Letters
to a third-year
Student
From The Class of 2010
School of Medicine
UT Health Science Center
at San Antonio
Editor:
David L. Henzi, Ed.D
Director
Office of Academic Enhancement
[
“There’s always the possibility that we will come to a new
understanding and to perceive the body as a primal mystery
and therefore sacred. Again and again, in patients deformed
or ravaged by disease, we are stunned by a sudden radiance.
This is not always comforting; there is terror in occasions
that lift the veil from the ordinary world.”
Letters to a Young Doctor, Richard Selzer MD
]
Letters
to a third-year Student
Table of Contents
2010
Foreword ............................................................................ Pg. 4
Detsky, Allan S. ............................................................... Pg. 6
Anonymous 1 ................................................................... Pg. 9
Anonymous 2 ................................................................... Pg. 10
Anonymous 3 .................................................................. Pg. 11
Anonymous 4 .................................................................. Pg. 12
Anonymous 5 .................................................................. Pg. 15
Anonymous 6 .................................................................. Pg. 16
Anonymous 7 .................................................................. Pg. 17
Anonymous 8 .................................................................. Pg. 18
Aguilar, Jennifer................................................................. Pg. 19
Ashton, Aaron ................................................................ Pg. 20
Azouz, Sol ......................................................................... Pg. 21
Blau, Adam ........................................................................ Pg. 24
Bocanegra, Ashley ........................................................ Pg. 25
Brown, Matthew ........................................................... Pg. 26
Caddell, Heather ........................................................... Pg. 28
Caldwell, Lindsay ........................................................... Pg. 30
Chang, Mimi ..................................................................... Pg. 32
De Los Santos, Denise .............................................. Pg. 33
Derrick, Dustin .............................................................. Pg. 35
Doan, Mai .......................................................................... Pg. 37
Fleischer, Raymond ...................................................... Pg. 39
Flores, Jess ......................................................................... Pg. 40
Gelabert, Chris................................................................ Pg. 42
Gibbons, Steve ............................................................... Pg. 43
Goswami, Varsha .......................................................... Pg. 44
Hadvani, Teena ............................................................... Pg. 45
Hunt, Audrey .................................................................. Pg. 46
Huynh, Christina ........................................................... Pg. 47
Jackson, Ian ....................................................................... Pg. 48
Johnson, Kiley .................................................................. Pg. 49
Kasinath, Vivek ................................................................ Pg. 51
Kim, Pam ............................................................................ Pg. 53
Kostibas, Megan ............................................................. Pg. 55
Lacey, Catherine ............................................................ Pg. 57
Mazzarella, Brian ........................................................... Pg. 58
McKnight, Michael ........................................................ Pg. 59
Muszynski, Melissa ........................................................ Pg. 61
Nguyen, Anh ................................................................... Pg. 63
Oak, Tina ........................................................................... Pg. 64
Ojo, Rosemary ............................................................... Pg. 66
Patel, Payal ........................................................................ Pg. 67
Petersen, Anna ............................................................... Pg. 68
Pham, Catherine ........................................................... Pg. 70
Potter, Shannon ............................................................. Pg. 71
Powell, Anna .................................................................... Pg. 73
Pu Yee, Woodward ..................................................... Pg. 75
Qiao, Jesse ........................................................................ Pg. 77
Seo, Jenny .......................................................................... Pg. 80
Sharron, Jennifer ............................................................ Pg. 80
Teegarden, Beth ............................................................ Pg. 83
Thomas, Stacey .............................................................. Pg. 85
Tom, Dina .......................................................................... Pg. 88
Wages, Mike .................................................................... Pg. 89
Waits, Shelley .................................................................. Pg. 90
Wald, Megan ................................................................... Pg. 91
Walker, Nicole ................................................................ Pg. 92
Waters, Jill ......................................................................... Pg. 95
Whitman, Ellen ............................................................... Pg. 97
Wild, Elaina ....................................................................... Pg. 98
Wisotzkey, Bethany ..................................................... Pg. 99
Foreword
Dear MS 3’s,
On behalf of the clinical faculty, I would like to extend my warmest greetings to the class of
2011 as you all continue onto one of the most exciting years of your lives. Yes, I do think that it
is a thrilling year, even though many students approach third year with trepidation. Two years
of filling brains with information has left many of you exhausted and wondering “Why did I do
this?” “If I had known that medical school would be like this, I would never have done it!”
Let’s look back a few years. One of the first experiences that set us apart from our friends
and families was gross anatomy. It was a time when we came face-to face with the reality
of death. It was a uniquely privileged experience that most people will never do and cannot
understand. Dissecting a human is an incredibly intimate way to experience humanity.
Then came the mountains of knowledge to memorize and learn. It was often overwhelming,
but was vital to preparing our brains for the information overload that is a daily fact
of medicine. Yes, most of us replace many of the pathways of biochemistry with other
information, but the formation of those neural connections was essential for understanding
further clinical information.
Third year accelerates transformation and change. It is a time when we continue our
metamorphosis into physicians. You will realize that you are doing something special when
you ask deeply personal questions, that you would not even consider asking your closest
friend. Now you have graduated to dissecting the living. As a medical student you may only
get to do the smallest incision or a few hidden stitches – but what an incredible privilege.
You will be able to touch and examine patients in ways that would not be acceptable in
other people. The hands of a physician are not the hands of ordinary people. The ears of a
physician are not the ears of ordinary people. Your white coat, though still short, makes you
special in people’s eyes.
With these privileges comes great responsibility. You started talking about the issues of
humanism and professionalism on the first day of medical school during the first hour. It is
that important. Sometimes, though, the humanism of medicine gets lost in the struggle to
master the clinical information. It is imperative to be competent, but it is also vital to be
compassionate. You will see many attendings and residents that emulate all of the traits that
we desire to possess. The reality, though, is that you will also work with those who do things
that you do not like. Recognize these flaws and strive to learn from them so that you do not
do the same.
Many students complain about their friends doing thrilling and wonderful things with their
lives while medical students are stuck under fluorescent light bulbs in the library or in the
dark halls of the hospital. Many students tell me that they feel that they have put their lives
on hold. I would argue that you are on one of the greatest adventures that anyone can
undertake. Just like an exciting trip to Nepal, there will be times of exhilaration, but there will
also be times of difficulty and even times of exhaustion and frustration.
My advice to you is to look at third year as one of the great adventures that only a few are
privileged to experience. When you are with your friends, for every few negative things
that you complain about, encourage yourself to discuss some of the wonderful things that
happen. What about when we break through the isolation of suffering by really knowing and
connecting with a patient? What about when we assist in surgery to remove a deadly cancer?
What about when we reassure a scared family that their child has only a viral respiratory
infection and not a deadly flu infection? It is always more fun to talk about the horror stories,
but let’s not forget all of the miracles.
Third year will be exhausting; it will be emotionally draining, some days you will just want to
quit. Other times though you will be having the time of your life, and things will be going just
right. Let’s not forget those times. It is a trek that few are capable of doing. We often talk
about elite athletes, I consider each one of you to be elite people.
Welcome again, and I hope that you enjoy and learn from the words of wisdom that your
fellow medical students share with you. Take the time to read the following letters. Also take
the time to start writing your own letter.
I look forward to working with each one of you as you rotate through pediatrics.
With great regards,
Glen Alejandro Medellin, M.D.
Letters to a third-year student • from the class of 2010
Dear Third Years,
You’re going to get a lot of advice about how to pick a specialty, what to look out for on
rotations and how to impress your attendings. Ask anyone, including me, and they’ll gladly offer
much more advice on these topics than you want. So, I think that I’ll let the other authors in this
compilation address those topics. The truth is that you’re smart and you will figure out the wards
and rotations sooner than you think and you won’t be relying on outside information anymore.
Don’t even worry about what kind of doctor you will be when you grow up. Life has a funny way
of settling out exactly the way it should. One day you’ll just wake up and you’ll know what you
want. So don’t worry about it. Instead I just wanted to remind you that in the end, you need to be
happy with yourself and your place in the medical system.
Every specialty in medicine has some level of associated stress. You have a great
opportunity to observe how individual attendings/residents/interns handle that stress. Some will
take it all in stride and seem to be able to handle all that is thrown their way (this includes your
presence). These tend to the “good” attendings/residents/interns to work with. Others will fail
miserably. These tend to be the “bad” ones. The good ones are nice, helpful to everyone no matter
what is happening around them. The bad ones tend to respond to stress with sarcasm, insults, and
impossible demands. I want to encourage you not to simply dismiss the bad ones as simply terrible
people to work with, instead try to identify exactly what makes them so “terrible.” Once you’ve
identified a pattern of poor behavior, actively commit to avoiding those behaviors or never starting
them in the first place. Also try to find positive examples of doctors in your specialty of choice
that can act as a sort of behavioral/moral model for the type of doctor you want to be. It can’t
hurt to have a role model to look up to from time to time. It is my belief that you can be the most
technically and clinically proficient physician around, but if you are a failure as a human being, you will
eventually fail your patients.
This may not be what you’re expecting from these letters, but I just wanted to remind you
to continue to commit to personal change and improvement. I think that doing so will help you in
ways that you won’t learn from “Case Files.” “First Aid” won’t teach you how to treat a nurse or
scrub tech with respect. These are all “little” things that make a world of difference in your day to
day function. But you’re smart, I’m sure you’ll figure all this out. Good luck third year! I know you’ll
all do great!
-Anonymous
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Letters to a third-year student • from the class of 2010
Dear Fellow MS III’s:
The single best piece of advice that I can give regarding third year is to come to the conclusion right
now that you’re enough, and to never let anyone or anything that you may or may not have done
cause you to question this. Every one of you got here, and every one of you will be a great doctor
if you work hard and learn from your mistakes and the mistakes of those around you. Third year will
cause you to constantly question whether you’re good enough, so when it does, just try to remind
yourself of the above!
With that said, there are a few things that I have come to realize, which I wish would have been
in the forefront of my mind when I first started my rotations. The first is that all anyone really
expects of you is that you try your best. They don’t necessarily care if you know all of the answers
to their questions or whether you’re skilled at performing procedures, just that you’ve been reading,
your interested in learning, you’re pleasant to be around, and that you’re a hard worker. As long
as you show up when you’re supposed to, work hard, show compassion towards your patients,
and respond to constructive criticism, you’ll receive excellent evaluations. Honestly! So just relax,
be yourself, and trust that you’re going to do fine on the rotation. This will bring you much peace
and allow you to spend more time focusing on what’s truly important, which is taking care of your
patients and learning from the disease processes that they have.
Second, it’s better to spend an extra minute listening to a patient’s story or asking a nurse to help
get something for a patient, than to rush through seeing your patient in order to “impress” your
resident or attending with your speed. Most of the time you will feel pressured (by your resident)
to speed through an interview in order to get to the next patient or back to your team, and when
you do, you’ll find yourself becoming more mechanical, less compassionate, and detached from your
patient. Every time that I rushed through an interview, I was left with an awful feeling about the lack
of compassion that I just exhibited towards my patient. However, when I resisted the urge to speed
through seeing a patient, I was surprised more times than not with compliments made by patients
and their families directly to my attending/resident, and the compliments are always what made it on
to my evaluations. Not once did I receive a comment on an evaluation about my lack of speed or
efficiency. So take the extra time to show patients that you care; it’ll make both you and them feel
better, and you won’t get dinged for doing so.
Lastly, remember that everyone makes mistakes, and try to be quick to forgive teammates who have
offended you. Everyone is just as anxious as you are to do a good job and to “impress” others with
their knowledge. If you can remember this, and try to understand where each person is coming
from, then it’ll help you be more merciful and forgiving when others inadvertently “make you look
bad.” You will probably unintentionally do the same thing to someone else at some point during the
year, so try to remember that it wasn’t malicious in nature (at least hopefully it wasn’t), and move on.
In all likelihood, your attending/resident didn’t even notice!
I wish you all the best,
Anonymous
10
Letters to a third-year student • from the class of 2010
One morning on rounds, we got the call we had been anticipating. We all walked up the
stairs like a long line of solemn migrating birds and trailed noiselessly into the room. Our comfort
care patient had died. In the hallway, the chaplain was speaking quietly to two family members. At
one point, one of the ladies lost it; she started weeping. There I was, a spectator in someone’s most
horrible grief. I imagined that if someone had taken a snapshot of that moment I would have looked
like one of those random people who happen to make it into family pictures, because they walked
by at the wrong time. Did I serve a purpose?
Every medical student must feel like a spectator at some point. As outsiders, we truly are
observers. Our primary functions are watching, learning, and gathering information. We fluff out
the edges of the history. We know the miniscule details that are 99% of the time superfluous. We
learn. We reason. We try. However, most of these efforts are quiet. We seem often to hang on
the periphery of this big bad medicine world that rarely makes sense and is highly confusing and
overwhelming, but, in the end, this role does serve a purpose. We are learning. That day in the
hallway, I was learning to cope, learning to comfort through observation. I was growing as a future
physician.
Then there are those moments when all the pieces of the puzzle seem to perfectly align,
when all those months of watching suddenly transform into something substantial, powerful,
and real. In those moments, the voices of previous lecturers, the wisdom of attendings, and the
countless hours of reading come together in harmony and make perfect sense. We are no longer
outsiders. We, too, can be a part of the solution. We can become the people we have always
dreamed of being.
This happened to me for the first time near the end of fall semester. I walked into one
of the last clinic visits of the day. The patient was quivering and tearful, huddled in the corner. Her
story was devastating. She was a recent rape victim. I remembered the words of lecturers: “Tell
them they did nothing wrong.” I remembered my attending that week: “For some patients, you have
to carry them through until they can carry themselves.” I remembered my books and countless
health issues and much needed tests filtered out of my brain reserve. I sat down with her. I looked
her in the eye. I took her hand. I knew what to say. My eyes filled with tears, too, and we talked. I
knew what to do, and for the first time, I knew that I could start a patient down a path to wellness.
This transition from outsider to helper is exciting and wonderful. We are reminded why
we wanted to be physicians when we are finally able to, with confidence, take a hand, lend an ear,
or provide a shoulder for tears. As a third year medical student, we get the opportunity to embark
on the great journey of finding confidence in ourselves as caregivers. Step out on that journey with
hope and excitement!
Anonymous
11
Letters to a third-year student • from the class of 2010
“Why don’t you pick up this case of Transverse Myelitis, it’s an interesting case,” my attending
told me on my first day of the Neurology inpatient service. “Maria Gonzalez, 48 year old female
with Transverse Myelitis versus Multiple Sclerosis admitted for management. Spanish-speaking only,”
I read. Already nervous about this Neurology rotation as neurology had been the bane of my
existence first and second year of medical school, I wondered how I was going to accomplish the
exam in Spanish no less. Though I had 6 years of Spanish, much of it had long been forgotten. That
night I dug out my Bates Guide to the Physical Exam and an old medical Spanish book. Going back
and forth I started jotting down the key verbs and anatomical names that I would need for the Neuro
exam. I even called up my best friend who fortunately was Spanish-speaking and got a crash course
in Spanish. Armed with my Neuro exam checklist along with my haphazard laundry list of Spanish
phrases and terms, I made my way to room 855 at 5:30 the next morning. The room was dark and
I had only seen my patient for a few minutes yesterday on rounds. Still unfamiliar with the layout
of the patient rooms and where to find the light switch, I stumbled across the room nearly landing
on my patient. Ms. Gonzalez was sound asleep. I gently tried shaking her awake, greeting her with,
“Buenos dias Señora Gonzalez.” Nothing. Then I tried shaking a little harder as I finally saw two eyes
slowly open and look quizzically back at me. I fumbled through with my broken Spanish as I tried to
explain to her that I was a third year medical school and needed to examine her. Being so early in the
morning, she quickly drifted back to sleep several times while I tested reflexes and tried to get her to
tell me if she could feel me poking her with a safety pin. I somehow muddled my way through the
exam communicating partly through Spanglish and partly like I was playing a game of charades. I was
immensely thankful for Ms. Gonzalez’s patience with me.
Over the next two weeks, I began looking forward to my early morning visits with Ms.
Gonzalez. She was such a pleasant woman, always wearing a smile on her face despite my shaking her
awake at 5 or 6 in the morning; she was very tolerant of my poking and prodding her, as I asked her
the exact same laundry list of questions everyday. During the day, we would return to her room on
attending rounds with the whole crew of attending, resident, intern and student. My attending, who
was proficient in Spanish, usually always got different information than I had elicited that very morning.
In the larger group, I stood in the back and looked on as my attending asked questions and examined
her. As we finished our quick visit at the bedside, I would linger back and flash Ms. Gonzalez a quick
smile before we moved on to see our next patient.
Having just finished my first two months of third year on the inpatient General medicine
service, I was already occasionally catching myself thinking or referring to some of the patients by
their diagnosis. But Ms. Gonzalez was different, perhaps because her story was so tragic. Only 48,
she already battled repeated episodes of weakness and sensory loss over the last four years that had
now left her completely paraplegic in her legs, incontinent and with progressive ascending paralysis
that seemed to now be affecting her arms. Already having been in the hospital for 3 consecutive
months bouncing back and forth between inpatient rehab and the wards for her acute exacerbations,
we seemed no closer to answers than before. It seemed like every blood test and imaging study
imaginable had been run, sometimes two or three times. Numerous other services like Rheumatology
and Heme-Onc had already been consulted several times and we still had nothing better to offer Ms.
Gonzalez than the diagnosis of “Idiopathic Transverse Myelitis”. Perhaps calling something “idiopathic”
somehow lessens the fact that we have absolutely no answers. As I read articles on her condition, I
stumbled across several papers that reported suicide secondary to depression as the leading cause
of mortality among this Transverse Myelitis population. I was at least comforted to think that Ms.
Gonzalez was not one of these cases. Out of all of our patients, she had the most right to be in the
pits of despair and yet it continually astonished me how she stayed so pleasant and upbeat. Everyday
12
Letters to a third-year student • from the class of 2010
I watched as her loving husband rushed to her bedside the second he got off work, bringing her
coffee, tamales and snacks from home to help offset the unpalatable hospital food. He stayed at the
bedside until the evening only to do it all over again the next day. It wasn’t until almost half way
through my rotation that I realized that my previous assumption had been naively wrong. One day
while checking on Ms. Gonzalez’s labs, I stumbled across a note in the computer that described how
she had been found crying by the physical therapist shortly after our team had rounded on her. We
had just discussed our long-term treatment plans with her that very morning and had broached the
possibility of pursuing more aggressive treatment such as chemotherapy since her symptoms seemed
to be progressing despite our previous treatment efforts. We had also discussed extending her
stay in the hospital for some thought to be beneficial rehab. Ms. Gonzalez appeared to agree with
the treatment plan and voiced no concerns or further questions to our attending. So I was rather
surprised to read how she had been found in tears. I realized how naive I was to think that everything
was fine just because I went in and found her seemingly in a good mood on my few visits to her
throughout the day. My concern grew but when I asked my resident, he didn’t seem to concerned
with it and as I didn’t see any additional signs over the next few days I did not pursue it.
My rapport continued to grow with Ms. Gonzalez and she often praised my Spanish before
my resident, despite my knowing the truth about how much I was really butchering the language.
Several mornings I found her asleep in her bed with the lights on and after waking her, I found her
apologizing to me that she had fallen asleep after trying to get up early so she would be awake when
I arrived. The day before my inpatient service ended, I went to check on Ms. Gonzalez and also
thank her for letting me care for her as I told her that I would no longer be coming by to examine her
after the next day. I was a little surprised that she took the news with such disappointment. To her
inquiries as to why I was leaving, I tried explaining in my limited spanish that I had to go do outpatient
neurology for my last two weeks. She then told me how much I would be missed. Often thinking
that I am doing more harm than good in bothering patients and waking them at 5 AM, there was
a sense of gratification to know that I would be missed. The next morning, I arrived at the hospital
a little earlier so I could have a little more time with Ms. Gonzalez since it was going to be my last
day. I went through my regular morning routine and told her I would return in the afternoon for my
goodbye. As I turned to leave, I suddenly felt her grab my hand to pull me back to the bedside. I
suddenly found my hands clutched inside hers as she began to cry. I stood there completely shocked,
unable to really move, trying to process what was happening. She quickly pulled herself together and
let go of my hand. I reassured her that I would come by for a last farewell that afternoon before I
left the hospital. As the end of the day approached, I gathered my things, said my goodbyes to my
neurology team and then headed down to room 855 to bid farewell to Ms. Gonzalez.
This afternoon she wasn’t doing quite as well, probably in part due to the previous day’s
chemotherapy. She looked to me with her intense brown eyes and asked me why all these things
were happening to her. I thought, despite all the medical and scientific advancements of the 21st
century with our having even unraveled the entire human genome, it was a shame that I still had to
stand there unable to offer anything better than “we don’t know.” She was a little more sullen than
I had seen her and this afternoon she was very homesick after the long 4 months she had been
here at the hospital. I think the gravity of her condition was really starting to sink in for her. I tried
to focus her on the positive benefits of getting rehab and why we thought it would be beneficial
before discharging her home but I quickly exhausted my arsenal of Spanish words. I could see the
growing sense of despair in her eyes. I quickly went to fetch a nurse to help me translate and when
we returned, we found Ms. Gonzalez weeping uncontrollably. She continued sobbing and talking
simultaneously. I only understood intermittent sentences, but what I could understand was that
13
Letters to a third-year student • from the class of 2010
she wanted to go home. She missed her four dogs at home, three of which had died while she
had been in the hospital. She also felt “useless” as a wife since she couldn’t even walk or go to the
bathroom on her own let alone cook and clean for her husband if she was able to go home. I heard
her interject “I’d be better off dead,” several times between the tears. Unprepared for this, I stood
there unable to move and unable to summon up any words of consolation and in fact knowing she
probably only continue to get worse. I hated standing there knowing that medicine had no answers
for her, we really didn’t; chemotherapy had been a last-ditch effort since we had exhausted every
other traditional therapy. There was a small chance it could cause the paralysis to regress but most
likely it would not; now I understood why suicide claimed so many of these patients; there wasn’t
much to look forward too. Ms. Gonzalez continued weeping as the nurse comforted her and tried
to redirect her. I just stood there utterly helpless. She then turned her attention to how I was leaving
her; I suddenly felt guilty of abandonment. I reassured her that I would come visit her in rehab but this
didn’t seem to reassure her at all. She made the nurse translate and insist that I absolutely promise
that I would come back to see her next week and made me promise several times, despite which
she still didn’t seem to believe it. She was finally calming down. An hour had gone by and I knew I
had to leave, there wasn’t going to be any “good” time to make my exit so I finally walked over to the
bedside, leaned over and kissed her on her forehead and then walked out of room 855 one last time.
I walked upstairs to find my resident to get him to order a Psych consult but as soon as I turned the
corner outside the room I felt the tears well up. As I entered the stairwell I found myself weeping
uncontrollably, the flood gates had opened. By the time I reached the team room I was a wreck;
my resident turned and looked at me expecting the worst. Between sobs, I tried explaining all the
happenings of that previous hour. He reassured me that he would take care of everything. I walked
to the bathroom and tried to regain my composure, realizing that I had just broken the cardinal rule
of third year – never cry. I stood there looking in the mirror, wondering in amazement how I could
feel such a deep-seated attachment to this woman that I had only known for two weeks and could
only communicate with in broken Spanglish and with gestures.
I drove home crying still, wondering how anyone can deal with this painful aspect of medicine.
I remembered a conversation I had had with a physician with a practice deeply rooted in geriatric
and hospice care; I recall asking Dr. Guerrero how she could bear repeatedly having to tell patients
they were going to die. She looked me in the eyes and said, “the day it gets easy to tell a patient
they are going to die is the day you should no longer practice medicine.” The humanism in medicine
that had long ago been precisely what attracted made me want to become a doctor now seemed
so bittersweet. I realized with the pressure for efficiency and speed in having to carry twenty-some
patients how easy it is to reduce them down to a room number or a diagnosis. So, I am thankful that
at least in my third year I experienced not caring for the patient “in room 855” or the “Transverse
Myelitis” patient but caring for Ms. Maria Gonzalez - my patient.
Anonymous
14
Letters to a third-year student • from the class of 2010
Dear unsuspecting third year,
Without sounding melodramatic, you are about to embark upon of period of your life that will
forever change you. You will find yourself in situations where you feel completely unprepared
and leave you speechless. You will share moments of absolute joy and utter despair. You will feel
overworked, unappreciated, physically drained, and emotionally exhausted. And chances are, when
you get the chance to reflect upon it all, you will love it.
Speaking only for myself, the shift from second year to third year is dramatic. The responsibilities
and expectations of you can feel overwhelming at times. And while you will not ultimately
determine a patient’s fate, you can get pretty close. Residents and attendings will ask you, “So what
do you want to do next for this patient?” Sometimes, they just want to see what you’re thinking,
and at others, they genuinely mean it, because they don’t know what to do next. And it’s at those
times where you really feel like you’re doing something powerful – that you’re beginning to actually
make a difference. And it will make you smile.
I’ll be honest – I struggled quite a bit during the first two years of school. And I know that some
of you are in the same position. Let me reassure you, it has little reflection upon you. What truly
matters is your work ethic and your attitude. Residents, attendings, and especially your patients
will appreciate your willingness to help each other out. Yes, you will invariably find yourself doing
things that are not “medically related.” Yes, you will occasionally find yourself doing scut work. But
you know what? By and large, it needs to get done, and in doing it, you’re helping the team. And
in helping the team, you’re ultimately helping the patient. And that’s kind of the whole point, isn’t
it? Once I spent 20 minutes clipping and filing the nails of a patient who could no longer care for
herself and was beginning to excoriate her skin. It wasn’t glamorous, it wasn’t even really “my job,”
but when I was done she was beaming with gratitude and my attending was equally gracious.
