At the threshold

Within days, I begin my third year of medical school. The start of third year marks a shift from the classroom to the hospital wards: I will be responsible for a panel of patients, arriving at their diagnoses and ordering treatments. Of course, I'll be closely supervised and constantly instructed.

I'm a bit uneasy, though, about the transition to third year:

• The grades matter. Our school grades us either fail, pass, or honors on our rotations, although virtually no one fails. Usually no more than a fifth of students doing a rotation will net honors. But you need honors to get into a competitive residency. This means that I will be competing directly against my classmates. Much of our grades is based on our evaluations by our superiors. These evaluations can sometimes be subjective and variable.


• The hours can be long. Students' clinical duties sometimes approach the school's 80-hours-a-week cap. In addition, we will need to devote extensive time to studying for our mandatory exams. There are only 168 hours in a week. If one works for 80 hours a week and sleeps for 8 hours a night, 7 days a week, that leaves only 32 hours for things like studying, driving to and from the hospital, cooking meals, doing laundry, and brushing one's teeth.


• The responsibilities can be emotionally draining. I have yet to witness a birth or a death, but certainly will during third year. Comforting the dying and appeasing the furious are taxing ordeals, especially when there's so little time to relax. Medicine routinely involves life-and-death decisions, and mistakes that harm patients inevitably occur.


• Medical students are at the bottom of the food chain. Although the practices are becoming less common, students are routinely quizzed on their medical knowledge ("pimped") in front of their team and put on mindless or unpleasant tasks ("scutwork"). Because medical students need good evaluations from their superiors, they have little recourse and little incentive to argue.

Although the older medical students I talk to confirm my picture of life as a third-year, most say that enjoyed their third year of medical school more than first year or second year. In particular, they loved that they were finally taking care of real patients.

I hope that by the end of third year I'll have adopted their view.

Halfway

Three of us were walking in the mall when we noticed a woman lying in a heap on the floor of a shop, pressed up against the window. A concerned employee stood over her. I told my companions that I ought to help, and rushed inside.

"I'm a medical student," I said, to the employee's apparent relief. She told me that the woman had been seizing and pointed out that her face was bloody. She added that paramedics were en route. I thanked the employee and asked her if she could kindly get some gloves. Then I knelt down next to the victim, who was still writhing but no longer seizing. She appeared to be breathing but unconscious. I said aloud, "I'm [Reflex Hammer], and I'm a medical student. You're all right. You're in a shopping mall. I'm going to check your pulse now."

Just when I first detected her pulse, the paramedics arrived. I quickly exited the shop so that the professionals could do their job. I rejoined my group and we continued walking.

_____

Not even 24 hours later, I was on a flight where there came an anxious request overhead for "any medical personnel: doctors, nurses, EMTs, anybody" to please hit their call button. I was the only passenger to oblige. A flight attendant rushed over and asked me to come to front of the plane. I was in the window seat, and the passenger in the aisle seat was asleep. The flight attendant woke him and hurried him out of his seat so I could get through. I grabbed a pen and paper from my bag and headed down the aisle. Although anonymous before, I realized that nearly every person on the plane was now looking at me expectantly.

At the front of the plane was a woman lying on the ground in a panic, a discarded oxygen mask lying on her stomach and a man crouched over her helping her. A different flight attendant sneered, "What are you?" 

"A third-year medical student," I replied. She sized me up head-to-toe, and then icily told me to return to my seat and that they'd find me if they needed me. As I walked back, I noticed that even more people than before were staring at me, their eyes searching me for some clue as to what had transpired. I put on my best poker face, hiding how upset I was at being immediately sent away after my help had been so urgently requested.

_____

I am almost exactly halfway towards being a physician. It is an odd, in-between state. Although I usually believe I'm able to help, people don't know whether to trust me to take care of them.

Boards

Today I sat for my Step 1 national boards exam. Every MD student in the country sits for this exam, and as such, residency programs tend to use it as a harsh initial screen to whittle down their applicant pool. Some specialties are considered to be out of reach if a student doesn't score at least a standard deviation above the national mean. Students who pass the test are not allowed to retake it, meaning that one's score is fixed for life. Those that fail typically cannot begin their third year of medical school until they have eked out a passing score.

