ms4 • med school chief • chicago usa
humanist • black / filipino • ucla '15
Preface & About Me
Some Things Soul Meaningful
Spilled Ink
To Be an M.D.
I. Shading a Dream: Ink Trails of an Undergrad
II. Hatchling Healer: Ink Trails of a Med Student
I’m flying back to Chicago today to pack my stuff up for my permanent move to California. This obviously requires me to brave the airlines.
I hesitated to wear an N95 into LAX, it being a non-clinical area, but after five minutes I am extremely glad I did. I’ve seen nothing but absolute foolishness here. No masks, masks half off, masks on and off and on every ten seconds. N95s half off. N95s off to whisper to a companion. N95s hanging loose around necks!
Forget even a sip of water — I will not so much as scratch my chin until I’m in my shower back in Chi. Craziness, I tell you.
covid chronicle: an MS4′s musings on present & future
ii. what is
With the doors of our medical school building literally locked at the start of April, I decided to retreat back to LA. Retreat is the deliberate word of choice; by the end of March, I was completely burnt out.
In one month, we went from planning Match Week celebrations to cancelling Match Week celebrations, then planning a virtual Match Day. We had all hands on deck to help students process the utter avalanche of curricular changes. Nobody could keep up. Any plan had a lifetime of about 48 hours before a new one had to take its place. I was spent, and buried my growing despair for the purpose of fulfilling what needed to get done. It was the perfect recipe for self-disaster, and I knew it.
I’ve now been home for nearly a month, wrapped comfortably in introversion. There are so many favorite pieces of myself that I’ve picked up again, and hopefully not only temporarily. I learned more Filipino dishes from Mom, started running these beautiful hills again, picked back up Robert Jordan’s massive Wheel of Time. I’ve bonded with my niece while my brother serves on the frontline. As you can see, I’m also back to writing.
I front-loaded my MS4 year with the knowledge that these last months before residency would be precious. They indeed are, much more than I would have ever imagined. With them, I've taken the opportunity to refortify and recondition. The Class of 2020 will be the reinforcements – some already are – in this fight, unseasoned as we are. It is a truly historical privilege, one that I’m sure a very wrinkly future Dr. Ty will mention not infrequently as an elderly attending on the teaching wards. Minted by the pandemic. I am tremendously excited to present for duty wearing the colors of an amazing program, alongside stalwart colleagues. Yet I also recognize these precious weeks for what they are: the calm before the storm. And the storm is coming. California has done an exceptional job in flattening the curve, but this measure is only temporizing. The wave that forms this very curve is, by definition, inevitable... and impending.
Thus, I rest and wait, steeling myself for the trials to come. What does the canvas hold in store? I know not, but the lines are starting to form, and new shades await.
covid chronicle: an MS4′s musings on past, present & future
i. what was
I once on this blog referred to 2015 and 2016, the years I graduated from UCLA and applied to medical school, as “championship years.” Years during which an immense, nearly half-decade grind involving a lot of sweat and sacrifice finally reached fruition. Toil, a trophy, followed by a dear celebration. All dynasties, however, are eventually followed by an extended period of rebuilding – patiently pushing yourself to put the pieces back together, rediscover success, and ultimately reach new heights. For me, medical school was my rebuild.
I shared the ensuing struggles with you all somewhat – imposter syndrome, stereotype threat, and the hard realizations of a first-generation student in a fairly prestigious graduate program – but also spoke to the moments where I could feel myself rising again like a tidal wave. You know when you’re a contender, and by 2019 I again recognized the blueprint: toil, a trophy, followed by some dearly earned celebration.
I wrapped up ERAS, Step 2, and interviews. I tried to make the most of the wonderful opportunities I had as Chief, cultivating dozens of amazing relationships with students and faculty alike, and even going so far as pouring hundreds of hours into designing a leadership elective for our first-years with Dr. V, to take place during Spring Quarter. It was my first formal foray into curriculum design, approved by our Curriculum Steering Committee – an amazing privilege to have as a medical student. I deployed a survey, wrote the needs assessment, formed the foundation for a publication, and recruited the necessary faculty – as a student. I felt immensely proud and fulfilled in the place I had come to love so much.
This year’s championship was March 20 – Match Day – and the trophy won was extremely precious. I matched at my top-choice program in Internal Medicine, back in my dear state of California. The celebrations in line were indeed dear. Revisit weekend and Graduation. Dates with my love ranging from Coachella to Tokyo. Sweet weeks of bliss with my classmates. Most excitedly, I was ready to teach my course.
