First Day of My Third Year

Today was my first day of the third year.  To be fair it wasn’t a true first day, so much as an orientation day.  This post is going to be a couple random thoughts about the day.

First off, I hate orientation days.  Being the kind of person who likes to jump right in and get my hands dirty – a learn as I go kind of guy – orientation days seem to drag on and are extremely boring from my perspective.  The “need to know” things in an orientation day can usually be summed up in maybe an hour.  They could just tack this to the beginning of the first day and call it good.

Another thing I hate about orientation days are the ice breaker and get-to-know-you games.  Today we had at least four different speakers have us go around the room, introduce ourselves, tell them where we were from, and a little about ourselves.  Doing it once is more than enough.  By the fourth time you feel like strangling a puppy.

Next random thought, I have my own business cards.  The program gives them to us to distribute.  How cool does that make me?  Admittedly, probably not very cool.  But I feel a ton cooler.  Also, I have a pager now.  I guess I’m important enough to page and give out business cards.  Whoa.  Moving on up the ladder.

Yankton, SD has over 65 practicing physicians.  Yankton county only has a population of 21,000.  I was unable to find out the size of the catchment area of the hospital.  But that seems like an impressive number of physicians for a community this size.  Also, while talking to the physician recruiter, she said that they are currently looking for family practice doctors, internal medicine physicians, endocrinologists, urologists, general surgeons, and 3 invasive cardiologists.  I asked if the Yankton community even had the resources to support three interventional cardiologists, and she stated that they had all the infrastructure in place, they could hire and support all three tomorrow.  I was shocked.  Not only does Yankton have 65 practicing physicians, but also it could support many more.  Crazy.

Talking about physicians, a neurologist has just started practicing with the large multispecialty group in the last two months.  I was excited to hear this, with my interest in the neurosciences.  Also, the hospital plans on upgrading their MRI to a 3 Tesla with fMRI capability, in conjunction with research funding.  So, fMRI research will be taking place right where I’m studying.  That is exciting.

We will be getting a TON of hands on experience.  Just recently a student interested in surgery who has been going his third year in Yankton, was allowed to do the left side of a hysterectomy under close supervision of an attending surgeon.  In what other medical school could a person get that kind of hands on experience as a medical student?  No where.

We will be required to do 42 history and physicals with a problem list – over dictation (with our own dedicated transcriptionist) over the course of the 3rd year.  We will be required to assit with twenty vaginal deliveries, assist with five c-sections, do twenty new born exams, and twenty-five well child exams.  There are medical students in the United States who finish their third year having never assisted in a vaginal delivery.  And here at SSOM, 20 deliveries is just the bare minimum requirement, some students log way more.  I wonder how many babies the Ivy league medical students deliver?

While orientation day was boring, the information I received over the course of the day made me super excited to get this year started.  It has a LOT of potential.

Sanford School of Medicine – Match Statistics

One thing that I learned sometime during my Pre-Med days was to look at match statistics of schools to determine how well they do at training their students.  I thought that was good advice.  Obviously, how well a school does training their students should correlate to a better match rate.  I mean it’s exactly like looking at how well certain colleges place their students into careers.

So, I took that to heart.  Now, I’ll be the first to admit, I wasn’t exactly afforded a large choice between medical schools.  What I mean to say is, I didn’t get into a ton of medical schools.  But hey, that doesn’t matter now does it?

So, before I even started medical school, I took an interest in the matching statistics of the schools I was applying to.  And after I was accepted at the Sanford School of Medicine (SSOM), I really concentrated on their matching stats, and to be honest we do pretty well.

I have compiled the matching statistics from SSOM since the year 2000 in a spread sheet, and I have found some interesting trends.

