Quarter of a Life

A quarter of a life
Is a breath and a gasp
A sigh and a heave
A whisper.

A quarter of a life
Is a leap and a bound
A step and a push
And yet a whisper.

A quarter of a life
Is a moment to a river
A flicker to a mountain
A whisper to a star.

Surviving Medical School: The Third Year

I write this entry with these people in mind: my unborn child, who [might] consider being a physician someday, for my future students [mwahahahahahaha!], and for myself, that I may be reminded ofwho I was as a student. This is the third part of the series. 

Third year medicine is, in my opinion, the “boss level” of your academic life. I have never worked as hard as I could until this year.

This year will sum up the discipline you’ve acquired throughout your years of formal schooling. This year will be a year of challenges, a year of great expectations, a year of tribulations. When it is finished, you will find that it will have also been a year of hope, a year of discovery, a year of vindication. By the end of third year, you will feel like a physician, at least in theory. By the end of this year, you will be one step closer to your dreams.

Keeping up the Pace

ECG

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A medical student is a marvel of creation. We are a juxtaposition of contrasts. We feel dumb, but we can answer (some) questions our consultants throw at us. We feel sleep-deprived most days of the week, but we manage to pull through our examinations. We are caffeine-laced junkies, but we can fall asleep on command. We feel like robots in a daily grind, yet we feel compassion and empathy when we talk to our patients. We feel stupid most of the time, but for some reason, our patients and our relatives believe in our abilities. (If you’re my child, I’ll probably be bragging about you to everyone.)

It is essential to keep in mind that taking care of yourself is your first priority. Eat a well-balanced diet, exercise often, go on dates or parties, don’t neglect your personal hygiene, and sleep adequately. There will be lots of times when you will feel burnt out. You’ll try to force yourself to keep going, but you won’t likely be productive if you do. I’ve done that many times, but I would just be frustrated and miserable after.

It is important to know yourself this year. It is important to accept that you are only human, and you will probably not be able to read everything or practice all your skills. It is equally important that you believe you have what it takes to be a doctor. It is important that you discover in yourself the grim determination that will spur you to face your fears.

The greatest challenge this year is not really the tons of material, the gaggle of paperwork, or the physical exhaustion, but the lack of motivation that will sap your strength and affect everything else. Keep up the pace. You’ll get there.

From a Marathon… To a Triathlon

Ocean

zarmeenk.wordpress.com

When I first started third year, it felt like being dropped into the ocean. Initially, you’ll feel the unforgiving chill, you’ll thrash about helplessly, you’ll be brought down by the endless waves.

Up to this point, I’ve treated medical school like a marathon, where all you had to do was to keep placing one foot in front of the other. This year, you will need to be faster and stronger and wiser. You will find that you have less time to study because you have to do a lot of paperwork and projects on top off trying to live like a normal decent human being with a social life.

The greatest skill you must master this year is time management. There are many ways to become productive, but the one I’ve always found useful is to divide your day into a pie. Allot 8 hours of rest and 8 hours of lectures everyday, and probably an hour or two for personal hygiene and eating. This will leave you with 6 hours to choose between studying and not studying. How you use those 6 hours is up to you.

If you’re like me, the internet is a bad distraction. I remember looking at a clock and saying: “Hey, I’ll just surf the net for half and hour.” When I look at the clock, it’s jumped by 6 hours. Try to remove distractions from your life and focus on getting to where you want to be.

Smart is the Way to Go

Tactics

forum.ea.com/uk

Studying smart is the norm for third year. You can try to read all the material, but it’s no use if you don’t understand it. I’ve applied new tricks to keep up with the material, some of which are:

