dear third year pdf

7/31/2019 Dear Third Year PDF

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Lettersto a Third-Year StudentFrom The Class of 2011

School of Medicine

ARTS AND HUMANITIES IN HEALTHCARE PROGRAMCENTER FOR BIOETHICS AND HUMANITIES

UNIVERSITY OF COLORADO ANSCHUTZ MEDICAL CAMPUS


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Letters

to a Third-Year StudentFrom The Class of 2011

School of Medicine

FOUNDING EDITOR: THERESE JONES, PHDDIRECTOR, ARTS AND HUMANITIES IN HEALTHCARE PROGRAM

MANAGING EDITOR: ANJALI DHURANDHAR, MD

ASSOCIATE DIRECTOR, ARTS AND HUMANITIES IN HEALTHCARE PROGRAM

COVER ART: ANJALI DHURANDHAR, MD

DESIGN AND LAYOUT: MARY DESIMONE

MARCH 1, 2011

LETTERS COLLECTED FROM HIDDEN CURRICULUM,

FOUNDATIONS OF DOCTORING

UNIVERSITY OF COLORADO ANSCHUTZ MEDICAL CAMPUS


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Table of Contents

Foreword

STEVEN LOWENSTEIN, MD MPH ................................................. 1

Introduction

THERESE JONES, PHD ................................................................. 3

Letters to a Third-Year Student

MYCROFT SMITH ......................................................................... 5CHRIS BREED ............................................................................... 6

LISA GILL ...................................................................................... 7

DANIELLE SHIMEK ....................................................................... 8

CASSIE LIGGINS ........................................................................... 9

JENNIFER BISHOP ...................................................................... 10

DANIEL JENSEN ..........................................................................11

CHRIS GALTON ........................................................................... 12BEN ELKON .................................................................................13

JOSH POTOCKO ......................................................................... 14

LEAH SWANSON .........................................................................15

DAVE TARULLO .......................................................................... 16

JAMIE WEBER ..............................................................................17

TYRA THORSTAD ....................................................................... 18

NICOLE ERWIN .......................................................................... 19

KEELY CHEVALLIER .................................................................... 20

CRYSTAL MEDINA ...................................................................... 21

BECKY HIGBEE ........................................................................... 22

Afterword

ANJALI DHURANDHAR, MD ........................................................23


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ForewordPrepare To Be Surprised

A FEW WEEKS AGO, I was asked to write a oreword to this frst edition o Letters to a Tird-Year Student. My

assignment was straightorward: encourage you to read this book; highlight the most important themes; oer wis-dom and some practical tips or success; and wish you well as you embark on your frst clinical rotations.

Te letters in this book, written by medical students in the class o 2011, speak or themselves. Tere is practicaladvice (On rounds, jump on the easy question early; remember that surgeons dont wear stethoscopes around theirneck; take o your white coat beore starting chest compressions; never have political discussions in the OR). Tereare cautionary notes (Practice your case presentations; read about your patients every day; i you didnt check a labtest or perorm part o the physical examination, never cover up and say you did; take care o yoursel, because youneed ood and water, too). Perhaps most importantly, these letters oer a hint o the adventures that lie ahead. Medi-cine is flled with wonder and great surprises. Cassie Liggins letter included this advice: Prepare. Prepare by throwingyour expectations out the window. Prepare to be surprised.

Kathryn Montgomery Hunter, a proessor o medical humanities, once wrote about the appalling moment at thebeginning o clinical training when students are compelled to realize that, despite their years o successul study inthe basic sciences, they know almost nothing that would be o any help to a patient.

Proessor Hunter is incorrect. No, you do not know the same amount as your resident, and you cannot answerevery question correctly on rounds (See yra Torstads letter: Get used to the act that you wont be the smartestperson in the room or a VERY long time). Te act is, third year isnt all about book learning or PowerPoint, andyou cant ace the practice o medicine. But you can always help your patients i you bring your whole sel to work not just your inquisitive mind, but also your gentle hands, your comorting smile and your heart flled with hope.Tats when your patients will insist on calling you doctor. Or as one medical students patient called him, baby doc.Its why you are here. Bring your whole sel to work.

One o the salient messages in these letters is that you must allow yoursel the privilege o talking with yourpatients o getting lost in their stories, even i, as Jamie Weber wrote in her letter to you, your patients will testyour brain and push your emotions to the brink. Very soon, you will care or patients who are dying, perhaps becauseo liver disease or emphysema or cancer. Ater rounds, when all the inspection, palpation, percussion and ausculta-tion are done, you may have the chance to go back to the patients bedside, just to listen. And you will hear the otherpart o the patients story that no one else on your team will ever know. You may hear about your patients lie asa teacher, perhaps, or a jazz trumpet player or a navy pilot in the war. Your patient may tell you about his wie, thechildren they raised and the dreams they shared. You may marvel at your patients resilience and grace. Your patientmay smile, call you doc and say that you lited his spirits. And he will lit yours. Cassie Liggins, class o 2011, wrotethis advice to you: Walk into each rotation with an open mind and an open heart you will need both.

I wish you all the best on your clinical rotations. Each o you will have a dierent adventure. But there is oneadventure that you will share with your classmates and with 100 years o medical students who have come beoreyou. Every day and oten late into the night, you will learn about medicine. You will make great diagnoses. You willgive outstanding medical care as members o your clinical team. And, with your laser-like ocus on listening, caringand comorting, you will inspire hope and touch lives. Its what you came here to do to save the world one eightyear-old, or one eighty-eight year old, at a time.

Steven R. Lowenstein, MD, MPHProessor o Emergency Medicine and MedicineAssociate Dean or Faculty AfairsUniversity o Colorado School o Medicine

1 Hunter, Katherine Montgomery. Doctors stories: Te narrative structure o medical knowledge.Princeton, NJ: Princeton University Press, 1991.


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IntroductionFROM 1903 TO 1908, Czechoslovakian poet, Rainer Maria Rilke, wrote a series o letters to a young, would-be

writer about surviving as a sensitive observer in a harsh world. Rilke wrote about taking risks not only to succeed butalso to ail: Always trust yoursel and your own eeling; i it turns out that you were wrong, then the natural growth

o your inner lie will eventually guide you to other insights. He wrote about being impatient to know everythingbut being comortable with knowing nothing: ry to love the questions themselves as i they were locked rooms orbooks written in a very oreign language. And he wrote about being aware o yoursel in the world but being cautiousabout taking yoursel too seriously: Dont be too quick to draw conclusions rom what happens to you: simply let ithappen.

Tat book, Letters to a Young Poet, has inspired many subsequent writers and teachers to share their own obser-vations and insights, their own words o wisdom and warning, with other young readers embarking on a lie in thearts, in religious and public service, or in the proessions o law and medicine. Tese individual works are now part oa series called Te Art o Mentoring and include such titles as Letters to a Young Jazz Musician by Wynton Marsalis,Letters to a Young Conservative by Dinesh DSouza, Letters to a Young Contrarian by Christopher Hitchens, andLetters to a Young Lawyer by Alan Dershowitz.

Te frst collection o Letters to a Young Doctor was in 1996 by surgeon and writer, Richard Selzer and meant tobe, in his own words, pedagogical and comradely--a reaching out to share. Te goal o the second, Perri Klass 2007volume, reatment Kind and Fair, was a combination o maternal and medical wisdom. Her letters are addressed toher son in medical school--the very child born during her own education at Harvard in the 1980s, where she was oneo only our women in her medical school class. Writing about and across their respective lietimes, both Selzer andKlass not only reveal the compelling mysteries o the world o medicine but also represent the tedious challenges othe job o medicine.

