Dr. Stranger or: how I learned to stop worrying and love my MS-3 year

It is widely accepted that the transition from graduate school (GS) to medical school third year (MS-3) clerkships is the most challenging transition in the Medical Scientist Training Program (MSTP). In attempt to lighten the blow, I arranged a hospital experience for myself a few weeks before starting clerkships. It had been over 4 years since I last stepped foot in a hospital ward, and I planned to shadow Dr. James Willig (Asst. Prof., UAB Division of Infectious Diseases [ID]) on his consult rounds on Spain Tower 9th floor (S9).  Dr. Willig was 15 minutes late, likely because I was supposed to meet him in Wallace Tower 9 (W9). While waiting in vain at the nursing station and observing medical students and house staff perform their daily duties, my throat dried, hands moistened, heart rate hastened, and I felt so lost. In spite of four years of lab work, publishing multiple manuscripts, traveling to various conferences, giving numerous talks, and obtaining expertise in a major biomedical topic, the regular workings of UAB hospital were extremely foreign to me.

I recently re-experienced a comparable mini-panic moment within hours of flying to Seoul, Korea. It was the first night of my 4-week international elective, and as I struggled to read the roadway signs while my Korean colleague drove me from the airport, a thought dawned on me: “I am stuck here!” This was my first trans-oceanic trip, and for the first time my grasp of English and Romantic languages were pretty useless for communication. My reactions at the S9 nursing station and Seoul highway heralded remarkably similar times of transition. And though experienced thousands of miles apart, I approached both transitions using the same strategies. Here I describe these approaches and give advice in an attempt to help readers achieve the smoothest MS-3 transition as possible.

Before heading to battle, have friends on the inside. This is probably the one best thing you can do. The drive from the Inchon Airport to Yonsei University was a lot more complicated than I thought when I originally planned to make the trip alone. I hugely benefitted from having friends and collaborators anticipate my trip, meet me at the airport, and get me settled in the dormitory where the doormen only speak Korean. Also, I owe multiple outstanding Korean meals and experiences to these friends.

Eating lunch with various faculty and house staff of the Infectious Disease division at Severance hospital at Wonju, Korea
Eating lunch with various faculty and house staff of the Infectious Disease division at Severance hospital at Wonju, Korea
A “ddong ppang” (loosely translated “poo bread”) stall in Insa-dong in Seoul
A “ddong ppang” (loosely translated “poo bread”) stall in Insa-dong in Seoul

Back at UAB, I had the privilege to befriend Dr. Willig years prior to shadowing him on rounds. Since meeting him, he was appointed the Internal Medicine Clerkship co-director and became my faculty career mentor. His advice and guidance helped me achieve my MS-3 milestones and develop my ID-focused training path. Beyond faculty, I was fortunate to have valuable friendships with non-MSTP students who started clerkships during my GS years. For example, my friends through Infusion (the UABSOM Acapella group) consistently shared resources and knowledge related to important topics limitedly addressed in MS- 3 orientation. MSTP upperclassmen and program leadership are important sources for MS-3 guidance, but you should not rely solely on our inherently biased knowledge. Foster multiple and diverse “insider” relationships during your GS years by regularly attending divisional seminars (e.g., ID seminar in the Bevill Building every Thursday at noon) and joining social or service medical student organizations (e.g., EAB), not just specialty interest groups (e.g., Surgery Interest Group) populated by like-minded students and potentially toxic relationships come Match Day. Moreover, forging friendships should not end on the day you defend your thesis.

Make new friends fast. In Seoul I have found great friends in the attending, residents and fellow to whom I was appointed. People who organize a Pizza Party solely due to an off-hand comment that you “craved pizza the other day,” have the ability to soften the hardships of any transition. Similarly, it is important to form new support networks with others sharing the MS-3 struggle. Start early. Invite yourself to lunch with other medical students during MS-3 orientation or organize dinner outings and coffee breaks after morning rounds. Identify students with whom to form mutually beneficial friendships. In addition to my friends from MS-1,2 and GS years, it was valuable for me to socialize with new people who I met during clerkships. We helped keep each other abreast of clerkship requirement and, more importantly, how to avoid bad situations. I continue to meet monthly with the same group of non-MSTP medical students (one with whom I shared almost every clerkship rotation) to gossip, discuss residency progress, complain and share success stories. Unfortunately, some students regard at MSTP students as different or unapproachable. The only way to change this perspective is to show people how awesome, yet equally vulnerable to MS-3 stress, we are.

Pizza party organized by the Dr. Han medical team, with who I worked at Severance Hospital at Sinchon
Pizza party organized by the Dr. Han medical team, with who I worked at Severance Hospital at Sinchon

Also make friends with Medical Student Services staff. For example, introduce yourself to Marla Ferguson, the impressively understanding woman in charge of scheduling our MS-3 and MS-4 courses. Introduce yourself to one of the staff who will likely write your Dean’s letter (for me it was Dr. Kezar). And do not let Dr. Hoesley’s fervent passion for student education intimidate you from approaching him for designing a course, say a course titled “Infectious Diseases in Korea.” There is a lot on our academic plates secondary to the unique nature of the MSTP curriculum. Trust me on this one: making sure that the key people know about your individual situation early makes the ride smoother.

