The Road to Residency

Tips to Prepare for USMLE Step 1 by Dr. Teoria Murray.

God has truly blessed me with strong, phenomenal, professional young women who are open to sharing their experiences and encouraging others in their journey. Today's post was written by Dr. Teoria Murray; may you find useful tips as you prepare for the USMLE Step 1 exam.

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Tackling the USMLE Step 1- One IMG’s Story

If you are a medical student or graduate anywhere in the world, chances are you have heard of the dreaded United States Medical Licensing Examination. This 3 step hurdle has been known to stir up fear, anxiety and frustration in the hearts of those with the goal of entering a US residency program. As a 2018 graduate of the University of the West Indies in The Bahamas, I was no exception to this rule. After completing medical school and then internship, I set my sights on the Goliath USMLE Step 1 and completed this task (mostly) unscathed. In this post I will share with you the insights I gained in the process so you can hopefully have an easier experience than I did. 

1.     Set clear, realistic goals

Medicine is vast with an estimate of over 120 specialties and subspecialties in the United States. What is the specialty of your dreams? Based on your research and experience thus far, what area do you think you could wake up and still enjoy practicing for decades to come? You may not have a clear frontrunner in mind and that’s okay. Maybe there are two or three that spark a light in you. Do not set a low bar for yourself because of the perceived disadvantage of being an international medical graduate. Look up the average IMG Step 1 score for your target specialty and aim above that. As you take practice tests, track your progress toward this goal. Work towards it. Pray about it. Hang it high in your mind as an achievable goal. 

Source: Charting Outcomes in the Match: International Medical Graduates, Characteristics of International Medical Graduates Who Matched to Their Preferred Specialty in the 2018 Main Residency Match. https://www.nrmp.org/wp-content/uploads/2018/06/Charting-Outcomes-in-the-Match-2018-IMGs.pdf

2.     Create a study schedule

Once you know your goal score, you also need to decide the amount of time you will dedicate to studying. Generally, it is recommended that IMGs spend at least 6-8 months studying for Step 1 for 6-8 hours a day on most days. When I made the decision to take Step 1, I realized that the long days of hospital-based medicine led to exhausted nights and I wouldn’t have the discipline or energy to study like I needed to. This led to the tough decision of taking 5 months away from work for dedicated study. If you can do this, that’s great! However, many persons can’t realistically afford to do so. In that case, study time will have to be structured around your work schedule and other responsibilities. Towards the end of the study period, set aside a dedicated study time for serious review. 

There are lots of study schedules out there than you can adapt to your personal needs and it may take some trial and error to find one that works for you. There are templates for 6 weeks, 3 months, 6 months, 12 months and everything in between. I settled on Cram Fighter’s 4 month schedule because of the time left before my exam at that point, but if I could do it again I would have chosen the 6 month option. You can have a look at some sample schedules here. 

 3.     Choose your resources wisely

The amount of information that’s available to us in the 21^st century can be both a blessing and a curse. On one hand, there’s so much useful information. On the other hand, there’s just SO MUCH useful information. How do you choose? The key isn’t how many resources you use but how well you utilize them. In this case, less really is more (especially since you will likely go through the material multiple times). For Step 1, the core resources are UWORLD, First Aid, and Pathoma (UFAP). To supplement these, I found Sketchy Microbiology and Pharmacology useful. Picmonic is also a good visual aid to cement these concepts. However, take consideration of your learning style as well. If you find yourself to be a more visual learner, you may use online learning systems like AMBOSS, Boards & Beyond or Lecturio to guide you through UFAP. The possibilities are endless, so the best advice I can give here is to CHOOSE EARLY. Then evaluate your decision and decide if changes need to be made but do this within the first weeks of study because changing tactics late in the process can be a costly mistake.

 

4.     Spend more time on weaker areas

Step 1 is divided into the major areas of Anatomy, Behavioral sciences, Biochemistry, Biostatistics and epidemiology, Immunology, Microbiology, Molecular and cell biology, Pathology, Pharmacology, and Physiology, with some genetics and nutrition sprinkled in. We all have those subjects that come easier to us. I would find myself almost enjoying studying behavioral sciences and pathology most days, but other areas of study seemed more painful than pulling teeth. (Biochemistry, I’m looking at you.) This is a discomfort you want to face head on. The subjects that you least enjoy studying and that you score lower on in practice tests are the ones that need your attention. Review them early and often.