Members o the Class o 2011 are now part o this long and respected literary tradition by giving you practicaladvice, helpul suggestions, and personal reections on the year ahead o you in this collection, Letters to a Tird-Year. Since I launched this project a number o years ago in another medical school, I, like all o the readers o allo such letters, have been given the opportunity to learn along with you, to marvel at your courage and creativity, toapplaud your stamina and resourceulness, and to bear witness to your pain and your joy. Just as these letters providea mirror o your own experiences and emotions in the third year, they also provide a window or those o us look-ing in at you and looking out or you as you make this journey, so please share them with your partners, your amily

members, your riends and your teachers.I will close, appropriately enough, with another passage rom one o Rilkes letters in which he encourages thatvery frst reader to experience and express all that is happening around him, to him, and because o him: urn towhat your everyday lie aords; depict your sorrows and desires, your passing thoughts and belies in some kind obeauty. Depict all that with heartelt, quiet, humble sincerity. I you ollow such advice, just imagine what letters youyourselves will write . . . same time, next year. I cant wait to read them!

Terese Jones, PhDSpring 2011


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Dear Phase III Student,

IN MEDICINE, AS IN LIFE, it is extremely important to eel comortable in your own skin. Te only dierencebeing that, in medicine, your skin is bright white, ull o pockets and has a black university logo over your right breastthat slowly ades to pink. I still vividly remember the white coat ceremony and the excitement I elt when I tried on

my new skin or the frst time. It seemed smaller than I anticipated in act, mine hardly covered my belt buckle andmy sleeves stopped about mid-orearm. I struggled that frst day, in ront o the whole crowd, contorting my armsbehind my back to try to fnd the tiny little sleeve holes. My arms eventually ound their way but not beore I elt alittle panic, a sense that this coat was too small, too tight or too restrictive.

I quickly orgot this eeling as I blended back into the herd o med students stacked stadium-style frst andsecond year. I somehow managed to avoid wearing my little white coat most o those frst two years. Ten, on the frstday o my frst clerkship, I again had to struggle with the white coat. I continued to eel a baseline discomort whenwearing the coat and to make matters worse, it was now loaded ull o books, tools and notes that oten clattered tothe ground in ront o amused residents. Tat frst week, I even had a resident tell me that he could tell I was a 3rdyear because it looked like a yard sale every time I pulled my coat out o my backpack.

I have to admit it wasnt simply the coat that made me eel uncomortable third year. You, too, will soon enjoythe conusion that is inherent when starting at a new hospital, with a new computer system, new residents, new

attending and a completely dierent subject matter every our weeks. Certainly both the coat and the environmentcontributed to my eeling o awkwardness, but or me it was overcoming the coat that made everything else all intoplace. It all came together or me one day when an old woman caught me in the hallway outside o her room and ad-dressed me as Baby Doc.

An occasional, conused patient and even a ew nurses had called me doctor in the past, but it never elt right.I always elt like I was an imposter. I knew it was my tighty whitey that conused them, and I think that is why itmade me uncomortable. It wasnt being conused or a doctor that troubled me. Our coats are clearly only o areal doctor coat, visibly warning all observant patients that we are only o a real doctor. For me, the problem wasthat I saw the coat not only as the symbol o a physician but o all the clinical knowledge a physician is supposed tocommand. When I wore the coat, I elt as though I were pretending to possess knowledge ar beyond what I hadreally acquired. When the sweet little lady called me Baby Doc, she somehow released me o the guilt that I eltor impersonating someone with answers. I elt very proud to be addressed as baby doc. It was a title more ftting omy training. A title that I could honestly tell mysel I had earned and not just received through social promotion by

virtue o being in medical school. She reminded me that we all start as baby docs, and it is okay not to know the rightanswer, even i your white coat suggests to others that you should.

Her comment made the coat eel less restrictive though my tiny sleeves still made me look as ridiculous as ever. Irealized then that, by avoiding the dreaded baby doc coat, I had not only ailed to learn how to properly put it on, butI had also missed the opportunity to become comortable in it. It is a powerul symbol, the signifcance o which I amstill learning to accept.

Tis year you will certainly eel conused, you will have diculties accessing computers systems, your badgesmay lock you in a stairwell, you will consistently have attendings give you contradictory instructions, you will un-doubtedly eel under appreciated and overworked, and many o you will initially eel uncomortable in your whitecoats. When you eel rustrated, just remember that all residents and all attendings started as baby docs in short coats

just like yours. Tey all struggled through an awkward adolescent phase in their medical training. Just like true ado-lescence, this third year will eventually pass. My advice or getting through it is to work on eeling comortable in your

own skin. Wear your coat oten, wear it proud and buy a bigger size, not just because your university logo has turnedpink but because you will grow into it as you mature into a physician.

Mycrot Smith


7/24

Dear Fellow Student Doctors,WELCOME TO YOUR THIRD YEAR CLERKSHIPS. I bet you are excited, but you are ner-

vous too, arent you? All who have come beore you know exactly how you are eeling, yet yourexperiences in the coming year will be uniquely your own. Tereore or me to oer advice suchas how to survive a clerkship, lessons you should learn, or how you should act would portendyour experience being similar to mine. Te only thing I can say with confdence is that it willmost defnitely not be.

So beore starting that frst day o your clerkship: Stop. ake a deep breath. Remind your-sel why YOU came here. Why are you at this place, at this particular time in your lie? Whatare you hoping to get out o the next twelve months? Who do you believe you are today? Do youthink youll be the same person in a year? What type o physician will you be?

Answering these questions will help you shape your 3rd year o medical school. I you areunsure o any o those answers, thats okay; you are not alone. Te truth o the matter is you willsurvive this. I you can answer that last question beore you answer what kind o a physician youwill be, then you were successul in your 3rd year.

My only advice, i I may oer some, is remember every day that to be here, to share in ourpatients experiences, to be part o their healing process, to engage them when they are weak andvulnerable, to learn rom themthis is a true privilege. Be honored every day. When lie is toughand time is short, remember they are human beings. Be grateul. ell them thank you.

Chris Breed


8/24


IF YOURE ANYTHING LIKE ME, you are terrifed o what lies ahead o you in the next year. In act, the last dayo ICC week I grabbed my pager and sprinted over to my preceptors oce to get a prescription or a beta blocker tokeep my giant nervous tremor at bay while I was presenting. I was convinced Id learned nothing the previous two

years and that I was fnally going to reveal just how incompetent I really was.In a way, I was right.

When I started my frst rotation, I did eel that I knew nothing. I absolutely elt incompetent. And guess what. Itwas okay! I was right where I was supposed to be. And it didnt stop with my frst rotation. With the start o everyrotation, I elt like I, once again, knew nothing and had to start all over again. But with every rotation, I learnedthings, many o which had nothing to do with the science o medicine, but just as, i not more, important. Hopeully,I can pass some o this on to you without inducing any panic.

1. You have to be selfsh. Tese rotations can only help you as much as you let them. So let them work or you.My real lie example: my medicine rotation. By that time (rotation #5), I knew I was going to go into OB/Gynand was truly dreading my time on the wards. In the end, I enjoyed this rotation, and I learned so much. ButI was also practical about it. I chose sites where I hoped to do my sub-internships so when I started 4th yearrotations, I could skip the orienting mysel to location step and get down to business. When I needed to do a

project, I turned the busy work into a mechanism to learn about what I really wanted to know: how do I applythis medicine stu to an OB/Gyn patient? I eel ready or my sub-Is and I eel like I got more out o that rota-tion than I could have i I had decided to passively muddle through. I might not have loved the work, but thebenefts were greater than I ever thought they could be.

2. Do something or yoursel, something or those you love, and something or school every day. No matter howhard the rotation, no matter how long the hours, you do have time to send that email, make that cup o tea, goor a run or a walk. At the end o 3rd year, yes, your grades and comments will be important, but i you get tothe end o 3rd year with a lie you dont recognize, being a person you dont recognize with a fstul o honors have you really gained anything? Lie doesnt actually stop because youre on call. Keep it in perspective.

3. Know when youre in over your head and get help. Whether this happens because your patient is getting sick inront o you or because you are truly losing your mind. Know who it is you can go to when things get bad andmake sure that when you need them and you will that you know how to reach them.

