, Family History, OBGYN, Social history, and sexual history).

5 minutes to do a focused physical exam. This depends on the patient’s presentation, but almost always includes heart, lungs, abdomen +/- Neuro, HEENT, and musculoskeletal.

3 minutes for closure. During this time, we summarize what we’ve learned from the patient’s history and physical exam and discuss a plan of action with the patient. Its important to counsel the patient on any unhealthy life choices that come up during the interview, including smoking, alcohol intake, diet, exercise, and sexual practices.

To pass Step 2 CS, you must pass 3 components of the exam: Integrated Clinical Encounter (ICE), Communication and Interpersonal Skills (CIS), and Spoken English Proficiency (SEP).

The ICE tests data gathering and data interpretation skills. Basically, this is gathering relevant information from your patient, performing a focused physical exam, and interpreting your information by recording everything into a patient note. The USMLE site offers a timed sample patient note form you can practice with http://www.usmle.org/practice-materials/step-2-cs/patient-note-practice2.html. This is the most commonly failed section on the Step 2 CS.

The CIS component is mainly a test of empathy. The simulated patients will evaluate how well you’re able to communicate with them and support their emotions. Overall, it tests your ability to conduct a patient-centered interview. The patient needs to feel that their concerns were addressed.

Lastly, the SEP score evaluates your ability to speak English. If you’re a native English speaker, you’ll have a pretty hard time failing this section.

To study for this, I mainly used First Aid for the USMLE Step 2 CS. It has 44 of the most commonly tested cases inside, with a sample note and appropriate diagnostic tests you should order for each. I also attended the Becker practice CS Course, which was very helpful in terms of timing. However, MAKE SURE TO SIGN UP FOR BECKER ASAP. Spots fill up extremely quickly for this and there are only a handful of locations available. In fact, the only reason I was able to get a spot is because someone happened to drop out and I was on the waitlist. Lastly, a good friend of mine sent me a list of mnemonics to remember what to ask on test day. I’ll share them here:

OLDCARTS is pretty popular to remember what to ask about the presenting complaint: Onset, Location, Duration, Character (of pain), Aggravating/Alleviating factors, Radiation, Timing, and Severity. That ones easy.

Adult Review of Systems: THEN FR CS PUB SAW ID: Travel/Trauma, Headache, Edema, Nausea/vomiting, Fever/chills/fatigue/sweats, Racing (heart)/Rash, Chest pain/Cough, Shortness of breath, Pain in joints, Urinary changes, Bowel changes (including abdominal pain), Sleeping problems, Appetite changes, Weight changes, Illnesses, and Dizziness.

Pediatric Review of Systems: FEVER CUD SAD: Fever, Ear pulling, Vomiting, Eye discharge, Rash, Chest symptoms (Cough, Colds), Urinary symptoms, Dehydration.

Adult Past Medical History: PAM HITS FOSS: Past medical history, allergies, medications, hospitalizations, illnesses, traumas, surgeries, family history, OBGYN, social history, sexual history.

OBGYN: LMP RTV CS PAP: Last menstrual period, Menarch, Regular periods? Tampons/pads per day, Vaginal discharge, Cramping, Spotting, Pregnancies? Abortions/miscarriages? Pap smear (Last pap smear and was it normal?)

Social History: WHARTED: Work, Home, Alcohol, Recreational drugs, Tobacco, Exercise, Diet.

Pediatric Past Medical History: PAM IF BIG DEALS: Past medical history, Allergies, Medications, Immunizations, Family history, Birth History, Illnesses, Growth and developmental history, Daycare, Energy, Appetite, Last Checkup, and Surgeries.

On test day, before I walk into a patient’s room I plan to write out these mnemonics as well as 3 differential diagnoses (based on the chief complaint). It should take about 1 minute to organize myself.

As for the physical exam, I’ve been watching Becker videos https://onlineusmle.becker.com/login that are available to AUC medical students for free through the school. I’ve been practicing those exams on my fiancé, Tylor. What a good sport!

I’ve also been practicing typing my notes into the template that the USMLE site offers. There’s not very much time to get in all of the information you gathered during the patient encounter, so it’s a good idea to practice typing it all out in a limited amount of time.