Match Stats


Since the year 2000 (including the 2010 match) – we have graduated and matched 545 students from SSOM with 93 going into Family practice which is 17.1% .   Compared to the US match rate of 7.4% matching into Family Practice (and only a 3% behind the leader), I would say that SSOM is doing pretty well meeting it’s mission.  And out of all the students who graduated since 2000 almost 45% of them have entered a primary care specialty (which would include Family Practice, Internal Medicine, Pediatrics, and Psychiatry).

Our medical school has also done a great job matching students into very competitive specialties as well. Dermatology has long been known as one of the most difficult specialties to match into.  Yet, three students from a class of 50, matched in both the 2007 and 2008 match.  Or to put it another way, 6% of our class those two consecutive years matched into a specialty in with only 1.8% of medical students are able to match (according to the 2009 match statistics).

While most of our students match in the midwest, some have matched into some of the most well known universities in the country including Baylor, Cleveland Clinic, Dartmouth, Emory, Massachusetts General, Mayo, UCSF, Rochester, Vanderbilt, Yale, and others.

So, if you’re a Pre-Med student, don’t worry if you don’t get into the Ivy league schools.  State schools, even little South Dakota, can help their students match into competitive specialties in well known programs.

——————
Top Ten SSOM Specialty Choices

  1. Family Practice
  2. Internal Medicine
  3. OB/GYN
  4. Anesthesia
  5. Pediatrics
  6. Psychiatry
  7. Emergency Medicine
  8. Radiology (Diagnostic)
  9. Pathology
  10. Orthopedic Surgery

Top Ten SSOM Match Locations

  1. South Dakota
  2. Minnesota
  3. Iowa
  4. Nebraska
  5. Wisconsin
  6. Kansas
  7. Michigan
  8. Missouri
  9. Texas
  10. Illinois 

Sanford School Of Medicine – Early Clinical Exposure

One reason I chose to come to the Sanford School of Medicine here in South Dakota, is because of the early exposure to real clinical medicine.  Sanford SOM is known (by those in the area) for it’s amazing clinical experience especially in the MS3 and MS4 years.  The medical students at this school work almost exclusively one-on-one with attending physicians.  Usually there is no senior student, intern, junior resident, senior resident, chief resident, or fellow blocking the third year medical student’s view of the action.

But little is known about the early clinical exposure in the MS2 year.  Here at the Sanford SOM, the second year classroom schedule ends at the end of March.  A transition to the clinical world takes place over the end of March and early April, and then the real fun begins.  Each MS2 gets paired with a rural family practice physician somewhere in the state of South Dakota, and we spend an entire month with them.

Almost all of us were exposed to serious trauma, OB/GYN, geriatrics, pediatrics, general medicine, emergency medicine, and some even were scrubbing into surgeries.  I personally was rounding on hospital patients, putting in stitches, doing history and physicals, seeing clinic patients, seeing nursing home patients, and assisting with surgery.

To give you an idea of how much exposure we had, I personally logged in over 200 patient encounters.  Some of these include:

  • Ear aches
  • Multiple Myloma (Cancer)
  • Well Child Visits
  • Physicals
  • Abdominal pain
  • Pneumonia
  • Allergies
  • Head trauma
  • Broken ankle/foot
  • Knee injury
  • Elderly falls
  • Vertigo and Dizziness
  • Constipation
  • Hypothyroid
  • Stroke
  • Heart Attack
  • Congestive Heart Failure
  • Flu
  • Breast Lump
  • Headaches
  • Low Back Pain
  • Smoking cessation
  • Pregnancy
  • Diabetes
  • Warts
  • Depression
  • Bipolar Disorder
  • Hypertension
  • Syncope
  • Hemorrhoids
  • Strep Throat
  • Hernia
  • Seizures
  • Cough
  • Acid Reflux
  • ADHD

I was also lucky enough to get to do some cool procedures too!