4. Be there or your classmates and dont be a competitive jerk!Even i its just a kind word, a smile or checking alab that you know they wont have time to do, be there or each other. When you are alone on the wards, youllmiss your classmates, so dont waste the positive relationships you get a chance to build. Tese people will beyour colleagues long ater the ames o competition have died. Some day when you are lost on what to do nextor your patient, youll want someone to call that you can trust. Give them a reason to trust you.

Lastly and most importantly:

5. Its okay to hate it. I remember someone telling me beore third year started that i you dont like 3rd year, youshould consider changing proessions. Tats crap. Tird year is intense and unique in the act that you start anew job every 4-8 weeks. When you start a new job do you instantly love it? No way! Just when you start to eelcompetent you get to begin again and that is not a great eeling. Just because you dont love the eeling o be-ing a 3rd year student in no way means you dont love clinical medicine. ake what you can rom each rotationand leave the rest behind. Dont question your capability as a uture doctor because youre not unctioning as a

resident when you start out as a 3rd year student. It gets better and better. Dont lose sight o that.ake what you can and ditch the rest. A theme o 3rd and a theme o any (particularly unsolicited) advice. It may

be useul, it may seem ridiculous I ll let you decide. All I can tell you, with absolute certainty, is that you will learnso much this year! And youll come out the other end (I promise you will!) knowing one thing more than ever beore there is still so much to learn. But its just as true in lie as it is in school, and it is all part o the ride. Enjoy it, keepit in perspective and learn to prioritize what really matters.

Oh yeah and keep brushing your teeth and showering. Seriously.

All the best Lisa Gill


9/24

Dear Phase III Students,

TO SAY THAT THIRD YEAR IS A CHALLENGE would be an understatement. I would say it is more trial by fre,y by the seat o your pants, orget what day o the week it is kind o un. I have assembled a ew Dos and Dontsrom my experiences that may help you navigate third year successully (or at least more successully than me):

t Do send out gruesome photos to your amily and riends. Great conversation starters or stoppers. (see photoo me holding my inaugural 3rd year amputated oot during my surgery rotation)

t Do keep an open mind. You may be surprised at what you like and what you dont like. I will be happy iI never have to do a well-woman exam again in my entire lie, but not many people can say they were giventhe opportunity to deliver about a dozen babies!!!

t Do practice your presentations. I you can impress your attending with a clear, succinct, well-organizedpresentation on your frst day o a rotation, you will not have to work as hard to impress them later.

t Do spend a lot o time with your patients gathering history and working on physical exam skills. It can bevery rewarding in act, I won a bag o M&Ms during my nursery rotation or diagnosing a congenital

hip dysplasia. Yum.

t Do take the stairs whenever you can you never know when you will make it to the gym again and thesandwiches at the VA are not exactly low-cal.

t Do extra reading about your patients and, i given the opportunity, discuss this inormation on rounds.Residents do not oten have the time to do this and appreciate that you were willing to take the extra time toadvocate or your patients and enlighten the team.

t Do take the time to jot down some memorable moments they will come in handy when you are writing yourpersonal statements, or i you need a moment to reect on how much you have accomplished.

t Dont take it personally when your attending tells you on the frst day o your internal medicine rotation,Te only person who actually cares i you show up is your mother.

t Dont wear your white coat when drinking coee or eating anything with mustard on it. Mine is downright

embarrassing to wear I really like coee and mustard. I would also suggest removing your white coatbeore attempting to compress a emoral arterial line. Tose babies can bleed.

t Dont make your ellow students or residents look bad no matter how good you think it will make you look(this strategy has a tendency to backfre).

t Dont arrive late, but Do leave early i someone gives you the green light to do so.

Best o luck to everyone!!Danielle Shimek, MSIV


10/24


PREPARE TO BE SURPRISED! Prepare to be shocked and amazed during this third year inyour medical education. What you will be doing is like nothing youve done beore. You will walkout o your frst two years o medical school ull o knowledge and inormation. You are eagerto take all that you know and see what it means in the hospital. You are nervous and anxious,you are concerned about how you will perorm, you wonder i you will have all o the answerswhen pimped, you wonder how you will do. You will fnd that none o that matters. You will fndthat your patients care less about what you know and more about how you treat them. You willfnd in the end that is all the attending and residents care about as well. We are taught so muchinormation, we are given the equations and taught how to apply them; we are walking vesselso knowledge. We are also human. We are daughters and sons, mothers and athers, sisters andbrothers, and riends. It is these traits that will carry us through third year. It is these skills thatwe could not be taught. It is this that will make us true physicians.

So i I have any advice to oer, it is this: throw your expectations out the window. Walk intothird year with an open mind and an open heart, and prepare to be surprised. I learned in thirdyear that I really didnt have my uture fgured out. I learned that patients expected more romme than I thought I would be expected to give, and I learned that these same patients would giveme more than any book or lecture I could experience. I learned that every specialty plays a cru-cial role to provide well-rounded patient care. You may hear physicians bash other specialtiesbut know that without this variety that medicine has to oer, we each may not fnd our places.Also know that our patients see us or help. Tey are in a vulnerable position, and they eachdeserve our respect. I think many times we can get caught up in the role and expectations o athird year medical student and orget that these are not SPEA patients or a test or us to pass.Tese are real people who need our attention and compassion.

Lastly, I would tell new phase III students to stop and think about where they are. Medicalschool comes and goes incredibly ast. Te frst and third years tend to be overwhelming and

outside o our comort zone, so we tend to get caught up in the action o what we are doing.I would tell new third years to remember that we are in such a unique and privileged position.We can really make a dierence in the lives o everyone we encounter. What a privilege and whata responsibility. Please remember this beore walking into the room, beore leaving just a ewminutes early rather than checking back in with your patient, beore aiming to impress yourattending rather than impress your patient. Please remember we are training to be physiciansand although we will always be students, we have a larger role to play now.

Good luck! You will all be antastic!

Cassie Liggins


11/24

A Letter to an Incoming

Third Year Medical Student,THIRD YEAR OF MEDICAL SCHOOL eels like swimming in a turbulent current in vast

open water. My arms are moving, my legs are kicking, and I am just ocused on keeping my headaoat. Occasionally, there is a lull within the waves once you are on your 4th week o your rota-tion and you know your team, the material and the expectations, but this is quickly ollowed bya blow to the ace and you are plunged back under the water at the start o a new rotation. Whatcan make it even harder is that, despite all your struggles to keep your head above water, you arein expansive open water, and there is not a shore in sight. It is a methodical repetition o stroke,stroke, stroke, breath. But the danger is, i I keep my head down and barrel through the current,I wont take a moment to look up and see the lie ring that has been thrown out by a rescue boatpassing by. Tat lie ring can come in many orms. It can be the encouragement to maintain acurious mind that comes rom my attending, or the kind smile rom my resident who believes

I will succeed, but the best is when it comes rom my patients.Even by this point in my training, I have images o countless aces lying in hospital beds.

I eel like I have seen the spectrum o patient attitudes toward disease. Some patients are quiet,reective and tearul. Others are angry, bitter and rustrated with the system. Some lay alone inbeds, without a visitor in their rooms they could name. Others are inundated with people, gits,owers and pictures on the wall. But within all these aces, there are some that just stand out.Occasionally, I will walk into a room, and my eyes will meet the eyes o someone with whomI just connect. In that moment, I pull my head above the current, or I reach or the lie ring andI fnd time to sit at their bedside and hear their story. In some crazy way, this gives me rest. It isan interesting concept to think that, with all the resources an academic training system has tooer, some o the best encouragement comes rom the patients that we are trained to heal.

All the responsibilities, the commitments, the long hours o studying, learning new hospital

systems, orders and team dynamics can be lited o my shoulders when I can recline in my seatand hear the wisdom and perspective that comes rom a person who has suered. I continueto ask mysel, how can this be? How can a person in such a time o need, o hardship, fll thisrole or me? Even more, what kind o person is able to shine this kind o light in the midst opersonal darkness? I am not sure I have an answer to this. Many o these patients are experienc-ing my greatest ears: a terminal diagnosis, excruciating pain, loss o their physical capacity. Butdespite this, they are still not plagued with despair. Rather, they shine.