  1. Strengthen your basic knowledge by brushing up on your past lectures. I’ve found that having a good background on pathophysiologic processes will allow you to quickly understand material, as well as allowing you to reason logically when confronted with a case you’re not familiar with. An example would be how you’d suspect leukemia in a patient presenting with anemia, easy bruising, and frequent infection. You’ll even know what type of leukemia it is just by recalling your basic knowledge. If you don’t understand what you’re reading, I strongly suggest going back to the basics. If it seems too tedious, know that ultimately, you’ll work faster as you master the basic sciences.
  2. Know the common diseases, their diagnostic criteria, their treatments, and their quirks. Staple cases would be lifestyle diseases such as hypertension, diabetes, and obesity. Infections and antibiotic treatment are also frequently discussed topics. How would you know what the common diseases are? Listen to your lecturers! Or if you really need to sleep in class, at least list down what they’re talking about and just go back to them later.
  3. Simplify! I would suggest using a small index card to take note of the important characteristics of a disease, as above. It will force you to put only the essential information, and it doesn’t hurt how writing helps integrate these into your memory. Another way to simplify is to consider how diseases can be grouped according to their core pathophysiologic concept and directing treatment accordingly. The Integrated Management of Childhood Illnesses (IMCI) chart is a good example of this. Find such material, or develop them yourself.
  4. Use mnemonics, use humor, enjoy the material! Think of funny ways to remember diseases. I remember Takayasu disease being a “pulseless disease” because you can’t “Takaya-pulse”. Or how to memorize the order of CT scan radiodensity: “be sure where fart arises” (bone-soft tissue-water-fat-air). Medicine has a lot of information, so you might as well find humor in it.
  5. Put in your hours everyday. Third year is the worst time to cram. Try your best not to fall into this, as the material this year is not only voluminous, but also requires time and effort to understand. By breaking up huge diseases into simpler concepts, you’ll have a finer understanding and appreciation for the material, as well as the luxury of good sleep during the exam weeks.
  6. Be a team player. Did you forget about the paperworks you’ll have to do already? Because there are a lot of paperwork. Our team created rotations schedules to guide those who are decked to interview patients. This ensures that we all get to hone our skills, as well as getting some respite. Now, don’t be that team member who hogs all the skills, nor be that team member who is just dead weight for the group. You are going to be a doctor, and how you behave with your team will reflect the kind of doctor you’ll be in the future.

For You, Only the Best

Heart

mozdex.com

I believe that a medical student should strive to be the best physician they can be. There will be many times when you’ll be tempted to just breeze through the material and pass the exams. There will be times when you’ll feel lazy and just read through previous exam review questions and hope those concepts will come out of the test. These things have happened to me. But now I have to brush up on cervical cancer because I know squat about it, and OB-Gyne will be my first rotation this April. I’ve learned how each concept you slack off from will bite you back someday.

Third year is the time to think about the future. When you’ll be in the clinics, patients won’t come to ask how you did in an exam; they’ll ask if you can help them. What good is knowing that secondary amenorrhea is caused by polycystic ovarian syndrome 80% of the time when you don’t know what the diagnostic criteria are, or how to treat it? You have to learn these diseases well enough so that you can spot them in the clinic, diagnose them, and treat them accordingly.

In the end, it will all boil down on how much you care about your patient. If you care sincerely enough, you will see all the exams and papers you’ll do as essential steps to become the best physician you’re meant to be. You will grumble and fret, but take each day at a time, and before you’ll know it, you’ll be where I stand now – at the brink of clinical clerkship, anxious and excited at the same time.

I hope this year will be good to you, and I hope to see you along the way.

Majesty

Mt. Pulag It was on a day like that when my father’s notion of the whole being greater than the sum of its parts moved from my head to my heart. The view from my sycamore was more than rooftops and clouds and wind and colors combined.

It was magic.

And I started marveling at how I was feeling both humble and majestic. How was that possible? How could I be so full of peace and full of wonder? How could this simple tree make me feel so complex? So alive.

Flipped by Wendelin Van Draanen, 2003 December 20, 2014. Sunrise on the summit of Mount Pulag, Northern Philippines

Paranoia

Hello. We were just talking about you.
We love how time flies and goes,
And then, poof, you’re someone we barely knew
Where are you now, nobody knows.

Yes, this is your validation
For the voices you hear in your head
Whispering thoughts of provocation,
Keeping you from the peace of your bed.

Then again, it’s not always about you.
We’re talking about someone we care about.
So sleep well and tight, won’t you?
Just curse your dreams of doubt.

The Great Pagliacci

I went to a play by Pagliacci,
He was recommended by my doctor.
So I went to his play to truly see,
His proven cure with sharp wit and humor.