And as you move through third year, you will find yourself changing as well – some for the better,
some for the worse. You will hone your skills and broaden your clinical judgment. You will know
which questions to ask and what exams to perform. You will learn how to take an H&P in 15
minutes. But you will also at times find your patience wearing thin, you eagerness to go that extra
step tempered, and your desire to sleep ever enticing. Focus on the positive changes and be
mindful of the negative ones.
So in the wise words of our sage, Dr. Keeton, “Be early, work hard, don’t complain, and be happy.”
It will serve you well in third year and in the many years to come. And finally, remind yourself, this
isn’t a competition. Be there for each other, because invariably there will come a time where you
need that little extra help from someone to get through the day. By lending your hand to a friend in
need, they’ll be there for you when your time comes. And that truly makes all the difference.
Best of luck,
Anonymous
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Letters to a third-year student • from the class of 2010
Dear 3rd year,
I just want to say, get ready for one of the most exciting and challenging times of your medical
school career. It is the year you learn “what you want to be when you grow up.” There is so much
you are probably asking yourself at this time, where do I go, what do I do, how do I study, do I
actually have to TALK to people, oh and I have to TOUCH that?? The one thing I would say is enjoy
all parts of it, study like crazy, and try to keep your head on at the same time, you can do it! For
me, third year has been a big change in the way I see the medical profession as well as learn more
about the way and kind of medicine I hope to practice in the future. I went from wanting to be a
primary care doc to being a critical care doc and back again, the different people and personalities
you will meet next year will influence you more than you will know. You will then finish the year
and look back and think, oh Dr. whoever made a huge impact on me and I didn’t even realize it. For
example, I feared internal medicine, thought it would be one of the scariest rotations, yet it turned
out to be one of my favorites, if not my favorite. So just a plug to remember to keep an open mind
about everything you do because it may be the last time you will ever get to do it. Just some short
reminders:
-don’t stop running/biking/dancing/playstation/tv
-study early, don’t “put it off ”
-eat (not crap food), drink (throw in a beer every once and a while), be merry (sleep)
-don’t forget about people outside of the world of medicine…family, friends they will be your sanity
-don’t forget there are people outside of medicine...
i.e.: don’t want to hear about the patient you just cut up while they are trying to enjoy a meal, or
that there is news happening everyday whether you know it or not
-the sun actually goes up and down everyday whether you are there to witness it or not…get a
watch with the date!
-enjoy every minute, remember what a privilege it is to affect peoples lives and you will do it
everyday whether you know it or not!
Have fun and good luck!
Anonymous
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Letters to a third-year student • from the class of 2010
Dear Third Year, I would love to be one of those people who say to you, “this is going to be the best year of medical
school,” but I believe that honesty is always the best policy, and so, I am going to refrain from saying
that to you.
For me, third year was complicated by life. Early in my first rotation, surgery, my dad got sick and
needed surgery. A month later, my mom got sick and needed surgery. I had to figure out fast how
to work the hours my surgery rotation required of me while still being there for both my parents.
I spent many post call afternoons with my parents at appointments. Prior to this situation, I had
been really fortunate in that during my first two years of medical school, my personal life had never
really interfered with school, so my biggest stress was always little things like the next test or step
one. Now all of a sudden, I was working very close to 80 hours a week, on my very first clerkship
of third year, and both my parents were sick! I seriously doubted my ability to handle it all, but I just
kept putting one foot in front of the other. It is difficult when you have to be a third year but also
find time to deal with and process the things going on in your outside life. Especially when you are
on a demanding rotation and the “things” in your outside life are not easy to handle. It isn’t easy,
but don’t doubt your ability to do it. I would give my advice on how to do it, but I think that this
is something you have to figure out on your own. Just know you are not alone, always believe in
yourself and your ability to handle these situations, and if you need help, ask for it.
On a lighter note, I want to encourage you to just accept early on that every attending is different
and will say, “you should present like this or that” and they will all tell you different ways you are
“suppose” to be doing things. Just smile and do it. I got tired of people complaining about that
because really, it is not a big deal. Most attendings know that it is like that, and they just want you
to be interested in the way they want things done. Believe me, they will grade you more on your
ability to adapt to how they want things done then on the fact that one time you did something the
way your previous attending asked you to do it. So when they “correct” you, don’t be offended or
annoyed, just smile and listen. In the end, you can actually learn a lot by listening to all the different
ways these people want the same thing done.
Last thing I feel the need to tell you is that there was a point in third year where I thought to myself,
“I made a huge mistake, and I don’t really want to be a doctor.” It really scared me because I felt
pretty strongly that I had made a mistake and that feeling persisted for almost two months. Prior
to this year, I couldn’t have imagined ever feeling any other way but thrilled and excited that I had
the opportunity to become a doctor. I wanted to know if anyone else had ever started to feel like
they made a big mistake. I did some research and I think you should know it is a common feeling at
least once in your medical school training and usually during third year. Apparently no one likes to
admit when or if they have felt this way. I am admitting it here to you so that you know if you start
to feel this way, you are not the first and probably won’t be the last. My advice is just to accept and
acknowledge the feeling but don’t panic—trust me, it will just make it worse! Just wait it out and
hopefully you will find like I did, that it was just stress and exhaustion clouding your mind and really,
you are privileged to be on your way to one day having such an amazing career that puts you in the
position to help so many people.
Good luck!!!
Anonymous
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Letters to a third-year student • from the class of 2010
Congratulations!!!
You have finished 2 years of medical school, and even though it may not feel like it, this is
a huge milestone. Third year is a whole different ball game as you probably already know. If there is
anything that I can tell you, it would be to remember 3 key things. You won’t know everything. You
will get out what you put in. You need to continue pursuing any non medical interests. Keeping this
in mind, you will inevitably work hard, you won’t necessarily expect people to feel sorry for you or
pat you on the back, and you won’t drive yourself crazy after you literally haven’t seen sunlight for
30 hours straight. Don’t take yourself too seriously. Accept criticism and praise equally, and you will
be successful.
It is tough, and there have been those days where I found myself walking through the
hallways of UH wondering why I didn’t just stop while I was ahead at undergrad. The thing to
keep in mind is that you have to make it about the patients. Every lab you look up, every rounding
list you help write, and every CBC trend that you have to follow has a face. The awesome thing
about 3rd year is that the only responsibility you really have is to know EVERYTHING about your
patients. Since this is the only time in your medical career that you will be carrying a lighter load
than the interns and residents, take advantage of it and read about your patients. If you do this, I
guarantee that you will never forget how to diagnose and treat those cases that you see. Case Files,
USMLEworld and anything else you use to study will help fill in the gaps.
Surgery- be prepared to function on less sleep than you thought was humanly possible
Study materials: Case Files, Appleton and Lange question book, USMLE world question bank,
Pestana packet, take very good notes during Dr. Esterl’s Case Files discussion, whenever he says
something is high yield, star it, bold it, and underline it because it will actually show up on the shelf.
Family Medicine- I had this rotation in Corpus and it was amazing, thank your lucky stars if you get a
chance to go.
Study Materials: Case Files
Pediatrics- this is a fun rotation and might be the last chance that you’ll ever get to do physical
exams on newborn babies.
Study materials: Case Files, Pre-Test, USMLE world question bank
Internal Medicine- your experience on this rotation is totally team dependent, you could be doing
anything from rounding for 6 hours or having 1 hour sit down rounds.
Study materials: Medicine Essentials, Step Up to Medicine, MKSAP, USMLE world questions
OB/GYN & Psych
-I am on these rotations right now, but if you noticed my pattern…Case Files will be the first choice
for both rotations.
Anonymous
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Letters to a third-year student • from the class of 2010
Dear Class of 2011,
En Espanol, por favor.
Always remember that your broken Spanish is greatly appreciated and our patients admire your
attempt. You are their source of healing - they will be patient with you and speak as slowly as you
need.
Grin and bear it.
Keep smiling. This is a Master Class in acting. You will be exhausted from call and ready to leave, but
you must maintain enthusiasm. Smile because I guarantee someone else has had it worse than you.
Stand up on the inside.
At times you’ll feel like defending yourself, arguing back, or sighing in disbelief. My advice to you
is to practice internal rebellion. I am reminded of a story of a grandmother trying to seat her
granddaughter, who insisted on eating while standing. Granny finally had enough and gave the
little girl a severe scolding. As the little girl sat down she hissed, “Alright, but I’m standing up on
the inside.” Protest in your mind or on the phone inside your car, just not with your resident or
attending.
And so it is written . . .
Journal whenever you can. Third year is beyond description, filled with sadness, joy, healing, and
heartache. You will have a defining experience in each of your rotations. Hold on to these
moments shared with your patient and families. Journaling can be very therapeutic. It was most
helpful during my neurosurgery rotation. You are never truly prepared for the harsh reality of
“breaking bad news.”
Remember our promise.
We are at the beginning of a journey, which can be overwhelming to say the least. Remember to
honor and listen to our patients above all. Treat each of them as though your own mom is lying in
that bed. She may be sad, scared, or lonely and here is our opportunity to offer emotional support.
When you are relieved of clinical duties and you happen to walk by the room of a patient you have
been following, drop in to say hello and wish them well. I have met husbands of patients, whose
kind remarks have brought me to tears. You will need these moments to remind you why you
came to medical school in the first place.
Duc En Altum
“Launch forth into deep waters.” Despite the fear and the doubts, dive in and embrace this
experience!
Many blessings and good luck to you,
Jennifer Aguilar
MS III
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Letters to a third-year student • from the class of 2010
Aaron Ashton’s Mad Money:
BUY:
-A year long subscription to USMLEWORLD Step 2. Its expensive but it will also cut back on the
books you will need to buy/borrow. It is most helpful for medicine, so at least use it for that period.
-A good alarm clock with battery backup. My grandmother gave me one with dual alarms and
it automatically syncs via radio signal so you don’t have to ever change the time. I know it’s not
expensive either because she buys most of her stuff at either the dollar store or Walgreens.
-Arch support for your shoes.
-A small thumb drive on your keychain. It comes in handy for presentations, collecting articles, or
other important documents. I recommend the super talent pico-c model.
-Confidence. Don’t be shy around patients. Wake them up, poke them, roll them over. Do what
you need to do.
-A life. Have fun on your days off. Schedule weekend trips to maximize your time off. Its odd,
but I actually had the most fun on my OBGYN rotation even though I’d rather take a swim in the
Riverwalk than round again in the L&D wards.
SELL:
-Your preconceptions. Go into each rotation with an open mind and make your own opinions and
decisions based on your own personal observations.
-Unnecessary stress. Once you realize that you don’t really matter as a third year student, things get
a lot easier. You are there to learn, build a skill set, and figure out what you want to do. Everything
else is extra.
-Your old books on half.com or to other students. Or give them away. They will only depreciate in
value and I can almost guarantee you will never use them except for maybe Netter’s.
-Informalities. Always be formal with your attending unless he/she tells you otherwise. I’ve gotten
burned by saying “Hey, Good morning!” Instead, say “Good morning, Dr. Zhivago.”
-Your guns. Don’t be a gunner. Be nice to your classmates.
-Yourself. Always act interested if you want to make an A. If you have time, look up an article on
uptodate and use it in your assessment and plan.
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Letters to a third-year student • from the class of 2010
Solomon Azouz –
Third Year Medical Student
It is a great privilege that I write to you, the class of 2011.
Look, I’m like you. I was once a third year medical student. I even sometimes sign off on my progress
notes as Sol Azouz, MS3.That’s how I know you’ve received enough advice on your first clerkship year
at this point to consult yourself in the mirror Stuart Smalley style (by the way, you are good enough,
smart enough, and dog-gone it, people like you!). I remember the barrage of advice I got: the order
of clerkships to take, the subselectives to avoid, the clothes to wear, the books to buy, and even advice
about where not to get advice. I recall being told that my white coat would be stained and tattered
by the end of the year. Not advice, per se, but a nice prediction. Here are some more predictions
I’d like to throw into the mix: pens will pop, pockets will rip, nametags will be good conversation
pieces (assuming, hopefully, that your name is awkward), and your patience will be tested. As will, well,
your will. And let’s not forget your sanity. You will learn a lot, though. Your white coat will be worn
and tattered. But so is a butterfly’s cocoon when it finally emerges. And you can always buy a new
cocoon.
Coat, I mean. It is my pleasure today to give you a little advice, and to share with you some of my
favorite encounters from my third year.
OBGYN
During my first rotation of the year, I prepared this delightful zinger for expecting moms: “It’s ok
ma’am, I can deliver your baby—I stayed in a Holiday Inn Express last night.” Somehow, when the
miracle of birth is right in front of you, it’s not so much a “night at the improv” moment; the gravity
of the whole thing overwhelms you. Sometimes the patients will see humor in the situation, though.
I remember one time where a patient and her husband were making idle, funny conversation. They
asked me what year of training I was in, what I thought of their soon-to-be newborn child’s new name,
and my interest in the field: “Are you interested in OBGYN?” the father asked me. “OBGYN is very
interesting,” I replied. In a manner that made me feel like the punch line of a joke on the Chapelle
show, the father responded: “Oh, yeah. It’s very interesting…”
If I can leave you with one word of advice: If you finish a good comedy set, it’s good to drop the mic.
A good delivery, on the other hand, is contingent on your not dropping the baby. Never drop the baby.
Don’t worry if you can’t remember; you will hear this advice again.
PSYCH
An overweight, schizophrenic man with an unkempt gray beard was perhaps one of my funniest
patients. I began with the basic psychiatric interview. “How is your mood?” “Thank G-d my mood is
great,” was his response.
“What have you spent your time doing recently?” I asked. “I really like studying the Will of G-d, I watch
Christian TV, and I enjoy reading the Bible.”
“That’s great,” I replied, “it says here that you also enjoy music. Do you still enjoy music?”
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Letters to a third-year student • from the class of 2010
“No!” was his reply.
“What about Christian music?”
“Yeah, that’s great I like it if it’s Christian.”
“What does the saying ‘don’t judge a book by its cover’ mean to you?”
“Man you must be a bible freak or something asking me all these Religious questions…”
SURGERY
Get ready to retract stuff. This includes retracting any objections you may have to serving as a human
retractor when you’re in the OR. Retracting seems simple enough, right? Wrong. No matter how
often I attempted to anticipate a surgeon’s next move, it seemed inevitable that I would be positioning
something incorrectly. This proved especially stressful in one particular instance. I was scrubbed in on
an emergency open abdominal exploration, and the attending surgeon was being particularly verbal
about his disappointment with some aspects of the situation: the patient was too old, the equipment
was the wrong kind, the lighting was poor, etc. He went after everyone with marked criticism: the
nurses, the scrub techs, the residents, every race, every geographic group. No one was safe. That is,
except for one person: the third year medical student. I thought to myself that I was being spared
by some small miracle and I had better not go looking for trouble. Trouble found me, though. During
the surgery, the power cord from the cautery gun got wrapped under my arm; the surgeon (known
for throwing and pulling tools) yanked the cord, causing the handle to fly up and hit him in the
face. It goes without saying this voided its sterility. This likely also damaged his forehead and pride,
subsequently voiding the immunity I somehow had from insults. I looked at him, and he looked at me.
He said, “The cord must have been wrapped around this rod. We will need a new one.” Uh, did he
just insult me? As I processed the seemingly innocuous comment, I remained silent. A veritable fish
in a barrel, waiting for a smackdown of blame or hostility. It never came. I guess sometimes being the
third year has its benefits.
FAMILY MEDICINE
Pain management seemed to be a large part of the Corpus Christi Family Medical Clinic. A woman
came in reporting that she had pain in her right foot. She limped into our examination room, taking
care not to put pressure on her right foot at all cost. On examination, she was able to point to a
position in the arch of her foot where the pain was the strongest. She said this had begun when
she stepped on something while walking. It was documented on her chart that she had malingered
in the past. On palpation of the arch she had no pain, and she was standing and walking with no
mention of pain. “I need some lortab for this terrible pain, and a note permitting me to miss work,”
she said. The Doctor and I left the room, both of us quite skeptical. “I’ll give her a few pain pills to
get over whatever she is going through,” he said. I presented that she seemed to be malingering, but
my attending insisted that she could do no wrong with a few lortabs. On her way out of the clinic, I
couldn’t help but point out she was limping on the opposite foot. He responded with, “what do you
know, she is.”
A few weeks later a patient who worked as a bouncer in a club insisted he needed some lortab to
get over the flu so he could work late that night. I was happy to convince my resident that lortab was
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Letters to a third-year student • from the class of 2010
neither a treatment for flu symptoms nor a panacea.
PEDIATRICS
I had previously been very good at separating working at the hospital from studying at home. There
was one patient, however, who was in such a horrible state that I couldn’t stop trying to figure out the
diagnosis even when I was “off duty.” Previously diagnosed with Cystic Fibrosis, Juvenile Rheumatoid
Arthritis, and a myriad of other terrible and unrelated conditions, the patient was lucky to be alive.
She presented to us with urinary incontinence and severe back pain. After imaging her spinal cord
and brain for tumors, we found nothing. All blood tests came back negative. The diagnosis? A likely
muscle spasm, possibly affecting her neuropathy. A diagnosis we were all unsure of, to say the least.
Sometimes, you just can’t know. Life isn’t House. Regardless, I’d like to think that my time spent looking
up papers and studying related chapters in my texts was helpful in her care. Reading can be beneficial,
even on the wards. Who knew? I do know that I will never forget the impression that patient made
on me.
Some other tidbits I picked up over the year: bleach can remove stains such as blood, ink, or…other,
but they can’t remove the knowledge of the stain having once been there. Name tags can be lost but
found just as easily, and pockets can be sewn. If all else fails, a new white coat can be purchased at the
book store. But the memories of those old, tattered coats from which we emerge will remain strong,
as will the memories of the patients who impact our development as educated and caring physicians.
See you on the wards!
Best of Luck,
Sol Azouz
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Letters to a third-year student • from the class of 2010
Dear Third Year Medical Student,
Congratulations on completing the first half of medical school! It is quite an accomplishment, and
it means that you now have the privilege of helping to improve the lives of many others in the
inpatient and outpatient settings. I would like to take the opportunity to offer what I hope is some
useful advice, before you commence work as a student doctor.
One of the most important pieces of advice that I have to offer is to strive to be a hard worker
that is a team-player. Being a hard worker is something that all of us know how to do, since it has
helped us to get into and succeed in medical school. Being a team player means that you contribute
to the team’s success by helping to care for patients, helping out fellow team members, and being
someone that is personable and easy to work with. If you make a significant contribution to the
team, you will succeed with flying colors as a third year medical student, including earning strong
evaluations and gaining more knowledge as you continue to be molded into a doctor of medicine.
That being said, while you strive to be a team-player, it is also vital that you do not sacrifice or
neglect your own individual studying. Most fourth year medical students will tell you that the NBME
clerkship shelf exams significantly impact your grade, which is why you must prepare for them. Keep
in mind, if you earn perfect evaluations, which in turn will give you an evaluation grade of “100,” yet
perform in the 20th percentile nationally on the shelf exam, you will likely not end up with an “A” for
the clerkship. It is easy to work hard all day at the hospital, and come home and not do any studying.
The good news is that you already have the tools to manage the long hospital hours along with
the long study hours. While the third year is very different from the first two years of school, many
would say that it is not more difficult. It is equally difficult. Just as it is challenging to make “A’s” as a
second year student, it is challenging to make “A’s” as a third year student. Have confidence that you
can succeed as a third year student, even though it is different.
Regarding clerkship shelf exams, I enjoyed reading the Case Files series as preparation. During each
clerkship, I read the associated Case Files review book. Depending on the clerkship, I read other
books in addition to Case Files as further supplement. However, I found that reading Case Files and
completing a question book provided a great foundation of knowledge that will help you to do well
on the shelf exams.
Begin the third year with the expectation that you will feel out of place initially. Expect to feel this
way to some extent when you begin each clerkship because each specialty has there own way of
doing things. However, as you progress through the year, you gain more experience and will feel
more comfortable. Expect to improve throughout the year, at which time you will begin to get in a
comfort zone.
Set two or more alarm clocks. This is the best way to ensure that you arrive on time. Make sure at
least one of the clocks operates on batteries, to be sure that it will have power.
Lastly, remember how lucky we are to be able to help people in such a unique way. It can be so
gratifying, and it is truly a privilege. Have fun and appreciate the road that you are traveling as you
grow into becoming a doctor.
I wish you the best of luck! You will do great!
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Sincerely,
Adam Blau
Letters to a third-year student • from the class of 2010
Letters to a Third Year
Congratulations for making it to your third year of medical school! This year will be very challenging
but hopefully rewarding. Here are a few tips about this year:
Each student has a different experience in each rotation, so try to go into each one with an open
mind. Consider specialties you think you will not like, and really evaluate those that you are truly
interested in. Residency is only a few years, so whatever you decide to do, pay attention to the
attending’s role and lifestyle, because that will eventually be yours.
Smile, be polite and respect everyone, even if others do not do the same to you. This includes your
team, other staff, patients and their family. Being friendly and courteous goes a long way, especially
when you find yourself needing help from others. Always put the care of the patient first.
Learn from your mistakes and the criticism (not always constructive) that you receive. You will
quickly learn that each attending and resident likes things done differently. Look at old notes or just
ask, and adjust your notes and presentations to their liking.
Take Dr. Keaton’s advice. Be early, be polite, be helpful, ask for more work, stay late, etc. But don’t be
scared to go home when they dismiss you. Time is precious in third year and you’ll find that there
isn’t enough of it.
Start studying early in each rotation! Six weeks flies by and before you know it you will be taking
the shelf exam. These exams are difficult and cover a lot of information. Try to study at least an hour
every day. Popular studying aids include Case Files, PreTest, NMS question books, and Blue Prints.
Have fun!!!
Ashley Bocanegra
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Letters to a third-year student • from the class of 2010
Dear new third year student,
Congratulations on completing the first couple of miles of a grueling marathon. If you have
made it this far, then you can make it the rest of the way. While third year is not always as idyllic as
it often seems when you’re hunkered down in the library studying, it is certainly a major step up
from the first two years in terms of satisfaction, as well as demands. In order to prepare yourself for
what lies ahead, consider the following thoughts and advice.
Perhaps the greatest obstacle to a fulfilling experience in third year is yourself. The times
when I was the angriest, or the most depressed, or the most doubtful about my career choice,
were always those times when I lost my focus on my calling to this noble profession because I was
selfishly trying to satisfy my own desires. Medicine is a miserable business if you focus on your
own comfort and ease. Third year will strongly reinforce what you’ve already started learning; that
medicine requires sacrifice. Remember that you will often have to sacrifice good, worthwhile things
in life, knowing that something better is in store for you. Coming to terms with the truth “It’s not
about me” begins at this stage and is a process that will continue for years to come. Focus on the
tremendous privilege and opportunity we have been given to learn things others will never get to
learn and to make a difference in others’ lives in ways most people cannot. The gratification that
comes from seeing someone’s life saved or improved because of your efforts makes all the strain
and toil worth it. These thought processes and attitudes will keep you going during the hard times
and insure a wonderful experience for you in the upcoming year.
Another unique aspect of third year is the experience you will have of being at the
bottom of the totem pole. You will be given menial tasks to do simply because the residents
don’t feel like doing them. Sometimes your superiors will not notice or appreciate your efforts,
and sometimes they will not respect your time constraints and your need to study. Unfortunately,
you will occasionally have to work with people who are calloused, cynical, scornful, abrasive, or
condescending. Learn to grit your teeth and move on, converting your annoyance into resolve to
never be that way when you get to their level. Remember that at the end of the day what really
matters and what people remember about you is how you treat them. Counter the rudeness with
kindness and enthusiasm, and you will always be successful.
One aspect of third year that kind of goes along with being on the bottom of the totem
pole is being under constant scrutiny. Realize that residents and attendings are always watching
you, even though most of the time you do not realize it. What will start to really drive you nuts is
constantly analyzing them and wondering what they will think about every little thing you do, and
how it will be reflected in your evaluations. My advice is to treat every single situation as if your
attending were breathing down your neck. What I always dreaded to hear as a third year student
was the phrase, “If you want to…(e.g. stay late to see a new patient).” In my mind, there really is no
choice; always do what they say, even though they make it sound like they don’t care whether you
do the thing or not. They are always subconsciously forming their opinions about you.
Something I found difficult about third year is that the learning environment is unstructured,
and you have to be very proactive if you want to learn a lot. For example, nobody ever sat me
down and taught me how to read X-rays and CT scans, and I went through most of the year not
taking time to really look at them. If possible, try to get someone to explain them to you early
in the year, and then look at them for every patient you have and try to see how the radiologist
interpreted them. You have to just pull residents aside and get them to explain things you do not
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Letters to a third-year student • from the class of 2010
understand, because the basic practical things related to patient care are often not covered in your
review books.
While it is important to know your patients very well in order to impress the residents and
the attendings, I consistently found that the shelf exam is what really makes or breaks your grade. If
you work hard, act happy to be there, and are nice to everyone, you will get good evaluations. If
you have stellar evaluations but do not do well on the shelf exam, there’s no way you will get an A
in the rotation. It is often easy to spend too much time reading up on your patients and preparing
for the possibility that you will be pimped. Some attendings will inundate you with supplemental
articles and suggested extra reading; do it as quickly as possible and move on to studying for your
shelf exams, because they are paramount. If someone tells you, “Go home and read up on ______,
and tell me about it tomorrow,” definitely do it, but do not spend all evening on it. In that situation,
it may help to quickly type up a summary of the topic to give to your team members, but just do
not let it suck up all your time.