What I do know is that the patients, who provide me with that perspective, throw me a lie ring.Tey remind me that lie is precious, and the human spirit is resilient. And i I could oer any onepiece o advice to an incoming third year student, it would be: Dont orget to lit your head up romthe current and take a look around you. Although you are in vast open water, there are opportunitiesor rest and perspective, and you just might fnd them in the most unexpected places.

Sincerely,Jennier Bishop, MS4


12/24

Dear 3rd Years,

THERE IS NO DOUBT IN MY MIND that medi-cal school possesses a unique set o challenges and thatholds especially true or the third year. It is truly the frst

great Waterloo o medical education, and it is duringthis time, our frst clinical playground, that we learnthe rules o conduct and set the course that will deter-mine what kind o doctors we will be. Some o the mostpopular advice regarding third year will be about how towrite an exquisite SOAP note, or how early to get to thehospital in order to pre-pre-pre-round. Tese are all verygood and timely. My advice, however, boils down to onething: come out o third year a better person than whenyou started.

Unortunately, many o your predecessors have allenvictim to cynicism ater spending time on the wards.Cynicism is very insidious in onset and rooted deeplyin the medical tradition. Really, theres no mystery asto why this is. We are taught to ask questions, look orproo and come to logical conclusions. We deal withpatients who do not take care o themselves or who evenseek medical attention or obvious personal gain. Youwill see it, too. Te lure o sarcasm and cynicism is great,especially in these settings. Te temptation is urthermagnifed when our interns, residents and attendingsparticipate in such behavior. What I would say to youis that you must resist the urge to descend to thoselevels. Your patients are real people with real lives andreal illnesses. Tey have amilies and riends who care

about them. Tey are looking to you or answers to theirmedical problems. Remember that while you will otenpossess the advantage over your patients o having medi-cal knowledge, the abuse o that position o authoritythrough sarcasm and cynicism will eventually beget abad physician. Do yoursel a avor and cut the cynicismout. Remember that your patients are real people.

We are oten taught to separate ourselves rom ourpatients in order to guard against emotional burden inthe case o tragedy. I personally eel that this, in and oitsel, is a tragedy. It will not be long beore you have apatient who dies or has a poor outcome. My recommen-dation to you is that, i possible, you open yoursel up

to these experiences and really try to connect with yourpatients. I had a patient with end-stage pancreatic cancer

who was unable to speak. Yet, while I cared or him inthe ICU, we shared a bond that was much deeper thanwords alone could produce. In his last hours o lie, he

grasped my hand and looked at me as i to reassure methat everything would be okay. What he taught me inthat moment was so much more valuable than creatinineclearance or proper vent settings he taught me some-thing about lie and something about death, and I wouldhave missed out on that i I had remained disconnectedemotionally. You will not always have the opportunity tospend a lot o time with your patients and connect withthem on a deeper level. ake the opportunity now, andyou may learn something you never expected.

Lastly, one o the most important things to rememberduring third year is to maintain proper perspective. Sure,grades are important and so is impressing your residentsand attendings, but they are not so important that youshould orget to take care o yoursel. Aside rom school,think about what is important in your lie. Do you haveamily or children? Do you love to hike or play the gui-tar? Dont neglect yoursel by omitting the spice o lieduring third year. Tere are probably many o you, whoare so saintly that you chronically put the needs o othersahead o your own. Tis, o course, is unsustainable inthe long run. It is important to nurture yoursel whenyou can and in doing so, you will be a better nurturer onthe wards.

Tere are many other things that could be said.

Tird year is a time o tremendous growth and sacrifce.Remember those around you who sacrifce or you to behere. Remember that you are becoming a physician, not

just someone who prescribes medicines and providestreatment. Tis is the time to decide what kind o physi-cian you will be and set a pattern o living or the rest oyour lie.

Daniel Jensen


13/24


IT WASNT ALL THAT LONG AGO that I sat in your seat. It wont be long beore you are sit-ting in mine. Although it may not always seem like it, this year goes ast.

Te frst time your alarm goes o at 0315, so you can make the pre-pre-rounds or surgerysucks. Te next day your alarm goes o at 0300 which isnt much better. By the end o yourrotation, you will convince yoursel that setting your alarm or 0400 is sleeping in, and i yousleep past 0500, youll be asking yoursel where the day went. One day your alarm clock will goo, and you will have an epiphany about paying expensive tuition or this opportunity!

Tere will be times that you wonder just how bad can it get? Every time those thoughtscross your mind, think o your amily and what they are going through to ensure your success.Tey are losing sleep, passing up their own opportunities, and giving up time with their lovedone. ake pride in your success, but dont lose sight o the people who sacrifced to give you this

chance.No one expects you to be dressed to kill at 0600 six days a week, but brushing your teeth

doesnt hurt. Te guy with the anciest tie does not win a prize. When your white coat looks likeyou just changed your cars oil, maybe its time to wash it. Te rotations you get to wear scrubshave an amazing eect on your laundry bill and your morale since you get to sleep or an extrafve minutes instead o struggling to fnd a presentable outft.

Not every rotation will have a proound eect on you. For some, none o them will. Tere areover one hundred specialty options available or a career, and third year clerkships expose you tofteen o those options i you are lucky. Go into every clerkship thinking that this could be myuture career, and i nothing clicks, there are always ourth year electives and sub-internships.

When in doubt, just remember that everyone teaching you was once in your shoes. Tey gotbeaten up just as much as you are now. Someday it will be your responsibility to teach those

junior to you, and they will be the physicians taking care o you and your amily. Dont orgetwhere you came rom.

Enjoy it when you can. Survive it when you have to.

Chris Galton


14/24

Dear Third Year Student,

CONGRATULATIONS, AND WELCOME TO

PHASE III o the CU SOM curriculum. You now haveStep 1 behind you and are ready to move orward withthe clinical portion o your training. Tis is truly themost exciting, challenging and rewarding period o your

medical training.Survival ips:

1. Bring your own ood. Many rotations do not havebuilt-in lunch breaks and even those that do may runlate and prevent your reedom to roam to the nearestcaeteria or Jimmy Johns or a nice lunch break.

2. On a similar note, bring ood with you on any ex-tended trip away rom your work room such asrounds, lectures, etc. You never know when youllmake it back to your neatly packaged lunch bag. Irecommend stung the pockets o your white coatwith small bar ood, snack bags, or small ruits

and veggies to prevent an embarrassing episode ohypoglycemia. Nothing says newbie like passingout rom a low blood sugar.

3. Be prepared to talk. Be as ormal with your prepara-tions as you like note cards, powerpoint, chickenscratch on the back o your hand, whatever your at-tending will expect you to read outside o the hospitalon pertinent topics. I you have a septic patient, youshould be able to talk or about fve minutes on theearly goal-directed therapy or sepsis. Know the com-mon causes o common conditions and be able to talkabout them on or ater rounds. Oer a talk frst thingin the morning that way, they know youre prepared,and the pressure is o.

4. Read!Tis goes along with number 3. Dont justgo to UpoDate all the time, either. Te required/recommended textbooks may be helpul. Youshould do your best to be an expert in whateverarea you are rotating in.

5. Do practice questions. Tis is especially importantor rotations that end with a shel exam pediat-rics, OB/GYN, and psych. Youll be amazed howrusty and slow you are ater a two month rotationwithout so much as a quiz. Keep your criticalreading and reasoning skills sharp with a Step 2

question bank. You can always reset your questionbank ater Phase III when you start gearing up orStep 2. You wont remember many o the ques-tions, I promise. And i you do, good or you, goget another question bank.

6. Show your interest. Some may conuse this withkissing a$$ or sucking up, but your enthusiasmwill be matched by your residents and attending. Iyou dont give two craps about Pediatrics, so what,tell your team what DOES excite you so that they

can help you get some useul inormation out oyour rotation. I you cant think o anything thatexcites you, just pretend, so that your team will beexcited, too. Maybe youll learn something. Youshould leave a rotation knowing that your team isthinking, Man, I really hope that student decidesto apply to our program, they would be great atGyn Onc, even i you have no plan to pursue acareer in Gyn Onc. You should prove that youcould be great at it anyway because you could be iyou wanted to.