The test is an 8-hour affair: 7 hour-long blocks of 46 multiple-choice questions, plus an hour for break. Each person's questions are culled at random from a large bank, leaving them at the mercy of the luck of the draw. Some major topics I studied in depth were never asked. And sometimes I received multiple questions about the same obscure medical topic (for example, I was asked five questions about conditions that cause women to have facial hair). I agonized over some questions because several of the answer choices seemed equally reasonable (or equally unreasonable).

A medical student friend warned me that I would emerge from the test feeling like I was hit by a truck. It's true. I still feel like I'm in a daze.

High-stakes standardized testing always struck me as a poor way to go about assessing learning, aptitude, and career potential. And I don't just say this because I'm sour grapes: I do well on standardized tests, even notching a perfect score on my college entrance exams. But these tests are an abomination, with multiple-choice answers that are starved of complexity. When a lot rides on one's standardized test score, it has a corrosive effect on learning and teaching. Learning becomes a game, at the expense of fostering curiosity and original thought. Many medical schools tailor their curricula to the boards exam, and make their course exams entirely multiple-choice to prepare students for the boards format. And so, what once was a means of assessing students' learning now dictates what we learn and how.

It frustrates me that my profession puts so much stock in this one lousy test, taken on a single day.

Arms race

From a July 2000 Reuters dispatch:

Being a successful floor trader at the Chicago Mercantile Exchange is all about standing out from a crowd of competitors in the chaos of the trading floor. All the stops are pulled out: giant-lettered ID tags, top-of-the-lungs shouting, bizarre gesticulations, neon-bright jackets you wouldn't dare wear on the street.

But the arms race now stops at footwear. The exchange said last week that, beginning tomorrow, shoes with soles thicker than two inches would be banned.

It's not women wearing spike heels or those flappy, strappy high-heeled sandals that the exchange most wants to deter: It is men in platform shoes. "I've seen them that big," one broker said, holding his thumb and index finger about 6 inches apart.

Why do traders want so much altitude? To see and be seen from the depths of the terraced trading pits [...]

But twisted ankles and foot injuries on the steps around the pits have been a growing problem that the exchange feels it must address, market participants said.

"They had a ruler out there the other day," another trader said. "I saw them measuring."

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I saw a few minutes of 500 Days of Summer, Zooey Deschanel's breakout film. For part of the film, she looks different because she is not slathered with her usual amount of make-up. Intrigued, I found a picture of her with no make-up and compared it to her more customary head-shot:

Although she is beautiful either way, her appearance has strikingly changed. It's commendable that Ms. Deschanel was comfortable sitting for a photo shoot with no makeup on. But it does concern me that the public is constantly bombarded with images of people with unnatural features, enhanced through makeup, surgery, or Photoshop. I steered clear of Seventeen and Cosmopolitan magazine in middle school and high school (I'm a guy after all), but now if I see a copy I'll thumb through it so I can see what adolescent patients are reading. What I see scares me. Their photo spreads give an unrealistic perception of beauty and of normalcy, and their articles fixate on the superficial, preying on readers' insecurities.

I fret about physicians' role in perpetuating this societal problem. Sometimes I see newspaper advertisements from plastic surgeons advertising cosmetic enhancement procedures. Some of the ads seem designed to make the reader feel insecure about how they currently look, with phrases like "haven't you ever wanted the perfect belly?" There are aesthetic fixes for things that weren't even aesthetic problems until recently. For example, rates of elective labiaplasty (surgical alteration of the female labia) have been going up. Is this really healing people?

By offering elective cosmetic procedures to patients, we are facilitating an arms race for beauty that echoes that in the Chicago Mercantile Exchange. It's an arms race that is unwinnable. But the race's casualties, those with eating disorders, surgical complications, and skin cancer, are largely hidden from view. That is, unless your profession involves caring for them.

What I see on the hospital wards is the opposite of what's on TV: I tend to see people when they are looking their worst. Because I'm becoming more accustomed to viewing the body in its more natural state, I am increasingly able to pick up on cosmetic enhancements, like eye shadow, make-up, and breast augmentation. And I am learning about the harms that come with trying to boost one's appearance: orthopedic damage from high heels, skin cancer from tanning, carcinogens in hair-smoothing products and nail polish. While it's one thing to be well-groomed, obsessing over one's looks just doesn't seem healthy.

We are supposed to treat patients as people, no matter what their appearance. I hope that doctors make their medical practices havens for their patients, for example, by keeping magazines like Vogue out of their waiting rooms, or by supporting efforts to eliminate Photoshopping from fashion magazines. We can be a force for making people feel more confident about their appearances.