It's well established in Medical Lore that the third year of medical school is the most taxing of the four. Over the past 4 months, I found myself doubting that assertion. Sure, the hours of third year are substantially longer and the clinical years require a more concerted effort to "bring it" every day, but I found myself having so much fun and time was passing so quickly that the days did not necessarily feel more "difficult."
Then I hit The Wall.
It hits your subtly. The fatigue from the chronic sleep deprivation becomes more pervasive. Your physiologic response to that third cup of coffee becomes less marked. The days drag on longer than you're used to. I was walking downtown the other morning, and unknowingly stepped in a pile of dog poop. I went the majority of my day ignorant to the fact that it was stuck to the bottom of my shoe until later in the day when I caught a firm whiff of it while charting at my station. Burn out is a lot like dog poop. It gets stuck to your shoe, lingers with you the whole day, and before your know it its stinking up your living room. When you finally smell it, its quite unpleasant.
So the days feel a lot more "difficult" lately. 
I know I'm burnt out, and just like the smell of dog poop, the sensation is quite unpleasant. Feeling tired all the time, feeling like you are just trying to survive your days, finding yourself feigning interest - it is not the ideal way one hopes to spend their days. And unlike the preclinical years, you are not afforded the luxury of being able to take a couple days or a weekend off to recharge your batteries. The alarm is going to go off at 5 AM tomorrow, rounds are going to start at 6:30, your first patient is going to show up in clinic at 8, your notes need to get done, you need to read up on your patients, you need to take that call night, whether you like it or not. That's the true challenge of third year and clinical medicine in general. Your patient's illnesses do not know nor care whether you are having a good day, a bad day; whether you're tired, or sick; whether you're rearing for a new day, or working for the weekend. Your responsibilities do not change with the color of your mood ring. Fatigue breeds complacency and apathy, both of which can be very dangerous, and the real difficulty in third year is learning how to suck it up and be at your best, even if you may not feel at your best.
Luckily, I have 2 1/2 weeks left on this rotation, then a week in the classroom and a 4 week block of research. The halfway point of third year. And a good time to wash off some dog poop.
One of the most overused cliches in medicine is the oft referenced: "When you hear hoofbeats, think horses, not zebras."
It's a valid reasoning in which to guide one's thought processes. After all, common things are common, uncommon things... aren't. But part of the responsibility of a physician also is to provide comfort and reassurance. It's our job to think "worst case scenario," to work up patients for those conditions, and provide reassurance when evidence is sufficient to quell our suspicions. Another common phrase in medicine is "until proven otherwise." Vaginal bleeding in a postmenopausal woman is cancer until proven otherwise. Acute onset of dyspnea or hypoxemia is a pulmonary embolism until proven otherwise. Severe epistaxis in an adolescent is a nasopharyngeal angiofibroma until proven otherwise. I recently had two patient who elucidated just how true this axiom can be.
A 62 year old woman presented with lateral chest pain of two weeks duration. On physical exam, her pain seemed very musculoskeletal in nature. Pain to palpation, pain on deep inspiration and with sneezing/cough, etc. The horse in this situation is a simple intercostal muscle strain. Regardless, we ordered a chest xray which showed ambiguous opacification of her right lower lung. It just didn't quite add up with the lack of any pulmonary symptoms. So, congresspersons and escalating health costs be damned, we decided we couldn't quite be comfortable with just writing things off, and sent the patient off with a referral for a CT scan and instructions for prn ibuprofen and heat. We saw her back today. The CT scan showed findings pathognomonic for lung cancer. Turns out, her pain was musculoskeletal in nature, as the cancer had begun to invade into her 8th rib. It had also spread to her spine. Zebra. Ironically, the patient returned to say that the heat and ibuprofen had really helped with the pain. If it wasn't for the CT, she would have been sent on her way with the belief that it was all just an intercostal muscle strain, while the cancer continued to grow in her chest.
A 22 year old woman presents with a painful unilateral cervical lymphadenopathy which had been present for 1 month. The horse in this situation is some form of infectious etiology: mononucleosis, cat-scratch fever, occasionally HIV (though this didn't jive with her history). She had been to several urgent care centers, and, going with horses instead of zebras, prescribed two antibiotic regimens, with no improvement of her symptoms. There was still a high likelihood her neck mass was viral in etiology, but we ordered a chest xray "just in case." It ended up showing an extensive mediastinal mass. One biopsy later, the diagnosis returned nodular sclerosing Hodgkin's. Zebra. Luckily, her prognosis is excellent and the delay in diagnosis likely will have no significant effect on her therapy. But it is never easy telling a previously healthy 22 year old that they have cancer, and there is a certain level of embarrassment that it took 5 visits to a physician to reach a diagnosis.
I think the most telling thing I've taken away from these experiences is how important the differential diagnosis remains in clinical practice. Most common symptoms can be attributed to the relatively benign conditions that afflict the gross majority of the general population. But it is important to always consider what else can be consistent with a clinical picture that is truly dangerous, as just because a condition is rare does not mean it cannot be affecting the patient sitting in front of you. Bacterial pharyngitis is common and fairly benign. A retropharyngeal abscess is not, and can often present identically. It is the responsibility of the clinician to use their clinical judgment and work up a patient to the point that they can confidently feel the patient is safe in the context of their illness.
After all, just one day, you may come across a zebra in downtown New York.
As a continuation on my previous thoughts on picking a medical specialty, I've once again channeled my Dear Abby and have a new column up over at Headmirror.com.