5.     Practice, practice, practice

Get UWORLD early in your study period. You may be tempted to wait until you have seen all the information to start practicing exam questions. After all, that’s usually the way most of us did things up until now. You learn the information then practice exam questions when you almost feel ready. Step 1 is a whole different ball game. UWORLD is a useful tool with over 2000 questions and explanations. The questions are very close to those that will appear on the real thing so you want to give yourself time to get comfortable with the question format and the thinking that goes into answering them. The UWORLD subscription also comes with a simulated exam (UWSA) that is a bit shorter than the real thing but can give you a taste of what it will be like. 

You will also want to take NBME exams. These are the closest to the real deal you will see before exam day and tend to approximate your Step 1 score +/- 9 points. It is recommended that you take at least 3 or 4 of these prior to the actual exam as a concrete way of measuring how effective your studying is. If your NBME score 1 month from the big day is still a far cry from your goal, it may be a good idea to postpone your exam and give yourself more time to study.

6.     Take care of your health

As robotic as the rigors of USMLE prep can make you feel, you aren’t a machine. You will still need sunshine, fresh air, water, exercise, and some social interaction. In the era of COVID-19 this may take some creativity, but a healthy body, mind and soul will go a long way in boosting your productivity. Set fixed times for study and stick to them, without multitasking. Schedule study breaks and take them. Eat healthy foods that can fuel your brain whenever possible instead of junk food that can make your brain feel foggy. Don’t use caffeine as a substitute for sleep. This is a marathon not a sprint and you don’t want to burn out. Do things you love. Stay in touch with your loved ones. Read a book or watch a show that has nothing to do with medicine, even if only for 30 minutes every day. 

7.     Give yourself grace

Preparing for and passing the USMLE is taxing. Some days you won’t feel like studying. Study anyway. Some days you won’t meet all of your goals. You may score lower than you expected on a UWORLD question block. Your NBMEs may be less than stellar. You may doubt yourself, your abilities, your goals, your calling, and all the signs that led you to believe you were on the right path. Don’t beat yourself up. Take a deep breath. Stretch. Pray. Reach out to someone you know is always in your corner for a pep talk. Talk things through with other colleagues preparing for the exam or who have taken it recently. But whatever you do, don’t give up. You already know that you are capable of amazing things. God has brought you this far and it’s only up from here. So keep pushing and at the top of this mountain, when you realize it was all worth it, reach back and encourage those still climbing. 

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Dr. Murray is a recent graduate of the University of the West Indies, currently practicing medicine in The Bahamas. Feel free to post your comments below if you would like to hear more from here in reference to the USMLE Step 1 examination. 

Tonight I felt like a Doctor...

“Most doctors are prisoners of their education and shackled by their profession.” ― Richard Diaz

Monday August 8th, 2018. That is the date, when it happened. I walked into the Paediatric Emergency Department as an intern. No longer a medical student with limited responsibilities and an early dismissal time. That night, I found myself a prisoner of my education and surprisingly shackled by my new profession.

I realised that the mould I had decided within myself to break, was beginning to settle. My environment was doing its best to imprint its treasured norms not only into my mind but also my heart.

It was my encounter with a parent and her child that made me realise that I now wore loose shackles of medicine. Her tiny hand, warm smile and vivacious giggle despite her ill-appearance broke the trance that I unknowingly had fallen into.

Hopefully this post shares some tips on staying afloat in the fun world of the Paediatric Emergency Room while ensuring you're remaining true to yourself, your morals and values and your God-given purpose while taking initiative.

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Nick had been out of work for three weeks. He had known the downsize was coming, but he hadn't expected to be caught in it. What's wrong with me?  Nick thought. He rationalised that he needed to get his resume updated before he started looking for a new job, but he knew that was just an excuse. He just couldn't make himself get started. 

Each morning he'd vow anew to check out leads, make phone calls, and get in touch with agencies and headhunters, but first-there was always a "first"-he had to run by the church to help repair the roof, or he had to mow his yard, or he had to go by the gym to work out his sore muscles, or he had to sit down and figure out a new budget...

Nick knew he couldn't keep putting off his job hunt. "Help me, God," he prayed. He picked up his organiser and started making notes.

Everyone has something in his life that he seems to put off doing. It may be finishing a college degree, buying a house, or applying for a promotion. It may be something simple like painting the house, cleaning the garage, or balancing the check book. Ultimately, if some project never gets accomplished you have no one to blame except yourself. What a waste to look back and say, "If only I had..." Make yourself accountable to God to get yourself moving. -Renewing Faith 2017 Planner

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As the first point of patient care, working in the Emergency Department requires honesty, accountability, strong attention to detail and the ability to take initiative.