Finally, a few parting suggestions. Do not talk or ask questions to the point of being
obnoxious, especially in the OR. Never assume anything; always check and double-check everything
you do. When someone says they will take care of something for you, always go back and make
sure it was done right. For all your rotations: do as many practice questions as possible. For
internal medicine: Step Up to Medicine and MKSAP! For surgery: read Surgical Recall (plus your
regular study books) as much as possible—I wish I had read more of it. For psychiatry: work hard
while others are slacking off. For ob/gyn: have your shoe covers, hat, mask, and gown on and be
ready! I can’t yet say about family medicine and pediatrics.
And most importantly: do not forget about those you love, and, if you are a person of faith,
do not neglect your spiritual life or your relationship with God.
Third year will be a challenging but wonderful experience for you—congratulations and I
wish you all the best.
Matthew Brown
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Letters to a third-year student • from the class of 2010
Top Ten Signs You Are a Third Year
10. You have resorted to the Danskos....and you like them.
I swore I wouldn’t get a pair but a day into didactics I gave in. After long hours of surgery,
medicine rounds, or just walking around instead of sitting in a classroom for 6 hours a day, you need
comfortable shoes. Spare no cost. Once you find a winner, get multiple pairs. In all colors available.
9. You have found yourself “leisurely reading” Case Files and Pretest….for all rotations.
These are your staples for this year. Treat them as you treated your syllabus during the past
two years. They are a great foundation but sometimes you will need another source. Questions are
pretty clutch so look into a test bank like World.
8. You have become a human countdown clock.
The emotions are constantly changing on a rotation. You initially feel incompetent and
nervous only to realize you are much smarter than you thought. Don’t always look forward to
what’s next or back at what you missed. Try to enjoy the moment but when it gets really hard then
remember, you can do just about anything for 6 weeks!
7. You find yourself wondering why you had never talked to the awesome person you probably sat
two rows away from in lecture the past couple years.
I had the opportunity to work with great people all year. It was refreshing to see what
amazing people were going into medicine. You will feel very blessed to have met some classmates
you never spoke to before and to share with them a piece of your life that you will never forget.
6. You think you possibly may have had a dissociative fugue….6 times this year.
Time will fly by. You will not remember your life before third year. You will wonder what you
used to do all day long. Each rotation changes you – it changes your perspective and it changes your
heart. You will learn to adapt to not only different goals as the physical setting changes but also as
your team and patients change. You will realize how malleable you really are and then you will start
to learn the areas that you want to be firm in. This year is all about exposure and choosing what to
take away with you – sometimes you may not even feel like the same person.
5. You report your debit card as stolen because there is no way you have spent $300 at the UH
cafeteria in 4 weeks.
Pack some lunches or else you will get fat or go broke, or even worse, both.
4. You start to wonder, “Did you really choose this?”
Medicine is hard work. It is long hours. Patients don’t always see things the way you do. You
get tired of someone else running your life. I expected to love every second of third year and to be
full of joy all the time. Although that represented a vast majority of my feelings, I also had doubts.
Don’t let fear and uncertainty paralyze you. Re-read your personal statement. Remind yourself why
you wanted to be a doctor and envision life even beyond residency and set your goal.
3. You start clinging to “your people”.
Whatever your support system – don’t isolate yourself from them. Let them into what you
are going through, including the good and the bad. Ask for hugs prn but don’t forget to return the
love.
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Letters to a third-year student • from the class of 2010
2. You realize Dr. Keeton is wise far beyond his years.
Memorize his advice. Everyone will tell you this. This is your number one key to success: be
early, stay late, never complain, always look for more to do, work hard. Although he tells everyone in
your class, not everyone listens. It is apparent. You will be shocked. Don’t be the one who sticks out
for their laziness or bad attitude. My suggestion is to find some music that calms you down, pumps
you up, makes you happy, or whatever you need and then listen to it on your way to work everyday.
1. You are heard chanting, “I’m good enough. I’m going to be a doctor. Many have gone and done
this before me. I can do this.”
By the end of it all you will be your own greatest cheerleader. These are some of the
best times of med school and the worst so far. You finally have some responsibility only to switch
rotations and be stripped back down to a shadow. You feel on top of your game after Step 1 to
realize that you only know the tip of a very, very large iceberg. This year you will learn what kind
of doctor you really do want to be. Many of you will realize that lifestyle is a little more important
than you ever realized before; others will recognize their passion drives them to a higher level of
ability than they knew for themselves; most will realize that it doesn’t make you a bad person for
not wanting to do primary care or for hating the OR. This year is about discovering who you are –
even if you think you already know. Embrace it as much as you can (although sometimes it can be
painful). Start saying it now, “I’m good enough. I’m going to be a doctor…”
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Best of Luck,
Heather Caddell
Letters to a third-year student • from the class of 2010
Make the most out of this year. It is 48 weeks of your life that you have a front-row seat for most
everything Medicine has to offer. If you love something it clicks, and if not, you never have to do it
again!
Smile. It’s easy and will get you through tough times with anyone from Residents, Attendings, Nurses,
or patients. You also look like you understand what’s going on (especially if you add in an occasional
nod during rounds) when all that’s really on your mind is what is waiting for you on DVR at home.
3 Overnight call rotations: Surgery (7-9 nights), Medicine (VA/BAMC 1 night), Psych (1-3 nights in
the PES) plus 1 Night-Float week for OB/Gyn. Make an overnight kit with a toothbrush, ear plugs,
money for the vending machines because the cafeteria closes at midnight and doesn’t open until
6a (of course that’s right when you need coffee because it feels like the rest of the world is asleep).
Anything to get you through 30 hours at the hospital.
Comfortable Shoes. Thank you Travis Cotton (circa Letters for 2010). His words of wisdom held
true during 5 hour medicine rounds or LITERALLY running out of the VA to catch a plane after my
psych rotation was over. Trust me the stiletto heels are way cuter than the ballet flats, but SO NOT
WORTH IT.
Learn to hide your emotions and take criticism. I have felt defeated, but instead of feeling bitter or
taking it personally, I realize in 95% of the cases it was amazing advice that has allowed me to grow
as a future physician. (Those other 5%, just wait and cry in your car!)
Eat before entering the OR. Always, always, always. It may be only 7:15a and you just ate your power
bar at 6:30, but I promise you never know what may happen to keep you stuck in the OR for 8+
hours. Worse case scenario, you are just full. This beats syncope, or taking a mental vacation only to
realize that your CT Fellow just asked you if you would like to sew on the heart during a CABG,
and you can’t find the dexterity or ability to use needle-drivers and forceps and he grabs them out
of your hand.
Read during any free time at work. It may rare, but coming home after a 15 hour day just does not
warrant itself to reading longer than 5 minutes. Advice that I was given regarding studying versus
asking for extra scut-work has held true. Your shelf grade is more important than asking again if you
can help with some scut task during down time.
Keep a Journal. It’s a wonderful way to keep tabs on how you really felt (good or bad) during
rotations to call upon when choosing a specialty months later.
Stairs. Take them. Gym time diminishes this year and “feeling the burn” can come just by boycotting
the elevators. Especially those VA/BAMC double level stairs.
Help out your classmates. Being a team player ALWAYS will payoff. It’s all about the karma! Even if
you have 5 minutes to go see your 5 patients before the residents show-up, if your teammate broke
the printer and is hyperventilating at the nurses station help them out. It reflects on everyone and
when you’re in a bind, they have your back.
In case of emergency with a patient: sit close to the door and have your pager number programmed
into your phone to call while rumbling through your white coat pockets for an escape. Some patients
may ask for your phone number, so have an excuse ready or give them an Ex’s number. 
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Letters to a third-year student • from the class of 2010
Presenting on rounds is all about practice and patience with yourself. I once did not have enough
time to prepare, but with a deep breath, confidence, eye-contact, and big smile, my attending was
impressed. I didn’t let him see me sweat and that made all the difference.
Get 1 review book, 1 question book, and use USMLE World for each Clerkship. Everyone is
different, but it is bad use of your priceless study hours to get consumed with multiple books. The
days of 8a-12p lectures and lots of free time are now over, so efficiency is key. Get through the
review book 2-3 times, do all of the questions, and with your clinical experiences you should walk
into the Shelf confident.
O.R. Etiquette: 1. Show up in the OR early to introduce yourself to the scrub tech and other nurses.
Place your pager and name badge on the desk and ask politely if they will return your pages. 2.
Ask the scrub tech if they have enough gowns out on the table. If not, get your own and 2 pairs of
gloves. ½ size smaller for the outside. Exp: I wore 6 on outside and 6 ½ on the inside. 3. Offer to
help place the Foley/IVs/SCDs or intubate if the anesthesiologist is cool. The OR staff will love you
and rave about you when the upper levels come in. 4. Wait to scrub until the Chief and Attending
do. This differs with teams, but it is a hierarchical thing usually. 5. When the procedure is over, stay
with the patient until you get vibes that you can go. Help transfer them and go to PACU if you have
time.
Let go when you’re off. It’s tough to turn-off your mind when you leave after a long day. Thinking
about your patients, how stupid you sounded calling that consult, what pimp question you knew but
choked on, that person you rudely didn’t say “hi” to on the way to the cafeteria because you were
in the middle of a mental coma….It’s ok. Go on a jog, read a fun novel, watch DVR, pray, meditate,
anything to allow you to just let go. It will all be there waiting for you tomorrow.
Don’t sit at the middle conference table for OB/GYN check-out and be quiet when they talk.
Students are frequently called-out for disrupting the residents and told to move to a seat along the
wall. Wear cute socks for OB/Gyn too! (if you’re a girl, I guess ) The residents and some faculty do,
and they will notice yours. Funny, but true.
This next year will magnify your best attributes and worst faults, and I don’t begin to think I have
the perfect equation to doing it “right.” But, you will learn. After many triumphs, horrible crashes,
boredom, fun and pure insanity you will learn how to do things your way. In the end, we will all find
ourselves within medicine and that is what has kept me going.
I wish you success, clarity, patience, luck, and many naps.
Sincerely,
Lindsay Caldwell
Class of 2010
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Letters to a third-year student • from the class of 2010
Things no one tells you about Third Year
1. You will feel like a doctor at some point. You will feel incompetent at some point.
2. You will get frustrated with your patients. Most of the time, you will not be able to change
them. But that should not stop you from trying.
3. Do not ignore your friends and family. You will need them more this year than you have
before.
4. Do not talk about bodily fluids, genitals, or butt pus when you are out to dinner. Most
people outside of the hospital find it unsavory.
5. Surgery has high sensitivity but low specificity. Some might like it but not be able to rule
it in for sure. Whereas others will quickly and absolutely rule it out. Very very low falsenegatives.
6. Do not take up hunting or fishing to impress your surgeons. If you were already engaged in
these activities, disregard last sentence.
7. There is actually very little about your evaluations you can control. Most attendings give
what they give to most students who work hard.
8. You will run into gunners during the year, in fact you will run into snipers. Some will be
totally unexpected. Watch your back.
9. To the snipers: there is really no need to snipe away at your fellow classmates. It will change
very little about your evaluation and everyone will just end up disliking you.
10. Do not lie and tell the attendings/residents that each rotation you are on is the rotation
you are going into. They can see through the bull-stool.
11. Do not get on anyone’s bad side. Learn to keep your mouth shut, even when you are right.
12. If you rocked a rotation, don’t be afraid to ask for letters of recommendation early. This is
actually a little-known fact.
13. You become confronted with mortality very quickly. You will contemplate more about your
humanity this year than you ever have before.
14. You may have the misfortune of having one of your patients die. Crying does not make
you weak. Not crying does not make you uncompassionate.
15. Use the bathroom and get something to eat before scrubbing into the OR.
16. Wear comfortable shoes on medicine. Use the bathroom and get something to eat before
rounds. You will soon find out why.
17. Do not date your residents/attendings. If you absolutely must, wait until the rotation is over.
18. Try not to sign up for rotations with your friends or significant others. You do not know the
future. Plus it makes it more uncomfortable for those around you.
19. One of the best parts of third year is becoming good friends with people in your class that
you otherwise would probably not interact with.
20. It was the best of times. It was the worst of times. But it goes by FAST. And know that
every terrible rotation has its end. Enjoy third year for what it is- a great learning experience
and the only time in your life you will not be held responsible for your actions. 
-Mimi Chang
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Letters to a third-year student • from the class of 2010
Blur.
That’s the best way I can describe third year. Your days are filled with reading, and sleeping and
grabbing charts, running from here to there and being “omnipresent” at every lecture and every
learning opportunity. One day melts into another, and before you know it, it’s July and you’re a 4th
year.
But amongst the blur that is third year, can stand out countless experiences that have
affected you in some way, either positive or negative. It can be the attending surgeon that
embarrassed you in front of everyone in the OR for not being proficient in knowledge about the
procedure you’re observing, or it can be watching an elderly lady hold her husband’s hand for the
last time in the Emergency Department as he slowly slipped into the beyond.
It was in my first or second week of general medicine outpatient service at Su Clinica
Familiar, one of several indigent clinics in the Rio Grande Valley. This clinic was close to the Port
of Brownsville and the journey there was an experience in itself. It took 30 minutes of traveling
through bare grasslands, construction of bridges and highways in the middle of what I thought was
just bare grasslands, and endless time lost getting stuck behind one 18-wheeler after another. But
there it stood, alone, next to a church, with its parking lot full of cars, and a waiting room full of
patients waiting to be seen.
I went in to talk to my next patient, Mr. Martinez*, who was here for follow-up after being
hospitalized recently. He specifically needed to be seen for a podiatric consult because he had an
ulcer on his right great toe. He was sitting comfortably on a chair in the examination room, and
greeted me as I walked in. Time came to examine him, and I asked him to please sit on the exam
table. I did a full physical, but time came to evaluate his feet, which was his chief complaint to begin
with. I helped him take the shoe off the unaffected foot first and removed his sock in ordeer to
test motor as well as sensory function, so I could compare with the affected side. As I removed the
athletic shoe from the affected side minutes later, I found him to be wearing a blue hospital booty
in place of a sock. This booty had dirt and some shrubbery on it, and a hole was present on the
affected area of his foot, so that his foot was still having contact with the shoe. I asked the patient if
he had any nice clean cotton socks to wear on that foot, but he said he did not have any.
My experience is not one of the miraculous or extraordinary, but it’s one that I still find
important in the shaping of my attitude as a physician. How would it feel to not be able to take
care of an ulcer like that, or still have to work on your feet and wearing closed toed shoes, risking
infection even more? I can’t imagine how it was like for him, being that he had that hospital booty
on his foot, even after he’s been out of the hospital at least a week already, as if it had magical
properties to protect his foot. And as I reflected on this experience, something came to mind. It
made me honestly, want to go and buy tons of cotton tube socks for patients at Su Clinica with
diabetes.
Sometimes, experiences don’t need to be loud with fireworks, but small and simple, as a
drop in a pond that ripples out to have a profound effect. For me it was Mr. Martinez, and the 70
year old man who, instead of spending his lunch money on bus fare, walked miles and miles in his
tired white sneakers to get to his appointment, or the mother who asked her 10 year old son to
step out of the room because she was going to tell us how she was depressed and needed help.
Take in these moments and reflect on them, because I feel during this year of schooling, you
are being shaped into the doctors you will become in the future. All of these patient encounters,
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Letters to a third-year student • from the class of 2010
faculty encounters, encounters with residents and interns, will teach you what to do, and what
not to do when the time comes for you to venture on your own, and become your own moral
compass.
Denise De Los Santos
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Letters to a third-year student • from the class of 2010
Medicine in Dog Years: The pseudo-pseudo-ripple effect of “truth” in medicine
Pseudo-truth courtesy of the patient:
What is the first thing you learn in medical school about admitting, diagnosing, making decisions,
and treating patients? History from the patient is of paramount importance and guides all thought
processes, clinical decisions, and treatments. So being the naive medical student on my first rotation
in medicine I spent hours upon hours getting minute details from the patients thinking I was such a
great clinical detective and I had the answers before I even read the charts. One of my last patients
(even after 11 weeks on the frontline in the war zone that is the wards) came in complaining of
severe 10/10 pain with a very detailed story about all her meds, diagnoses, detailed history, etc. By
the end of the history, even though I thought it was futile, I did a cursory physical exam because I
was so convinced by the intense detail the patient has described her battle with sciatica pain and
how she had tried everything from acupuncture to multiple doctor’s medications making her feel
like a phase 1 trial guinea pig. Her pain was so bad she broke down and decided to go to a nurse
practitioner pain management doctor to get nerve radio ablation in hopes of any moment of
painless life. The next day I presented my patient with such pride because of my hours of detective
work spent with the patient that no one else had done, and presented my A/P as if I had discovered
a congenital prolonged QTc syndrome in a neatly wrapped Christmas present under the tree. I
was about to prescribe a lady with a documented drug seeking past narcotics because I was totally
convinced of her story. After she had gotten her free doses of her sought out vice and was about
to be discharged on 2 narcotics we learned of her past, I was humbled by my wanting to believe
the patient’s story above any book, and we quickly corrected our plan of action. Lesson learned,
is the patient’s story the truth or the pseudo-truth? She did have many documented neurological
problems that might require heavy narcotics daily, but was her story a stretch of the truth?
Pseudo-truth courtesy of the team treating the patient:
It was one of the dreaded early morning rounds after 25 hour all night call stent in which everyone
is on edge and “just wants the facts.” My intern and I had gotten hammer paged all night and were
left with minimal time to pre-round and get ready to succinctly present patients after capping the
night before and dealing with all sorts of cross cover issues on patients we knew only through a
2 sentence description provided by other post-call interns that wanted to leave as bad as we did
the night before. We furiously and vigorously pulled the overnight events, consults, labs, imaging,
and all sorts of other issue on patients before pre-rounding on them. We then proceeded with
grueling rounds where even the attending only got a couple hours of sleep the night before. OK
patient one, two, and three down. Patient four had no overnight events, no X-cover calls, PE
was unchanged (CTAB, RRR, no m/r/g, no c/c/e, PERRLA, EOMI, etc, etc), labs yada yada, and no
significant changes on imaging. Halfway through this I realized things were being reported that our
cursory exam hadn’t even covered, but these things were “more than likely/more or less true.”
Then patients five through seven were reported as though we were a well oiled machine getting
geared up to clock out. I noticed that our patient who had been there for weeks and was well
known (know as rocks) had not even been laid eyes on by the attending that day b/c the newer
patients were more acutely important. Right before I left I saw that our patient had “tanked” and
was being upgraded to the ICU because his AIDS with newly diagnosed lymphoma had taken him
for a crashing downward spiral. The next day I noticed the patients whole HPI, PE, etc. had been
copied from my intern and I to our attending who didn’t exam the patient, to probably another
overworked ID consulting intern assigned to my ex-patients case. Now my tanking AIDS lymphoma
patient with a recent CD4 count of 119 was being documented by the attending and the ID consult
as having a relatively benign, unchanged PE/imaging with a CD4 count of 340 (a cursory post-
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Letters to a third-year student • from the class of 2010
call PE and a CD4 count documented from previous notes that was taken 5 months ago). This
patient was being intubated in the ICU, empirically treated as though his CD4 count was above
that all important 200 mark, and was going down quicker than a boxer behind on his mortgage.
Lesson two learned, just because the note is titled attending physician doesn’t mean it has the most
accurate or most “truthful” information. Was the pseudo-truth of this patients cursory PE and spot
check of his pseudo-latest CD4 count going to really change the management for my patient who
was knowingly going to be overcome in the next couple days by his illness?
Bottom line- If you haven’t investigated something yourself, your account of the truth is only as
real as a pseudo-seizure. Medicine’s “truths” can be skewed by the patients as well as overworked
nurses/med students/interns/residents/staff physicians alike so who and what can you trust? When
you get down to the nitty gritty the only truth in medicine is just this: trust no one and do your
own investigating until you have convinced yourself. Diagnoses/pharmacology/treatment in medical
books doesn’t always equal diagnoses/pharmacology/treatment in real life sometimes, so you must
always be skeptical of everything. Don’t take someone else’s word just because it’s more convenient
and displaces due blame when things blow up b/c if and when they inevitably do you only have
yourself to blame for not seeking the truth on your own. The medical field is changing so rapidly
that physicians are required not to be sole medical experts but also engineers (how are we going
to transition a patient from large bore IV’s that don’t luer-lock with smaller medication syringes
of different non-fitting gauges), entomologists (what DDx is drawn for my patient because of his
history of possible encounters with snail vectors for parasitic tapeworms?), geographically inclined
pharmacologists (My pt can’t be put on the empiric fluoroquinolone treatment for his UTI b/c there
is an acute highly virulent MDR E coli strain running rampant locally), humanists (Yes oral iron is the
treatment for Fe deficiency anemia and we get paid to blabber about smoking cessation and the
utility of exercising at least 45 minutes daily, but are these treatments something I would subject
myself to or be able to follow through on myself?), common-sense physicians (yes the patient needs
strict I/O’s to assess his CHF exacerbation volume status, but can this be done without removing
his bathroom privileges status?), and self-seeking journal article EBM aficionados (Yes last year HRT
was once part of the postmenopausal mainstay Tx, but new journal articles question the efficacy
and even the adversity of blindly prescribing HRT Tx to postmenopausal women). Medicine is
such a rapidly changing field that aging occurs in dog years, so if you don’t seek your own truths
continuously then in no time you will be confined to your own mental “SNIFF” prison.
Dustin Derrick MS3
36
Letters to a third-year student • from the class of 2010
Medicine is a strange field. It’s a never-ending love-hate relationship. A battle, if you will,
between what we want to do and what we should do. A wise person once made the observation
that while we’re spending our best “20 something” years in the hospital, our peers, who chose to
major in fashion, engineering, and “business”, are out there making bad decisions every weekend.
What is it that makes us think that being young translates into “having it all”, that youth and beauty
somehow make us better people, more intelligent, more capable, more—entitled?
Mr. Henderson was an 87yr old man with PMH significant for CAD s/p3vCABG, HTN,
HLD, GERD (and the list went on, and on) who presented in the ED with atypical chest pain.
Reading his PMH made me cringe. His medication reconciliation list had more meds on it than my
actual age. His clinical chart dated back to a year before I—or my parents--were even born. “Just
great” I thought to myself, “another Vet, another forty minute work-up to go.”
I entered Mr. Henderson’s room, and despite my initial pre-conceived notions, was
pleasantly surprised. He was a jovial older man, friendly, talkative and the work-up was painless.
With a PMH significant for so many coronary problems, we immediately performed a cardiac workup on my patient. The next day however, when all the labs were finalized, they were negative for an
MI, or any other acute coronary event. We continued to investigate other possible cardiac etiologies,
performing a multitude of tests over the new few days.
Over the course of his hospital stay, Mr. Henderson became consistently more ill-appearing.
Thus, my intern and I insisted on a GI work-up. Our resident was skeptical, but he obliged. We
gave Mr. Henderson a GI cocktail and ordered a KUB. The KUB showed a partial small bowel
obstruction, explaining his symptoms. One of the first things you learn as an MS3 is how to workup chest pain. You immediately think: cardiac, pulmonary, gastric, and trauma as possible etiologies,
it’s rarely ever a clear-cut presentation. Due to Mr. Henderson’s PMH, a gastric etiology was
overlooked by both the ER and the primary team when evaluating him. A mistake, a big mistake.
Although Mr. Henderson had every right to be upset with the long time course it took for
us to diagnose his symptoms, and the agony he experienced while waiting, he never expressed any
disdain when I came to visit him. Instead, he told me about how he attended Church services every
Sunday in the BAMC hospital, how he’d been living alone since his wife had passed on 11 yrs ago,
and about the 52 inch plasma television and leather recliner in his study where he’d watch CNN.
I would come in to his hospital room to find him leaning over his television set watching
Anderson Cooper and the presidential debates, and he would jest about how this 13” monitor was
nothing compared to the plasma TV he had at home. From time to time my classmates and I would
sneak in to see him, and attempt to “rile him up” by arguing our democratic viewpoints to this very
Republican former Lieutenant. Needless to say he was well informed, and very sharp, even at age
87. Mr. Henderson was thereafter transferred to surgery, and discharged home in stable condition.
After initially reading his medical history I expected to find nothing more than an incapable, illinformed old man. A mistake, a big mistake.
With Mr. Henderson gone, I picked up a new patient. Ms. Duboise was an 86yr old woman
who presented with a severe case of pseudomembranous colitis. She was a lovely older woman. You
know, one of those women who you could just tell used to break hearts back in her day? (or in her
case maybe she still did, or at least I think she did from the stories she told me). She was an active
woman who lived in an assisted living facility after her husband passed on several years ago. Ms.
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Letters to a third-year student • from the class of 2010
Duboise still managed to have luncheons and dinners with her girlfriends, spend some time with her
“younger man” George (he was 65) volunteer on the weekdays, and was extremely sharp and witty.
I told Ms. Duboise that if she was ready for a serious relationship and not just a fling, like
the one she had with George, she could start going to church at BAMC every Sunday and meet
Mr. Henderson—who was well-equipped with a wit and humor that matched her own. She
laughed and casually brushed off the suggestion, but I saw a flash in her bright eyes that told me she
definitely would be going there the next Sunday after I discharged her.