7. Always make a ormal assessment. An assessmentshould ollow the ormat: Mr Jones is a 55 yearold with a history oXXX and XXX who presentswith X days oXXX symptoms or problems. Heis NOW..., and explain how they are doing withtheir problems now, i.e., is he crashing and burningor is he improving?

8. Always have a thorough dierential, even i yourattending wont listen to it. Just give it and let them

cut you o. I youre doing well, they will listen toit, and your team will respect you more or havinga thorough dierential prepared. Be thorough. Gothrough systems and EXPLAIN your dierential.Say things like, For his chest pain, my dierentialincludes PE, pneumonia, MI, reux, and costalpain. At this time, PE is most likely because o theacute onset o the pain, the pain increases withdeep inspiration, and because he has a historyoDVTs. Pneumonia is less likely because o theacute onset and the lack o ever or cough, aswell as the normal physical exam. MI is unlikelybecause o a normal EKG. Go on and on here andbe thorough. Explain your clinical reasoning to theteam and, again, be thorough!

9. Make a GOOD plan. Tis cant be stressed enough.ake the two seconds to look on UpoDate atthe management o acute chest pain and know thediagnostic tests to rule out pertinent items on thedierential. Be prepared because most o your ques-tions will revolve around your decision making andwhy you want the tests and treatments that you choseto include in your plan. Tis means that you need toread beore rounds so that you have answers to thesequestions. Te answer because my resident told me

to never looks good.10.Lastly, and I do mean lastly, please do take care o

yoursel. Tis goes along with points 1 and 2, butgoes urther to say that not only do you deserveood and water, but you also deserve a comortablebed, good relationships and a general sense o sat-isaction and well-being. I you lose any o these,your education will surely suer and you wont bedoing yoursel or anyone else any good.

Benjamin Elkon


15/24

Dear Third Year Students,

AT FIRST GLANCE, medical education appears quite random. Te subjects include every body system rom headto toe, studied at various levels rom the micromolecular to the metaphysical. For example, one day you might try tounderstand the impact o excessive radiation on stem cells in a developing etus, the next you might have to fgure out

how to respond when a dying patient asks, Do you believe in God? Here are my thoughts on maintaining perspec-tive and peace o mind during Phase III while trying to assimilate the inormation youve learned into the process oproviding care.

1. Embrace your role: Ultimately during third year, some patient will call you doc (most likely at the VA). Youwill explain that you are a 3rd year student, not yet graduated. Tey will call you doc anyway and treat you assuch. Your role is doctor in training and in my opinion, that includes giving advice to patients and providingyour opinion. At frst, I ound it very dicult to provide an opinion, even on subtle matters, e.g. Instead o tak-ing a statin, cant I just take fsh oil instead? It seemed that I always needed more inormation, a return to theliterature, or that I should seek expert approval frst. oward the end o each rotation and especially toward theend o the year, I elt more and more comortable providing an opinion when it was appropriate. Patients willcome to see you, the 3rd year medical student, as their doctor and you should embrace that role to the maxi-mum (sae) extent!

2. Become interproessional: By this I mean that no person working in the oce or hospital should be inacces-sible to you. Tis includes the pharmacists, nurses, social workers and other providers, o course, but I wouldalso include the secretaries, translators, janitors, orderlies, ood service workers and so on. Some o these olkshardly ever interact with physicians directly. Some also carry around valuable insights into the workings o thehospital and/or your patient population. Personally, I wish I had made more o an eort to communicate witholks who were other than physician.

3. Disregard grades entirely: Study daily by reading about your patients because there is never time to cram or aFriday shel exam when you work 8 to 12 hours Mon-Tur. Work daily to improve the quality o care given byyour team, volunteer and be proactive oten. Dont be surprised i you work your ass o, read every day, acethe test and still get a Pass. It doesnt really mean anything or your ego or your career- honestly! Medicalschools are stuck with the act that they must try to take something subjective (your perormance) and makeit objective (numbers on a piece o paper). Also, there is no Pass that cant be superseded by a great letter orecommendation during your 4th year Sub-Is. Just work hard and hope or the best. Ten move on to the next

block without regret or bitterness.

4. Avoid cynicism: Sel-explanatory.

5. Go above and beyond: Is it beneath you to get a cup o water or a patient? Or an extra blanket? Or to call apatients spouse to explain a procedure? Or to call a patient you were worried about at home a week aterthey are discharged, just to check up on them? Or to call that patients PCP personally, to see i they receiveddischarge paperwork? Some blocks have this last part built into the curriculum, but I think its highly benefcialor the med student to go above and beyond in every block as time allows.

6. Its not all about you: You think it is because, hey, when you go home everyone asks about med school andspecialties and how do you like it, etcAnd in the syllabus, it says you need to write a paper, take a test, see aSPEA, log in -Res, write up H&Ps, etc.but its not really all about you. Its about taking care o patients.

7. Finally, embrace the idea o servant leadership: http://en.wikipedia.org/wiki/Servant_leadership

Tats about it.oh, and dont plan any major lie events during 3rd year. Having to do wedding planning while inthe surgery block = bad idea!!!

Josh Potocko


16/24

Dear Phase III Medical Student,BE BRAVE. BE KIND. BE PRESENT. Be prepared. Be excited.

Be caring. Be humble. Be patient. Be honest. Be probing. Be sincere. Be willing.Be helpul. Be loving. Be grateul. Be amazed. Be thick-skinned. Be pro-active.

Be confdent. Be assertive. Be wholehearted. Be sensitive. Be motivated.Be inquisitive. Be sympathetic. Be open-minded. Be optimistic.

Be compassionate. Be enthusiastic. Be a team player. Be strong o heart.

Dont be arrogant. Dont be pretentious. Dont be dispirited. Dont takeanything personally99% o the time it is not about you. Dont be easily

oended. Dont do just the bare minimumeven i youre rotating on amilymedicine and want to be a neurosurgeon. Dont think youre alone in your eelings

o inadequacyeveryone eels that way though some will not let on.Dont eel you have to know everythingno one really expects you to know

anything. Dont be discouragedi you are, talk to someone who has been there.Dont let time pass without gleaning everything you can rom each rotationes-

pecially i it is not your uture career as this means it may bethe last time you will be exposed to that feld.

Accept yoursel. Accept your atigue. Accept your duties.Accept your circumstances. Accept your limitations. Accept where you are.Accept the inherent discomort that is third year. Accept the subjectivity.

Accept the humanity o yoursel, your patients, your residents, your attendings.Accept the lack o control. ake ownership o your patients. ake time to listenand hear what they say or they are the ones rom whom you will learn the most.

ake your job seriously. ake advantage o every opportunity.

ake care o yoursel, your relationships. ake time to breathe andenjoy the moment, lest it pass you by.