  • Interpret X-Rays, CT scans, and MRIs
  • Assist with ultrasound of the bladder, cartoid arteries, and pregnancy
  • Put in stitches
  • And scrub in and first assist on 8 surgeries including open appendectomies, laproscopic cholecystectomies, C-sections, and a hysterectomy.  
So, here’s a taste of the clinical exposure we get at this medical school.  If you’re interested to read more about what I have to say about the Sanford SOM, read my medical school review Part 1 and Part 2.  It was an awesome first clinical experience, and I cannot wait to get started with the 3rd year!

Medical Students Have To Learn Sometime

[The dude in this picture is just a random guy I googled, not the real patient talked about in this post]

Another medical student and I were hanging around the emergency room at a small town hospital the other day.  The weather had been particularly nice that day and a man decided to fix some of the gutters and siding on his home.  So he climbed up his ladder and started working, but his guardian angel must have taken a coffee break and his ladder broke.  The man fell 15 or so feet down to the concrete, and was transported by ambulance to the ER.

Unfortunately this man had a large laceration across his forehead, and another long his arm.  Lucky for us medical students, this man had two large lacerations that required stitches.  For story completeness – this guy was completely stable and had absolutely no life-threatening injuries.  The lacerations were the only injuries he sustained as a result of his fall.

The doctor working in the ER with us decided this was a great opportunity for us to practice our suturing skills, and so the doctor told the other medical student and I to come over “and assist him with stitching up.”  The man’s wife did not like the sound of that at all, and she asked if the students would be allowed to put in the actual stitches.  The doctor told her that we would, under his close supervision.  The wife wasn’t convinced that this would be ok.  So she asked if there was ANY way that the doctor could call in another physician to help “assist” with the stitches.  He said that the other doctors were too busy to be called in for this, and the medical students were available and have had plenty of training in this type of procedure.  The man’s wife told the doctor that she really didn’t want students practicing on her husband, and the doctor reassured her that we have had lots of training and that medical students can do this.

It felt weird to be in the middle of that disagreement.  On the one hand, I completely understand the wife’s concern of having medical students essentially “practice” on her husband.  Yes we’ve had 6 years of post high school training, but in all honesty probably less than 5 hours of suture only training at this point.  But on the other hand, us medical students need to practice on someone.  If you only had the most experienced people do the job every time, then how would you train the next generation?  Also, if I completely mess up and a suture falls out, then we can always put another in or just let it heal without the missing stitch.  It won’t make a big difference.  I also understand that the wife may not have known that this was a fairly low risk procedure on the grand scale of things, and so I can understand where she’s coming from.

Yes we have to learn sometime.  If everyone says no to medical students, then there will never be an experienced group of physicians.

Real Board Scores for Step 1

The other day in Pathology class we had the lecturer tell us that if you want to get into a competitive specialty then you have to get a 260 on the USMLE Step 1.  I know for a fact he was exaggerating, but others in our class think this is true.  


Maybe those people don’t realize how high a 260 is for a score on the Step 1.  Let me give you a base of comparison, according to the Medfriends Score Estimator, a 260 on the Step 1 is like getting a 42 on the MCAT.  Possible?  Sure.  Probable?  NO. 


Yes it’s true, the match is getting more an more competitive with each passing year.  As medical student enrollment (as thus graduates) as been steadily increasing, slots for residency have not.  Thus creating a situation in which the match has become more competitive than ever.  But what kind of scores does it take on the USMLE Step 1 to match into things anyway?


Well out of 14,958 US graduates who applied to match in 2009, 13,646 of them matched (91.2%) and 1,312 did not match (8.8%)*.  The average score on the Step 1 for matching US grads was 225 across all specialties.  Obviously the score was dependent on specialty.  Which I’ll list here.  The average score for non-matching US grads was an average of 216.


*But what if you don’t match?  You scramble. This is a time where unmatched applicants and programs go in an all out free-for-all of faxing, calling, and emailing to match students to program openings.  From what I understand, it’s a nightmare.  If you’re interested, you can find a lot more about the topic on SDN and other medical student blogs.  