The last group worth mentioning is MS-4 students. Chances are if you meet them on your clerkship it is because they want to be there. And unless they are there only for themselves and a recommendation later (you can easily spot them), most MS-4’s are excited about the field and will want to teach. I owe my passing the Surgery Clerkship to the three MS-4 Acting Interns (AIs) on my Trauma ICU rotation. They showed me the ropes, and gladly accepted all my unwanted OR trips. In my experience, most MS-4’s are supportive, so don’t be bashful about bugging them and sharing a few drinks.

Do not let “Day 1” be your first day back. I am very glad about the efforts by the Griffin Society and Dr. William Geisler, our new MSTP Associate Director, to introduce clinical exposure during our GS years. I was fortunate to stay clinically active through Equal Access Birmingham, Cahaba Valley Healthcare and Objective Standardized Clinical Examination (OSCE) employment. They kept my physical examination and patient- physician relationship skills sharp outside the hospital. The statement “Juan, I would not have guessed you were an MSTP student after observing your interaction with that patient,” from my supervisors was a repeated confidence boost, albeit containing a somewhat back-handed compliment.

Wearing contact precaution gear in the Vancomycin Resistant Enterococcus Isolation Ward
Wearing contact precaution gear in the Vancomycin Resistant Enterococcus Isolation Ward

But as I explained above, what I did was not enough to prepare me for how to fulfill hospital duties. Research has repeatedly identified that a large amount of stress in medical students in general stems from the first two years ill-preparing us for how to perform MS-3 jobs. I beseech readers to seriously approach learning how to write a history and physical, and shadow residents or MS-3/4 students as much as possible during your GS years. Familiarizing yourself early with the clinical environment and basic skill set for everyday functioning will save you a lot of anxiety, and get you on your way to learning about real patient care a lot sooner. Unfortunately there was no opportunity for Korean exposure prior to my Seoul trip. However, Seoul “Day 1” was made a lot better by following by the following means.

Learn basic communication as soon as possible. During the 12-hour plane ride to Korea I was fortunate to be seated next to a very friendly Korean. She had recently studied biological engineering in Illinois, and her ability to teach me Korean was superb. By the end of my plane ride, I was able to read and write using the Korean alphabet, Hangul (a surprisingly easy feat). My Korean vocabulary is brutally lacking, and by no means can I have a conversation in Korean. However, knowledge about reading and writing gave me insight into communicating with Koreans. For instance, there is no “f” sound in Korean, so every time my attending tells me “we are giving this patient plucanazole” [sic], I easily understand. I also identify signs pointing to Severance (세브렌스) Hospital or Yonsei (욘세) University. Learning basic reading and writing drastically eased my adjustment.

Seal of Yonsei College of Medicine, where I performed my away rotation in Infectious Diseases
Seal of Yonsei College of Medicine, where I performed my away rotation in Infectious Diseases

Similarly, you do not have to be a master of clinical medicine when starting your MS-3, so do not stress about rereading Bates and Robbins. Instead, familiarizing myself with just common abbreviations, procedures and medications early freed me to earlier to learn the more intricate details of ventilator settings or diagnosing Kikuchi disease. Which brings me to this controversial advice: as MSTP schedules become more flexible thanks to the strong effort of program’s leadership, consider doing Family Medicine as your first clerkship back. I had literally forgotten about the existence of statins during GS years. The 4 weeks of low stress medical exposure (MSTP student do not take the Family Medicine shelf exam) was a great time to identify and teach myself the bread and butter of patient care, e.g., hypertension and cholesterol control, common antibiotics and anticoagulants, general medical lab testing, reading X-rays, etc. I believe actively approaching your Family Medicine clerkship as protected time for clinical learning can enable one to hit the ground running early in hospital clerkships. (That, and at all costs avoid doing the Surgery clerkship before Internal Medicine).

Do not wait to get the help you need. On my first day at Severance Hospital, I needed to meet my attending at the medical school but had no idea where it was located. So I walked into the first hospital-looking building I saw and asked for an English speaker at reception. The next series of events is a testament of how incredibly helpful Korean people are. The receptionist ran and pulled a nurse who knew functional English from the back. Not knowing the location of the school herself, she instructed a nursing assistant to escort me to the International Health clinic in the adjacent main hospital building. One of the clinic translators then snatched my phone (because it contained the e-mail with location and time of my meeting), paged my attending, and organized a dispatch of no less than three women (including a Russian fluent in English) to walk me to my meeting place. We obtained further directions from various receptionists and doormen on this last leg of my trek. I got to my appointment (embarrassingly) 30 minutes early, forcing my attending to run from his morning rounds to meet me. People will surprise you when you ask for help.