Leah Swanson


17/24

Dear 3rd Year Med Students,

THERE IS SUCH A THING as too much advice. Sometimes, you just have to plow ahead

in semi-ignorance, lest you produce more anxiety than is needed. Nevertheless, what ol-lows is a short list o practical tips that I elt helped me play the game.

t 4NJMFCFFOFSHFUJDBOEXJMMJOHUPEPXIBUFWFSJUJTTPNFPOFNBZBTLPGZPVJTXJMMHPBlong way towards endearing you to the team and will help everyone orget how much youdont know.

t %POUPFSFYDVTFTGPSXIZZPVEJEPSEJEOUEPTPNFUIJOH*GZPVHFUDBMMFEPVUPOJUjust apologize and be willing to be corrected.

t %POUEJTBHSFFXJUIUIFSFTJEFOUTPSJOUFSOTJOGSPOUPGFWFSZPOFPOSPVOETFWFOJGZPVBSFSJHIUI its something that would aect patient care, then talk to the resident aterwards. I it doesntreally matter, then just let it go.

t 8IFOUPMEUIBUUIFXPSLGPSUIFEBZJTEPOFBOEZPVDBOHPIPNFBTLPOFNPSFUJNFJGthere is anything else you can help with, either on your own patients or someone elses.I they say no, then go home.

t "MXBZTNBLFUJNFGPSMVODI$SBQQZEBZTJODSFBTFUIFJSDSBQQJOFTTFYQPOFOUJBMMZJGZPVare hungry. I your residents are pretending they are superhuman and not stopping orood, then carry snacks in your pockets.

t %POUCFBGSBJEUPMFUZPVSPXOQFSTPOBMJUZTIJOFUISPVHI6OMFTTZPVIBWFBCBEQFSTPOBM-ity. But hopeully, you would have fgured that out by this point and have attempted thenecessary changes.

t ,OPXUIBUPGUFOUJNFTUIJOHTXJMMCFVOGBJSTVCKFDUJWFBOEQFPQMFXJMMCFGPDVTFEPOZPVSaults rather than your strengths. Dont take things personally and know that while thisattending thinks your presentations are too long, your tie is too ashy and your knowledgeo endocrinology woeully lacking, the very next one will ask you why your presentationsare so short, why you wear such boring ties and why you spent so much time memorizinghormone eedback loops. Choose to be amused by this instead o rustrated.

t .BJOUBJOPVUTJEFJOUFSFTUT1FPQMFXJMMUFMMZPVUPHPIPNFBOESFBEBCPVUZPVSQBUJFOUTevery night, but sometimes, ater a long day, the last thing you want to do is spend moretime thinking about medicine. Reuse to eel bad about taking a break once in awhile.

t &BDICMPDLJTPOMZNPOUITUPQT:PVDBOEPBOZUIJOHGPSNPOUIT"OEJGZPVIBUFJUwell, then at least you know that youll likely never have to do it again.

t 3FNFNCFSUIBUJOKVTUBGFXTIPSUZFBSTZPVXJMMCFUIFJOUFSOPSUIFSFTJEFOUXJUITPNFsnot-nosed medical student tagging along ater you. When that time comes, try to be theresident that you wished you had had.

t *USFBMMZJTGVOBUUIFFOEPGUIFEBZGood luck! Youll do great!Dave arullo


18/24


FIRST OF ALL, I would like to welcome you to ayear that you will remember orever. Te third year omedical school represents the beginning o your clinical

career, and you will fnally begin to understand what yougot yoursel into. When you are out on the wards, youwill be meeting patients, writing H&Ps, and pre-round-ing, rounding and pre-rounding again. You will laugh,and you might cry. You will have days when you experi-ence the greatest sense o accomplishment, and the nextday you are so overwhelmed and exhausted that you earyou have orgotten all that you learned over the past twoyears. Some o your colleagues will take these obstaclesin stride and others will struggle, but at the end o thirdyear, you will all take in a big sigh o relie.

So ater just completing this roller coaster ride, Ihave come up with a ew pieces o advice that I wishedI would have known when I started approximately oneyear ago.

One, you do not have to like everything that you dobut you still have to do it. Tis took a while or me tofgure out. I was starting to eel guilty and to eel likeI wasnt meant to be a doctor, but maybe I just wasntmeant to be a neurologist.

wo, take advantage o every second you can to spendwith amily, riends, or walking your dog (yeahdontorget about your dog). But also dont eel like you haveto do it all, just take care o the people and things thatmean the most to you.

Tree, dont orget that above all else, you are still astudent. You may eel as though you are paying to go towork, but you are paying to learn, so learn. ake sparetime to read. I know you will be tired at the end o theday, but ten minutes reviewing heart ailure will beworth it, and you wont regret it in the end. And mosto all, ask questions.

Four, dont be too scared o pimping. Your teamexpects that you will not know the answer to everyquestion that they ask you. So think o it as a learn-ing opportunity because you can never know what youdont know.

Five, know your patients. Te people you will meetduring this year will change your lie orever. Tey willtest your brain and push your emotions to the brink.

When you look back, this year will be a series o aces,not power point slides illustrating disease and I guar-antee you wont orget. When I was on pediatrics, I meta nine year-old girl with hemolytic uremic syndrome,do you remember that slide? Or the sixty-two year oldgentleman I met on medicine with pancreatic cancer hewent home with hospice care and likely passed within aew days, comorted by his wie and children.

And fnally, number six. Tis is my last piece o adviceand perhaps the most important. During this year, youwill become really close to the classmates that you workwith, so be a good riend and help each other out. Younever know what they are going through maybe hisparent passed away, or she got in a fght with her boy-riend. So dont be the person who throws someone elseunder the bus, just to make yoursel look better. Instead,oer to help them out and be sincere because the realityis that we are all in this together.

So that is it . As you will soon fnd out, thereare many layers to the year you ace and countless thingsto learn. At the end, you have to pass your next licens-ing exam, but just as important, you have to decide whatyou will do with the rest o your lie, so consider eachspecialty with care. But also enjoy the opportunity to dosomething you will never do again.

Good luck,Jamie Weber, Class o 2011


19/24

Advice for the

3rd Year Medical Student,

t FIRST: DO NOT GET IN THE WAY. Second: try to behelpul. Tird: learn things. In this order.

t #FJNQSFTTFE:PVXJMMCFTVSSPVOEFECZUIFTNBSUFTUpeople you have seen yet in your lie. Get used to the actthat you wont be the smartest person in the room or aVERY long time.

t 5SZUPBOTXFSFWFSZRVFTUJPO&WFOJGZPVBSFUPUBMMZXSPOHNo one is as mean as you think theyll be.

t #FFOUIVTJBTUJD*UIJOLUIJTNFBOTTNJMFBMPU"OETBZJOHyes when anyone asks you i you want to do something.But I could be wrong.

t FSFJTOPTIBNFJOIJEJOHPVUGPSBGFXFYUSBNJOVUFTJOthe bathroom i you need a minute to yoursel. Or i yourlegs are sore.

t %POUMJFBCPVUMBCWBMVFTUIBUZPVEPOULOPX*GZPVTUBSUnow, you wont be able to stop later.

t 8IFOBOBUUFOEJOHBTLTZPVJGBMBCUFTUJTSFBMMZOFDFTTBSZthe answer is always it wouldnt change what we do next,so no.

t 5SZUSZTRY not to listen to specialty or other servicebashing. It is everywhere and cannot possibly beneft youin any way.

t %POUDPOHSBUVMBUFPSCFSBUFZPVSTFMGUPPNVDI

t %POUGPSHFUUIBUZPVBSFTNBSUJTNBZCFUIFIBSEFTUthing to do since youll probably be the least smart personon your team, but you are still smarter than most peopleon this earth.

t &WFSZPOFUFMMTZPVUPCFOJDFUPUIFOVSTFT"OEZPVTIPVMEBut dont ever expect them to be nice to you.

t $BSSZBQPXFSCBSJOZPVSXIJUFDPBUBUBMMUJNFT

t 1SFUFOEUIBUZPVBSFFOKPZJOHFWFSZSPUBUJPOFWFOJGZPVare not. It will never hurt you to act happy, smile and eigninterest. A lot o 3rd year is this game, and it defnitelyavors extroverts.

t 3FNFNCFSUIBUZPVXJMMGFFMMPTUBUUIFCFHJOOJOHPGFWFSZsingle rotation. You will eel like an idiot who has no ideawhat to do, and you may even be sure that you will ail this

rotation because o this. But everyone eels this way, andyou will get the hang o it sooner than you think.

t :PVDBOTUJMMEPXFMMJOTVSHFSZFWFOJGZPVQBTTPVUJOUIFOR.

t &OUFSFWFSZUFBNTJUVBUJPOXJUIBOPQFONJOEFQFPQMFyou dislike most in your class right now may end up beingthe ones who impress you the most on the wards.

t %PPOFUIJOHFWFSZEBZKVTUGPSZPV&WFOJGJUTEPXOXBSEdog in the unoccupied nurses lounge at midnight. Onething.

t "TLGPSGFFECBDLBMMUIFUJNF/PNBUUFSIPXTUVQJEZPVeel doing it. Ask.

t %PBTNBOZQSPDFEVSFTBTQPTTJCMFOFWFSUVSOPOFEPXOeven i you really dont want to. You will be happy that youdid.

t (PPWFSZPVSBTTFTTNFOUBOEQMBOXJUIZPVSJOUFSOCFGPSFpresenting. Its pretty embarrassing to say your plan andthen have the resident say, Well, actually, no, were going todo this.

t .FNPSJ[FBGFXHFOFSJDBOTXFSTGPSQJNQJOHTFTTJPOTFor example: Question: What are the side eects othis medication? Answer: GI disturbance. Question:What else could be causing this patients symptoms?Answer: A side eect rom a medication, or Sarcoidosis.