The point is this: we’re living out our twenties in the hospital whether you like it or not,
while our counterparts are out making bad decisions every weekend. Despite what we’ve been
taught, and what our youth-obsessed culture has engrained into us, life doesn’t end at 30. And
from what I’ve witnessed at least, it doesn’t end at 87 either. Being young doesn’t make us any
more capable, intelligent, or entitled than anyone else. But being able to live in the hospital, and
to do what we do, to see the people we see, to touch their lives, and to learn from them, is an
opportunity.
So while you’re young and living in the hospital, please look at it as a privilege, and don’t
make the mistake, the big mistake, of thinking of it as a punishment. Because while your twenty
something counterparts are out making bad decisions every weekend, you’re making a difference in
the life of somebody else (or, you know, possibly trying to set up your 87 year old patients on blind
dates), and if anything, you’re doing what most of us have dreamed of doing since we were five.
This is what all those years of living in the library, and cramming, and spending entirely too
much money at Starbucks have surmounted to. If you’re wondering whether or not it was all worth
it, like most of us do from time to time, let me implore you that it is.
Mai Doan
38
Letters to a third-year student • from the class of 2010
A Year of Growth, In Knowledge and Wisdom
Dear upcoming medical doctors,
As I sit here writing this letter I think back upon all of the experiences I have been through
this past year, and I wonder to myself what the future has in store for you all. I know your minds
are racing through all of the many questions that contribute to the daily stress of your lives while
beginning third year. What review books should I get? What if my attendings don’t like me? How am
I going to study for the finals? What specialty should I go into? I’m sure there will be many letters
that cover these topics, so let me share with you something else that I believe is vitally important
to grasp throughout this year. What I’m referring to is your potential for a huge growth in maturity
throughout the entire 3rd year experience. Although the goal of the third year of medical school is
to master and apply your clinical knowledge, I challenge you to make an even more substantial goal
of gaining wisdom and maturity that will stay with you for the rest of your lives. This year you will
have a great number of new experiences, some good and some not so good. You will also meet
hundreds of people, not just doctors and patients, but nurses, social workers, techs, etc. This is your
chance to define the inner meaning of what being a doctor will mean, not only to yourself but to
everyone around you.
I implore you to not only work hard in your clinical knowledge but to also observe and
analyze every situation that you are put in. Do not forget the reason that you went into medicine...
to help people through the healing powers of medicine-people of every shape and size, of every
religion and background, people that will praise you for your help, and people that will spit in your
face as well. I urge you to learn from them, all of them. Watch how other people throughout this
year work with patients and start molding yourself to become the doctor that you want to become
one day. Let me warn you, do not be swayed into the humdrum of medicine. Always realize that
these are people’s lives that you are affecting and picture yourself in their shoes. Many times you
are tired and worn out, and it is difficult to prioritize your values; however, you have now been put
in a place where the way you treat people matters. I urge you to do everything in your mental
power to preserve that thought throughout this entire year. During this time, it is also important for
you to maintain and uphold your own set of morals and values that are part of who you are. You
will observe a number of doctors and staff that will help you to create in yourself the person that
you want to be. Learn from both the positive and the negative situations that you face. There will
be times when you are frustrated about being at the bottom of the food chain, but always realize
that although you may not have the final say right now, you will some day. Now is when you want
to start yourself on the correct path so that when that time comes you can make huge differences
in people’s lives. Again, I challenge you to observe, analyze, think, and mold your actions into the
wisdom and maturity that will guide your knowledge in a positive direction for the rest of your lives.
If you do so, you will have a far greater success than you could ever imagine. Do not take your
eyes off of the primary goal-helping people. I hope you all have a wonderful experience during this
year.
Sincerely,
Raymond Fleischer
39
Letters to a third-year student • from the class of 2010
Letters to a third year,
You spend a lot of time during third year feeling like you are wrong. Feeling like nothing you
do is right. Feeling like you don’t know the answer. Feeling like everyone else does know the answer.
Feeling like if that surgeon tells you one more time that he is saving a quarter so you can call your
mother and tell her you will never make it as a doctor you will punch him in the face. Yeah. You feel
like that a lot. And I think I would be able to recognize, from a mile away, the look of disappointment
some patients get when they realize that they are indeed seeing you with only a brief greeting from
the “real Doctor.”
Not more than two days would go by that somebody – staff or patient – would ask me
how old I was. (No exaggeration, I think my max was four days without someone asking, but there
were weeks where I would get asked everyday) Some would timidly ask. Some would demand to
know the minute I walked into the room. And some looked altogether confused. Apparently, I look
like I am 16, was the average consensus, making me feel extremely self-conscious and like I needed
to prove myself to be much more experienced that my appearance would imply. This is hard to do
when you have slim to no experience.
So…welcome to the mind of a third year…but then there were days when everything
seemed to come together.
On Day #1 of my HIV clinic rotation, I was thrown in very quickly. My attending said, “OK,
go ahead and see the patients, and call me if you need something.” When we did see patients
together I would try to remember how he would phrase things, how he would break bad news,
how he would try to convince non-compliants, etc. On day #3 I had a 25 year old patient who
came in with a wart on his nose. Flipping through his charts and most recent labs I saw that he had
a history of warts on his face and was not currently on anti-retrovirals; his viral load was relatively
high and his CD4 was in a reasonable range. I remember walking into the room and thinking that
he seemed very nervous. He sat with his back hunched over, hands between his knees, staring at his
feet which were swinging back and forth in front of the examining table. Initially all of his answers
to my questions were one word or two. Anything more than that would come out in a sheepish
little voice. I sat down at eye level in front of him and proceeded with his HPI. When did you first
notice it? Well I, I have had it for a while…it just, well it just wont go away. I’ve tried everything for it over
the counter and last time the doctor froze it but it just keeps coming back. OK, I said, have you noticed
any similar lesions anywhere else on your body? His eyes kept nervously glancing from me to the
floor. You know, I continue, it is very common to develop warts in other places, the extremities,
sometimes the groin or genital area – have you noticed any new growths in any of these places?
Um, well yeah. In my…um, around my…Around your genital region sir? He nodded defeatedly. The
poor gentleman looked so ashamed. Well, I told him, I understand that you are embarrassed and
that it can be difficult to talk about such personal things, so thank you for trusting me enough to
tell me. We are all professionals and are here to help you, so all the information you can give us will
only benefit you. He asked me, do you think the doctor will have to look at them? I told him he more
than probably would, but that if he was absolutely uncomfortable, if he would feel more at ease, I
could leave the room. I understood that I was about his age and that he was not sure what to make
of how to feel. I assured him that I wouldn’t mind and that it was more important to me that he
felt comfortable and was getting the care he needed. I felt like it would probably worthwhile for me
to see the lesions, but in this specific case, having already seen the lesion on his face and the fact
that he seemed so distraught I felt it appropriate to let him know I would excuse myself if need be.
He seemed very relieved at this idea. We started to talk through the rest of his history. After the
40
Letters to a third-year student • from the class of 2010
interview, he seemed to be much more relaxed. I had taken time to get to know him, his career
goals, his lifestyle, and his body language opened up, he wasn’t stuttering and whispering as much. As
I got up to get the doctor, the patient said. Miss, do you think that you will learn a lot from my case? I
said, of course, I learn a lot from every case. And he said no, but you know, from looking at my warts?
I replied, yes, I think so. Well then I would like for you to stay if he has to examine me. So that you can
learn from me. I told him I thought that was generous of him and that I appreciated his gesture. The
attending and I reviewed his case and discussed his plan. The ultimate thought was he needed to be
started on anti-retrovirals because the dermatologic involvement was really just a manifestation of
the disease. All of the freezing would be futile as they would just return. When the doctor explained
this to him, he looked as if he had just been shot. The doctor scurried out but I lingered behind,
and the patient started to cry. I sat in front of him, put my hand on his shoulder and he explained
that he felt like starting medication made his HIV “more real.” So we sat and we talked. We talked
about the medications, about what to expect and what not to expect. We talked about HIV being a
disease and not a death sentence if he took care of himself. I told him he could lead a very normal
life, with just a few minor tweaks here and there. We talked about this in great detail. He nodded
and sniffled along to the conversation. At the end, he dried his eyes and he looked up to me and he
said, Thank you. So much. Thank you for being here for me…you don’t even know me, but you have made
this whole ordeal a lot easier for me to take. You are going to be a really good doctor. I am sorry I cried,
but you made me feel really comfortable and I just had to let it out. I felt a lot better after talking to you.
I’m really glad you were here. Thanks again.
I walked out of the room feeling a whole new perspective. This encounter was so humbling
for me. I was pretty much on cloud 9 for the rest of the week. I felt as though I had made a huge
difference in his life. And no matter how many times I had been wrong in the past year, and how
many times I didn’t know the answer – this day I had many answers that were very much needed.
And I noticed that there were also other days when I knew answers that mattered as well. A family
friend was admitted to the hospital and, like many hospital stays, there were a lot of very confusing
drugs and procedures. I would stop by every day to see how she was and to help translate medical
jargon into English for her and her husband. One day, her husband said, “Man, it must be cool to
know the things that you know.” And all I could do was smile.
Just when you feel like you know nothing, just remember that while you may not know
everything, you do know something. Having reached this milestone in your career – the beginning
of your clinicals – means that you have worked extremely hard to get to where you are. Just be
patient, and trust that your hard work will pay off. There will be bad days, but just keep in mind that
there will be good days too. Good luck, God bless, and stay strong.
Jess Flores
41
Letters to a third-year student • from the class of 2010
Dear Third Year,
You will find that this next year will be full of transformation—from basic science to clinical,
from library to hospital, from student to student doctor. You’ll learn certain things about yourself you
never knew before; how you act after working for 30 hours straight, how to truly work as part of a
team, what drinking lots of caffeine really means, etc. You will learn the types of people you really get
along with, and a lot that you really don’t, but regardless of personality conflicts, you still have to put
the patient first. You will see your classmates more than ever before—more than your family—so
be nice. Most of all, be nice to every nurse, secretary, medical assistant, and scrub tech and your life
will be much easier. Be mean to them and…well just don’t be mean to them.
Despite all the hard work, studying and long hours, there is plenty of good. It’s a bunch
of fun, you’re actually out and about seeing patients, acting like a doctor, and for the most part,
patients will treat you like their doctor. Things will go wrong; you will have bad moments, bad days,
and maybe even bad rotations. During my general surgery rotation I woke up at 4 am to take my
freshly-washed white coat out of the dryer only to notice giant black ink stains all over the shoulder
after inadvertently washing a pen. I quickly panicked, knowing I had to be at the hospital by 5. After
a quick bath in bleach and hot water, hardly a dent was made. So now I had a white coat stained
with black spots that’s also wet and soapy. I threw it in the dryer for as much time as I could afford
(about 3 ½ minutes) before darting out the door. I knew my chief was a stickler for wearing the
coat, so I drove toward the hospital, one hand on the wheel, the other out the window, air-drying
my coat along Fredericksburg. I made it to the hospital on time and despite not being totally dry,
got through rounds, making sure to show my chief “my good side.”
Even though you will have moments like this during third year, you also need to think about
your patients. In many situations, you are seeing them on some of the worst days of their lives.
In the medical field, we can sometimes forget the fact that patients tell us some things that they
don’t even tell their spouses and take it for granted. Try to put yourself in their shoes and imagine
yourself on the other side of the examining table and realize and respect their vulnerability.
Lastly, even though third year is a whirlwind with long hours, hard work, and difficult-toplease people, don’t become cynical. It’s not the patient’s fault you haven’t slept much or had a
bad day, so do your part and do what’s best for them. Think back and remember why you came to
medical school, what you said to those interviewers about how you wanted to help people and
make a difference in people’s lives. Third year is very rewarding; you finally realize all those hours
studying in the library mean something and the hard work pays off. And most of all, enjoy yourself.
Chris Gelabert
42
Letters to a third-year student • from the class of 2010
Dear Newly Anointed MS3,
You have graduated from the library to the hospital.
Surgery – toughest rotation in terms of hours. It is not uncommon to be at the hospital from 4am
to 8pm, so just expect to live there. BUT, you get to be in surgeries and cut/sew/staple and all the
other cool stuff that goes along with it. Biggest advice is to make sure you have snacks in your coat
at all times – you may be in a surgery for hours without a break, so top off the tank. Review your
anatomy and don’t worry about getting all the pimp questions wrong at first, b/c it happens to
everyone. On call in the ER every 5th night, once you get the hang of it be proactive. You will be
allowed to do just about anything if you ask – so do ABGs, suture lacerations, fix fractures, etc. And
the peeps you are with during general surgery will be like your tank mates, so have fun and help
each other out.
Medicine – this is where you will use all the info you learned for Step. Make sure you read up on
whatever ailment your patients have, so that you understand why you are treating them and what
the next step is. Step-up to medicine and a question bank/book are golden for the exam, and the
red book is the most important thing you need in your pocket during this 12 week marathon.
OB/GYN – what is cooler than delivering babies?!?! Well, there probably are things that are cooler,
especially if human genitals make you uncomfortable, but you know what I mean. Basically my only
advice is to work hard and do as much as you can, b/c it is only six weeks and most of you won’t
see it again.
Family – here you will see it all. Kids, adults, joints, diabetes – you name it. The residents are
probably the nicest group in all rotations, and you will get to do a lot of the work yourself. And this
is where Spanish really comes in handy. So get your hands dirty, and enjoy the experience.
Peds – very fun rotation. Best advice – don’t fear the children. You will have the hardest time ever
trying to look at 2 year old ears. But remember, children are like snakes – they are more afraid of
you than you are of them. And afterward, all your friends in the neighborhood can bring their kids
to you to see if they should take them to the doctor. Then you will be an American hero.
Psychiatry – best rotation in terms of hours. And you will be really impressed at how much better
people get with treatment. Other than that, work hard and enjoy your time off!
Steve Gibbons
43
Letters to a third-year student • from the class of 2010
Dear Third Year Medical Student,
Congratulations! You have finally finished the basic sciences and made it to the clinical years. You will
have a love-hate relationship with third year. Soon you’ll be getting excited for a “short day” after
working 8 hours, or when you get to “sleep in” and be at the hospital at 8 AM. But this is a time
when you are not just memorizing facts for exams, but actually seeing and learning diseases. You will
never forget a disease once you have had a patient with it. You will enjoy meeting new people and
figuring out what you want to do with your life.
Here is my advice for third year:
Surgery:
1.) Study more than just Case Files and Dr. Esterl’s notes for the weekly quizzes. This way you
are studying for the shelf exam as you go.
2.) Buy Surgical Recall and read over the section over a particular surgery before you head to
the OR.
3.) When on call in the trauma pit volunteer to suture, staple, or whatever you can. You have a
great chance to improve your skills and it keeps you from falling asleep.
Psychiatry:
1.) This is a rotation that you can get an A. Just spend some time from the beginning studying
First Aid for the Psychiatry Clerkship and questions.
2.) This rotation has great hours. Enjoy it.
OB-Gyn:
1.) This is another rotation where an A is easier to get. There is a limited amount of
information to learn.
2.) Use night float to study. There is a lot of down time.
Medicine:
1.) The pocket medicine book is great. Carry it with you all the time.
2.) MKSAP Essentials book is great.
3.) Do a lot of questions.
Family:
1.) Do the extra credit Photorounds.
2.) If you can, go to Corpus.
Enjoy 3rd year. Don’t forget to have fun, sleep, hang out with friends, and enjoy yourself.
Best of Luck!
Varsha Goswami
44
Letters to a third-year student • from the class of 2010
Dear MS3,
Welcome to the start of 3rd year! You are probably experiencing a mixture of emotions ranging
from excitement to anxiety, but third year will be one of your best experiences in medical school.
Third year is a lot of work, but the beauty of it is that having a great attitude and a willingness to
learn will get you very far. And Dr. Keeton couldn’t be more correct with his advice: be early, be
happy, work hard, never complain, and always look for more to do.
Here is some advice I picked up throughout the year:
1. Have a good attitude. Even if you’re on a rotation that you are not enjoying, tell yourself
this is the last time in your life that you will have to go through it.
2. Be on time.
3. Always keep food on you. The last thing you want to be doing is scrubbing out of a case
about to pass out while in the OR.
4. Be nice to the nurses and OR techs. This could make your life much easier. In most cases,
they aren’t out to get you, but they are usually looking out for the patients’ best interest.
5. Grow a thick skin. If someone is rude / degrading to you, it’s probably their own personal
problem coming out. Brush it off and move on.
6. You won’t know all the answers. The pressure of third year is that for the first time, you
are learning in front of and with your peers. It is okay to not know everything. You are a
student, and you are there to learn.
7. Try to not to rotate with your friends if possible. Third year is also a great way to meet
classmates that you didn’t hang out with during the first two years of medical school. Take
advantage of it! You may find a new great friend that you never got to know earlier!
8. There is a fine balance between being helpful and being annoying. Find that balance, and be
assertive and efficient. The key is to help out your residents, but don’t follow them around
without purpose.
9. Say goodbye to your weekends. And social life. Sleeping in on the weekends past 7AM is
considered a luxury.
10. No matter how much you try to explain 3rd year, your non-medical friends/family will not
understand it. But know that you will also receive pity/empathy.
Lastly, have an open mind. Third year is YOUR year to figure out what career is best for you. Even if
you may already know what you are interested in before starting, consider each rotation, and have
a willingness to enjoy it. If you don’t enjoy a rotation, find joy in the fact that third year will be your
only time to explore it. This is the year where you experience patient care first hand, without any
direct patient responsibility. So be enthusiastic and you will have a memorable experience!
Good luck!!
Teena Hadvani
Class of 2010
45
Letters to a third-year student • from the class of 2010
Audrey Hunt
3rd Year Medical Student
January 2009
My Stranger
I met Jordan for the first time in my first day of the NICU rotation. He was there for Neonatal Abstinence
Syndrome. “Neonatal what?” I thought. I had no idea what that meant. I found out that his mom was a heroin
addict who ultimately made Jordan an addict in the womb and that now, after being born and removed from
the source of heroin, he was suffering from withdrawal symptoms. That meant Jordan was a very irritable boy,
having tremors, jitteriness, tachycardia, tachypnea, crying spells and other things. I was filled with righteous
indignation. It just seemed cruel and selfish to make an infant an addict from the womb.
I continued to check on Jordan everyday, which meant looking up labs, ask his nurse how he spent the night,
and brief physicals that were mostly a never ending crying exercise for Jordan.
Jordan’s mom could not come to visit because she had a MRSA wound infection on her c-section incision. So
most days, Jordan would cry and cry and cry endlessly, without anyone to comfort him.
One early morning I came to see him and as usual he was crying. His nurse asked me to hold him for a while
as she was attempting to care for two other patients as Jordan was particularly inconsolable that morning.
My first thought was “no way, I don’t have time right now, I have to get ready for rounds!” Second thought, “I
have no experience with kids, I can barely hold a baby, and I’m certainly not equipped or prepared to console
a newborn.” Third thought, “Not the mama!” I finished my brief physical on him and got ready to go see my
other patients, but for some reason I lingered just long enough to be captivated by his need.
I picked him up carefully as he continued to cry at the top of his lungs. I held him close to my chest and
started to gently cradle him. I started to sing a lullaby that my mom used to sing to me as a child. Immediately
Jordan stopped crying and turned his eyes towards my voice. I couldn’t believe what was happening. I
continue to rock him and sing the familiar melody.
He started to calm down as he listened to the song. He was looking at me intently as if he understood every
word. And even though I knew on a rational level that he could not understand first because I was singing
in Portuguese, my native language, which I am pretty sure he had never heard before, and second for the
obvious reason that he was a new born, in a surreal, unimaginable, incredible level I knew he understood me.
In this particular moment on the continuum of time and space in the vast universe, I connected with this
human being in a way I had never before connected with anyone. Don’t get me wrong, I have had amazing
connections in my life with amazing human beings in many diverse and incredible ways with a complete
range of emotions that were unique and awesome in their own respects. To that gamut of emotions and
relationships I could add Jordan - this complete stranger whom I had met merely days before with whom I
had an exclusive professional relationship until this point.
I captivated his gaze, he was mesmerized by the music, I continued to sing as a held him close to my heart. He
started to doze off, but was fighting the sleep almost as if he wanted to continue to listen. He was ultimately
overtaken and finally surrendered to sleep. I continued to cradle him as he went into deep sleep and finally
experienced rest. I laid him in his crib and swaddled him tight. No longer strangers, that was my Jordan, my
Jordan.
46
Letters to a third-year student • from the class of 2010
Third-year is an emotional rollercoaster. Scared, angry, excited, confused, worried, bored, anxious,
hopeful, frustrated – the list goes on and on. But I assure you, if you don’t feel any of these
emotions, then you should go back and do it again because you didn’t do it right… OR… you are a
robot and you have no friends.
At the beginning, every patient I saw was a case, a disease that I had to figure out and present. I
became methodical in my approach and treated each case as textbook. I found myself getting
flustered when the patient didn’t meet every criterion that I learned was part of a disease process.
And much worse I found myself treating each patient… as a patient. After the two years of our
training in the AAB building, it was second-nature to perform a head-to-toe exam; but now it was a
real patient, a real person. For some reason this didn’t occur to me until much later.
I was working in the pediatric ICU when my resident informed me that we would have a new
arrival in the afternoon. I nodded and went on with my work. When the patient was brought to us,
he was laying on the stretcher, incoherent, posturing in decorticate-form (I know all you nerds are
trying to remember the neuropathology for decorticate posture right now). As I sifted through his
chart trying to figure out why he was admitted in the first place, I read “5yo male diagnosed with
pre-B cell ALL.” I stopped. I turned around. And I stared at this five-year-old boy, who had no hair
on his head… who had the chubbiest cheeks of any five-year-old I had ever seen… who had cancer.
I stood aside and watched my team of residents working hard to thoroughly assess our new patient.
Normally I would assist and ask to help in any way I could. But I just stood there. I couldn’t take my
eyes off of him. I heard the neurologist say, “the patient had a drug reaction to his chemotherapy…
he is cortically blind.” I just stood there. Partly in disbelief. Partly confused. Partly angry at the
unfairness of it all. And all of a sudden, a wave of humility washed over me.
I would like to tell you that it was a “happily ever after.” The truth is I don’t know the ending. As
soon as he was stabilized he was transferred off the unit. This was my slap of reality. Patients are
not always going to be cured. Medicine does not always do wonders. Third-year is not always fun.
Because patients die… medicine fails… and third-year will change you. Although there will be times
when you feel like you are a spectator and that your role is insignificant, here is your reality: you have
been granted one of the greatest opportunities of all time – you are learning how to save lives, you
are learning the human condition, you are learning the breadth of your own potential.
This is my advice to you: remember. Remember that each and every patient is inviting you into
their life. Remember that you are now cultivating relationships that will forever change the way
you perceive life. Remember that every patient is someone’s father, mother, sister, or son, and soon. Remember that a hospital is a cold and scary place… remember what it feels like to be scared
and alone… remember what it is like to be a patient. And when the day is entirely too long and all
you want to do is go home because you are physically and mentally exhausted, remember that your
patients have to stay. And when all else fails, go dig up your personal statement for medical school
and try to remember why you chose medicine.
Good luck to you all,
Christina Huynh
47
Letters to a third-year student • from the class of 2010
Here are a few bits of advice.
“Don’t focus on what you don’t know, only focus on learning more.” -Dr. Usatine
Always strive to have an assessment and plan, you may not always be able to, but give it a try.
I recommend being assertive and asking for permission to do tasks and procedures (ex: start iv’s in
the OR, suture, arterial lines, central lines, anything), the worst that can happen is they tell you no.
Sometimes, it is more important to know where to find an answer than to know the answer off the
top of your head. www.UpToDate.com is awesome.
I have been learning that perhaps the most important and crucial responsibility and privilege of the
third year medical student is to be an advocate for the patients; the interns, residents, and attendings,
are sometimes too busy to be thorough; they miss things at times, things that only we have the time
to find, or check, or correct; by bringing up these concerns or details, we help our patients and give
a voice to unrecognized issues.
Most of you will absolutely love third year, and won’t look back, but perhaps a few of you will be like
me and greatly struggle. It was often draining, tiring, soul strangling, frustrating, and discouraging for
myself. I questioned myself, my place here, and my capability, daily; others have questioned it for me
even. If anyone tells you that you can’t do it, don’t listen to them. If you ever feel this way, know
that you are not alone. If you find yourself in discouragement and would like to vent or hear from
someone who has felt the same way, you’re always welcome to call me.
Ian Jackson
48
Letters to a third-year student • from the class of 2010
Hello new MS3s!
I just want to start off by congratulating you all- you just survived the two toughest years of medical
school and the fun part is about to begin! You may still have the Step 1 exam looming ahead, but
you’ve made it this far and the test will be over before you know it. Becoming an MS3 is both
intimidating and awesome at the same time- you will begin a whole new role in patients’ lives and
take on many new responsibilities. As corny as it sounds, you are about to take a huge step toward
becoming a doctor.
I think almost everyone I knew was nervous about starting third year- you don’t feel like you have
a clue about what’s going on around you. Guess what though- all of your interns, residents, and
attendings understand this, and they really ease you into things. They know you won’t know how
to use the computer system, how to write a progress note, or how to correctly present on rounds.
That’s okay! You will pick up on everything faster than you think- so much will become second nature
to you within a week or two. And making mistakes pretty much becomes an everyday occurrence,
so don’t worry if you mess up, can’t answer a question, or forget to write down something important.
The key is just to show improvement over the course of each rotation.