Outside Severance Hospital
Outside Severance Hospital

Unfortunately, I did not follow this piece of advice until late in my MS-3 transition.  I share this personal story to emphasize the importance of this lesson. Since college I had always experienced a basal level of anxiety and would repeatedly have 20-minute conversations Marla (my wife) without registering a word because “my mind was elsewhere.” Furthermore, on car drives I would hit the steering wheel in bursts of frustration for no apparent reason. They happened so regularly we playfully named them “Tourrete’s” moments. “Stress and zoning out is a normal part of this career” I would tell myself. The problem was that, during my first three clerkship rotations, all this worsened and started to affect life outside of research and school. At Marla’s insistence, I sought advice from Dr. Robin Lorenz, who strongly suggested I visit the counseling services available for all medical staff and students at UAB. After hearing my symptoms and significant family history, the counseling staff advised me that, while experiencing stress is completely normal, the way I was experiencing it was abnormal and perhaps reflected an underlying Anxiety Disorder. I was referred to a neuropsychologist and subsequently a psychiatrist, and was instead diagnosed with ADHD. After marking all the yes boxes on the screening panels and reading more about the disorder, she once chuckled to me, “this makes too much sense to be wrong.” I started medications in the middle of my Medicine Clerkship, and the haze of uncontrollable intrusive thoughts lifted. As expected, I did not get markedly better grades than before, and people with who I interacted daily (including MSTP co-graduate and friends with who I worked at the time) did not appear to notice any changes. However, my overall well-being and home relationship considerably improved, and now Marla, who can easily tell when I forget to take my meds, makes sure I stay medically compliant.

Not everyone requires medical intervention. However, please remember that stress and anxiety is a normal part of our careers, and many seemingly normal medical house staff and medical students at UAB seek professional advice and support in order to continue functioning at healthy levels. Ask the nursing staff for the bathroom usually used by medical students. Talk to your mentor if you are experiencing trouble staying afloat with the new daily requirements. Please remind yourself, do not hesitate to ask for help.

Though the first days back to clinics can make MSTP students feel like a six foot two inch balding Latino in the middle of Korea, there are ways to ease the stress. The thoughts discussed above focus on making active efforts to plug oneself into the mainstream of MS-3. I observed that MSTP students too often choose an isolationist approach and tend to limit meaningful non-MSTP interactions to only people directly encountered through work. This attitude may contribute to the mixed reception we come to expect from house staff and other medical students. Because of this reception many of us choose to not introduce ourselves as MSTP to avoid “being different.” Do you see a vicious cycle forming? I firmly believe that a key to an easy-as-possible transition back to clinic is active and timely integration.

I do not claim that these suggestions are silver bullets, or that these steps are appropriate for everyone in every situation. Furthermore, it has been my experience that the transition is only the first step, and that in order to excel during clerkships (e.g., get strong letters, get “honors” designations, and more importantly, become good physicians) MSTP students must appropriately stand out in ways permitted by our unique training. MSTP student experiences vary, and comparing viewpoints through collegiate conversation about these issues should help others navigate these very important MS-3 and MS-4 challenges. To this end, I will start regularly sharing more of my experiences as part of the MSTP blog and invite everyone to read and contribute to these topics. Also, readers should consider attending upcoming “Topics in Transition” meetings sponsored by APSA, where students from all years in the program meet to discuss the topics in person. Lastly, I also plan to blog about my experiences in Korea and on how others can participate in this valuable exchange opportunity.

Taken from Severance Hospital overlooking Muak Hill and the rest of the Yonsei University Campus – the dorm where I stayed is 2/3 the way up the hill
Taken from Severance Hospital overlooking Muak Hill and the rest of the Yonsei University Campus – the dorm where I stayed is 2/3 the way up the hill

I end with one more personal story. Six weeks into my surgery clerkship I was dumb enough to read the section of “Surgery Recall” describing the “ideal medical student.” As I perused this inane list of requisites, I started to freak out because I am so different from the “bladder of steel, never saying no to procedures, 40 minutes early and staying until your residents leave” person that the section describes! After having an arguably successful clerkship tenure (i.e., receiving clinical honors in all but Surgery and Psychiatry) while not adhering to the those guidelines, I now firmly believe this principle: being a “model medical student” and getting the best grades does not make you a good physician; however, be a professional student physician, take interest in your patients, learn from them, and be a good team worker, and I promise you the reputation as a model medical student and good grades will come to you. If I had really believed this from the beginning, I would have been spared a lot of stress.

– Juan Calix, (PhD) MSTP-8

Juan Calix obtained Ph.D. in Microbiology in August, 2012. For his residency and fellowship, he plans to join a physician scientist track program and sub-specializing in Infectious Diseases. At the time this article was written, he was participating in an international medial rotation in adult infectious disease at Yonsei University Medical College in Seoul, Republic of Korea. He always welcomes direct contact and hate mail concerning his views.

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