Question:What would you do frst or this [critically ill]patient? Answer: ABCs! and IVF.

t %POUGPSHFUUPESJOLXBUFS'PSTPNFSFBTPOSFTJEFOUTBOEattendings can get away with dehydrating themselves ordays on end. Med students who try this will undoubtedlyend up with a headache. Or acute renal ailure.

t "DDFQUUIFGBDUUIBUZPVSFNPUJPOTXJMMVDUVBUFPOBEBJMZbasis. Sometimes you will question your choice to go intomedicine. Other times you will eel like nothing can bringyou down. Tis is okay.

t 1SJOUPVUBMMPGUIFOJDFFWBMVBUJPOTUIBUZPVSFDFJWFBOEread them when you have a particularly hard day.

t %POUXFBSDPOUBDUTJOTVSHFSZ4PNFUIJOHWILL get inyour eye during an 8 hour operation, and you will look likeyou are crying.

t %POUXPSSZUPPNVDI0SEP:PVQSPCBCMZXPOUCFBCMFto stop worrying, but understand that i you try to prepareor every potential bad outcome, you will run out o timeto learn medicine, and you will probably orget the one badthing that actually does happen to you and look like anidiot despite your preparation.

t %POUUBLFBOZPOFTBEWJDFUPPTFSJPVTMZ

t -BTUMZZPVDBOUHPXSPOHJGZPVSFNFNCFS

One o the essential qualities o the clinician is interest in

humanity, or the secret o the care or the patient is in caringor the patient.

Frances Weld Peabody, Te Care o the Patient.JAMA 88:877, 1927

yra Torstad MSIV


20/24

Dear Phase III student,

FIRST OFF, CONGRATULATIONS,you have been deemed worthy to see patients. Tirdyear, though the most stressul, can be the most rewarding year o your medical school. You

are no longer a puppy ollowing the doctor around in admiration. Te patients you see areyour patients. You are a part o the team and have the ability to positively impact your pa-tients health care experience.

My frst patient was a 13 year-old having an appendectomy I quickly realized that I didntknow what I was supposed to do. I walked in and introduced mysel to the amily, Im Nicolea second, sorry, third year medical student that will be helping care or you while you are here.Te amily had already consented or her surgery and had all o their questions answered bythe resident and as my hand was on the door, my patient began to cry. I walked back in, saton her bed and asked what was wrong. She was worried about the male resident seeing hernaked. I talked with her a little more about how we drape and prep her or surgery, and Ipromised her I would do my best to keep her covered up. I now had something I could do to

help my patient. And that is what it started with. Do what you know, and be willing to learnwhat you dont.

Your role now is that o a doctor in training- a helper and a learner. It is important tobalance the two. As a helper, you are an extra set o virgin hands to be used or your patient,including scut work. But remember, the people you work with are your evaluators, and smallthings are noticed and rewarded. Te attending thought I was silly or trying to cover up my13 year-old, but I have a eeling this act was why I had the honor o cutting the appendix. Asa student, try to read a bit about a topic related to your patient as it will help you remember.Also keep a list o the objectives or each rotation and seek out learning opportunities on thatlist as that will also help you with the written exam. You are paying to be there make it yourlearning arena.

While on whatever rotation, always, in the back o your mind, ask yoursel, Is this a feld

I would like to go into? Ask your attending how they chose their specialty (great way to starta conversation and learn a lot!). Keep a list o pros and cons o each specialty. Surgery pro:dont have to worry about what to wear, scrubs daily! Surgery con: the Bovie smell makes menauseous. It is oten easier to determine what you dont want to do. And i you determineyou dont want to do pelvic exams or the rest o your lie, then keep in mind this will be yourONLY opportunity to be profcient at one. You never know when you will be the ONLYdoctor on the plane with a woman in labor.

Last, but not least, dont orget to take care o yoursel. ake the time you need or sleep.Dont use the elevators- walk up stairs while you are at the hospital. Buy healthy snacks thatyou can keep in your car. Wash your hands (especially on Pediatrics those kids are walkingPetri dishes). Send your loved ones an email letting them know you are doing well. Lie hap-pens, and when it does, let the appropriate people know. You are supported. Youll know itsworth it when your patients call you doctor.

Congratulations student doctor,

Nicole Erwin


21/24


SURELY BY NOW you realize that the next year o your lieis going to be flled with new challenges, exciting opportunitiesto grow as both a person and as a uture physician, and perhaps

somewhat lacking in sleep. Congratulations or making it tothis point. As you likely remember rom the process o apply-ing to medical school, simply getting here is an accomplishmentthat you should be proud o. Now you have made it throughthe basic science years and actually get to interact with pa-tients. Tis is the payo that you have been waiting or.

Even though the next year is going to be a learning andgrowing experience or each o you, this year will present youwith challenges that you may or may not have anticipated whenyou applied or medical school all o those years ago. AlthoughI cannot pretend to be some sort o expert in how to negoti-ate the many hurdles o being an MS3, I have some pieces oadvice that I hope will maximize your ability to grow and learnrom this experience.

Rule #1: Give your residents and attendings every oppor-tunity to teach you something. Although seeing patients isun and exciting, your primary responsibility as an MS3 is tolearn something, so that you can take better care o each newpatient that you meet. Residents and attendings have boatloadso experience in clinical medicine, and this is the most impor-tant skill set you can hope to learn rom them. When someonewalks into your oce/ED with a chie complaint o chest pain,you can probably list o ten possibilities or what might becausing it. What you can learn rom your residents and attend-ings is how to think about each patient, considering the most

likely and most serious cause or the problem, and how to goabout narrowing down the possibilities. Tey might teach youthe magic questions that dierentiate ACS rom pneumoniai you dont ask, but they certainly will i you do. How did youknow that Mr. Jones was going to have an infltrate on CXR?When I was thinking about Mr. Smith, I was wondering iyou could explain to me how you knew that he had mesentericischemia as opposed to an ulcer? Te more questions you ask,the more teaching points your residents and attendings willhave to start with, and the more nuanced your understandingo patient care will become. Its your job to view each patient asan opportunity to learn something rom your team.

Rule #2: Show up and be present. Hopeully your caeinetolerance has almost normalized rom your board study periodas I have ound caeine to be a wonderul way o eeling morealert than I should. Sometimes high volume, upbeat music onthe way to the hospital at 5 am makes a big dierence in howyou eel when you show up. Regardless o how you do it, makesure that when you walk into the hospital, your head is in thegame. Te greater the responsibility that you have on yourteam, the more important it is or you to be present and active-ly thinking about each patient. Te greatest sign o respect youwill receive is when your team lets you take care o a patient asi he is your own. Te next thing you know, the patient

will be asking ater my doctor and mean you. Both your teamsand your patients will know i you are just standing in the backo the room, counting down the hours until you can go home

and go back to sleep. I have ound that the best way or me tostay awake is to get my head in the game and participate in thework-up, diagnosis or care o a patient. I you work hard andpay attention, you will learn so much more than i you passivelyabsorb the experience by proximity alone. I you work hard ona regular basis, you will notice that sometimes you are not upto your normal par, and these are good times to ask or help.Realizing that you are too tired, hungry or upset to take careo someone is one o the most sel-aware and impressive thingsthat a medical student can do. I your team knows that youknow when to ask or help, they will eel much more confdenttrusting you to work independently with less supervision.