The two most important qualities that an MS3 needs to succeed are 1) showing interest and
enthusiasm and 2) reading on your patients. All of your superiors will notice whether or not you
pay attention during rounds, know what’s going on with your patients, and whether you’re interested
in learning about that area of medicine. Even if you don’t plan on going into a certain area, it is still
essential to get the most out of your rotation by asking questions and showing interest in a physician’s
area of expertise. Second, it’s always important to learn about the disease processes of your patients.
If you read about the pathophysiology of each disease that you see, you will reinforce these concepts
for yourself and your attending will notice that you know what’s going on with each of your patients.
Hard work will pay off in the long run!
I can only offer advice for the rotations that I have completely already, but here it is, in a nutshell:
Internal Medicine: This is a long 12wk rotation, and the rounding feels even longer. It’s important to set
up a study schedule for yourself over the course of the 12 weeks, because there isn’t much guidance
in terms of studying. Do as many practice questions as possible for the shelf exam (UsmleWorld!).
As long as you show up on time and have your information together, your evaluations will be fine. It
is important to show improvement over the course of each month while learning how to present
a patient, develop a list of differential diagnoses, and write thorough notes. I also used Step Up to
Medicine and the MKSAP question book for studying.
Family Medicine: This is internal medicine on a smaller scale, with clinic and all ages groups. Overall,
I found FM to be a lot of fun and less intense than IM. For the 6wk rotations, it is important to start
studying right from the beginning. On FM, a huge emphasis is placed on preventative medicine and
screening methods. I used UsmleWorld Q-bank, NMS question book, and CaseFiles.
Pediatrics: Overall a lot of fun, there is a lot of variety to the rotation, which is nice. I spent two weeks
in an outpatient clinic, two weeks in the nursery/NICU, and two weeks on inpatient. Dr. Medellin does
a great job running didactics sessions each week and makes it a point to ask for feedback about the
rotation. The pedi shelf can be challenging since it’s all about kids, so take this into account from the
beginning. UsmleWorld, CaseFiles, PreTest, and some Blueprints for studying.
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Surgery: There’s no way around it, you’re going to be tired, especially on your 6 weeks of general.
Hang in there and suck it up are my best words of advice- everyone’s gotta go thru it and everyone
survives. Dr. Esterl does a fabulous job of running didactics and weekly quizzes help you keep on top
of your studying in a completely manageable way. You are very well prepared for the shelf exam by
the end of surgery. A helpful hint for surgery that applies to all the other rotations as well: Know
when it is appropriate to ask questions, and don’t ask questions that you can look up the answer
to. If you ask a ton of questions during a surgery, you will draw a lot of attention to yourself and
end up getting pimped a whole lot more than if you ask an appropriately-placed question or two.
For studying, use Surgery Recall for all your ‘pimping’ needs, Pestana, NMS Case book, CaseFiles,
UsmleWorld, and a question book.
I can’t say anything about Psychiatry or Ob-Gyn yet, but I think the advice above is completely
applicable to both.
Something important to remember about third year is that everyone you encounter or work with
in the upcoming year has something to teach you. Make sure to take advantage of all the resources
around you and remember that it is up to you whether or not you take something away from each
rotation. Also, life isn’t always fair third year- there are times when you feel like you are doing grunt
work, doing someone else’s job for them, or taking the blame for something you didn’t do. Just keep
in mind that life isn’t always fair, suck it up, and do your best- you will succeed.
Best wishes for the upcoming year!
Kiley Johnson
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Letters to a third-year student • from the class of 2010
Dear Third Years,
In lieu of a long drawn-out essay that you wouldn’t want to read, I have decided to give a
few snippets of advice. Keep in mind that many of the following statements can apply to multiple
clerkships.
INTERNAL MEDICINE:
• Even if you weren’t there when the resident admitted your patient, don’t rely solely on the
resident’s H&P. Make sure you know your patient’s history firsthand. Never trust anybody
else’s information about the patient when you can get that information yourself.
• Your presentation is everything in Internal Medicine. Find a routine for presenting and stick
to it.
• Always read up on your patient’s diseases. You’ll be surprised by how much more easily
information about a disease sticks when you follow a patient with it.
PEDIATRICS
• This clerkship might be the best one in which you can work on your presenting. It’s a lowstress rotation, and your patients usually won’t be too complicated.
• Cherish the time you spend in Santa Rosa. It has free catered food and comfortable chairs.
Believe me, both of these are huge advantages during third year.
• Dealing with a patient’s family members is a large component of pediatrics. Make sure you
always acknowledge their presence in the room and address their concerns.
FAMILY MEDICINE
• This rotation can lull you to sleep in a very insidious manner. Make sure you start studying
early, because the shelf exam covers a little bit of everything.
• Always demonstrate your enthusiasm, even if you’re seeing the 10th patient that day with
diabetes, hypertension, hyperlipidemia, and/or chronic pain.
• You’ll have a good deal of free time during this rotation. Make sure you enjoy it.
SURGERY
• Always introduce yourself to the surgery patient and the scrub nurse before an OR case,
and make sure you’re in the OR before the attending gets there.
• You can learn a lot of things during your call nights, because there’s fewer staff around. Ask
to perform procedures, and you usually will be able to do them or assist in them.
• Try to carry a couple of granola bars or other small snacks in your white coat pocket at all
times. You can go days without eating lunch during this clerkship.
PSYCHIATRY
• Take your time with your patients. I found out a lot more about my patients by simply
sticking around a few extra minutes with each during pre-rounds.
• In some of the locations during this clerkship, you’ll be the one writing the orders and
calling the consults. This is a great way to get a taste of what it will be like to be an intern.
• Make sure you get used to reading a half-page clinical vignette and answering a question
in less than 1.2 minutes. The material on the shelf exam isn’t difficult, but doing practice
questions is especially important in this clerkship.
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OB/GYN
• Don’t be inhibited or embarrassed to ask your patients anything related to their history.
They’ll understand that it’s your job, and you’ll simply provide better patient care.
• Try to be as proactive as possible in delivering babies or assisting in surgeries. You have a
limited time in each rotation during this clerkship, and you may not get the chance to do
many of these things ever again.
• You can use this clerkship to work on your Medical Spanish. Believe me, it will come in
handy.
Good luck!
Vivek Kasinath
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Letters to a third-year student • from the class of 2010
Dear Class of 2011,
You are about to start the long awaited Third Year of medical school. Yay? So many people tell you
it’s a great year. You finally get to “apply what you’ve learned” and see what this medicine business is
all about.
But... you have to realize that it is also a crazy year. You are going to feel every emotion possible. You
are going to be tired and sleepy most of the time. You are always going to be hungry. You will get
yelled at. You will do stupid things. You will, sometimes, just not want to get out of bed when your
alarm clock goes off at 3:30 in the morning. Sometimes, you may simply not like the supposedly
wonderful third year.
During the hectic, tired, frustrating times, you have to remember what is important and why you
worked so hard to become a third year medical student. Indeed, it really IS a great year. Amid the
craziness, you meet wonderful people, have amazing experiences, and learn a lot about who you
are. Those moments make you realize that medicine truly is what you want to do, and help you
remember why you wanted to do it in the first place.
Family Medicine:
I met a cheerful, 95 year old man who came in wearing cowboy boots and red suspenders, who
shared his life philosophy with me: go to bed early, wake up early, take a walk two times a day, and if
desired, smoke 1 cigarette a day and eat one can of green beans every evening.
Pediatrics:
I met a sweet 6 year old boy with a brain mass. He liked bears and video games. He taught me
Spanish words and always asked for animal stickers whenever I entered the room. We hung out
every afternoon and watched cartoons. During his stay, his brain mass was found to be rapidly
growing and inoperable.
Surgery:
I put my hand into a man’s open chest and held his beating heart. He had a prolonged recovery, but
we always waved to each other whenever I passed his bed in the SICU. I removed his staples. He
had 32. We chatted every day, and talked about bananas. He always wanted bananas for his cereal.
Finally, on the last day of my rotation, just before he was discharged, I snuck in some bananas. The
expression on his face is something I will always remember.
Ob-gyn:
Catching babies. To know that I was the first person to touch and hold those newborns was
amazing. Exhilaration and fear would run through me as I desperately tried not to drop the child
while realizing that I was holding a tiny new person.
Psychiatry:
I met a man struggling with horrific memories of war and mass graves filled with babies. Severe
flashbacks and nightmares led to depression so severe he attempted suicide. So many individuals
just like him who heroically fought for noble causes are now unable to save their own lives. He pain
etched in his face was profound and real.
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Letters to a third-year student • from the class of 2010
Internal Medicine:
This is currently my first week of internal medicine. Even so, I already know I will meet some
remarkable people who I will remember throughout my career.
In every rotation, you will make memories that remind you why you are doing what you are doing.
You will not only learn medicine from your patients, you will learn about compassion, the impact
you have on other people’s lives, and realize things about yourself you did not know. Yes, there
will be moments where you just don’t want to do it anymore. However, you should cherish and
remember the moments where you are inspired. Those moments will help you become the type of
physician we all aspired to be as we entered this profession.
- P.S. Kim
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Letters to a third-year student • from the class of 2010
I Tried My Best
In the hustle and bustle of 3rd year, with early mornings, sleepless nights, and constant stress, we
sometimes forget what drove us into medical school. Whether it was the thought of saving lives,
helping a coughing child, or finding a cure, we all applied with the hope of being THE best physician
to our patients. It is sometimes the patients who remind us best of our duty to always give 100% in
their care.
While on my medicine rotation during this last year, I was assigned to a 50 y/o man with pneumonia.
Mr. Omar was the “prototypical” favorite patient. He was always kind, patient, and always had a
large smile on his face when I walked in the room. Mr. Omar never asked for much and was always
appreciative of the team’s help. Throughout his fever, hemoptysis, and pain he remained hopeful and
energetic.
He was admitted to the hospital and many scans and lab tests including cultures were performed.
Unfortunately, he was found to have a large mass in the hilum of his left lung. Upon hearing this
news, I knew what this meant. He was a smoker with a 30 year history, coughing up blood, and
recent weight loss. I knew he had cancer. After a biopsy, a diagnosis of far advanced squamous cell
lung cancer was made with metastases to his brain, adrenals, and spine. There would be no cure for
Mr. Omar and his cancer. Our goal was getting him over this post-obstructive pneumonia.
Every day after rounds, I would take Mr. Omar on “the walk of life.” Strolling down the halls of the
12th floor of University Hospital, Mr. Omar and I would both anxiously watch the pulse-ox machine
in hopes of seeing a stable oxygentation status. Every day, and I mean every day, Mr. Omar would
always energetically say to me at the beginning of our walk that “I will try my best,” and he always
did. Our walks became the highlight of my day. He would tell me about his life, his family and the fun
things he was looking forward to doing once out of the hospital despite his terminal diagnosis.
Unfortunately over the next 5-7 days, he was getting worse. The antibiotics weren’t strong enough
for his pneumonia. It was literally stuck behind the cancer, and both the cancer and the pneumonia
were spreading fast. Each morning that I would check on Mr. Omar, he seemed to be getting weaker
and the glow in his almond shaped eyes dimmer. Despite his worsening status, he continued to
remind me daily that he was trying his best and giving it his all. He was still determined.
Later that week, on a chilly Thursday morning, I arrived at the hospital to find that Mr. Omar had
taken a turn for the worse, something that I knew was inevitable. Nasal canula oxygentation was
replaced by bipap, a DNR/DNI was signed, and his family was at the bedside saying last goodbyes.
Mr. Omar was in the final hours of his life and our goal as a team was to ensure a pain-free and
gentle transition. Later that day the resident and I were paged to come to the patient’s room.
He was complaining of intense pain. Upon entering the room, anyone could realize that this was
it. His use of accessory respiratory muscles, rapid respiratory rate, pallor, and grimace upon his
face illustrated a frail man about to give his last breath. We then gave him a rather heavy dose of
morphine IV for his pain. Seconds later, Mr. Omar hastily removed his oxygen mask and looked at
me with a rather large and very unexpected smile on his face. He managed to whisper to me with
obvious dyspnea, “I tried my best.” He then made one final look around the room in an effort to say
goodbye to his family and then closed his eyes forever. He was gone just 30 minutes later.
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I will never forget those final moments with Mr. Omar. A man so ill, fragile, weak, but a mind and
spirit so determined to do his best. There will be many times in your 3rd year where you are
tempted to do what is easiest, what will get you home the earliest. You will be reminded that you
are “at the bottom of the totem pole.” But, you truly do make a difference in people’s lives. To many,
you are their physician and you are their voice. In the words of Justice Sandra Day O’Connor, “Do
the best you can in every task, no matter how unimportant it may seem at the time. No one learns
more about a problem than the person at the bottom.” Just like Mr. Omar, end each day knowing
that you can say, “I tried my best.”
Megan P. Kostibas
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Letters to a third-year student • from the class of 2010
Professionalism
“Oh, I am not worried. I am sure everything will turn out fine. Everyone has been so
professional here at this hospital.”
I was mildly taken aback the first time I heard this comment out of a patient’s mouth
during my first week of my internal medicine rotation. I wondered to myself, “What does the
professionalism of a physician have to do with trusting the decisions he or she makes for you?” It is
not as if wearing a tie to work or addressing a patient as ‘sir’ or ‘ma’am’ is an adequate indicator of a
physician’s ability to successfully diagnose and treat disease processes. Why would a patient consider
a doctor’s skill to be reflected by his or her bedside manner? To my surprise, I continued to hear
such comments from several patients throughout my rotation. As I further pondered the statement
though, I realized that patients really have no way of assessing the level of medical care that they
receive. They are not familiar with guidelines set out by the American Heart Association for the
acute treatment of unstable angina or the recent randomized trial that demonstrated the benefit
of antibiotics during the treatment of an acute COPD exacerbation. They do not have a medical
knowledge base that would allow them to critique the decisions of their physicians, nor to recognize
whether they are receiving the standard of care for their condition. Instead, patients see only two
things when evaluating a physician—whether or not their symptoms improve under his or her care,
and whether or not they are treated respectfully. While we as physicians know that such criteria are
no where near representative of our skill at managing disease processes, we must accept that this
is the criteria to which we are being held accountable by our patients. With this in mind, my whole
outlook on professionalism has changed. Not only should my motivation for treating my patients
with compassion and integrity be based on the golden rule of ‘Do unto others as you would have
done unto yourself.’ Professionalism is also a way in which to instill confidence in my patients
regarding my clinical decisions about their care. Patients view the skill of their physicians based
on their entire experience while under that person’s care—a great part of which is determined
by the manner in which the physician relates to the patient at the bedside. For this reason, after
such experiences I am more motivated than ever to commit to the highest level of professionalism
during my care for my patients, in order that my patient’s may have complete confidence in my
ability to care for them during their time of need.
Catherine Lacey
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Letters to a third-year student • from the class of 2010
Letters to a Third Year
I know all of you will receive plenty of advice about books, rotations, etc from my colleagues, so
I’d like to keep my advice brief. While this lesson is easily summed up, to me its impact can be far
reaching. My advice is this: do everything you can to encourage your residents and attendings to
be great teachers. Let me elaborate: Your interns, residents, and attendings are very busy people.
Working with you is about 93rd on their list of priorities. Since you are not sick or dying, this is how
it should be. Do not take the attitude that you are owed anything; you are not. So, if you want an
excellent experience on a rotation, it is your responsibility to motivate your residents and attendings
to work with you. You do this by being the best medical student you can be. They do not expect
perfection from you, just a good effort whenever you can provide it. Realize now that whatever
investment you make into your team will be repaid to you, on the whole at least, if not on a specific
team. A rotation is made or broken by your relationship with your team. Make it worth their while
to work hard on teaching you to be a great future physician.
Putting this advice into practice yields many of the same principals as you have already heard:
• Try to study a little bit, and do so in advance…at least sometimes.
• If someone takes the time to try to get to know you, reciprocate, but be mindful of the
boundaries of the resident/attending – med student relationship.
• Look professional: no one wants to think they are teaching a slob to be a doctor.
• Do not discuss politics or religion. Ever. But healthcare is a good topic to be interested in
and educated about.
• Never allow yourself to fight with anyone. No matter how badly your fellow med student
does their work, how rude and dismissive the scrub nurses may be, or how unreasonable
your intern assigned workload might be, fighting is a suicide attempt: you will be labeled a
bad team member regardless of circumstances.
• Be a good team member: do your share of the work. Don’t do more than your share:
everyone deserves the opportunity to show what they can do. Certainly don’t do less.
• Thank people for taking the time to teach you; it is an incredible privilege.
Good luck, enjoy as much as you can of third year, it will be over before you know it.
Sincerely,
Brian Maz zarella
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Letters to a third-year student • from the class of 2010
Non-candy coated letter to a third year. If you are short on time just read the bolded text.
Two take home points for this year…
1. Your experience will be 90% team dependent.
2. The only thing that you can control that determines your happiness is your attitude.
3. You can use experiences both good and bad to improve yourself in the future.
Point one:
The double edged sword of third year is that your team determines your experience. A good
resident can make the most demanding/painful rotation interesting and fun. Sometimes a team
can bond over the fact that what is asked of them by the attending is so utterly ridiculous that it is
comical. This is especially true of your fellow med student. If from the start you establish a good
relationship with your teammates where you are both “in this together,” whatever that means to
you, the 3-6 weeks will be much more enjoyable. Personally, I was very surprised at which of my
classmates I was able to really bond with. Fortunately, it doesn’t pay to make your fellow classmates
look bad. No one, including your attending, wants to work with someone who is willing to sabotage
a colleague.
Point two:
Another surprise finding was that the rotations that I was dreading the most were actually the
ones that I ended up liking. I was terrified of surgery. I found that since I thought it was going
to be absolute torture, working long hours in exchange for doing procedures and learning an
extraordinary amount was doable. (Back to point one: it helped that I had a great team)
No one likes hearing how much you hate what you are doing, especially if they have to do it with
you. Thus, if you are going to complain then save it for your mom, significant other, or best friend
who is not in medical school. Put a smile on your face no matter how difficult and you will find that
sometimes it will convert your mood.
There will always be that person who has a cake schedule and wants to tell you about it. The reality
is that 3rd year is not fair and sometimes you get a bad rotation. Usually this evens out and the next
time you get a great one, but just hang in there and remember YOU CAN DO ANYTHING FOR
A MONTH. If you are the person with the cake schedule then DO NOT tell everyone about.
Thank your lucky stars and again tell your mom, significant other, or non-med school best friend
about it.
In order to keep a good attitude it is important to give yourself the things that you require to
maintain a good outlook. My list is as follows… an occasional sleep in day, exercising >3 times
a week, a glass of wine 2 nights a week, daily chocolate, and at least 20 minutes of friend/family
phone time a day. Figure out what your list is and do it. If that means sacrificing study time then so
be it. This year is a marathon so pace yourself, if you hit a wall early then you will not finish well.
Point three:
There will be all types of personalities who will be teaching you. Some are very gifted as teachers,
some are truly nice people, and some will care about you as a student and a person. However,
some will be none of these and you may find that you will be “called out” in front of large groups of
people. Being embarrassed is an inevitable part of third year. Public learning, although emotionally
more taxing than private learning (I.e. sitting at home reading a book), is actually much more
effective. The goal here is to learn as much as possible from everyone you encounter. I wish I could
say that it will all be good and none of it will be personal, but that isn’t the case. Just seek the piece
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of the puzzle that those teaching you have to offer and move on. In the end you will even learn
from the people who are challenging to deal with.
If I had to summarize third year it would be…
Your third year is like traveling in a foreign country alone; at times it is uncomfortable but the overall
gain from the experience is completely worth it. The more you risk seeking out a new experience
the, more you will have gained from the trip. It is a year filled with growing pains that will make you
stronger.
Just know that no one feels like they know what they are doing, especially the first week of any
rotation. You will quickly figure out that anyone who proclaims they are an expert at the beginning
of a rotation has a huge ego or is delusional. To paraphrase a wise man, “there is comfort in the fact
that everyone is just as lost as you are.”
Good luck with this year. You are going to surprise yourself, just wait.
Michael McKnight
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Letters to a third-year student • from the class of 2010
Tricks of the Trade
First of all I would like to say, congratulations! You are finally a third year medical student. The years
you spent miserably hunched in a dark corner of the closest library are over. No more trying to
convince yourself that you enjoy learning the coagulation cascade, and you can stop pretending that
listening to Goljan is better than EVERYTHING else on your Ipod. During third year learning will be
fun and purposeful because now you are doing if for your patients.
As I sit here, eleven weeks from being a 4th year, I’m amazing how fast this year (and medical school
in general) has flown bye. When I was in your shoes I was overwhelmed by all the advice I received.
Although I could go on forever about what books to use, websites to reference, and other clinical
pearls, I’m going to focus my letter on some tricks of the trade (if you want the other ‘pearls’ just
email me).
Number 1.Third year will be the most eye-opening year of your life. Take time to contemplate what
you want to do when you grow up, what you like and dislike about each rotation, which of your
attendings should be role models, and which make you cringe at night.
Number 2. Be a team player!! Answer questions when they are directed at you, help your classmates
if you get done with your work, and share your knowledge. Everyone will notice how well you work
with others.
Number 3. Even if you came into medical school wanting to be a neonatal cardiothoracic surgeon
– please keep an open mind this year! I started every rotation with the thought, “could I be
happy doing blank for the rest of my life?” Unfortunately, I said yes to everything this year but
ophthalmology. It may take till the end of the year – even the last rotation – to find your passion.
But when you do, it WILL be worth it!
Number 4. Try not to get wrapped up in studying for shelf exams – they are important, but if you
are too stressed about studying you won’t enjoy the rotation. You will learn that most of your
evaluations count much more than your test grades. Take time to ask your interns and residents if
they are happy, if they would go into their field again, and what their regrets are.
Number 5. Take care of yourself! Sleep a lot, eat well (except on call days), and exercise. For
example, if you find yourself pouring coffee on your cereal instead of milk – on your day off – go
back to bed!
Number 6. Don’t worry about how late you are going to stay at work and just study. You will
probably be more productive in the various team rooms that you would be at home anyway.
Number 7. If you are not too pleased with your step score, don’t stress too much. According to the
4th years, it takes tremendous effort to do worse on step two. Many of them went up as much as
10-20 on their second exam.
Number 8. There will be many days where you go home with adrenalin rush so high that sleeping is
impossible. For me those days included: diagnosing an atypical case of secondary syphilis and having
the opportunity to counsel my patient, watching the skill of a fifth year surgical resident repair an
aorta blasted in half by an AK47, and holding a dying man’s heart in my hands for its last few beats
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Letters to a third-year student • from the class of 2010
(then observing the attending inform the family he had passed).
Number 9. This year will be very humbling. You will get yelled at, humiliated, and probably talked
down to. I promise no matter how personable you are there will be people you clash with –
just try to make the best of the situation. Try not to stress so much about one bad experience,
everyone has at least one. Most likely it was not your fault and the person unloaded on you
because they were having a bad day.
Number 10. Make time for those who are closest to you. Just an inside tip here, you will actually
have tons of time this year for significant others and friends (so don’t let everyone scare you).
I hope this letter was helpful! I’m sure your year will be filled with memories and patients that you
will never forget. I wish you all the best of luck…..
Sincerely,
Melissa Musz ynski
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Letters to a third-year student • from the class of 2010
Third year is in a word: limbo. As Britney Spears perhaps best stated, you are not a 2nd
year, not yet a doctor. As a third year medical student, you will reside in this strange place where
you will have responsibilities, but there will always be someone checking your work. It is a place of
anxiety, frustration, and contentment that will come and go over the next year.
The first stage is usually anxiety. Many students feel this about starting third year, and in
many ways, it stays with you. For the first two years, someone has always held your hand. You
are told when to be in class, what to read, and your diet usually consists of an unusual amount of
Subway. In third year, your job is to figure out exactly what your job is in as little time as possible,
so you can actually get working on it. This will happen at the beginning of each rotation, and that
anxiety of not knowing what to do will come creeping back every time. It’s okay though. You’re not
alone. Every team that you will work with will run differently, and the best advice I can give you is
to be flexible. Don’t expect anything to be done the same way twice, and don’t expect anyone to
hold your hand. Everyone’s busy using both of their hands, and you should be too. Adapt to your
environment quickly, and you will have won half the battle.
After you get into a routine, things can become frustrating. You’ve been dreaming about
third year since day one of medical school. Practicing medicine is what you came to do, not being
a medical student. Now if only they would let you in the hospital, right? You will quickly come to
realize that you are getting in a long line of people waiting to practice medicine. Just as you think
you are stepping up to the plate, you will realize that there’s an intern in front of you who has a
resident in front of him, and the actual person up to bat is the fellow. As a third year, you won’t
get to do everything, but get in the game and do what you can. If you’re lucky, there are moments
when it’s you that is up to bat, and you will be grateful for all those times you stood there watching.
The final stage is contentment. After experiencing it all, you realize that this is the most
time you will be able to spend in the hospital where your sole responsibility is to learn. Unlike the
residents, you are free from writing orders and discharging patients. It is an environment that you
can take advantage of or take for granted. Take time to talk to your patients, because at the end
of the day, it is usually the medical students that know them best. The diseases that you have read
about in the textbooks and wondered how it all played out in real life are all there at the hospital,
affecting people’s lives everyday. Medicine is not always beautiful nor does it always turn out for
the better, but it is happening around every corner. As a medical student, every step you take now
towards learning medicine makes you one step closer to being a better physician.
Medical students often talk about waiting for their lives to start when they become a
doctor. In reality, your medical career has already begun, and as all things shall pass, limbo too will
pass. It is a rare time that will be filled with mixed emotions, but in the end, it is all what you make
it. As a third year, you have finally become free to choose what and how much you learn in the
hospital. It is a big responsibility, so choose wisely. Also because the pit stop only comes once, enjoy
it!