In came with flair The Great Pagliacci,
Rotund, vacuous, clown on a bike riding,
His appearance filled the crowd with glee,
As he regaled us with inane rambling.

“I sure would like to be Pagliacci,
Seems he never loses his wit and smile!”
Said the people beside and behind me.
I found my cure with his devilish wile.

I left with mem’ries of Pagliacci,
How funny the world through his sight may be!
He takes life with zest and security,
How happier can a person ev’r be?

One day I chanced passing by the theatre,
To my surprise there was no queue, no line,
No people demanding that they enter.
“Pagliacci is dead” was on a sign.

I mourn for him, The Great Pagliacci,
I wonder how the world without him will be.

I dedicate this to Mr. Robin Williams (1951-2014), a great man who made the world laugh, cry, and think.

Fine

We pass one another everyday
You ask me how I am
And scripted I would always say:
“I’m fine.” (But I don’t give a damn.)

We go about our separate way
Ignoring the flowers and the music
At dusk I go home alone and say:
“I’m fine.” (I’m going to be sick.)

On the pillow my head I lay
And decide to let myself feel
I think I’m going to be okay
“I’m fine.” (But I don’t want to feel.)

It always goes the same way
I don’t want to feel
It hits me like a truck and everything turns black and I say it’s all going to be okay and lie and say:
“I’m fine.” (I’m not still.)

I’m happy and I’m grieving and I’m hurting and I’m okay
I just want to turn it all off
I just want to lie to myself and say
“I’m fine.” (But I won’t.)

On Homosexuality

I used to be a homophobe.

I studied in an all-male school for 13 years. As can be expected in a school full of confused teenagers, there would be bullying among the batch. I once bullied a classmate who was gay. Her name is Angel.

I don’t know where it all began. I guess if you put boys together, the ones who “aren’t like the rest” get treated differently. It started out subtly enough. I was weirded out by Angel. Where we would have dirty bathroom jokes, Angel wouldn’t laugh. Where we would curse and banter like sailors, Angel would just be quiet. Where we would play basketball, Angel would be at the bleachers, opting to play volleyball instead.

Then there were others like Angel, who would openly strut their stuff in the hallways, who would have rumors saying that they had a crush on a fellow classmate, who would group together and be noisy in a way that bothered me then.

Then the teasing started. It would be subtle at first, such as ignoring the person intentionally. It would then escalate to name-calling, to outright mocking of the person. I remember being such a condescending piece of shit those days. Angel was a good person. One day she just ignored me. She kept being herself despite the hurtful words and deeds we did. She even seemed happy with her friends. We who were looking down on her found ourselves being looked down by her.

Why did I do this? I realized then that I did because I felt inferior. I too, was bullied when I was a kid. I was a scrawny, wimpy, nerdy kid who got picked on by the bigger kids. That produced an anger within me that I projected to those I perceived as “weaker”. How foolish have I been! Angel is one of the strongest people I know. Angel was a better person.

I apologized to Angel for what I did. I asked for forgiveness for the taunts, the jabs, the harsh words. It was at a hallway in our school. I told her these rather awkwardly. She didn’t say anything, but from then on, I got to know her better and found out that she was like one of us, in that she eats without a tomorrow and she’s strong as hell (she once dislocated my right thumb during an accident).

My Christian Living teacher once told us how she boarded a bus full of passengers that she had to stand. Near her were two seats occupied by two men; one was the typical “macho” guy, and the other was a gay man. The gay man promptly stood up and offered her seat to my teacher.  Our CL teacher then posed the question: “Who was more of a gentleman of the two?”

The standards we live by are no longer confined to “What is manly? What is feminine?” The standards we live now should answer “What does it take to be a decent human being?”

Homosexuality is not any threat to the concepts of manliness, or femininity, or family, or society. It is merely a question of which we have miserably failed to answer.

In Russia, there is an anti-homosexuality law that represses this minority from being themselves. “You could say that being gay in Russia is like living in the closet, a very big and very comfortable closet.”, so says Alexey Mukhin, Director General of the Center for Political Information under Putin. But then again, a cage is still a cage.

In the Philippines, being gay is still seen as being taboo. Some parents are ashamed that their children are gay. Some of my gay friends are ashamed they’re gay, and don’t want to admit it to their parents. I won’t be surprised if there’s still bullying in my former school for being “different”. It’s not only a problem of boys being boys, but of the milieu these boys live in.