Alas, you know how this story is going. Trips were cancelled, Revisit and Graduation were mutilated. I handled that, although sullenly. When I found out my elective was cancelled for Spring, I cried. I pour my heart into everything I’m passionate about, and this class was the epitome of this nature.
Yet when I realized that dozens of dear friends and mentors will not receive the goodbyes, hugs, gratitude and time we all deserve, I broke. My very way of life as a member of my scholastic community has come to an abrupt and premature end. There are many – too many – people I care about that I may never truly lay eyes on again, or at least for a very long time. I have grieved, and in many ways, am still quite broken.
There is one, and only one, silver lining to this, which I shared with Dr. V: this experience has proven without a doubt that I love academia. Watching the institution I love so much come to a screeching halt, its members dispersed with the wind, has wrenched me. Regardless of the the communities I share my future years with, I want never to experience this again. The fabric of human connection, warming us only a finite lifetime, is much too precious to see torn. I wish nothing more than to be enveloped in it again.
a decade in review: fragile foundations (2010-2011)
down from the door where it began
~
There is both inspiration and fragility in every foundation. Of myself, this is true... so what exactly is my foundation?
Ty of 2010 was a dreamer... an utter dreamer, a daydreamer, a never-doer-but-always-dreamer-dreamer.
Things I loved: fantasy, romance.
Things I hated: high school, sometimes reality, sometimes myself.
Ty of 2010 was extraordinarily awkward and shy, with limited social skills and fairly low self-esteem. Ty-ten had a fair amount of difficulty addressing interest and attention from others, because he was simply not used to it. Ty-ten’s main strength didn’t even come from within, but came from the few friends and the special girl who decided to love him (by the way, whenever this girl tells me that she doesn’t know why I love her so much, I laugh... she decided to love 2010-me back! what!? unbelievable. I’m hers forever.)
You see, these friends nurtured me and made me feel wanted, even if I didn’t always feel that I deserved it – even if I didn’t have the most invigorating personality, even though I was quiet and frankly quite nerdy. Writing this ten years later, I now realize... I always thought I first learned the power of relationships at UCLA, but I actually learned it here, at the wonderfully shitty NDHS, from a few special people I still love today. Reflection is worth it.
I lied a little – there is strength to being a dreamer. It’s the strength of not recognizing limitations, because of the vast amount of time you spend in the realms of the boundless. Walking onto those Rolling Hills of Westwood in 2011, I carried that strength. I carried it when I failed my first two gen-chem quizzes, locked myself in Powell Library for two weeks, and set the high on the following midterm. I carried it when I defeated imposter syndrome without knowing what imposter syndrome was. I carried it when I realized that the particular dream of being the first doctor in my entire family could, just maybe, just possibly, actually become a reality. I carried it, and very very slowly, beneath the dreamer, grew another: the believer.
work: Put a pause on everything to prepare for and knock out Step 2 CS! This is the practical component for medical boards, where you examine and diagnose 12 standardized patients portrayed by actors & actresses in a role-play style exam. I’m officially 3/4 done with medical boards, and likely won’t have to even think about Step 3 for another 1.5 years or so!
life: Caught up with another friend from undergrad! LA is a little too distracting, hence my relative lack of progress during the challenge (*sigh*) and which is why I’m pretty glad I left for medical school.
clinical: There have been some hefty cases in the last week. Crohn’s disease in a young adult who, for years, elected for alternative therapy in lieu of standard treatment, and unfortunately developed amyloidosis, a devastating consequence of autoimmune disease often resulting a short mean life expectancy. NB: There are times when alternative medicine has a role in disease management, but never in place of scientifically proven, clinically effective treatments. Yes, big pharma has become increasingly exploitative and abusive of providers’ good will in recommending the best treatments possible (and there are definitely bad egg physicians who prioritize their self-interest as well), but it always hurts to see patients suffer from an utter lack of trust in therapies that work. please help us help you :(
Why do medical schools do the white coat ceremony for new students? Wouldn't it make more sense to do it at the end for graduating students since they'd be MD/DOs?
Hi anon!
You ask an interesting question that led me to look into the history of the white coat ceremony, which I actually knew very little about!