Anh Nguyen
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Letters to a third-year student • from the class of 2010
Dear Class of 2011,
Rather than echoing other students who say Keeton was right (which he is), or to avoid the
UH cafeteria (which you should), or to invest in that pair of comfortable shoes (a necessity, by the
way), I decided to discuss some of the finer points of the rotations that baffled me for a while and
which may or may not be apparent to you at this moment as you get ready for your third year.
People usually complain how with every rotation, you have to learn a new computer
system, or a new hospital layout, or new clerkship requirements, but those to me were minor in
comparison to the bigger question on my mind: what new personalities do I have to work with
now? And I do not mean individual persons, I mean the field as a whole. As you may very well
know, it is true – every specialty draws certain types, and with it, certain expectations. So my main
advice is to be sensitive to it and to realize there are unspoken rules which you have to pick up on.
It would be impossible to list them all because many of them I already forgot as I changed rotations,
but I have tried to just include a few pearls pertinent to certain rotations based on that premise.
Surgery:
• If there is any rotation in which to voice that you are at least interested in that field (even if it is
far from the truth), it is surgery. Frankly, they like their own. But really, of all the rotations, surgery
will have the most moments where you will be thinking, “Cool!” anyway. (Preferably quietly in
your head).
• Jump into any opportunity to do a procedure, particularly in the trauma pit. Initiative, willingness
and (polite) aggressiveness is often what is noticed in surgery. You will be surprised by how many
truly believe in the adage, “See one, do one, teach one.” So pay attention the first time you see it,
be prepared to do it on the next patient, and ACT CONFIDENTLY.
Medicine/Pediatrics/Family medicine:
• The team mentality is very important in medicine. Lend a hand to your classmate if you are not
busy and always offer help to residents and interns (but do not annoy them). If you can do things
that help the team go home earlier, everyone is a winner. That kind of behavior gets noticed
more than showing up (or “gooning”) your classmate to look good.
• To shine in medicine, go the extra mile when possible by helping your patient’s hospital course.
This may mean scutwork. Everyone complains about scutwork, and residents are usually sensitive
about dealing it out to medical students, but remember: you are only 2 years away from doing it
yourself, and if you do not learn how to do it now in a low-pressure setting, you have to learn it
when you will not receive any grace about it.
• Rounding sucks. No one likes it. Yet it is the heartbeat of medicine. Enough said.
Psychiatry:
• The medical student’s efforts in the interview and input during patient discussions can actually
make a profound impact on the treatment plan for psych patients. Sometimes residents
and attendings do not have the time to spend the extra time to muddle through a patient’s
complicated history, but you do, and you may discover crucial information. Do not be afraid to
speak your thoughts – they are psychiatrists, they WILL listen.
Ob/Gyn:
• I have not had ob/gyn yet, but it is similar to surgery in that the more you act interested, the
better your experience. That is been consistent with everyone I have talked with who has done
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the rotation.
The best of luck, and always think to yourself; the things you see in the third-year you may never
see again during your future career. At the very least, you will have some good stories to tell
incredulous family and friends back home.
Tina Oak, MS3
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Top Ten Ways to Shine while Learning on the Wards
10. Get there early (or at least on time). I struggled to keep to this rule but always be on time! 9. Read up on your patients! Read at least 1 hr a night, this will ensure testing success when
shelf exam rolls around.
8. Learn to do a good H&P and present well to residents and attending. Be concise! Less is
more. Say what you mean and mean what you say.
7. Always be honest. If you didn’t do that part of the exam, don’t say you did.
6. Function as a member of the team and stick close to your interns and residents. They don’t
care for the disappearing medical student act. If it is helping them write orders, lab results,
check on the patients or doing la lista (the list), do it! Do not wait till they tell you to do
something, it is really annoying when you keep asking them “is there anything I can do for
you.” They sometime see it as a ploy that you want to go home. 5. Learn to be flexible, each rotation is different and everyone has different expectations of
you. Keep an open mind during every rotation, use this opportunity to start thinking about
your specialty selection process.
4. A great friend told me this the first day of 3rd year rotations, “when you get a bad
evaluation, you are not really that bad and when you get a good evaluation, you are not
really that good. That should keep you grounded.” When you get a bad evaluation, try to
learn and move on. Don’t ruin the rest of your year by harping on that one bad evaluation
and when you get a good one, do not get big-headed, the next rotation might bring you
down a notch.
3. Do not try to throw your colleagues or residents under the bus. It’s not a good look. Have
respect for team members.
2. Medical education and training is a marathon, not a sprint. Never forget about your own
basic needs. Go home when you are allowed, sit down when you can, and eat when you can.
1. Talk to your patients! Sometimes your residents and attending are busy, you as a medical
student can really be instrumental in keeping the family updated and talking to your patient.
Know their cases and stories inside and out.
Good luck Class of 2011.
Rosemary Ojo
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Letters to a third-year student • from the class of 2010
Dear third year,
You’re scared. Yes. I’m still scared, and I’m almost done with third year. It’s ok to be scared,
that’s the first thing I want to pass on. You’re about to embark on a pretty incredible journey
through the field of medicine with a few frightening flight attendants. That’s the best way to put it. I
was thrilled at the experiences I had and the things I saw this year and I was simultaneously terrified
half of the time that I would do something really stupid. It shapes up well, you’re the bottom of the
totem pole, so not much is expected of you, but at the same time, you’re the medical student, so
you get to see everything. And you will do something stupid, it’s okay, you are forgiven and you’re
definitely forgotten.
Outside of the hospital, time will become a blur. You will have to deal with this at some
point, so I’m going to tell you now, you will not go to the gym as much as you did this year. I hated
hearing this last year, I had developed a relationship with my bike at Spin class, and now we only see
each other once a week. But, there is a silver lining, it’s called fourth year. And your Family Medicine
rotation.
The three month rotations become endless. I have no idea what happened in world or
national news while I was on surgery. I literally thought about crawling into an empty hospital bed
in the TICU during the Olympics because I wasn’t able to watch a single event. Plan accordingly.
Keep phone dates with friends who live far away and have no idea what third year is like. Call your
‘rents, they will get a kick out of watching their kiddo blossom into a physician. My parents love
kicking back on our patio and letting me tell stories about third year. You will be the life of the party
this year when you do end up going out because you will always have a story to tell, unless you fall
asleep while telling it. Which brings me to my most important advice: sleep. [when you are not in
the OR]. I also must bring up the food issue. You will be eating like royalty while at Santa Rosa, and
the rest of the time, you will be on the verge of kwashiorkor, keep some Odwalla bars in the white
coat pocket, and find the nursing fridges, you can store your goodies there.
I don’t want to tell you some corny story because I know you will experience the corny
yourself, but I’ve got to say, the corniness is what makes you wake up and come to work. It’s so
comforting that you can actually help make patient’s lives and hospital stays better. Smile a lot, it
helps. Talk to your patients, you definitely have the time, and they will really appreciate it. Think
about how you would feel if you were in that hospital bed, and then go into see every patient, it’ll
change your approach to everything.
Somewhere along the way, you start becoming a doctor. It’s really weird, I know. But, I think
they had this master plan all along.
Best of luck!
Payal K. Patel
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Letters to a third-year student • from the class of 2010
Hey MS2-3s. Welcome to a year you won’t forget.
That’s not to assume everything unforgettable is good, heartwarming and inspiring. More often than
not, you may feel like your impact is minimal and pointless. And waking up early to do an exam and
progress note that will, ultimately, be erased and re-done by an intern anyway, will make you feel
pretty inconsequential. However, all of a sudden, you’ll look back and find that you have made it,
and better yet, you did it (semi) gracefully…
Here are things I did right and wrong (but mostly, stuff I got away with doing):
--Don’t be afraid to joke with your team.
Now, I’m not suggesting to joke about your patients. That’s usually looked down upon by
most Attendings. Unlesssss, it’s a patient who has a soft tissue abscess on her butt and is bipolar
with acute episode of psychosis, and tells us how she feels like a horse one day and a bird the next,
with occasional flying red cars going by the windows. Presenting her case and her abscess was
usually difficult to do, without putting in a pun within the 8 minutes of subjective and objective data.
But it wasn’t until my Attending finally cracked a smile during my accurate and *cheeky,* description
of her backside, that I knew my attempt at tactful humor was actually appreciated. Remember
that it’s not possible to be stone-cold serious within every presentation during a 4 week medicine
rotation; especially within a 15-hour call day. Lighten up. Life can be funny (as much as it is tragic).
Just don’t assume yourself to be a full-time comedian, either, and take it over the edge. You still want
good feedback without an attending or resident calling you “heartless.” And the bottom line: be
respectful, always.
--You won’t always have to wear your short coat.
This is a piece of advice I think everyone should consider. I am a strong advocate of not
wearing my coat when given the opportunity. I mean, consider it: they’re hot, mildly itchy, and the
wide sleeves usually end up dipping into the macaroni & cheese that you were trying to manipulate
into the Styrofoam to-go box at the salad bar, while stuck in-between 8 other people inside the tiny
UH cafeteria. Plus, I found that white was a color in which several things clashed with: iodine, blood,
coffee, any fluid during ob-gyn, silver nitrate, surgical marking pens, Gatorade, and once again, coffee.
Feel out each rotation. I tried to take cues from my upper-level residents. If they didn’t wear
them, then I’d “forget” to wear my coat on rounds once or twice a week, and then by the end of
the rotation I could usually get away without wearing it at all. Some psych rotations are pretty lax,
as well as pediatrics, the ICU, etc. Weekends are another great time to forgo the “go-fer” coat.
Trying to eat lunch at the Santa Rosa doctor’s lounge is not a great time to leave it off. And if your
Attending doesn’t wear a coat, then it’s highly probable you won’t have to either. Just never forget
your ID badge. Oh, or when on surgery. Never, ever, “forget” to wear your white coat—or forget
where you stand—while on general surgery. Otherwise, they’ll quickly, and loudly, remind you.
--Don’t expect to always have something to do.
This was a hard one for me to swallow. Looking back, I remember thinking that most of my
first semester was me, waking up early, and hoping to do something by myself that day—whether it
was doing an entire H&P and physical without the resident, or actually delivering a baby and not just
the placenta, performing a paracentesis (with a resident by my side, naturally), or just putting in an IV.
Whatever it was, I just wanted to feel trusted. And yet, I did not get that chance very often. Here’s
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the bottom line: it’s team/attending/resident/patient (but usually resident ) dependent!! And we all
deal with it.
However, every medical student’s experience is different. You will hear many many stories from
classmates and friends (most of them bragging about some cool day on a rotation), and feel like
you’re getting jipped. But you’re not. So maybe I never performed a thorocentesis during 8 weeks
of inpatient medicine or got the chance to do a LP on a pediatrics patient; yet, keep in mind,
the time will come when you get to do one, and there are plenty of other things to learn in the
meanwhile. And don’t whine to your team about your “missed” opportunity. Just like nobody wants
to hear another student brag, no one wants to hear you complain.
Also, observation is a powerful tool. And that is what I didn’t realize during the first semester that
I know now. Even on the long days where I mostly read and only watched as the Interns fumbled
through placing a femoral A-line, I was still learning. Just listening, , asking *a few * questions, and
soaking in the medical terminology that I still didn’t know, was a successful day as a med student.
Osmosis, surprisingly, is a valid learning method for an MS3.
--And lastly, keep exercising.
So I would get out at 4-5p, after getting to the hospital at 6:00a, and think about being
tired and hungry. But mostly, I was mentally tired. There was only a few times each rotation where
I bounded between floors and ran many flights of stairs (behind Dr. T. Brown on psych consults,
while also being taught that insulin control was a huge part of psychiatric illnesses, and staircases
should really have more windows), and ended up exhausted at home. Even surgeries aren’t more
than standing and retracting or watching. Hence, I’m a huge advocate of being active at least 3-4
times a week, after work. It’s such a great way to clear the mind, work through frustrations about
the clerkship mentally, and it helped me to sleep better. Sleep is precious, obviously, and the more
physical activity I did during the day, the more restful I felt after the night---even if I got only 5-6
hours. “Eat well, work well, workout well, sleep well,” has been my daily mantra this past year, and
I feel as though it is reflected in my evals. But I should probably add, “drinks lots of coffee well” to
that, too.
Godspeed and God Bless, you guys. Make us proud.
Anna Petersen
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Letters to a third-year student • from the class of 2010
Dear 3rd Year Medical Student,
This incoming year for you will be many things. It is a unique experience and I urge you to enjoy
it; because you will see and do many things that you will never again. I’m not going to say it was all
awesome, but I think you will be surprised and pleased by what this year has to offer.
With that, here are a few random pieces of advice that come to mind:
Surgery: Be aggressive!! It is so much more fun when you are actively participating in the surgery,
even if it is just cutting suture, suctioning, or tying a knot. Use Surgical Recall to refresh before every
OR case (a lot of questions you get asked will be in there). Don’t read it to study for the shelf
though. Use USMLE World and NMS Surgery for the shelf. I would actually subscribe to USMLE
World for the whole year and use it for every shelf exam – it’s worth it. Read the Pestana review
twice for the midterm (it’s a big portion of your grade so don’t blow it off).
Psychiatry: Take this time to enjoy your life! There’s lots of free time. I don’t know many people
who didn’t like this clerkship. Useful books: First Aid for Psychiatry, Case Files, and Appleton and
Lange question book.
Ob-Gyn: You are going to love or hate this rotation. Many people used Blueprints and First Aid.
The best part of ob-gyn was getting weekends off. And delivering babies (for some people).
Internal Medicine: Get to know your patient. Apparently there are criteria for everything… know
how it applies to your patient. Medicine is where your knowledge all comes together. There is
not much to do after rounds and lunch most of the time, so you can get a lot of USMLE World
questions done (and read up on your patient).
One of the best parts of third year is that you get to know and become close friends with people
in your class you didn’t know in first and second year.
Showing up early and staying late is overrated. Sometimes it helps and other times it doesn’t. Apply
accordingly and maximize your free time. Always leave when someone tells you to go home. It is
not a trick.
Somewhere along the way, you’re going to find yourself no longer looking at the clock, wondering
how long rounds are going to take. You find yourself wanting to go in early, wanting to learn more
and do more. And you just know, that that is the kind of doctor that you want to be. It is a great
feeling and I can’t wait for you to get there.
Wishing you all the best,
Catherine Pham
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Letters to a third-year student • from the class of 2010
Dear Third Year,
My favorite chief resident said: “Never take yourself seriously, but take your job very seriously.” It’s a
simple phrase, but it is full of wisdom. The following is a random collection of advice for the year. I
hope it is helpful as you begin your clinical journey. I will end with a quote by the wisest man who
ever lived.
Be flexible. You are constantly changing specialties, locations, attendings, and residents. You will not
generally find out exact schedules until the weekend before or the day you start your clerkship.
This is frustrating for planning anything, but it’s life. Each rotation begins at 8am on a Monday with
an orientation for the morning. The afternoon is usually a time to find out where things are, to meet
your team, and to perhaps find something to study about for the next day.
You do not have the power to kill your patient.  But you do have a great ability to make life better
for them by spending more time with them and advocating for them during rounds.
Always ask the nurses questions. They can help you look good for the resident by telling you what
medicines they usually see prescribed and in what doses. They can also teach you a lot.
It’s comforting to know that you are the least trained on the team. If anyone shouldn’t know an
answer, it is you (unless it is something in the H&P). Generally, relax and know that they don’t
expect as much from a 3rd year, but there is always a chance to shine.
On pimping: Always guess unless you have been told specifically not to. When you get an answer
wrong, consider that you will probably remember it much better than if you had gotten it right.
Many times, they do not expect you to know the answer because they want to teach you.
Sometimes, they are trying to gauge your knowledge base to determine what to teach.
Don’t ask your resident or attending something you can easily look up.
Don’t answer a question with a question. If your attending says, “What do you want to do for the
patient?” Don’t say, “Should we put him on a Beta-blocker?” Instead, you can stall with “Yesterday
we treated him with ____ but this happened.” Or you can simply say, “I would like to start him on a
Beta-blocker.” They can always tell you it’s a terrible idea, but at least you had an answer.
Get familiar with Epocrates and you will be able to help your residents sometimes to find the
correct drug dosage to use or to avoid a drug-drug interaction.
For general tips for books and other tidbits, there is a pretty good summary at http://
doctorsintraining.com/3rd-yr-advice/
For each rotation, study from 1) a review book with reference to up-to-date and/or a text, 2) a case
book, and 3) make sure to do lots of questions. USMLEWORLD was a great investment for the
whole year. I would devote the entire last week of the rotations to doing questions.
Oral presentation tips:
Anticipating 3rd year, I was most nervous about oral presentations because this is a skill I felt
we hadn’t mastered during our ACES experiences. To compound this, each attending may want
something different, it takes time to learn exactly what information needs to be gathered, and
presentations are rotation-specific. Remember that it’s a presentation, usually not a conversation.
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Say what you are going to say through the end unless you are interrupted. It surprised me that on
some larger teams, some residents would be busy doing other things or the attending may look
like he/she is not paying attention, but keep going until you told otherwise. Watch for visual cues
such as frequent nodding to know if you are giving too much information, but it is always better to
give too much and be told so than to give scant information and require a lot of questioning. Be
over prepared for oral presentations on internal medicine especially. Try to learn to present without
staring at your notes.
One tip for assessment and plans is to continue with a SOAP format. For example: [one-liner]
30 y/o M with pleural effusion is improving on HD#4. [S] He states his breathing is easier and his
pain is decreased. [O] His chest tube output was decreased from yesterday. H/H trending up. [A]
Effusion seems to be resolving. [P] Plan to continue meds, repeat chest CT, remove chest tubes,
plan for discharge (at this point, if you really don’t know, simply state what you did yesterday and
continue this, or let your resident/attending interrupt. However, if you have the Doctors In Training.
com Resident Handbook [$45], you may know exactly what to do).
Lifewise:
Keep playing intramurals if you have played during your first two years. It gives you a good social
outlet and is good for your health too! It is a huge change to go from seeing over 100 of your
classmates on most days to seeing only a couple classmates each day. Get on a big team and come
when you can.
Keep going to church and bible studies (or your preference of spiritual support) when possible. I
have found it very beneficial to have that support to process the ups and downs emotionally that
3rd year presents. You may be tired, you may need to express your disappointments, your difficulties
with end-of-life issues, your excitement, and your successes and failures. While classmates, family,
and friends cannot always be there, I have found that my relationship with Jesus and with other
Christians has been invaluable.
Specifically for surgery:
Use Surgical Recall to read before your specific surgical cases. It is usually very helpful when getting
pimped, but don’t use it to study for the shelf. Casefiles is good, and NMS Casebook gives you
scenarios and changes them slightly to show you how to distinguish questions on the exam. Also,
you will probably be allowed to do more during surgeries if you take the initiative to ask if you can
sew in a JP drain or close. You only get better with practice, so if you do this from the beginning,
you will be able to continue to do more later in the rotation. Make sure you gauge the resident/
attending to see if it is acceptable to ask. For oral presentations, make them short and sweet.
Enjoy the journey!! Always remember what a privilege we have to learn and discover!
“It is the glory of God to conceal a matter, But the glory of kings is to search out a matter.”
King Solomon Ps 25:2
Shannon Potter
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Letters to a Third Year: “Dr Healing Hands”
On one of my ward months during the Internal Medicine rotation, I overheard an intern
talking about an experience during his psychiatry clerkship where he thought he had basically cured
a patient. Apparently, the patient had a terrible memory and was always asking to be reminded of
the intern- then 3rd year’s- name. One morning, the student asks his patient, Do you know who
I am?, and the patient said, Sure, you’re [so-and-so]. The intern said he had a moment where he
thought of himself as a “Doctor Healing Hands” until he realized the patient had just been reading
off of his nametag and probably had no recollection of the previous conversations. The concept of
“healing hands” seems very salient to our profession because our hands tend to be symbols of our
abilities to cure disease and relieve ailments. That phrase made me laugh and I think it tapped into
some of my hopes and fears of third year: you want to believe that you’re going to be a critical part
of the treatment team, and that the patient will call you their doctor over everyone else, and that
you’ll be able to remember minutia from first and second year to really wow your attending with
the breadth and depth of your knowledge. Sometimes, the reality is that no one really reads your
notes; no one remembers that you called torticollis a dystocia instead of a dystonia. The concept of
being “Doctor Healing Hands” is hilarious, because we all like to think that even as medical students
we’re harnessing this awesome Hippocratic power to know and do amazing things. I think the
people that most directly benefit by our services are the patients—maybe less than we’d like from
our medical expertise, but certainly more from our ability to be there for them during stressful
moments in their lives. The optimism we all entered medical school with is often stretched and
tested a bit, but hopefully weathers the storm unscathed. You certainly don’t have to be “Doctor
Healing Hands” to understand what it means to have your life disrupted by an illness. So the best
way to shine, at least in your patient’s eyes, is really just to be there.
One particularly memorable experience for me on medicine was following a Mrs. C who
had a history of breast cancer and was admitted to our service with leg pains. She stayed for a very
uneventful week of waiting around for labs and imaging without much change in her status until one
morning, during pre-rounds I told her that we were trying to rule out multiple myeloma but that
a recurrent breast cancer was a highly likely cause of her symptoms. Both our intern and resident
had spoken to her about our differential diagnosis and possible treatments, but nothing seemed to
stick. She became thoughtful and suddenly tears began to roll down her face. I sat down beside her,
held her hand, and couldn’t help crying either while things she began to face what was probably her
worst fear. She described her hesitation to worry her adolescent children with her diagnosis. “We
made it through [my initial breast cancer diagnosis], and now we have to deal with this.” She passed
the box of Kleenexes over to me. I said that if she were my mom, I would be very concerned as
well, but that she should tell her children because it was important for them to know. This woman
was suddenly my mom, waiting to hear what the doctors had to say but secretly already knowing
what she was up against. My heart went out to her when she told me she had undergone chemo
and radiation therapy for a treatment course but had then basically been lost to follow up until she
started experiencing severe hip pain. There was a different, much warmer, tone to our conversation
after this point, and I came by to chat with her a few more times, to ask about how she enjoyed her
meal, how she was feeling, if PT was helping her get out of bed. Mrs. C had not been discharged
yet by the last day of my ward service, so I came by and wished her all the best, and was greatly
encouraged when she told me that her family had been very supportive of her during her
admission with frequent visits and phone calls. “I don’t know you, but I love you,” she told me at one
point. I was really honored to be her medical student right then. The conversation could have taken
a completely different turn if I had made a hasty retreat out of the room to see other patients, so
I’m very glad I stayed and sat with her. Her insight was comforting, but also reminded me to be
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careful with making assumptions-- if you don’t ask, you won’t know.
There were numerous occasions during that month when I was really proud to be part of
my medicine team because, despite being in a hurry, our resident and interns knew how to offer
comfort and empathy to our patients, and made an effort to understand why they were refusing
medications or lab draws, or what worried them most. Such experiences served to remind me that
a hospital stay can be an extremely intimidating, stressful and impersonal experience for people,
especially if an unfavorable diagnosis is given. It becomes increasingly difficult to sit down and speak
to patients on a more personal level when you are responsible for more than three at a time, but
we will not forget to practice medicine compassionately, as I saw demonstrated by my interns and
residents and fellow students over the course of 3rd year clerkships. “To care for anyone else enough to make their problems one’s own, is ever the beginning
of one’s real ethical development.” – Felix Adler
Anna Powell
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Letters to a third-year student • from the class of 2010
Third year. I remember being incredibly worked up the night before starting internal medicine and
reading Letters to a Third Year trying to find answers on how to be perfect. I showed up the first
day and found out I was doing neuro, which immediately brought up nightmares of the multicolored
Amy Lee packet. I arrived on the floor and called the resident who said she was swamped and
immediately wanted me to go see two epilepsy patients. I was nervous and suddenly wishing I
hadn’t gone out as much before/written off ACES activities in second year. An hour and a half
later (which I would later realize was way too luxurious in terms of H&P timing), I called back the
resident to present. My presentation was all over the place! My nerves made me bring up some of
the most bizarre aspects of the social history, including the epilepsy patient’s response to “Do you
prefer men, women or both?”: one episode of kissing another girl on a dare in college but is very
happy with her current boyfriend. The resident started laughing somewhere in the middle of my
dysfunctional presentation and kindly went over how to present and do an efficient neuro-focused
exam.
The next day I tried again, and although it wasn’t the most bang up presentation ever, it certainly
was an improvement. Afterward, I actually wanted to see more patients so that I could improve my
physical exam and presentation skills.
I started to really enjoy the challenge of coming up with the diagnosis instead of just treating
symptoms with hydration or diurectics or cholecystectomies. It’s really rewarding when you know
you helped the patient get healthy again and feeling better. It also feels great because you’re part
of a team and you want to get out of bed and see how your patients did over night. Not that you
have to put your personal life on hold, I definitely still had ample time to live it up in San Antonio
or fly to visit college friends on all the rotations. That shouldn’t be a concern. Third year gets you
really excited about the coming years because you want to have a schedule and make a difference
and use all the knowledge you’ve learned since kindergarten and simple salt water evaporation
experiments.
So some final advice I would give you guys entering third year:
1. Try to get as many patients as you can handle. It helps tremendously in learning about the
different disease processes and human physiology. Managing patients truly is the best way to learn. It
also helps with the shelf exams because you remember your patient instead of having to memorize
text. It also is good for history taking and physical exam skills. And for general social skills.