Rule #3: each your patient something. Ask all o your asth-ma patients which medications they are on and why. You willbe amazed at how inrequently even highly intelligent patientswill not understand why they are taking specifc medications.Evidence shows that asthma patients who take long-acting betaagonists without concomitant use o inhaled steroids suergreater mortality. Yet i a patient does not know which one othe medications is albuterol vs. steroid vs. long-acting betaagonist (LABA), how will he be able to take his medicationscorrectly? When I say teach your patients, I dont mean tellthem which colored inhaler is which medication, I mean teachthem about airway inammation vs. airway constriction andhow each medication treats each condition. ell them that

they need to use their inhaled steroid and their LABA every-day even i they are not having symptoms. each them thati they fnd themselves using their albuterol more oten thatthey need to see their doctor or medication adjustment. Helpthem understand that when they start having symptoms o anattack that are not controlled by their inhalers, they need tocome into the hospital sooner rather than later. And everythingyou just read is only about asthma, think about how much youcould teach your patients i you took the time. Maybe one othem will even be interested in the role o cAMP regulation inpertussis!

I hope by now that you realize that you will get out o yourthird year what you put into it. Te next year o your lie is

one o the greatest opportunities you will have to learn aboutmedicine, and even to learn about yoursel. In summary, showup, be present, and remember that at all times, you can be ateacher and a learner.

Sincerely,Keely Chevallier, MS3.99999999999


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To the Rising Third Year Class,

YOU HAVE MADE IT. Finally, you get a chance to step out rombehind the books and learn how to practice real medicine. Here are aew words o advice or you as you take our place on the wards.

Never have political discussions in the OR- you will pay.

Never correct your attending or senior resident, even i they arewrong.

No complaints.

Be enjoyable to be around.

Avoid eating lots o fber bars on call days. sel-explanatory.

When released to go eat, make sure you ask how much timeyou have- no omelets.

Always act interested- they can tell.

On rounds, jump on the easy question early.

Continue the elusive search or the 18 hour shoe..

How will you get up at 4:30 in the morning? Fear.Dont worry, youll wake up.

Sleep in your scrubs when on call.Be confdent.

ake the dicult patient i nothing else, you will havea good story or later.

Laugh you cant make this stu up.

Your answer is always Yes!

Learn your brand names or drugs that is all you will ever use.

Beore starting pediatric surgery, study yourstorybook characters.

Warn your signifcant other that you will not be around.

During medicine, presentations = your grade.I you dont pre-round, plan on ailing.

Be nice to nurses they can ruin your lie.

Its not over when the baby comes out

Select your words careully when describing patients.

Call your mom.

ake the stairs this will serve as your exercise.

Go the extra mile or your patients and or the team.

Read, read, read.

ake the time to sit and talk with your patients.

Perorming procedures is a privilege, not a right.

You will be wrong... a lot.

Sleep when you can and where you can.

Listen to your patients and their amilies.

Know your limits ask or help.

ragedies happen; its okay to be sad.

Dont eel guilty or being happy even when there are sad thingshappening.

Surgeons do not wear their stethoscopes around their neck.

Do not bring your beverage into the patients room.

Respect your ellow medical student.

Cli bars are a necessity; many times they will be yourbreakast, lunch, and dinner.

Remove your white coat and stethoscope beore startingchest compressions.

Do not pimp others.

Your pager will be used on medicine and meeting other medicalstudents or lunch thats it.

Pediatricians like eating candy, so buy gummy worms or theteam and youre in.

On the frst day o third year, you are already a certifed retractordrain puller, and limb holder.

Psych is on every rotation, and the best psych stories will not berom your psych rotation.

Showering everyday is ideal, but not always a reality.Dont eat crackers on neurology rounds.

Te mini-mental status exam does not work on patientswho are aphasic.

Many patients will identiy themselves as Jesus dont be ooled.

Nothing gets a group o neurologists going like a good stroke.

Learn the two-handed tie, then give yoursel a high fve.

Never tell a prisoner when his next medical appointment will be.

Be sure to stop a prisoner rom showing you his ake eye.rust me you dont want to see it.

Now might be a good time to put a bun in the oven.Learn to swaddle.

Know your patient inside and out.

o circumcise, or not? your decision will be made during yourpediatrics rotation.

Detailed descriptions o secretions (colors, viscosities, etc.)are a plus.

Keep your penlight in your pocket.

Make sure your patients have teeth beore asking them when thelast time they went to the dentist was.

Never go to the bathroom during labor and delivery you will

miss it.

Cheyenne Wells beware o the cheeseburger soup

I hope this helps you during your third year. Some o your mostvivid memories o medical school will be made during this year.ake every opportunity to push yoursel and get the most out oevery rotation. When all else ails, ask a ourth year to help you.Tey know exactly how you eel.

Crystal Medina


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Congratulations!

TODAY IS YOUR DAY.

Youre o to the hospital!Youre o and away!

You have brains in your head.You have pockets stued with books.Youll see sick people everywhere you look.

But youre not on your own; you know what you know.And youll be part o a team everywhere you go.

Youll have lots o patients. Look em over with care.About some you will say, I dont want to go in there.But with your head ull o brains and your pockets ull obooks, youll ILS hard patients with empathetic looks.

A word o caution: on the oors things can happenand sometimes doto people as green and wide-eyed as you.

So when a patient crumps on you, dont worry.Dont puke.

Just walk into the hall and call a Code Blue.

Oh! Te Places Youll Go!Youll learn to gown up!Youll learn retractor technique!Youll wear colored scrubs and look very sleek.

You wont lag behind because youll have the speed.Youll pre-write your notes and present with great ease.Wherever you rotate, youll be best o the best.Wherever you go, you will ace every test.

Except when you dont.Because, sometimes, you wont.Im sorry to say so, but, sadly, its true:burnout can certainly happen to you.

You can get all hung up on a prickle-ly attending.And the days will drag on.Tey will seem never-ending.

Youll go into the hospital eeling down in dumps.And the chances are, then, that youll be in a Slump.

And when youre in a Slump, youre not in or much un.Un-slumping yoursel is not easily done.

But stick with it! Keep smiling, chin up andpush through!

Just two months and youll be as good as new!

And then youll escape all that down-in-the-dumping.Youll fnd Childrens where everyone is happily jumping.With IDs ip-a-apping, youll work on new oors!Ready or anything to come through the doors.Ready because youre excited to see more!

Oh, the places youll go! Tere are sutures to knot!Tere are MMSEs to be scored.Tere are babies to be caught.And the magical things youll do with thatreex hammerwill make you one bad-ass mamma-jamma.MS3! Youll be happy as happy can be,fnally eeling like a doctor-to-be.

And will you succeed?Yes! You will, indeed!(98 and percent guaranteed.)

Medstud, youll do great!

So be your name Buxbaum or Bixby or Brayor Mordecai Ale Van Allen OShea,youre o to the hospital!

oday is your day!Your patient is waiting.So get on your way!

Adapted romOh! Te Places Youll Go!by Dr. SeussBecky Higbee, MS4

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AfterwordWE ARE DEEPLY GRATEFUL to all the students who contributed their letters o advice to

the rising thirdyear medical students. Students had the option o writing these letters or thefnal Phase III Hidden Curriculum session. We received many wonderul submissions, and wewould have loved to publish all o them, but we wanted to avoid repetition in content. Teseourteen letters represent a diverse sample o the experiences o a third-year medical student.Tey contain a mixture o stories, thoughts, practical advice, humor, creativity and inspira-tion and also illustrate the vast array o eelings that a student might have during third year:excitement, anxiety, enthusiasm, exhaustion, hope, despair, compassion, joy. Beore startingmy third-year clerkships, I remember my nervous anticipation, yet I was reassured by the ewwords o advice that a rising 4th year student gave me. I would have loved to be given more

advice such as this collection o letters, which can serve as a manual to help novice studentsnavigate a completely unknown endeavor. We greatly appreciate all o these students or thisgit that they have provided or their colleagues.

Anjali Dhurandhar, MD

dear third year pdf

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