Ok, so what does it take on the Step 1 to get considered in the specialty you want to go into? Well here’s a list of the AVERAGE MATCHING USMLE Step 1 scores for each of the specialties.  

  • Anesthesiology: 224
  • Dermatology: 242
  • Diagnostic Radiology: 238
  • Emergency Medicine: 222
  • Family Practice: 214
  • General Surgery: 224
  • Internal Medicine: 225
  • Internal Med/Pediatrics Combined: 225
  • Neurological Surgery: 239
  • Neurology: 225
  • Obstetrics & Gynecology: 219
  • Orthopedic Surgery: 238
  • Otolaryngology (ENT): 240
  • Pathology: 227
  • Pediatrics: 219
  • Physical Medicine and Rehabilitation (PM&R): 214
  • Plastic Surgery: 245
  • Psychiatry: 216
  • Radiation Oncology: 238
  • Transitional Year: 236
So with some mathematics applied = (13646/14958)*225 + (1312/14958)*216 = we can figure that the average score for all (matching and non-matching) US grads applying to the match in 2009 was around 224.  So, you can look above data and get a good idea how competitive the specialties are based on USMLE Step 1 score.  

I better get studying for that exam.  


[Similar Post – Check Out USMLE Step 1 – 2010 Percentile Score]

Some Objective Data

 Pre-meds are eagerly awaiting acceptance letters from medical schools and can’t wait to get started with the “busy” life of being a medical student.  But what is busy?  That’s such a subjective term.


Currently, we (MS2 students) are studying for our second exam in pharmacology.  Other than pharmacology we take 4 other classes currently.  One difficult one (Pathology), and two others that have lighter loads comparatively (Intro to Clinical Medicine 3 & Behavioral Science).  Our second exam in pharmacology is this coming Monday (Dec 7th).  Over this last 2.5 (that’s two and a half – not twenty five) weeks, we have learned/are learning this list of drugs:


Methacholine
Bethanechol
Carbachol
Cevimeline
Pilocarpine
Ambenonium
Demecarium
Edrophonium
Neostigmine
Physostigmine
Pyridostigmine
Tacrine
Donepezil
Rivastigmine
Galantamine
Atropine
Scopolamine
Cyclopentolate
Tolterodine
Dicyclomine
Oxybutynin
Tropicamide
Nicotine
Mecamylamine
Guanidine
Botulinum Toxin
Succinylcholine
Varenicline
Atracurium
Cisatracurium
Pancuronium
Rocuronium
Tubocurarine
Vecuronium
Norepinephrine
Epinephrine
Isoproterenol
Dopamine
Dobutamine
Albuterol
Formoterol
Metaproterenol
Pirbuterol
Salmeterol
Terbutaline
Clonidine
Guanabenz
Guanfacine
Alpha-methyl Dopa
Apraclonidine
Amphetamine
Dextroamphetmaine
Pseudoephedrine
Ephedrine
Cocaine
Tyramine
Phenoxybenzamine
Phentolamine
Prazosin
Terazosin
Doxazosin
Tamsulosin
Alfuzosin
Propranolol
Timolol
Nadolol
Metoprolol
Atenolol
Esmolol
Betaxolol
Pindolol
Acebutolol
Labetalol
Carvedilol
Histamine
Diphenhydramine
Chlorpheniramine
Meclizine
Fexofenadine
Loratadine
Desloratadine
Cetirizine
Levocetirizine
Azelastine
Phenylephrine
Naphazoline
Oxymetazoline
Pseudoephedrine
Beclomethasone
Budesonide
Flunisolide
Fluticasone
Mometasone
Triamcinolone
Theophylline
Ipratropium
Tiotropium
Levalbuterol
Omalizumab
Singulair
Advair Diskus
ProAir HFA
Flomax
Nasonex
Spiriva
Detrol LA
Chantix
Proventil HFA
Combivent
Flovent HFA
Nasacort AQ
Allegra-D 12 Hour
Toprol XL
Astelin
Xopenex HFA
Patanol
Pulmicort Respules
Alphagan P
Vesicare
Xopenex
Clarinex
Coreg CR
Ventolin HFA
Rhinocort Aqua
Xyzal
Veramyst
Asmanex Twisthaler
Uroxatral
Allegra-D 24 Hour
EpiPen
Zyrtec
Enablex
Symbicort
Qvar