2. Get to know the interns and residents. They are quite friendly! And helpful. Most of them are
wonderful teachers and can provide a lot of advice about 4th year and the application process
and how much time you can expect to have. Not that you should try to be buddy-buddy but
sometimes it just happens that way. Don’t stifle what feels natural.
3. Do questions early! My heavens, it is so key to do practice questions. Not just USMLEworld.
Those are helpful but sometimes they’re just too experimental. The Lange question books are good.
And practice under real time constraints. I ran out of time on the medicine shelf (my first shelf) and
having to be fast and furious with bubbling “C” is not the best.
4. Don’t sweat the OSCEs. They can be like cupcakes, quick and simple. It’s nothing you haven’t seen
on the rotation. Plus, it’s mildly amusing/borderline hilarious when you’re sitting in the OSCE and
you encounter one of the really intense actors. Appreciated, nonetheless.
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5. Be yourself! Gracious, I know that’s kind of a cliche concept, but it is so true. On the first rotations,
I would make myself not talk too much even though I felt comfortable talking about what I did over
the weekend or about how awesome the Demon Deacons did this year (Wake Forest alumna!). Of
course be respectful of attendings but I’ve definitely encountered some really awesome attendings
that invited the team over to their house to eat, drink, hang. But there certainly are some attendings
that don’t bother to introduce themselves or talk more than is necessary. Just feel it out and don’t
make things awkward. You don’t want an evaluation that says you were quiet, reserved or shy
(especially if you know you’re the life of the party).
Have such a wonderful year, it’s the best yet, mistakes happen but you learn so much from them.
Hang ten!
Yee Woodward Pu
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Letters to a third-year student • from the class of 2010
Title: A Faulty Assumption
On my first day of Ob/Gyn at University Hospital, we were told that the majority of patients who
come in to L&D triage spoke very few or no English at all. In fact, it is essential for every resident
(and medical student) to be able to elicit an Ob or Gyn history in Spanish. Luckily, there were
templates en espanol for us to read off of while we’re doing a history.
The resident assigned me the first patient that arrived, and the nurse informed us that she does not
speak English. While I know my Spanish is not that great, I know I had the ability to at least enunciate
& ASK questions, hoping that they’ll respond “si” or “no” instead of going on & on at 100mph in my
left ear and out the right.
So, I walked into the patient’s room and greeted her, “Hola, me llamo Jesse. um... perdonme, hablo
poquito espanol.”
The patient just nodded her head, shook my hand, but didn’t say anything. She looked like in the
early 30s and looked like she’s ready to deliver in a few weeks.
Using the template, I began with her history, “Cual es su problema?”
Again, she didn’t say a word and just looked at me as if she’s like “what the heck are you saying??”
So I asked her again, “Cual es su problema? um.. dolor? Tienen dolor? What problems do you have
today?”
Then, she pointed with her left finger at her right wrist.
Then I asked, “Cuando comenzo el problema?” (When did the problem begin?)
She mumbled back, “no.. no understand”
So I thought, maybe I should skip to the review of systems, where she’ll just say “si” or “no”.
“Tiene nausea/vomito?”, she shook her head
“Tiene dolor abdomen-- I mean, abdominal?”, she shook her head
“Tiene diarrea?”, she shook her head
“Tiene sangre por la vagina? Vaginal bleeding?”, she shook her head
“Tiene febrile-- fiebre?” – at this point she wanted to take a look at the template which I’m reading
off, I showed it to her and pointed out the question that I was asking, and told her, “esta aqui
preguntas.” She stared at it and shook her head in confusion.
I was starting to feel irritated. But I thought to myself at first, I need to CALM DOWN. I’m probably
not pronouncing Spanish words at the right rate or tone, so it’s probably my fault. Maybe I should
go back to asking her Ob/Gyn history. In the Obstetrics service, you always want to ask patients
how many times they’ve been pregnant (gravid), how many term, premature, living births, and
abortions (parity).
So I tried to ask her how many times she’s been pregnant, “Cuantos enbraz-- embarazos ha tiendo-i mean.. tenido usted? Cuantos embarazos ha tenido usted?”. She still didn’t respond, so I said it
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again, S-L-O-W-L-Y, “Cuan-tos em-ba-ra-zos ha te-ni-do us-ted??”
For the second time, she wanted to look at my template, AGAIN. That irritated me more. I thought
to myself, something’s not right here. Do I REALLY suck this bad at Spanish?? It can’t be!! I showed
her my sheet, AGAIN, pointed to the question I was asking, and said (in a more abrupt manner),
“mira, look, esta question, cuantos emb--ararazos ha tien-- tenido usted? do you see it?”.. I waited,
she didn’t say anything and shook her head, and I said, “so.. cuantos? how many times have you been
pregnant?”
She finally said, “two”. And I thought to myself, “THANK GOD!! OMG that took forever.”
So I went and continued, “usted ha tenido siempre en-ferme dad-es transmitos-- transmiti-tidas
sexualmente? Do you have any STDs?”
She was like, “no understand, my husband over there, he speak English.” She took my paper &
wrote out his full name. I saw it and I thought to myself, “what kind of name is that??? I’ve never seen
that kind of name in Spanish before but oh well... I should go find her husband. This is not going
anywhere. And why is my Spanish so HORRIBLE today??” So I told her, “Esperar, hang on, I will be
right back.”
So I went to the waiting room and went looking for this patient’s husband. The OB waiting room
was relatively empty. The only man I saw there was someone with very dark complexion, and I
thought to myself, “could HE be it? But wait a minute, he’s black, he can’t be the husband of some
Hispanic lady who doesn’t speak English!!”
I went back to the OB triage to the patient and told her in English, “I can’t find your husband. He’s
not there.”
I had to accept the fact that my Spanish sucked big time, and that I was going to continue this in
English. I thought to myself.. “Dangit this is gonna SUCK, this is gonna be my first crappy presentation
for my resident...”
I ended up asking her additional questions, and then she started pointing to me that her wrist hurts,
which made me confused. I also did the best I could to get data about her previous pregnancy, with
limited success. And finally I gave up with obtaining the history from this lady who spoke English un
poquito who could NOT understand my Spanish...
When I was done interviewing & examining the patient, I went back to my resident and told her I’m
finished.
She said, “so, what’s going on with this lady?”
I said, shaking my head, “well.. I.. um.. tried my best, she just couldn’t understand my Spanish at all, so I
got what I can out of her in English, but probably missed a lot as well.”
She said, “well, we’ll go take a look at her & see how she’s doing.”
I said, “is there something wrong with the way I’m speaking in Spanish??”
... then she replied, “well.. hang on, let me see. Actually, it says here that she’s from Bangladesh.”
“AH!!!!! NO WONDER!!!”
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THAT’S WHY SHE HAD A WEIRD LAST NAME & NO WONDER SHE DIDN’T UNDERSTAND
MY SPANISH!!!
And I suddenly thought, wait a minute, that man in the OB emergency waiting room whom I
thought was black at first is probably her husband! (I did know that people from Bangladesh may
have a darker complexion) I went back to the OB waiting room, and he was still there. I introduced
myself to him and asked him to come with me to help translate for his wife. It turned out that
she only had unilateral joint pain and was here primarily for pain relief, and she had no obstetrical
complaints at all.
Interestingly, the SAME RESIDENT who TOLD ME that the patient is Bengali went back to see the
patient HERSELF 15 minutes later and SHE started speaking to her en espanoll!! I was there with
someone else on my team, and we tried so hard not to laugh as we watched the patient continuing
to be dumbfounded as the resident repeatedly asking her en espanol.. Finally, just like me, the
resident said, “this is not gonna work.. we can’t get a single word out of her.” And she gave up as
well!!
In San Antonio, we all have an inclination to assume that every Hispanic-appearing individual who
doesn’t speak English would speak only Spanish. While 99% of the time this assumption is valid, our
lady didn’t understand a single Spanish word I was saying, not because my Spanish sucks (well.. it
probably does, but at least not THAT bad), but because she’s from Bangladesh to begin with!! And
her husband, which I overlooked to be African American, turned out to be Bengali as well. Lesson
learned.
Jesse Qiao
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Letters to a third-year student • from the class of 2010
Dear Class of 2011
Congratulations on completing half of medical school! I am sure many of you are anxious
yet excited to start and explore the field in a whole new light: 95% clinical and 5% classroom. This
upcoming year is a time of self growth and realization of what you have really gotten yourself into.
It is a lot of hard work and mentally draining, but I think if you keep 4 goals in mind you’ll be able
to “survive” and better appreciate what you’re experiencing. Credit for the first three goes to Dr.
Hanley of internal medicine in Harlingen; the last one I added from my own personal experiences.
#1 Patient Care – Since you’re going to be a doctor, it’s quite obvious as to why this is one of your
main goals during 3rd year. We all had exposure to this during ACES but it’s quite different when
you become the first line of communication between the patient and the medical team. You take
the first steps of finally taking some responsibility of another person’s well being. It can be quite
frightening but you will adjust fairly quickly and will realize, as the months go by, just how much you
have grown in such a short period of time. The patients are your main priority while in the hospital,
so be proactive in their care; however, because you’re also human, don’t go overboard to the point
of unnecessarily burning out not only yourself but your team.
#2 Learn – No matter what anyone says you’re still a student; consequently, you have to learn. One
of the difficult aspects of 3rd year is being able to balance hospital work and independent studying.
I’m nearing the end of my 3rd year, and I still haven’t mastered that yet. Everyone is different; as a
result, everyone will eventually find their own way of balancing the two. But one strategy many
will advise you with, take advantage of the clinical experiences to solidify the book information. In
addition to the academics, it is equally important to observe and learn bedside manner/patient
interaction because you’re no longer in a bubble, but rather out in the real world with real people.
Another unique aspect of 3rd year is the fact that you’ll learn a lot about yourself: your interests, your
values, what and who you care about.
#3 Have Fun – What’s life if there is no joy? You have to have fun (while working and during your
free time) or you will go insane. Hopefully you got into this field because you wanted to; otherwise,
it will be quite difficult to enjoy what you’re doing. Not every rotation will go the way you want
and some will make you quite miserable, but if you look at the positives and surround yourself with
supportive people, you’ll find yourself smiling in no time. For me, no matter how much I disliked
a particular field or a particular attending, I found comfort knowing that at least I always loved
interacting with my patients. Of course, if your attending/resident/team is awesome, then that makes
the whole experience even better. Lastly, maintain friendships, keep in touch with your family, do
something fun at random moments, and don’t give up on your hobbies. 3rd year is a part of your life
experience, make it a good one.
#4 Be True to Yourself – I am not going to lie, 3rd year can be quite brutal to your self esteem. My
lowest point was with one of my surgeons and his 2nd year resident, both of whom made me feel
like I could never be anything more than an assistant and question if the school made a mistake
for accepting me as a medical student. They both expected me to learn in ways I cannot and be
someone I was not. Things I had valued they really did not care for, and parts of medicine I enjoyed
they hated. I was with them my first week of surgery but they expected me to be at the level of
someone who already had internal medicine and knew her way around the hospital system on
day 2. It also didn’t feel good when the attending compared me to the 2nd year resident (who was
actually PGY 3). Fortunately, this experience only lasted 3 weeks, and I never had a repeat since.
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Not every attending is like this, and not everyone will experience something like this. However, if
you ever find yourself in a similar situation, take a step back and admit you cannot please everyone.
Don’t compromise who you are because, for me, every other physician I’ve been with (even
other surgeons) acknowledged my learning style, accepted my personality, and loved the fact that I
enjoyed interacting with people and that I wanted be around terminally ill patients. So to reiterate,
do not lose yourself for the sake of one or two people; I did for 3 weeks, and it was one of the
most dismal things I had experienced.
Good luck to you all,
K yung ( Jenny) Seo
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Letters to a third-year student • from the class of 2010
Most letters start with congratulations, so CONGRATULATIONS!!! 3rd year may seem intimidating,
but trust me, you will get it…speaking of intimidating, my first week with General Surgery at Wilford
Hall, Team Eagle. My story is short, embarrassing, and hopefully a good 3rd year lesson.
It was my second day, but the first with a new 3rd year resident. After a long day of clinic with
follow-ups and pre-ops, it was just me, my partner Ian, and our new resident. There was just one
more piece of paperwork left, and the resident asked me to give it to a tech. Papers in hand,
I walked down the long, dark hallway, and found it was dark for a reason – nobody was there.
Everybody had gone home already! So I reluctantly returned to my resident with the paperwork.
Me: “I’m sorry, but nobody is here.”
Resident: “Is that an excuse?”
Me: “Uhhhhhh…..”
Resident: “Is that an excuse?”
Me: “Um, yes?”
Resident: “Excuses are the foundation of failure……..”
He went on for what felt like 5 minutes talking about failure. I just stood there with the blood
rushing out of my face, but with it feeling ironically…very hot.
……….”I’m just kidding”
Me: <bursting into tears>
I can’t explain it. I couldn’t stop. It was as if someone had cracked the levee, and the flood waters
just came. It kept coming and coming. The resident probably thought I was some crazy person, or
worse – weak.
I was embarrassed. I’m not a crying person* and I think that if he hadn’t said he was kidding, I
probably would have at least been able to keep it in until I had gone home. I eventually calmed
down, the resident apologized, I apologized. He went on to tell me how I need to be able to handle
tough stuff – mean doctors, yelling, criticism, etc. – with a story on how he dealt with an attending
who liked to yell expletives at an intern.
So I guess there are two lessons. The one my resident told me: Don’t take it personal – somebody
might yell at you, but take it, deal with it, and move on. The second lesson: things happen!
Embarrassing things happen! I did not think that this would be something I would look back on and
laugh at, but here I am today…laughing. That resident actually ended up being my favorite resident
on the team. He was a great teacher, great surgeon, and a great joker.
Thinking back, there’s one more lesson. If you have a partner on the service, they are a valuable
asset (and not competition). I was so embarrassed I had actually tried to hide my tearing incident
from him. He knew of course as my puffy eyes were hard to miss, and was not only cool about it,
he was a great friend to lean on at the end of that crazy day.
Good luck,
Jennifer Sharron
*There is one other incident with me and my car being towed
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Letters to a third-year student • from the class of 2010
Dear Incoming Third Year Medical Students,
First off, congratulations! It has been a long two years and another long year is ahead of you, but
finally you’ll be able to don the white coat and put all that you have learned to good use. You’ll no
doubt read many letters that summarize each rotation and suggest the “perfect” book to use. My
only suggestion is that you limit yourself to a review book, question book and case book and really
know them. Instead of detailing the rotations I am using my letter to tell you about my first patient
of third year.
My third year started off the following case … a 25 year-old, newlywed, Caucasian female presented
to her PCP with a 2 ½ month history of an enlarged supraclavicular lymph node, gradually
worsening lower extremity pruritis x 6 months and mediastinal lymphadenopathy (as determined
by CT in the ED 1 ½ months prior to seeing the PCP). Pt denied weight loss, night sweats, fever
or cough. She was immediately scheduled for an excisional lymph node biopsy, and upon review
by pathology it was determined to be nodular sclerosing Hodgkin’s Lymphoma. Further staging
workup, which consisted of bone marrow biopsy and PET-CT, revealed Stage 2A disease. What
makes this patient interesting is that it is me.
This probably wasn’t what you were expecting, but don’t worry I wasn’t prepared for it either!
Being diagnosed with cancer wasn’t the life altering third year event I was expecting, but looking
back on it there was a lot in the experience for me to learn and I feel like a stronger more
empathetic person for having gone through it. Plus I got to have a faux hawk hairdo for a while.
Seriously though, I honestly feel I have learned as much, or more, about how to be a doctor “on the
other side of the white coat” as I have during third year with it on.
For example, we all expect our patients to “just trust us” when it comes to diagnosis or treatment
but you don’t know how hard that is until your life is in the hands of another. Also, we go about
our day ordering labs and studies without really thinking of the implication the result may have on
our patients. For example, each time I have a PET-CT the result isn’t just positive or negative, to
me it means I am either still in remission or I’ll need a bone marrow transplant. So try to keep the
patient as a person in mind when you are talking with them or their family. And on the family note,
remember that those people are the support network for your patients and will most likely be key
in their recovery so talking with them is just as important as talking to the patient.
Personally I have learned to appreciate my health and to take care of myself first. There were
countless days during treatments (chemotherapy and radiation) where I had to accept my
limitations and rest when I needed it. This policy didn’t change once I resumed clinical rotations. I
realized that some days sleep had to come before studying and I think I did better by listening to my
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body and resting when I needed to. Secondly, take time to enjoy being with your your significant
other, friends and family. I believe more than ever that time is a precious gift and you never know
when it is going to run out.
Best of luck with third year and beyond, I wish you all good health and happiness.
Beth Teegarden,
Hodgkin’s Lymphoma survivor
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“I think we can’t go ‘round measuring our goodness by what we don’t
do, what we deny ourselves, what we resist, and who we exclude. I think
we’ve got to measure goodness by what we embrace, what we create,
and who we include.”
- Pere Henri, ‘Chocolat’
Dear Third Year Medical Student,
Congratulations on all that you have accomplished thus far! With third year comes obstacles unlike
those you may have previously faced in your medical school career. Third year is your first taste of
“real doctor stuff,” and it can be somewhat intimidating. The physical demands of getting to work
at 4 AM with only one day off per week can really take their toll. Exhaustion plus stress make the
perfect scaffold for emotional instability.
I had heard the horror stories of medical student emotions: fighting back crying fits in the presence
of your attending, staking out the perfect restroom in which to finally release your big sloppy tears,
and hoping to regain your composure before your make-up melted off and your absence was
marked as unprofessionalism. I knew I was going to be a crier from the very beginning of third year
(and so did everyone else who knows me). I was actually surprised that I hadn’t broken down in
some way after my first three weeks on the wards. Still, I had never imagined my first time would
be quite like this.
He said, “I just miss being able to take a piss,” and my eyes unexpectedly swelled with tears.
He wasn’t tragically cachectic.
He didn’t have desperate, wispy, white hairs clinging to his balding head.
He wasn’t very old or very young.
He wasn’t tangled in a web of tubes and wires.
He wasn’t being ravaged by some gruesome disease.
He wasn’t dying.
He was funny and feeling very well, despite his persistent bacteremia. It was almost a joy to check
on him in the mornings. Everyday, he would answer “no” to my laundry list of possible overnight
issues. Then, he would chuckle and say, “I can make up something if you want. I’m sorry that I’m not
very interesting.”
Mr. M, with his history of neurogenic bladder and anal sphincter, made me realize how much I take
the simple things in life for granted. A few years ago and again in August of this year, I lamented
being unable to wash my hair and having to use a bedside commode for a couple days when the
chest tubes for my pneumothoraces kept me near bedside; nevertheless, I had not given much
thought to what life would be like if I was physically unable to maintain normal GU and GI function.
I could never imagine having to self-catheterize, let alone self-disimpact, several times a day.
I wanted to cry because I was touched by how this man could maintain such a sunny disposition
despite the daily burden of his body. I wanted to cry because I felt so privileged to know him and to
partake in his care. I wanted to cry because I was ashamed for everything I had ever whined about;
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those “dramas” were so insignificant compared to what this man endures day to day.
Strangely enough, I didn’t cry when Mr. G, a middle-aged man with severely metastatic cancer,
whispered in weak gasps his hopes to go home for hospice and his comforting coffee mug.
I didn’t cry when I first saw Ms. V’s swollen and necrotic, purple hands. I didn’t even cry when I
learned that the doctors were waiting for the right time to amputate.
I suppose that I had expected to cry over something enormously terrible… like pain or death; so, I
think my defenses were prepared to handle malignancy and mutilation.
Who knew that I’d (almost) cry over unspilt urine.
From prose to more practical advice:
1. Trade books with friends on different rotations. It will save you so much money.
2. When starting a rotation, call everyone “Dr. ______” until they correct you. Your interns will
usually tell you to call them by their first name, but don’t make assumptions. And NEVER call a
nurse, “Nurse _____.” It’s “Ms or Mrs ____.”
3. Hold your tongue. Even outside of the hospital, don’t make disparaging comments about UH,
indigent patients, or the people with whom you work. Your attendings, residents, and patients
are out there. They will hear you and take what you say into account.
4. Punctuality & attendance matter, perhaps unlike first and second year when lectures were
optional.
5. Always carry a small packet of tissues in your pocket. Every week of third year, I had at least
one snotty baby or tearful patient/family member/resident who needed a tissue, and there
were never tissue boxes in the rooms. You never know when a casual ROS question is going to
trigger a confession of longstanding depression or memories of childhood abuse.
6. Know everything about your patient. This rings especially true for Medicine, where patients’
pets and marital status may be considered pertinent positives.
7. Carry extra pens for attendings and residents who lose theirs/“permanently borrow” yours.
8. A little Spanish goes a long way. Learning Spanish (if you’re not already fluent) is beneficial
for all services, but ObGyn has >80% Spanish-only patient population. No one will translate
for you. You will be expected to get through a full H&P along with well-woman exam using
whatever pocket dictionaries and translation cheat sheets you can. You can pick up the free
Spanish booklet from Dr. Kosub’s office.
9. Listen. Like Dr. Jones has quoted, “Patients don’t care how much you know until they know how
much you care.” Sometimes, what they really want is to feel like someone understands them.
10. Don’t take it personally. Try to develop a few extra dermal layers. Attendings, residents, nurses,
scrub techs, and patients will displace their negative emotions to you because you are lowest on
the totem pole. You may also receive this “special attention” for the shade of your skin, the size
of your belt, the name of your God, or having an additional appendage/lacking one. Do NOT
cry in front of them, especially on Surgery and ObGyn.
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11. Learn the difference between complaining, choosing your battles, arguing with your
superiors, and standing up for yourself. If it doesn’t improve patient care, then it’s not really
that important for everyone to know that “it’s not your fault” or that “you’re right.” Third year
requires you to swallow your pride more often than not.
12. Carry a “call bag” with you. Even when your team knows that you’re post call, patients still
prefer that you didn’t look like a train wreck with morning breath when you round on them in
the morning. At the very least: toothbrush, toothpaste, deodorant, wet wipes, eye drops, and
brush/comb.
13. Play nice with others. You catch more flies with honey than vinegar. Being a team player is
not limited to working with other medical students or MD’s. Be humble and gracious with all
staff. There have been disgruntled techs and nurses who have filed complaints about students
with the attendings. “Thank you” and “please” can make a big difference in the clinics and ORs.
14. Don’t pick up bad habits from your superiors. Yelling at patients, blatantly disregarding the
sterile field, sticking pens in you mouth, flaunting your M.D. at techs and nurses as if it makes you
untouchable, throwing instruments across the OR… It’s never okay just because the attending
does it.
15. Keep your compassion. It is a special challenge, to which we must rise, to care for those who
refuse to take responsibility in caring for themselves. Continuously remind yourself of all those
reasons that made you want to become a physician because multiples forces and frustrating
patient experiences will try to transform you into that jaded, cynical doctor (who would fail
the patient interaction and professionalism part of the OSCE). Avoid becoming that “horrible
doctor patients once had” who then scares them away from going back to see a doctor for 30
years.
16. Your loved ones may never understand. With the profoundly personal experience of a
physician comes a burden and a privilege that few “non-meddies” can truly understand. You
have 30-hour trauma calls and substantially less control over your schedule as a third year, which
translates into less time for family and friends. Try to keep balance in your life, and maintain
those relationships.
Your third year of medical school can truly be “the best of times, and the worst of times.” While
it is incredibly physically, intellectually, and emotionally challenging, you will never have another
experience like this one. Take advantage of the time you have to spend with patients because as
an intern, your schedule will not permit you to get to know them as much as you might like. Ask
questions and learn as much as possible (even if it won’t be on the shelf exam). There will come a
time, in not too many months, when you can no longer say, “I don’t know. I’m just a medical student.”
Soon, you will have an M.D. after your name, and you will be expected to know the answers and
take responsibility for lives other than your own. Enjoy your final years of medical school, and make
the most of all the unique opportunities that come your way.
Best of luck,
Stacey Thomas
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Letters to a third-year student • from the class of 2010
Dear 3rd year,
Congratulations! You should be very proud of yourself. You have worked so very hard over the
past two years, and you are ready! Ready to share what you’ve learned and who you are with the
patients, residents and attendings that will shape you over this next, most important year, of your
medical education.
This year will be amazing. It will test your physical and emotional strength. It will move you and
stretch you, as you encounter people and situations that will make you question your beliefs and
expectations. You will affect people’s lives. And patients will change you. It is wonderful!
My first piece of advice is to make two lists. In one, list five things that you hope to have learned,
or to have retained, during your 3rd year of medical school. In the other, list five fears. I was asked to
make this list prior to 3rd year, and I’ve looked at it several times this year. I am not the person I was
at the beginning of 3rd year, but I have already accomplished my “hopes” list and my “fears” list is...
well...I’ll let you find out for yourself.
This may be simple and repetitive, but here is my advice for 3rd year:
1. Care. (All the time, with everyone.)
2. Be on time. (If your late, it may overshadow how wonderful you really are.)
3. Be flexible. (Everyday is different, every patient is different, every resident is different.)
4. Have fun!!!!!!! (This is a unique opportunity. Embrace it!)
5. Oh, and go to Harlingen! (I was sent for Family Medicine at the beginning of my 3rd year and
loved it so much that I asked to go back for Internal Medicine.)
Last piece of advice: have a balance. When you have time off, spend time with friends and family,
pamper yourself, take a weekend trip, etc. You will deserve it, trust me.