Some last words of advice – make sure to schedule the USMLE Step 2 CS exam as soon as you know when you want to take it. There are only 5 available evaluation centers (Atlanta, Georgia, Chicago, Illinois, Houston, Texas, Los Angeles, California, and Philadelphia, Pennsylvania). These centers fill up quickly! Also, keep in mind it takes 1-3 months for you to receive your scores. It all plays a factor in residency applications and graduation timelines.

Anyway, that’s what I’ve been up to this month. My exam is April 30th, so wish me luck!

Smiles 🙂

CG

*EDIT:

So yesterday I took the Step 2 CS exam. I got a quaint room through Airbnb in Philadelphia specifically meant for medical students taking the CS exam. It was within walking distance from the testing center so there was no need to navigate an unfamiliar public transportation system. Here’s the link to the house in case anyone is interested: https://www.airbnb.com/rooms/13061695

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Philly Sight-seeing!

This exam was quite anxiety inducing. It is very different from the previous 2 step exams, because it involves live patients and thinking through an interview real-time. Because of the time constraints for the patient history, physical exam, closure, and patient note, it is important to familiarize yourself with every aspect of the encounter before the exam to minimize mistakes. If I could do anything differently, I would practice typing sample notes more often into the USMLE practice interface. I consider myself a pretty quick typer, but that note combined with the stress of the exam was definitely challenging. I was able to transfer everything from my blue sheet into the computerized note, but did not have enough time to check over my work. I can only imagine the amount of typos within each submission.

I’ve never felt so unsure of myself with an exam before. Every major exam this far has been sitting in front of a computer screen and plowing through hundreds of questions. This time was so different. Throwing a real person into the mix sort of messed up my mojo. I have no idea if I did enough for the physical exams, listed the correct differential diagnoses, supported those diagnoses with sufficient detail from the patient encounter, or ordered the right tests. Only time will tell I suppose. My scores should be reported around June 20th.

UPDATE: I PASSED CS!!

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Infectious Disease – NUMC (+Match Day 2018!)

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Last month infectious disease, this month Rheumatology!

 

As many of you know, March is the month of “The Match” and results were announced today, March 12th. Congratulations to all of my fellow colleagues from AUC who matched today! Thankfully, every friend I’ve spoken to has matched! Now, they must wait 4 anxiety-provoking days to know WHERE they matched. Although I am not participating in this year’s residency match, a large number of my September 2014 class is, and I saw many happy Facebook posts today. I cannot wait to go through this process myself in just a few short months. Right now, I’m working on my own application list, building a spreadsheet of residency programs that are IMG friendly, have a history of matching AUC students, and perhaps most importantly – are in a location where I could spend a considerable amount of time.

 

Infectious disease, like my remaining rotations, was scheduled at Nassau University Medical Center, or NUMC. The infectious disease elective involves managing patients with bacterial, viral, fungal, and parasitic infectious. If antibiotics/pharmacology in general is your weakness, than this is the rotation for you! You’ll learn about drug management in depth, and QUICKLY. I saw a variety of cases during my time in this elective ranging from common colds to flesh eating bacteria. Some presentations jumped straight out of my medical textbook, like endocarditis due to intravenous drug use. Now that I’ve taken Step 2 CK and have a little more time on my hands, I’ve decided to write up a case report on one of these patients and will (hopefully) be presenting it at the AAFP annual family medicine conference in Kansas City! I’ve also started volunteering for 3 hours every Saturday for Project Happy, teaching children with disabilities how to swim. Its all been going swimmingly.

 

The schedule of the infectious disease rotation wasn’t too bad, a typical 9-5. Some days were earlier/later than others. Medical students rotate with 3 different attendings that switch week to week. Each brings a different patient management and teaching style to the arena. There are 1-2 residents on the team at a time with whom you work directly underneath. They like the medical students to see 2-3 new consults daily and present them to the attending during rounds.The infectious disease team is on an entirely different level when it comes to hygiene. I’m talking hand sanitizing every few feet and placing an extra glove around the bell of their stethoscope so it never actually makes direct contact with the patient. I felt like such a dirty grub around them, their hygienic techniques were so flawless.