And that’s a list of the 2nd exam drugs.  Remember this is a list of only the drugs we need to know, not the mechanisms, receptors, or enzymes involved that’ll also be on the exam.  Keep looking forward to medical school my pre-med friends!  Also, use this list and start memorizing right now, that’ll get you ahead.  

Sanford School of Medicine – Social Networking

Currently, the Sanford School of Medicine is in the process of getting a task force together to write a code of conduct regarding the use of internet social networking and other technologies.  


I wonder if this is in response to that JAMA article that recently came out.  If so, I wonder how many other medical schools are getting committees together to address social networking issues.  How many medical schools already have code of conducts for social networking?  – If you are in a medical school with some kind of official professionalism document which refers to social networking could you email it to me?  

I think this is a good step for the medical school, and will really help clarify things for the future.  We don’t need to have the same problem the University of Louisville had with Nana Yoder.  

The patient interview

As I continue along my medical school education journey, I am really starting to realize one of the real ‘arts’ of medicine is the patient interview.


The Sanford SOM does a great job teaching medical students the basics of a good patient interview. During one of these teaching sessions I was stunned to learn that may doctors do not get around to addressing the patient’s main concerns during the patient interaction. How could this happen? When the patient calls in to setup an appointment, don’t they tell you the main concern they are having? I guess it’s not really that simple.

One gold nugget of interviewing knowledge we have gained during our patient interview sessions, is to ask the patient an obvious open ended question to get the interview rolling. Ask a question such as, “What brings you into the clinic today?” or “How can we help you today?” This may seem silly, as the chief complaint is probably already on the chart when you walk in, but it’s amazing how quickly the patient will tell you the main points they want covered in the visit and how much time it really saves.

After following a couple doctors who cut off the patient very quickly and try to do all the talking themselves, I am really amazed at the lack of basic interviewing skills these physicians have. While they are extremely smart clinicians who really cared about their patients, the fact that they didn’t acknowledge obvious patient concerns during the interview worried me.

For example, construction worker in his early 30’s comes into clinic with a chief complaint of headaches. He is being seen again after having come into clinic with this complaint last month. Last visit, the doctor diagnosed migraines, ordered a two medications, and highly recommended a CT scan of the brain. This week, the patient comes in stating that he has been having headaches of the same frequency and duration. The quick acting medication works, but he has not been taking the preventative medication, and he didn’t get the CT done. During the interview, the doctor is trying to gather information using almost all yes/no or very short answer questions, while at the same time lecturing the patient at the importance of getting that CT scan done. During this time the patient seems to almost offer excuses why he didn’t get the scan done but at the same time trying to voice these as concerns. He stated that this is a very stressful time of year for him, he hasn’t been sleeping well, and that he thinks he may have something wrong in his chest. The doctor did not acknowledge any of these, brushing them all off very quickly with the response, “I know.” Then fixated on the caffeine usage and the importance of the CT scan.

I can tell you right now, I am not a doctor. But, it seems to me that just asking about the stress, sleep, and worries about the chest may have eased the concerns of the patient and wouldn’t have taken the doctor too much longer. To me, it seemed like stress, problems sleeping, and the chest worries easily could have been the things causing the headaches. But again, I’m no doctor.

At the start of our patient interview classes, I thought we were really wasting our time. I thought it really couldn’t be that hard to address our patient’s concerns and that teaching us a standardized patient interview was a waste of time. I also thought that doctors were probably more competent at fishing out a patient’s underlying concerns better than our instructors and the statistics would have us believe. After a few clinicals, I can say that I am glad I’ve been getting this patient interview training. I have been amazed at the basic patient interview skills some physicians lack, and really appreciate the ‘art’ of the patient interview.