Congratulations and have a great year,
Dina Tom
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Letters to a third-year student • from the class of 2010
If you are reading these letters you are probably looking for some guidance, assistance or general
reassurance. I can tell you that reassurance is probably the most needed during your third year.
There will be times when you are overwhelmed.
There will be times when you are scared.
And there will be times when you question why you chose to do this and you’ll want to quit.
But you will make it, just as the people before you have made it. Everyone has horror stories and I
am most certain after you finish this upcoming year you will have horror stories of your own. Just
remember what makes you happy now and do not lose it. You are going to need it. When you
start spending 80hrs a week in the hospital these things can be the first to get sacrificed.
This year should be fun. It is an interactive learning experience that cannot be created by a book
or simulated patient. This is your chance to make mistakes and learn from them. You have a safety
net of interns, residents and attending physicians that will be watching what you do. So study, have
a plan and make suggestions. You will either look smart or learn from your mistake. Either way you
will look engaged. That is what matters. The doctors tend to remember the things you get right
more than the things you get wrong. So one shining moment may be all it takes to leave a lasting
impression. Remember they are teachers and they want you to succeed.
Everyone worries about how to study or when to study. These questions are the most easily
answered.
1) Study early in the rotation, it seems that every rotation gets busier towards the end. You
become more proficient and take on more responsibility. More is expected of you, and
you become fatigued. There will be days where you can’t study, so be prepared. Start early
and stay on top of it.
2) One good study book and a question book/bank is all you need. I used CASE FILES for
every rotation and I am a believer in USMLE WORLD. The Lange question books or
PreTest probably work just as well for less but I like WORLD.
Most importantly, treat others like you want to be treated. That includes patients, nurses, classmates,
residents…everyone. Your attitude is going to be what determines how you are treated. So put
your best foot forward. You are going to meet classmates you haven’t spoken to for 2 years. Who
knows, maybe you will be lucky enough to make a new friend. If you are really lucky maybe you will
find something you truly love. There are rotations you are already dreading, some you are looking
forward to, some rotations you are going to hate, and some that you will love. Keep your mind
open because you can be surprised. Also I would suggest making a pros/cons list for each rotation
and be vigilant about keeping notes. As the year passes sometimes you forget some really good/
bad things about a certain rotation.
Good Luck,
Mike Wages
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Letters to a third-year student • from the class of 2010
I did my general surgery rotation at Wilford Hall. I was on the acute care/trauma team
referred to as “Viper.” I was on call and we had a trauma rolling in. It’s an MVA. 23 yo male with a
prolonged extrication from his car. We’re not sure what happened that made his car flip and roll
until it met a tree, effectively pinning him inside. But we’ve been told that his passenger was ejected
and they’re still looking for him. No bones appear to be broken, but his scalp has been torn almost
completely from his head, and he’s not responsive. His GCS is 8 (you’ll know soon enough), HR 145,
BP 95/62, and he’s effectively bleeding out from his head wound. We’ve got peripheral IVs in, and
pushing a couple liters of fluid and pRBCs.
The debate starts: CT vs directly to the OR? Well, CT wins out. So as I stand there watching
the techs set everything up, I notice his HR and his BP are dropping. He’s crashing in CT. So we
rip him out, and run to the OR. Nothing is sterile. People with no scrub caps or masks are in the
OR. It’s a crazied frenzy, and I still don’t understand how things can get accomplished with so
many people running around and yelling at the same time. They’ve debrided his scalp, cauterized
the bleeders and are closing the avulsion. Yet, he’s still bleeding. We spent 4 hours trying to stop
it. Anesthesia is giving him pressors. He’s gotten 14 units of pRBCs, 10 six packs of platelets, 6
bottles of albumin, and only the scrub nurse knows how many liters of normal saline. They even
made me call down to pharmacy and ask how to dose Factor VII, thinking that maybe this kid was
a hemophiliac. Nothing worked. We put a pressure dressing on his head that was so tight that his
newly reattached scalp would have necrosed, and it was soaked before we got him off of the OR
table. We loaded him up and took him to SICU. He coded the moment we got him in his room.
They ran it for 15 minutes, until his family caught up with us and told us to stop.
In sitting with his parents, I learned that this was not the one car accident we’d thought it
was. There was no ejected passenger. A drunk driver with 3 DWIs and no drivers license had hit our
patient, and then fled the scene. When he heard the sirens, he pulled over and tried to hide. He was
currently in a bed on the floor upstairs (he’d been admitted while I was in the OR), waiting for my
fellow 3rd year and me to stitch him up. He’d apparently sustained a 3cm deep, 7cm long laceration
when climbing a fence, running from the cops. It might be the only time I have wished pain on a
patient. I wanted so badly to plant pseudomonas in his wound and suture him without anesthesia.
I wanted him to feel the pain that the family downstairs was feeling. I truly wanted him to suffer.
Instead of acting on my desire to hurt him, I might have done the best suturing of my life. (That
would be an example of reaction formation).
The point is that there will be days that you hate your job. You will be frustrated when diabetics lose
a limb to their disease, because they refuse to change their diet. Patients will die. That’s the nature
of our work, but if you love medicine, it will all be worth it in the long run. Placing a newborn in its
mother’s arms for the first time, making a cancer patient smile, watching a CF patient recover from
their most recent bout of pneumonia… it gets you through the bad days. Hold on to that.
Shelley Waits
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Dear Class of 2011
It’s 1am in the SICU. And I was just snored on. And it made me happy.
My patient needed a central line. My coagulopathic and claustrophobic patient with severe
abdominal pain and mental status changes needed a central line. Two trauma residents gowned up
and explained to the patient they would need to cover his face for the procedure. Of course, a
central line requires a sterile field. On top of his face.
Because he was coagulapathic, the surgeons would work with great patience, no haste. Because he
was claustrophobic, this did not bode well for his cooperation.
I slipped my hands underneath the sterile field to hold his face to one side, all the while feeling
his humid breath snoring against my hands. While the surgeons prepped and poked, the man
continued to snore loudly across his nasal cannula and repeatedly moaned in agony. He was
claustrophobic – He needed to see daylight.
An unforeseen glitch in his anatomy prolonged his line placement. Subclavian – no good. Starting
over for an IJ. “I need light! Please hurry! I need to see some daylight!” He writhed in agitation.
Slowly, I lifted my wrists and shifted my weight to a crouch. I ached in my pretzeled attempt to
avoid spoiling the sterile field with my arms and elbows. My fingertips tingled, oxygen starved as my
forearms were pinned to the side of the bed.
One green eye peered out at me from the darkness under the towels.
And a whisper from within this chasm – “Thank you.”
And so Sometimes you’ll be thrown under the bus when other third years suggest extra presentations or
projects, opt out of their turn to C-section during the wee hours of night float, or volunteer to tell
the pit boss you didn’t show up for your call when, in fact, you are assigned to another floor for the
night and working hard. *(Don’t worry – I still love you all.)
Sometimes your fatigued brain will just not be able to hang on to the latest H&H of room 1065,
the number of blocks a 2-year old can stack, or the mechanism of thrombotic thrombocytopenic
purpura. Sometimes people will yell at you – and yes this includes a misplaced “F” bomb meant for
the furious little bleeder that could not be coagulated. Sometimes you’ll be the butt of the classic
bad joke involving a certain exam that starts with a “D” and ends with an “RE”.
When things turn sour, go get yourself snored on! Go check on your patient, talk with your patient,
laugh with your patient, listen to your patient, etc. You never know when you’ll enjoy a story about
meeting a famous Tejano musician, or a peek at a sweet tattoo of yoda under the blankets. You
never know when their quiet panic will need to burst forth to any kind ear. You never know when
you too might hear that little whisper – “Thank you.” And it will make it all worthwhile.
M Wald
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“My First Death”
Looking back, my days on surgery all fade together. From what I remember, my morning typically
started with me being rudely awakened by four alarms (to ensure I didn’t oversleep, of course…
at 3:45AM, anyone would). Then, stumbling half-asleep, coffee in hand, I would make my way from
my car to the hospital doors. The sun was a long ways away from waking up, and the cleaning crew,
ever so cheerfully, never failed to greet me with a “Mornin’, doc!” as I passed them in the hallway.
The days themselves leave me were an eclectic mix of long OR hours, snacks hastily eaten in locker
rooms, the occasional palpitation, and a determination not to upset any scrub techs or surgeons, for
that matter.
In the midst of these blurred memories shine those of the patients. One in particular that truly
challenged me, not in what she said or did, but in that she died. This is the story of my first death.
It was my first day on trauma surgery. We walked into her room, greeted Mrs. D and her husband,
and my attending proceeded to calmly explain that her small bowel obstruction had not resolved—
she would need an emergency laparoscopy. She was visibly nervous, and her husband stood silent
at her bedside, accepting the news. I promised her that I would be in the OR, there to greet her
when they rolled her in.
The surgery was supposed to be simple. But the laparoscopy converted to an open exploratory
laparotomy, and midway through, the bowel perforated. The expected two hours turned into nine
hours. By the end of it, all of my focus was on the clock and how badly I wanted to be home, asleep
in bed. The surgeons closed up, and we were dismissed.
The days following, I visited Mrs. D. We had our typical morning conversation discussing her lack of
bowel movement, which, by the way, is the favorite and most important question asked by surgeons.
Once that was behind us, we’d chat about her children and her life outside of the hospital. When
my long work day was over with, there was always that urge to run out of the hospital, to get back
to freedom outside of the hospital doors. But with Mrs. D I was always tempted to swing back
by, check on her, make sure that she was not in pain, and simply chat. The days went by, and she
remained comfortable, but still no bowel movement.
During those days, I’d see Mr. D in the cafeteria, always a lost, soulful stare, anxiously awaiting the
recovery of his wife. It seemed as though he rarely left his wife’s side. Then the day came that her
awaited bowel movement came. She and her husband finally got their awaited journey home.
A week later, I heard a somber report from my chief resident. Mrs. D had presented to the ED
the night before, septic from bowel contents spilling into her abdomen. She had coded twice in
the ED and now lay in the SICU. I was dumfounded. At the end of rounds that day, I made my way
downstairs. As the SICU team stood in front of her door, rambling off grim electrolytes and O2
stats and debating her prognosis, I met with Mr. D outside of the SICU where he waited until the
team allowed him back inside. He attempted a half-smile on seeing my familiar face, and we stood
there quietly for a few moments. Slowly he began to ask me the questions I dreaded: how she was
doing, whether she’d get better, what her prognosis was. I didn’t know how to honestly answer. I
was a mere medical student. I lacked the years of training, the confidence, the immense amount of
knowledge that those surgeons in front of her room possessed to answer his questions. All I felt
was that I could offer was my sympathy and some time to talk: a mere distraction. So I talked: asked
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him about his sons, whether they were visiting, how he needed to take care of himself in a time like
this, how much she appreciated him being there even though she couldn’t tell him.
The next morning at trauma check-out, I looked down at the SICU list. Mrs. D’s name was missing.
And then the words that I feared were spoken: “Mrs. D died last night.” The rest of that morning’s
check-out faded into a multitude of indecipherable voices as I focused on those harsh words.
My whole team was solemn that morning when we returned to the workroom. My chief was only
silence, hanging his head in his hands, soberly asking himself what he could have done differently. My
attending’s innocent, young eyes simply had a look of disbelief. The days following, I often overheard
them reassuring the other that there was nothing else that could have been done. They had done all
they could, given the circumstance.
A few weeks later at M&M I sat there, as I did ever Monday, waiting. And there it was: M&M
presentation of “Patient: Mrs. D. Case: complication of small bowel obstruction with intraoperative
perforation.” It was the same type of presentation I watched every Monday, telling of patients with
complications and the occasional death. To those around me, she was simply another case. Another
set of anonymous initials with a pathology, a surgery, and an unfair yet inevitable complication that
led to her death. And yet, there I was, listening to the somber voice of my chief resident, with a
heavy feeling in my heart, still unable to comprehend how this had happened. Thirty minutes later
the presentation was over. A few surgeons suggested how they might have proceeded differently.
Case closed. Next patient.
As medical students, many of us anticipate our “first death.” How we will feel, how we will react,
how we will cope. It’s something that we are subconsciously aware of as we step into the doors of
medical school and yet never truly grasp or understand until we experience or witness it. These are
the things that we face on a day to day basis by choosing a life in medicine. There is the heartbreak,
that gut-wrenching feeling when an innocent life is taken too early. There is the presence of
self-blame, of doubt in one’s abilities, even in the finest surgeons. I don’t know what effect this
profession will have on me or my view of death. But as I watched my chief resident and attending
that day, I realized that no matter how long we practice, how many patients we treat, the death of
a patient never gets easier or tolerable. Sure, we can rationalize, intellectualize it. The brain tells us
there was no other way, it was inevitable, incurable. But the heart still sighs. The patients are not
forgotten. Life goes on.
It’s spring now: a new rotation, a new team, a new hospital. And I still think often of Mrs. D. How
she suffered the day prior to her surgery, how she improved post-operatively, her giddy excitement
of a bowel movement, how she hopefully anticipated her eventual trip home. Now, months later,
I walk into the hospital and the typical morning routine of “Mornin’, doc!” still brings a smile to my
face. I like to think I’ve changed much since those first, naïve days of third year. By choosing this
path, this destiny, we submit ourselves to much heartbreak, to much unfairness. But in the end, we
must focus on the good. The chance we are given to save a life, the hope that we provide for others.
So brace yourself. You are about to be challenged and changed in ways you never thought possible.
In telling you this story, there is nothing that I can say to better help you to prepare, to help you
learn how to deal with what you will encounter in the hospital. True, you will learn plenty from
your books and vast knowledge from your attendings. But the true wisdom will be in those early
morning conversations at the bedside with your patients that will teach you true compassion and
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kindness, the exact virtues that deep down drives each and every one of us to come in to work
before dawn, say a friendly “Good mornin’!” to those still awake, and begin a new day again in
dedicating our lives to helping others.
And this is only the beginning.
Nicole Walker
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Letters to a third-year student • from the class of 2010
Dear Class of 2011,
By now, you’ve been bombarded with advice about 3rd year. And, here we are giving you a book
full of it to add to the stack. YOU are unique and your 3rd year experiences will be different from
everyone else’s— past, present, and future. In light of that, I will preface the following advice with
this: take it or leave it.
(1) KEEP an open mind. I can’t think of more than a handful of classmates who haven’t had the
experience of LOVING a specialty they thought they would HATE (or the reverse, which is
unfortunate, but equally enlightening, as you’re trying to find your best career fit).
(2) DON’T judge a book by its cover … and don’t judge a rotation by the first day. The first
day (or 2 or 3 or 4) of any rotation is rarely a great day. It’s stressful and overwhelming
because everything’s new: new residents; new attendings; new patients; new note-writing;
and new expectations. This last one is the hardest to handle because you won’t usually
know what the new expectations are, but don’t worry – either you’ll figure it out on your
own or you can just ask someone!
(3) COMPLAINING is contagious and rarely helpful. When Dr. Keeton advised us to “never
complain,” I didn’t know how hard that would be. You WILL get frustrated during 3rd year. I
promise. You’ll get bored because you have nothing to do, or tired because you’ve worked
30 hours straight. You’ll be hungry because you haven’t eaten all day, or gain weight because
you eat UH food and never have time for the gym. It’s easy to turn to your classmates or
your interns and complain. While venting to a close friend may be necessary at times, get
it out of your system, and move on. Negativity is bad for your health and maybe even your
grades.
(4) FOCUS on good things: how you got to close on a surgery or put in a chest tube; how
you diagnosed a pneumonia or a new heart murmur; how your 87 y/o patient thanked you
for caring about him and told everyone who’d listen that YOU were going to be the “best
doc in San Antonio.” You will be a part of peoples’ lives more intimately than most of their
family members. You will get to do and see amazing things that most people will NEVER
have the privilege – and some may never have the desire – to do and see. Eat it up.
(5) FORGIVE your teammates. Undoubtedly, you will encounter attendings, residents, and
interns who on a few days – or in rare cases, daily – bug you, frustrate you, or are even
downright mean. For this I have two pieces of advice: (1) if you think you should talk to
the clerkship director about a negative incident, DO! It will make you feel better, and
they are very receptive to student concerns; (2) if it’s not that bad, forgive the person and
move forward. Holding on to a grudge can make the rest of your time on a given team or
rotation miserable. It’s not worth it.
(6) DOUBT and CONFIDENCE will take turns in your head. At first, you may feel shaky
about your exam skills, your note writing competence, and your ability to present a patient
to your attending. After a few days or weeks on a service, you’ll start to get the hang of
things and realize that you’re actually functioning like a real doctor! Then, just as soon as
that thought crosses your mind, you’ll do or say something wrong and feel like an idiot. You’ll
see progress in yourself and then wonder where it went. Don’t worry. It’s happens to
everyone. The following is from an anonymous “letter to a 3rd year” from a couple of years
ago, and I think it is comforting and very true:
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“REMEMBER that you will make mistakes. You will write something
down incorrectly. You will lack information that’s important. You will
ask the wrong questions. You will come to the wrong diagnosis. You
will forget an answer on rounds.You will completely forget to record
things.You will be in the wrong place at the wrong time.You will get
lost.You will suggest an inappropriate plan.You will drop instruments.
You will break sterile field. We’ve all done it… The most important
thing is to learn from those mistakes. If we were all perfect, third
year would be unnecessary. Mistakes are what make us stronger.”
With all its ups and downs (MOSTLY UPS!), by the end of 3rd year, you’ll step back and realize how
far you’ve come. In just 12 months, you will have gained more confidence in your knowledge and
ability to care for patients than in the past 20- or 30-something years of your life. Enjoy the ride!
Best wishes,
Jill Waters
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Letters to a third-year student • from the class of 2010
Hello third year,
I truly hope you enjoy everything you get to do this year. Although I’m not quite done with third
year yet, I feel like I’ve done enough now to be able to do some legitimate looking back—and in
looking back I can say I’ve actually learned quite a bit and had a good time. I’m starting out positive
with this because the following might give you the impression that all my rotations drove me to the
point of needing a psych eval, and while I won’t dispute that most medical students, me included,
might need psych evals, I don’t want you to think it’s because of the trauma of third year.
First things first: do all the stuff you’ve been told. Choose the specialty that makes you happy, keep
food in your pocket, show up early (which is the same as being on time), follow Dr. Keeton’s advice,
don’t throw your classmates under the bus, be confident, and so on. I didn’t find these things too
difficult. The tallest order for me was getting in a good mood before showing up in the mornings…
and then maintaining it. On the few rotations that I hated, I found it hard not to spend the time
between waking up and walking in the hospital doors every morning questioning my career choice
and then the rest of the day wondering if the interns cried themselves to sleep every night because
they got duped into picking their specialty. How miserable I was before I entered the building had
a direct effect on how my day went (or at least how I perceived my day to have gone), so I always*
got up an extra five or ten minutes early just to make sure I could sit in front of my laptop and
waste some time emailing my best friend or my brothers or watching stupid YouTube videos. Then
in the car, before even backing out of the driveway, I cranked up the iPod. No talk radio for me.
Getting pumped—a term I’m using loosely—to wake up patients long before they really want to
be awake requires some awesome music beforehand. God bless Mom for giving me an iPod car
adapter for Christmas, right before my least favorite rotation (though admittedly this was a tie with
another pre-Christmas rotation).
Maintaining a decent mood throughout the day in the face of four hour rounds, VA patients that
grabbed my face and pinched my nose, being reminded how terrible I am at camera-driving, thirty
minute talks outside the patients’ rooms about whether or not hepatorenal syndrome really exists,
and nurses telling me how incredibly tired I looked was even harder. It required some stealth work.
I found my sanctuaries in random scut work (yes, scut work) and bathroom breaks. Did I want to
pull a drain on Mr. A? Of course I did! Just the trip to the patient’s room gave me some time to
myself. Did I want to go down to the cafeteria and bring back drinks for everyone even though it
had nothing to do with my learning experience? You bet! That was another ten minutes I could
have to myself. Now I’m not saying to go disappear. If you spend twenty minutes on a bathroom
trip your team will either think you’re being lazy and hiding or, quite possibly worse, having a bowel
movement. Terrible options, the both of them. I just mean you should actively look out for ways you
can capture some sanity in the middle of whatever particular rotation it is that makes you nuts. It
makes a huge difference. If you’re on overnight call, though, and think that doing a little dance down
an empty hallway on the way somewhere is a good way to find that sanity because it’s the middle
of the night and the chances of being caught dancing are slim, just think twice. That’s all. Good luck
and have a great year.
*well, usually anyway.
Ellen Whitman
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Easy steps to follow for a good third year:
1. Always be professional, which means be respectful, punctual, appropriate, polite (even if you are
the only one being polite), and always watch your etiquette.
2. Work hard - which is not all that hard, all you have to do is actually take an interest in your
patients and the rest will happen naturally.
3. Show interest always. You will learn so much and also earn the respect of your team.
Third year is a wonderful time where you start to feel what it is like to be a part of the greatest
professions of all time. Don’t forget to take the time to actually enjoy yourself!
Elaina Wild
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Dear MS3,
First let me congratulate you! You’ve done what you probably did not at first think possible and
survived two of the longest years of your life to date. Now, you might be saying to yourself, “Well,
that’s great, but now how am I going to get through this next one?” The bad news: it’s not easy
and there is still so much more to learn. The good news: you finally get to see and touch real live
patients, and when you look back on this moment in a year you will say to yourself, “ok, that wasn’t
so bad after all.” Before you start, let me tell you one important lesson I learned during my third
year.
It was my first day on Internal Medicine; the day I was waiting for all year, the day that I would start
a rotation I was actually considering as a possible career choice. The time when I could truthfully
answer in the affirmative when an attending asked the ultimate question that you will soon begin
to hate as a third year, “So, do you know what you want to go into yet?” and more specifically “Do
you have any interest into going into this particular field, my field?” The follow up to this question
generally includes telling you that you can just be honest with them because they don’t, after all,
expect everyone to want to be a Surgeon, ObGyn, etc. However, no matter what the assurance,
you will always find yourself trying to be diplomatic and will end up saying the same thing, no
matter how trite you may believe yourself to be: “Well sir, I’m not sure yet, still trying to just keep
my options open.” It’s a safe answer after all, and in some cases possibly even the truth, but when
you do know what you are interested in and then you enter that rotation, you will find yourself
practically jumping in anticipation at finally being able to answer the question without feeling like you
are about to offend someone or set yourself up for failure. But, I digress.
Back to my first day. Things were up in turmoil as usual. The hospital overcrowded, the interns
overworked, and us third years wondering around in a daze not having any idea where to go or
what to do. Almost immediately after settling into our new team room, I met my first patient, Mr.
E. Little did I know that Mr. E would soon become a regular part of my days on internal medicine.
He had multiple medical problems that started with the very familiar list of diabetes, hypertension,
hypercholesterolemia, and then for him ended with CHF, CAD status post CABG, and recurrent left
sided pleural effusions. This last problem is why he ended up on our service in the first place. He
couldn’t breathe, which really is not that hard to imagine considering his entire left lung had filled up
with pleural fluid for the third time in six months.
You spend a great deal of time as a third year feeling like a big fake. Here you are dressed up in
your white coat, talking to patients, asking questions, and reporting information while simultaneously
feeling like you know nothing and are just playing doctor. There are moments; however, that make
you realize that you really are useful. My moment came this first day on internal medicine. Mr.
E was unstable when he arrived and immediately had to be placed on supplemental oxygen. My
intern and I spent the entire day checking on him and worrying about him. At the end of a very
long day, I found myself still by Mr. E’s bedside watching the pulmonology fellows place a chest tube
to drain the pleural fluid. When we finished, I noticed Mr. E’s wife, who had just arrived at the
hospital, waiting anxiously outside. I went to find my intern so that someone could speak to her
and inform her of her husband’s status only to discover that our team room was dark and that
everyone else had left for the day. This is where I could have just went ahead and left also, after all, I
technically was not responsible, but not wanting my patient or his wife to be concerned overnight, I
went back downstairs, found them, and explained in the best possible way that I could, and using the
most convincing “doctor’s voice” I could muster, what the situation was and what we were planning
to do. The wife was so grateful afterwards, I knew that I had made the right decision.
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It gets easy to stop doing the little things when you’re tired, stressed, and just want to get out of
the hospital and run home so badly, and when you see things as “not really your job,” but it truly
is the little moments that make it worth it. I learned this again and again as I visited Mr. E every
morning. He was always happy to see me, always grateful, and always reminding me that I was
in fact important. Mr. E’s long list of problems and past procedures quickly became a part of my
memory, which proved to be vital when our team completely turned upside down a week and
a half later. The interns had finished their month and were switching teams, as was the third year
resident and the attending. The next morning we had a brand new team, save me and the two
other med students. All of a sudden, I wasn’t just a lost and blundering medical student, I was
actually helpful. I knew all the details that had transpired concerning Mr. E and his care and I was
able to share them with those in charge and to advocate for my patient. You will hear this over and
over again, but I will reiterate it now. As the medical student on the team you really do have the
most time to spend with your patients. At times, I’ll admit, this means that you have too much time
on your hands and end up feeling useless and bored, and wishing the resident would just tell you to
go home. However, there are the times when you get to speak up for your patient, because, just
like with me and Mr. E, you know more about them than anyone else. Those are the times that you
should value and that make it all worth it again. On my last day of the rotation, we discharged Mr. E
and I thanked him for teaching me every day for the past month. If I can give you any advice about
third year, it’s this: Be confident in your abilities and your importance, be thorough, be kind to all of
your patients, and know that they will teach you more than you can ever teach yourself.
Sincerely,
Bethany Wisotzkey
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