 

At the end of this month, I’m scheduled for the Becker CS practice exam, a mock Step 2 CS exam. My actual USMLE Step 2 CS exam (the last one I’ll take as a medical student before I graduate!) is scheduled for the end of April. Once I take it nothing will keep me from completing the last of my rotations in June and graduating at the end of August. After years of studying my a** off, stressing about my future, and having a nonexistent social life, my goal of becoming a physician will finally be accomplished. Of course, the workload of my future residency program will not offer much of a social life, but at least I’ll be making money instead of accumulating debt!

 

Once again, CONGRATULATIONS to everyone who matched this year! YOU DID IT!

 

Smiles

CG

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Emergency Medicine – NUMC

I spent my January in the clutches of NUMC’s emergency department, a level 1 trauma center in Nassau County, Long Island. During my time there, I witnessed a variety of accidents, injuries, and illnesses, ranging from common colds to unresponsive patients. In 4 weeks I saw gunshot wounds, motor vehicle accidents, heart attacks, sexual assault victims, lacerations, massive hemorrhages, delirium, overdoses, and many psychiatric cases. I can only imagine what a 4-year Emergency Medicine residency would bring. There’s no way to anticipate what will walk through those doors.

 

Medical students have a love-hate relationship with the schedule. Most students are in their 4th year during this rotation and bouncing back and forth between interviews and the hospital. The schedule offers much flexibility for this, but 12-hour days in a very busy ED are exhausting. You’re usually scheduled 3-4 days a week. Before beginning the rotation, you can send interview dates to the preceptor, who will schedule your shifts accordingly. There are 14 total shifts to work with, 2 or 3 of those will be night shifts. Day shifts are 7am-7pm and can be spent on Team A (+recess), Team B (+trauma), or Pediatrics. Fast Track shifts are from 9am-9pm. Critical care shifts are from 11am-11pm (not everyone is scheduled for a CC shift). Night shifts are from 7pm-7am. You are always given the day off after a night shift to recover.

 

Lectures are once a week from 8am-2pm and are mandatory for students even if you have the day off. The preceptor will usually send you reading material for the lectures a few days in advance for preparation.

 

All in all, I thoroughly enjoyed emergency medicine, but I was grateful for the recovery time after the rotation was over. In such a high stress environment, it’s no wonder that Emergency Medicine ranks number one as the specialty with the highest burnout rate (https://wire.ama-assn.org/life-career/report-reveals-severity-burnout-specialty). As with all clinical rotations, there were pros and cons to Emergency Medicine. For me, I loved the procedures. The days could fly by if you found yourself wrapped up in procedures accompanied with a encouraging resident that loved teaching. I did many IVs, blood draws, sutures, castings, ABGs, EKGs, joint reductions, wound care, and several rounds of CPR. Befriend the nurses and it’s amazing how much they’re willing to teach you. However, because it is a fast paced environment and everyone has a long list of tasks to get through, not all have the time or patience to sit with you through a procedure multiple times. It truly lives up to the saying “See one, do one, teach one”.

 

As for the cons, I miss following through with a diagnosis. With emergency medicine, there are only 3 objectives in mind: stabilize, admit, or discharge. EM docs are trained to look for any red flags that the patient may die from. When further studies are needed for a diagnosis, the patients are relayed to other specialties or admitted to the floor for the internal medicine team to take a look. I suppose that’s why I’m so attracted to family medicine. I need to know what’s wrong and crave the continuity between doctor and patient.

Right now, I have a week to prepare for my infectious disease rotation. Only 4 more rotations to go! I just registered for the Step 2 CS exam permit ($1565), which I’ll schedule at the Philadelphia site for the end of April. Even though it’s still the 2018 residency season, I’m beginning to prepare for my own residency cycle. There’s so much to be done! Speaking of which, I’m off to get a professional photo taken for my residency application. Time for an hour of awkward smiling.

 

Smiles 🙂

CG

 

 

 

 

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