-Apparently this is a relatively new fangled ceremony which started only in the 1990s
-No longer just for MD or DO students, this ceremony has been extended to other healthcare professions as well like pharmacy
You ask if it would make more sense to do it at the end. Based on what I am understanding from the original intention of the ceremony, it sounds like it would not. Arnold P Gold, the neurologist who originally came up with the idea, appears to have wanted to use this ceremony to highlight the start of the students’ journey in the medical profession by ceremonially giving out a medical student’s short white coat; to remind them of the responsibility and privilege of their positions as medical students about to undergo rigorous training.
Of course, we could then suggest various ‘start points’ of one’s medical career. One might argue that the start of the medical profession is when one interacts with patients; however, work with patients now also starts in the first year of medical school for many in US med schools. It could also be said that the start of one’s medical career begins with licensure; however, that would not occur for most physicians until after their intern year and by then you’re probably taking on more and more clinical duties during your third and fourth year as a medical student and feeling more and more likely a practicing physician of some type.
That all said, it depends on where one logically feels a medical career starts, to give the short medical student white coat. And I think most people do still feel that the start of medical school marks a huge life event. I would agree with Dr. Gold’s belief that your life changes dramatically with the start of medical school in a way that should be acknowledged. But hey, this is a relatively young ceremony. And it’s just a gesture. If it makes no sense to you, it’s cool.
Good question, I had fun learning more about this ceremony, thank you!
Techinically, administrators at the university of chicago med started handing out white coats to students as an effort to build professionalism in medical school.
Then, Dr Gold from Columbia Med heard through a conference and happened to have money to start the official white coat ceremony. His ceremony started stating the oath at the beginning rather than the end of medical school.
work: Updated CV. Finalized my list of residency programs to apply to on ERAS. Planned to advocate for certain curricular changes with my co-chiefs. Was awarded an amazing opportunity this year by the American Medical Association (AMA)! In the midst of all this, did not do as much reading as I should have though, sigh...
life: Bought plane tickets to Japan, on the cheap! Caught up with a good friend from UCLA.
clinical: Lovely patients with bad disease. How one stays an oncologist without becoming jaded in an instant, I’m not sure.
work: Reading on physiology of stress. Delved into the ERAS residency application. Secured a chiefs’ office with my co’s... yes, we have our own office that we’ll be sharing with a faculty member for parts of the year – but it’s mostly ours! Literally leaving a tangible legacy already :)
life: Playing with my munchkin. She has gotten used to me being around, and “ah-koo” (uncle) is probably her fourth most-used word, after mama, dada, and “uh-oh!” Also... got approved for the bougie chase card!!! Now time to plan Japan!
clinical: HLH. Lymphoma, lymphoma, lymphoma. Apparently my home institution is very well-regarded in the heme/onc world? Every attending I’ve met here comments on our faculty.
research & curriculum: Pulled more papers on weathering & allosteric load... now I have to read them lol.
life: Best part of being back home is getting to see this girl every day. Also, I’m getting fat from being fed at noon conference every day (a very nice thing for a program to do for its own medical students, nonetheless visiting students) and dinner every night... usually with dessert... because that’s how my family is.
Goals:
Read additional lit on weathering and allostatic load
clinical: One exceptionally sad case today. Lung adenocarcinoma in a middle aged adult with no smoking history, presenting with dyspnea and hoarseness from laryngeal nerve invasion – classic board correlates, but depressing to see in real life.
research & curriculum: Dug a little into cited papers from the article on weathering/allosteric load. Designated official lecture topics for the academic medicine elective; it will end up being a 9-10 week course with one lecture a week!
life: Tacos, tortas... also, almost got kidnapped by a pair of overeager Scientologists today. “Want to take a personality test? Just walk with us a couple blocks.” Lol, welcome to LA.
Much like last time, I’ll try to strike a balance between clinical, research, and life updates!
clinical: First day at Kaiser! I’m here as part of a scholarship program I applied to back in second year, working on the heme/onc service. Already seeing so many things (e.g. essential thrombocythemia) I’ve read about the last two years, but have never encountered in reality! I love going to work in the morning knowing I’m back in my beloved California, long commute or no. I think I’m ready to come back for residency :]
research & curriculum: Goals for this week are to do lit review on the John Henryism, weathering, and allostatic load theories on how stress interfaces with health. Also drawing up a needs assessment survey for the academic elective.
life: I’m staying with my brother and sister-in-law for the month. My niece, who is about 1.5 years old, has started consistently calling me “uncle” and runs to play with me!!! She used to have stranger anxiety around me – now she’s comfortable with me being around, and it’s the absolute best :)
Not too much substance for the first day but I’m about to fall asleep – will begin work in earnest tomorrow!