Where do we find the answer? I come from a religious family. I used to teach catechism for Sunday school. I once preached that homosexuality is a sin “because the Bible said so.” I didn’t teach it just for the heck of teaching it; it’s in that syllabus we use for teaching children. Yet I was not a decent human being, for I preached denying someone their right to be themselves.

I found my answer in the many gay friends I’ve made along the way. I found the answer in the shoulders I could cry on, upon ears that would listen, and the in arms that would give a tight embrace. That my fears were unfounded. That I had been very, very wrong.

That I could change. That we can, too.

Surviving Medical School: The Second Year

I write this entry with these people in mind: my unborn child, who [might] consider being a physician someday, for my future students [mwahahahahahaha!], and for myself, that I may be reminded of who I was as a student. This is the second part of the series. 

It’s a Marathon, not a Race

thehealthybackblog.com

I wrote earlier that going to medical school is like running a seemingly never-ending marathon. In the second year, you will feel out of breath, out of strength, and out of willpower. This is normal, and you’ll experience it every once in a while. But if you took my advice and took care of yourself and your studies, you’ll be very surprised at what I have to say.

The Parable of the Snowball

I will never forget the advice told to my college roommate by his uncle, a medical doctor:

Take the basics seriously.

I was told how his uncle regretted not taking the first year subjects seriously, and how he struggled with catching up on the higher subjects. I would have to say that this advice is one of the best I followed, and I wish to emphasize this with a parable.

redbitbluebit.com

On a mountaintop, a boy rolled over two snowballs. One snowball rolled downhill and became larger in size. It unfortunately slowed down when it hit some rocks, and stopped completely when it hit a tree. The other snowball rolled resiliently, and despite opposition from jagged rocks, it accumulated more snow and turned into a mighty avalanche that carved the mountainside a path of destruction.

Moral #1: Avalanches are bad for your life.

Moral #2: During the second year, I’ve found out how Medicine is like rolling a snowball on top of a mountain. When you begin the path towards becoming a doctor, you start out as a tiny little snowflake. During the first year, you accumulate the language and grammar of medicine, just as a snowflake rolls over more snow and turns into a snowball. Eventually, this turns into a powerful avalanche  that becomes unstoppable.

A practical illustration would be that during a subject you will take in second year, Pathology. This subject builds upon the knowledge you have of Histology and Physiology, and some Biochemistry. If you don’t know what a kidney looks like under the microscope, and you don’t know the three phases of renal physiology, you will have a difficult time understanding why a kidney looks weird in a case of renal failure.

Practical Tips Section

leadershipfreak.wordpress.com

I realized that my posts up to this point aren’t really about practical stuff for medical school. Hehehe. The reason is that no two medical students learn the same way. These are some techniques I’ve come up so far to learn medicine effectively and efficiently. My disclaimer is that I’m more of a visual-kinetic learner, but I’ll put in some feedback from audio-learner friends:

  • Take care of yourself: body, mind and spirit. This is the foundation that you will build your character as a professional.
  • Know what you don’t know: I’ve once ploughed through a chapter of a book without understanding a single word of it. Never again. I’ve learned that when I don’t understand something, stop, look for the concepts that I don’t understand, review those concepts, then continue learning. It’s no use reading the different mechanisms of diuretics if you don’t know the renal pumps.
  • Write stuff down!
    • For processes (such as the RAA cascade or the fetal circulation), you can use flowcharts to illustrate how things are interconnected. This really comes in handy during Pathology, where you can see the disease processes simultaneously. Also works great for Pharmacology, for learning the modes of actions of drugs.
    • For info-overload subjects, use tables! This especially comes handy for Pathology, where’ you’ll be asked to compare the different types of cardiac failures (Left vs. Right, Systolic vs. Diastolic) and the different types of cancers (the bane of every medical student).
    • For memory-retention, use index cards. This is especially useful for information that requires one to memorize numbers *shivers* such as equations for Epidemiology, Pediatrics, and Medicine. I also use index cards to summarize some chapters from Harrison’s such as “Approach to a Patient with Rash”, writing the important points to be found when faced with a patient with a rash (Number one: watch out for meningococcemia!)
  • Say concepts aloud: my audio-learner friends tell me that in order to learn, they sometimes talk to themselves aloud to get aural feedback. They also said that they like listening or talking to people about the information they need to learn.
  • Realize that there are a ton of material that can help you learn!
    • YouTube, and other Video sharing sites: can’t understand a concept? Look for videos! I learned the intricacies of the renal countercurrent exchange mechanism *puts nerd glasses up* that way.
    • Board Review Series, “Dummies” books, etc.: I remember in Biochemistry that I understood nothing reading up on the Central Dogma on the prescribed text *puts nerd glasses up*. So I read a simplified book on Biochemistry. When I attempted to read the prescribed text again, I understood it. Disclaimer: simplified books are no substitute for the big books but are a great place to start if you have any difficulty.
    • Your colleagues: this includes your medschool friends and your teachers. A medical student is not a John Rambo cutting through the vast forests of medical knowledge. A medical student is a part of a community that works together for the advancement of medical knowledge.  It’s better to look like a fool asking a question than doing a foolish action that could cost someone’s life.
  • Practice makes perfect: Throughout second year, you’ll learn skills that will help you diagnose disease. Skills are attained through constant practice. I practice my physical examination skills by checking up on my father every other semester; to my unborn child, I’d be willing to be your dummy.
  • Expose yourself to experiences and opportunities: During the second year, you’ll start doing paperwork (at least in the medical school I’m attending), which, while it adds to the workload, exposes you to the drama of the human condition. There are some things that my patients taught me that aren’t in the books. There are also conventions and medical missions you can participate in to hone yourself further.
  • “See one, do one, teach one”: This is a tenet of Surgery, in which one progresses from being a passive observer, to an active learner, to a teacher when learning surgical skills. The ultimate form of learning is teaching. Help others understand a concept that they have a difficulty in. After all, our professional oath exhorts us: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.”

Learn to be a Doctor, not Study to be one

vgalt.com

There’s a fine line between studying and learning. Studying, according to the MW dictionary is “the activity or process of learning about something by reading, memorizing facts, attending school, etc.” Learning, on the other hand is “to gain knowledge or skill by studying, practicing, being taught, or experiencing something.” On these definitions, one can discern that the former is a passive process and the latter an active one. Strive to be the latter.

Let’s face it: medicine is a competitive profession. In pursuit of good grades and high marks in order to secure good training programs, I’ve seen how the pursuit of knowledge becomes a rat-race in which only one person wins. Medicine should not be like this; it is a profession where teamwork is of utmost importance. The foe of an aspiring doctor is not the subject matter; it can be learned. The foe of an aspiring doctor are not the marks of his peers; it won’t affect him in any other way anyway. The foe of an aspiring doctor is the self.

It’s quite existential, but second year is a continuation of the struggle against yourself. You see in your everyday medical school life forks in the road that diverge into paths that you will never cross again: “Will I spend 2 hours discerning the intricacies of the protozoa, or will I spend 2 hours playing this awesome video game?” “Will I go out this weekend or will I use it to learn the difference between the different types of cardiac drugs?” I’m not saying this to tell people to become hermits, only to emerge into medical prodigies without a social life (read the first post again); I’m asking you, a future doctor, to make choices. “To be a doctor, will I study, or will I learn?”

Keep going towards your dream! I’ll see you along the way.

Concept

ConceptJonas hesitated.

“I certainly liked the memory, though. I can see why it’s your favorite. I couldn’t quite get the word for the whole feeling of it, the feeling that was so strong in the room.”

“Love,” The Giver told him.

Jonas repeated it. “Love.”

It was a word and concept new to him.

The Giver by Lois Lowry, 1993

March 31, 2009, in a messy room

I Know Not How

I know how the body heals
After it is cut by a blade
Yet I know not how the spirit is strong
In the face of undeniable defeat.

I know how consumption
Takes its victim
Yet I know not how the human spirit
Moves on with a loss of its own.

I know how to heal broken bones
When they are shattered and bent
Yet I know not how the spirit
Mends that which I cannot.

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    For people who love to think.

    Jian Carlo R. Narag, MD

    2005-2017