Third year update

One month complete.

Each time I actually sit down to type up reflections about third year, I get all stressed out because the great insight had earlier is now gone. And so I sigh and go back to my reading. Or just sit and stare and think. Out of the blue another reflection comes along, and then before I am motivated to sit down at the computer, it too fades out. So then I'm left with a series of strands, unarticulated ideas; incomplete sentences. Which is to say, this will be appropriately scatter-brained.

The last month has felt like an eternity. My fellow med students keep remarking about how fast one month went by. Not so for me. One month has felt like one year. Not to get dramatic about it, because really that's not the point, but the clinical years of medical school are different than everything that came before. That constitutes one reason for third year's difficulty. It's just a steep learning curve -- learning to round on, examine, take histories from, develop plans for, and answer questions of one's patients, while working as part of a team where your role is entirely redundant and usually slows things down, and then finding time to go home at night and fill in critical gaps in knowledge, skill, and understanding. And then arriving the next day, rested, and ready to absorb more information and get just a little better at the other stuff. It's endless, and perhaps third year is one of the most humbling times of my life. Or it, better yet, makes the "constantly humbled and fine with it," the default setting from now on. Because as far as I can tell, third year of medical school is just the start of realizing how little we know and how far we have to go. It's deja vu all over again, because I felt exactly the same way at the beginning of this program in 2006. It's the same, rinse and repeat.

The extent of my naivete is overwhelming at times. It usually happens in the setting of a false light-bulb-going-off: I feel so sure that one thing should be done a certain way because I've done the hard work of thinking through a process, a treatment strategy, an investigative approach to a problem, and then I am gently corrected that in fact the opposite scenario is correct, and this is all for a series of very plausible explanations that I had not even begun to think of when I was crafting my alternative reality. So that's a scary moment, because I plead with the powers-that-be that this won't happen when more responsibility is in my hands.

Of course it's rarely so clear-cut such that I'm completely wrong, and in fact often several steps of my logic are decent. And that's when positive reinforcement of the entire process is crucial. You learn from what you did right, or that which you drummed up using sound logic, and the hope is  that the next time you amplify the good and squelch out the rest. As an example, in the OB world, there's a very scary group of conditions interconnected by their potential harm to both mom and fetus: Preeclampsia (gestational hypertension plus proteinurea) and HELLP syndrome. From what I've seen so far, the typical presentation of these diseases is found only in a textbook, and patients have slightly to significantly different presentations, and this makes deciding what to do for each patient such a challenge. When do you emergently deliver? When do you admit for further observation? What tests do you order and in what frequency do you follow them? How are decisions about ante- and post-partum care made? Much of the time, because the adverse outcomes in these pregnancy associated conditions are potentially so devastating to mom and fetus, one can't learn by seeing the adverse outcomes. Rather, prudence and a keen awareness of how to spot early warning signs is the learned skill. So we have to use our imagination, imagine how bad it would be for a woman to seize in pregnancy, and prevent it before it becomes a reality. And in what we hope will be events spaced far apart, never let important lessons be missed when things go terribly wrong.

At least that's the hope of this all. I suppose the key point here is that medical school in the third year is a lot about learning to triage -- to assess what's really dangerous to a patient and what is relatively benign. To at least get the "this is serious" vibe right is all we're being expected to do at the moment. The more subtle refinements come along the way. But for now, it's learning to triage, to learn the difference between a mountain and a mole hill.

And life gets a bit triaged as well. Not much more to say about it than that -- there's less down time, more structure, and in a way that's the best litmus test for deciding on whether a specialty is right. You either manage to enjoy your life outside the hospital and can get everything else taken care of, while also getting sufficiently rested, such that said specialty is The One. And if everything can't be satisfied appropriately, other options are entertained, or the grumbling begins. But it's fine, may as well deal with triaging from the beginning of the clinical years. And more than anything else, the bottom line is that it's not that bad. It's not easy, but it seems like things will work out.