Not necessarily a thesis, but I have two main projects I’m working on this month. One is a paper on the coping mechanisms patients in violence-ridden neighborhoods use to cope with community violence – this is from a project I started back in first year. The second is designing a curriculum for a new first-year elective at our school centered on leadership & demystifying academic medicine (i.e. explaining the hiring & promotion process for academic faculty, tenure, training grants, the importance of mentorship & negotiating, career paths available at a major academic medical center, etc.) This is an area not many medical students get exposure to, and I’m excited to work to put this on the table for our incoming first years.
what has been your experience with graduate school/university thus far:
I love my program and I’m honored to serve as one of three Chiefs (like chief residents, but for medical school!) My school is rather unique in possessing both a genuine endeavor for excellence in supporting minority populations and a warm, close-knit community that continuously fosters camaraderie and mentorship amongst its members. I’m thankful everyday that I’m here!
is this your first #gradblrchallenge: Nope!
what do you hope to accomplish with this challenge: If I can make significant headway in the two aforementioned projects this month, I’ll be really happy!
where do you see you self in five years: In fellowship back in California, either in pulm/crit or in hospital medicine!
meaning behind your url:
“Every day I try to find color in this magnificent world. I strive to shade this dream of mine in brilliant hues of wonder and fulfillment. With the years come more tints – tints of people, tints of relationships, tints of love. I live to shade this dream, a dream to offer shade to the dreams of others…” -me, circa 201X
a random fact about you:
I have a huge sweet tooth, an unwelcome (but very much earned) beer belly, and a new Nikon D5200
Hello all! After many delays, I come to you with a new edition of the #gradblrchallenge! Like the original August 2016 challenge, this particular round will focus on creating a support and accountability network for graduate students who run gradblrs.
As before, the general plan for this challenge is not immensely structured. I understand that we all have different needs. Once more, the point is simply to connect with fellow graduate students!
THE GOAL: For most of the month of August, all participants will be asked to commit to at least 3 blog posts a week, detailing their work (assignments, research projects, readings and so on). Moreover, to keep up with the spirit of community, each participant will (try to) comment/reblog or engage in some way with the weekly posts of at least 3 other participants. (For more detailed rules on the structure of the challenge, see this page regularly as it may be updated before the start of the challenge. For more information on the gradblrchallenge itself, see the F.A.Q. page.)
The challenge should start on Monday, August 5th and conclude on Friday, August 30th 2019.
**If you own a gradblr and want to register for the challenge, simply state your interest here. In your request, please include your name (or nickname) with your area of study. (All messages will be kept private.) The last day to register for the challenge is July 31st, 2019!
Sometimes when I’m in surgery, I just don’t know how I’m supposed to learn. I feel silly asking questions like, “where’s this?” or “where’s that?”, especially now that I’ve seen the inside of the abdominal cavity dozens of times and can usually orient myself. Still, even if I’ve looked up the procedure beforehand, I don’t really know how to ask “smart” questions. I hate the advice to just ask questions - I have no idea what to ask! I don’t know enough about surgery to ask intelligent questions about the methods they are using or why they chose to do something one way or another. Everything I can come up with to ask is easily found on google and stuff I should probably have looked up before the surgery anyway.
So what do I do, medblr? I want to show that I’m interested and engaged, and I also want to learn something, but so many attendings don’t offer any teaching unless I ask questions.
And I know I’m being a whiny brat but after 2 months in the OR I really just don’t want to only be observing anymore…
IMO if you’re always thinking about risks, potential complications, and patients’ post-surgery functionality and quality of life, you’ll never be too far away from a good question. If they’re clamping a vessel, how long till you have to worry about ischemia? Is there collateral? If they’re resecting small bowel, are they taking out enough to potentially cause malabsorption/short gut syndrome? If they’re working around a particular major nerve, what’s the risk of post-op neuropathy for that patient? For any surgical patient: what will their post-op follow-up look like?
These are examples I’m throwing off the top of my head but you’ll get the gist. Surgery is a lot about risk reduction – asking these questions will show that you’re interested in the actual implications of the procedure, not just the technical aspects (which is what you’ve likely already read about)!
MS4′s notes on the Oral Presentation – what isn’t taught
NB: If you can demonstrate to your new attending on Day 1 that you can deliver a concise and thorough oral presentation, regardless of the strength of your A&P, you have already earned a High Pass (or at least, you should, given the RIME model of medical student evaluation, but more on that later). Instead of spending chunks of the rotation working on your presentation skills, you can concentrate on managing your patients – that is the most enjoyable and truly rewarding part of third year!