Avera Clinical First Steps

The Avera healthcare system offers a nice 6-week summer course to the Sanford School of Medicine medical students between their first and second year called the “Clinical First Steps.” The program setup for two primary purposes.


The first is to give the early medical student a glimpse into what clinical medicine is really all about. To do this, the program tries to educate the medical students about what the supporting staff do in the hospital setting. The creators of this program had some stories as based on physicians who sometimes wondered, ‘why didn’t I learn that in medical school?’ They have also heard their fair share of, ‘how come that doctor didn’t learn that in medical school?’ types of comments. So six years ago they decided to create this program to give us the type of experience that generally isn’t taught to medical students.

Today during our orientation, the leaders of this program really wanted us to take home this first goal of the program. The example was one of a young 3rd year student. The ER physicians during this trainee’s time let the student ‘lead’ on a some-what critical case. The student started barking orders and requesting tests (an ABG to be exact). Getting carried away in the moment, the student demanded to see the results of the ABG ordered only 5 minutes prior. (NOTE: I have no idea how long it takes to get results from an ABG, this is just the story we were told.) Moral of the story was that medical students need to learn how long tests take to order, how long rooms take to clean, what a social worker, PT, OT, case manager, administrator, et cetera does all day. Knowing these things will makes us more effective and understanding physicians, and is the first goal of the Clinical First Steps program.

The second goal of the program has a little different spin. According to the opinion of one of our leaders, there are some doctors out there that were not meant to be doctors. Of course these doctors were smart and dedicated individuals, but they just don’t have the compassion (or whatever) to be good physicians and just work pay-check to pay-check not ever really caring about the patients. Luckily these people are a small minority. Our leader continues on to say he feels that unfortunately a larger portion of doctors end up in specialties where they are not truly happy. He feels that many physicians do not work in a specialty where they are truly engaged in what the specialty offers and the types of patients that doctor encounters. These doctors careers quickly become just jobs. When this happens these doctors also start to live from pay-check to pay-check looking forward to the day that they retire. This man’s opinion scares me, as I (and I’m sure my colleagues as well) want to work in a specialty where we are happy and fully engaged in it throughout our careers.

Finding this calling, is the second goal of the Clinical First Steps program. Throughout the next six weeks program leaders hope to expose us to as many different specialties as possible to help us get a feel for what we may someday want to do.

I am excited to go through this program and I have high hopes that it will help me narrow down my calling. I also can’t wait to start interacting with patients again, I really miss the hospital environment and it really brought back good memories being on the floors again.

Primary Care Preceptorship

Today, I had my preceptorship with a Family Medicine doctor at the McGreevy clinic on west 41st street in Sioux Falls. It was a good day, we saw a well rounded sample of patients from psych to a red toe.


First of all, during my day today, I really felt like I was connecting with the little kids. Something about the pediatric cases really seemed like it was up my alley. I was not expecting to ever go into any kinds of pediatric specialty, but now I might have to give it some consideration.

The other thing that I really noticed today was the door dance. The equivalent of the middle school dance in the exam rooms. During our after-clinic medical student dinner get-together, we brought up how weird it was to stand in a little exam room and try to get out the door. Other medical students went in to see a patient with an attending and a resident or another student. So a medical student, an attending, a second student (or resident) and a patient crammed into a tiny exam room.

As you can probably imagine the patient and attending would be the farthest into the room, while the first year medical student would be closest to the door (ie: farthest from the patient). When the clinic visit wraps up, as a first year trying to make a good impression, you want to open the door for the patient and higher up medical people to go out the door ahead of you. But due to the tremendously small amount of room you have to work with, you just throw open the door and walk out first like you’re dying to get out of there.

This probably doesn’t leave a good impression on the attending, but what can you do?