Check it out here: Why ENT? Choosing a specialty and what drew me to ENT (navigate to Medical Students -> Blizzog)
So I have to say, hindsight being 20/10, I ended up enjoying my psych rotation a lot more then I expected. I'll readily admit my preconceptions of patients with mental illness were too skewed by popular culture; I think I was expecting more of a Hannibal Lecter flavor. A "What are the voices in your head telling you Mr. Williams?" "TO KILL YOU!!!" sort of thing. But, fortunately, I found my interactions with patients to be generally pretty interesting and much more pleasant on the whole (exempting one interview with a drunk patient with narcissistic personality disorder). Especially gotta love the schizophrenic patients. Such a sad disease, but a rich source of some purely AWESOME conversations.
Anyways, like it happens time and time again during third year, just when you get comfortable in a rotation, 
the dean's office picks you up and plops you down in another unfamiliar location. For me, for the next 5 weeks, into a low income family practice clinic on the southeast side. It's been a tough adjustment coming from a rotation where I was afforded a great deal of autonomy and input into patient care, namely because the physician I'm working with has somehow come under the assumption I have the IQ of a sheet of dry wall. Cue one interaction I had today in clinic:
*MedZag, presenting patient to attending while in patient room (I know, awkward.)*
MedZag: Ms. Rogers is here today complaining of persistent worsening of allergies of the past 8 months. She states her main symptoms have been rhinorrhea, nasal stuffiness and sneezing, sore throat, and some intermittent wheezing. No sinus pain or pressure, no cough, no shortness of breath. She tried a trial of Claritin for 2 week...
Attending: So what brings you in today Ms. Rogers?
*Physician and patient proceed to start talking and cover all pertinent points I was about to distill in my presentation*
*Attending begins physical exam*
Attending: Now, if you see here MedZag, if you look up her nose you can see fluid.
*biting tongue*
Attending: You can also see swelling. This is very characteristic of allergies.
MedZag: Hmmm, yes, interesting. I also noticed that when I performed a physical exam (not so subtle hint). I had some ideas of an assessment and plan, would you like me to continue?
Attending: Oh no, that's ok. We'll just give her some Allegra.
This is going to be an interesting 5 weeks.
One of the unofficial purposes of the clinical rotations of medical school is to expose students to a wide variety of "styles" of doctoring by rotating beneath a wide breadth of physicians. At its core, medicine is a service industry, and there is much to be learned on how to navigate the landscape of illness besides basic science and "standard of care." One of the benefits of working with a variety of clinicians is the opportunity to steal small techniques or tricks to incorporate into your own future practice. I learned how to use the otoscope on children by pretending there's a bird in their ear, then asking to see the other ear because it flew across. I saw a brilliant and humbling example of how to break bad news when I had a patient die from a PE and sat it on the conference with the patient's parents. From discussing end of life care, to learning how to sternly (and compassionately) say to patients "sorry, I will not prescribe you vicodin," to motivational interviewing, to diagramming medical conditions in an understandable way on a piece of paper, I've been fortunate to have hoarded a small arsenal of personal experiences up to this point which aid in my clinical acumen.
Along the same lines, ever so often you come across an experience where the way a physician handles the situation makes you grimace on the inside. These are also valuable pieces of information to incorporate into your own clinical style, as who you are as a person is just as much who you aren't, as who you are (courtesy of the Department of Redundancy Department). I recently had such an experience today. So, without further ado, I will now impart upon you the latest addition of Things MedZag Will Not Do As A Doctor:
If you are interviewing a patient and are faced the opposite direction to update their active medications list on your EMR, and the patient begins to talk of their recently deceased spouse of 40 years and breaks downs in tears, PLEASE do not continue to chart with your back to the patient while they sob in your general direction. For the love of God, turn around and face the patient.
The medication list can wait. That is all.
Jumping through hoops is a familiar feeling for any medical student. After all, it's something we have been doing at every level of our education. High school had its own set of hoops, filling college applications with National Honor Society merits, projects, AP classes, and the ilk. When time came to apply to medical school, there was a whole new set of hoops to tackle. Dean's lists, president's lists, scholarships, shadowing experience, personal statements, activities lists. Many experience a sense of relief on the arrival of that medical school acceptance letter. A feeling that you're finally reached the upper echelon of your training and the jumping of hoops is finished.
But alas, medical school brings its own new set of hoops. 
Anatomy, physiology, pathology. Step 1 and Step 2. Networking, schmoozing, research, clerkship grades. Once again, I will be pounding my head against a keyboard attempting to coherently produce a personal statement within the coming months. With my decision buck up and shoot for an ENT residency, the theme of the past month has most definitely been one of hoop jumping. I've been (somewhat) frantically trying to throw things together for a research elective coming up in November/December. Working on trying to network and get some clinical and OR experience in the process. Basically filling up my free time afforded to me by psych with numerous small projects all to play the game. Who wants to be bored anyways?
I tell myself this is the last time, but know that's just a personal delusion. But hey, I hear hula hooping is a great core workout.
I know I'm burnt out, and just like the smell of dog poop, the sensation is quite unpleasant. Feeling tired all the time, feeling like you are just trying to survive your days, finding yourself feigning interest - it is not the ideal way one hopes to spend their days. And unlike the preclinical years, you are not afforded the luxury of being able to take a couple days or a weekend off to recharge your batteries. The alarm is going to go off at 5 AM tomorrow, rounds are going to start at 6:30, your first patient is going to show up in clinic at 8, your notes need to get done, you need to read up on your patients, you need to take that call night, whether you like it or not. That's the true challenge of third year and clinical medicine in general. Your patient's illnesses do not know nor care whether you are having a good day, a bad day; whether you're tired, or sick; whether you're rearing for a new day, or working for the weekend. Your responsibilities do not change with the color of your mood ring. Fatigue breeds complacency and apathy, both of which can be very dangerous, and the real difficulty in third year is learning how to suck it up and be at your best, even if you may not feel at your best.