~
So how do you deliver a concise and thorough presentation?
I assume knowledge of the proper presentation structure already. Here’s what isn’t always realized: a good presentation, for medstud purposes, doesn’t actually require possession of a large fund of knowledge. The most important components – and this is not stressed enough – are the soft skills that go into being an excellent communicator: organization, confidence, diction, perception and insight (the last is where clinical acumen really comes into play).
Organization and confidence: these go hand-and-hand, for the more organized you are, the more confident you’re going to be – not stuttering over your words, or having awkward multi-second pauses because you get lost in your presentation. Flow from one section to the next smoothly. Don’t repeat yourself. A great way to achieve fluency in your presentation is to make use of excellent scut sheets – or better yet, to not have scut sheets at all, but to have notes printed before rounds, even if they’re not 100% complete. Printing autopopulated labs and vitals on Epic is 10x faster than having to write them down by hand, every morning, for every patient. Plus, the EMR note should already be organized in the correct format for oral presentation – making it near impossible to get lost. That said, try not to spend 100% of your presentation reading off your notes; making eye contact and acknowledging each member of the team will keep people engaged with what you’re saying.
Diction: This requires some use of medical knowledge. Be succinct, not wordy, by using the appropriate medical terms in the appropriate contexts. Ex: “the patient started having chest pain that was associated with their breathing, and their oxygen saturation decreased from 98 to, uh, 92,” vs. “the patient developed pleuritic chest pain and de-satted from 98 to 92.” Convey the same information more precisely and in half the words. This is not the easiest skill to develop, but it’ll help if you…
Perception: ...watch what your residents do and say! This is so valuable. Their presentations are not as thorough as yours should be, so what they do say is extremely important. How do they organize their HPIs, subjectives and objectives? What aspects of the patient are they prioritizing? How does the attending react? Paying attention to these nuances in the context of patients’ illnesses will make you a better presenter and clinician, period.
Insight: So the aforementioned hypothetical patient developed pleuritic chest pain associated with an O2 desat. Pretend your attending is hearing this for the first time; that’s all the detail he/she needs to know to be highly concerned about the possibility of pulmonary embolism. They will then be paying attention to whether you are concerned about PE and if you assessed the patient’s history and physical with that must-rule-out diagnosis in mind. Is there anything in the patient’s history indicative of Virchow’s triad? Cancer? Immobilization or recent travel? How’s their cardiopulmonary exam? Is there any sign of DVT? Did you assess the components of Well’s criteria? You don’t even need to mention the words “pulmonary embolism” during your subjective & objective – just by stating the pertinent positives and negatives, your team will know that you were actively pursuing that possibility. Even if your plan is crud, by focusing a thorough examination towards a reasonable diagnosis and communicating the results, you have positively impacted the care of that patient. This is the skill that will take you time to develop through your reading and studying, and you’ll get there.
Let’s say you worked to incorporate these fundamentals; how do you know how you’re actually doing? Ask for feedback. This is an awkward habit to build at first, but it’s by far the best way to convey to your attending that you’re genuinely dedicated to improvement. It forces them to assess both your strengths and weaknesses, and allows you time to build upon them, as long as you incorporate that feedback (they will be be paying attention to whether you do, I promise!)
IMO, soft skills and the overall art of communication are highly important yet massively overlooked components of the everyday practice of medicine. I hope this primer is helpful in building habits that make a difference!
The hospital is literally the only place on campus you’ll find coffee on a summer Sunday. The lobby Starbucks is closed, too, so if you want dat caffeine you gotta go deep in.
Cue the CK-dazed MS4, dressed in street clothes, tip-toeing my way up to the 7th floor, slithering into the staff lounge, frantically hoping I don’t run into anyone I know and having to explain myself.
That moment when you read about a national drug shortage and think, “that’s our bad, guys, sorry. We’re doing our best to nudge our providers away from the current ordering trend, sorry.”
I find drug shortages to be one of the more fascinating situations to encounter in a hospital – mostly in terms of how providers react.
“Sorry team, we’re actually on a shortage of IV amiodarone right now...”
“So... can I order IV amiodarone???”
Lol. It really delineates between the docs who are willing to acquiesce to inconvenient circumstances vs. those who just really want what they want, and nothing else.