You will often be faced with persons and their egos which may lead to a delay in patient care and hence overall patient satisfaction and/or survival; do your best to maintain professional rapport, however you're not required to accept that type of behaviour as normal or adequate. 

These two weeks in the Paediatric Emergency Department has taught me: 

1. How to listen to patients (and their parents)

2. How to differentiate the battles that I can fight and those that would require referral to the "David" of the department and 

3. How to tame my shaky hands when unruly, frightened adolescents wiggle and continuously scream "doc, dat needle hurt!"long after the anaesthetic has been applied and taken effect and all sutures have been tied off, covered with topical antibiotic cream and secured with Bactigras paraffin gauge dressing and an IV 3000. 

THE DO's

1. Know your schedule.

By the end of this series of posts, I'm going to sound like a broken record, but I cannot say it enough. Know your schedule.

The rotation through our Accident and Emergency (A&E) Department is short and done in shifts. It is vital to know when you're expected to show up as some senior personal won't send you an email or any form of notification regarding which shift they have scheduled you for.

How it works here, is simple. For each specialty rotation there is one selected Consultant who is responsible for the interns/house officers. They are the persons everyone in the department goes to when they have an issue with the group or simply want to comment on how good the group is doing. That person is also responsible for the scheduling of the interns and organising our class and final examination.

As each section of the Paediatric department has their own expected work report times, the intern coordinator doesn't schedule you for a particular shift during a particular area of the rotation, that is done at the discretion of the persons in charge of that area.

For example, A&E has two shifts from Monday-Thursday, two shifts on Friday and one shift on Sunday and Saturday. Monday-Thursday you can be scheduled for the morning shift  or the evening; 8a.m.-4p.m. and  4 p.m.- 12 a.m respectively. On Friday the morning shift starts at 10 a.m. and ends at 6 p.m. with the night shift staying the same as Monday-Thursday. The weekend shift is from 8a.m.- 4 p.m.

Knowing your schedule allows you to mentally and physically prepare for your time in the department. It can also allow you to check (and see with whom you'll be paired with) if a printed schedule is available.

If you're switching from one area say on a Tuesday (which is how our switches happen every two weeks), use the Monday evening to find out where and when you're to show up. It helps with saving gas and allows you to make the most use of your time. Imagine, you've been scheduled to work on Tuesday night and you show up at 8a.m. thinking you're to work the morning shift. What a waste of sleep time and gas. Don't give anyone anything negative to say about you if you can avoid it. We all know there are lots of haters in the world.

2. Get Oriented

Maybe it's just me, but I like to know all the nitty gritty about any area I'm scheduled to be in for a certain period of time. It just makes the transition easier and affords me the opportunity to focus on  patient care without wasting time looking for things that I would need to perform my tasks during my shift. 

Since this part of the department is very different with its own set of needs and management, it is good to have a senior person give you the run down of how things work. 

As the intern in A&E, during the shift you're scheduled for, you're responsible for the following things: 

• Seeing the patients before being asked to,
• Present (Discuss) all patients to a senior person before initiating treatment,
• Manually log all persons seen for the shift in the patient log book (physically write each person's name and particulars along with the nature of their injury, the service provided and the disposition),
• Manually log all patients who had cultures done that are needing follow up in the culture book,
• Check the culture book before the end of the shift and update (transcribe their report) it. In the event a patient's results need to be acted upon i.e. Blood culture grew a bug, inform your senior and contact the patient so they can be treated if warranted. 
• Ensure the dry-erase board is updated at all times with the names of the patients who are currently being treated in the department or those who were admitted. This makes for a smooth handover and reduces mismanagement or a patient being overlooked from one shift to another. 

Also, in terms of being oriented, know where your supplies are kept. 

Our department has a cupboard that is usually locked at the end of the shift, that houses hard to come by supplies such as culture bottles, paediatric specimen tubes, aerochambers and other tools for educational purposes and even paediatric textbooks, computer mouse, diagnostic kits and working staplers. I sensed your eyes widening at the 'working staplers', trust me, it's hard sometimes to find a stapler. 

What I did at the beginning of the shift especially if I worked the night shift, was to stock up all of the trays and storage units on the floor with supplies such as sterile urine cups, IV catheters of various sizes, made splints for the night and stocked the cabinets, ensured we had specimen tubes for the basic laboratory investigations we ordered as well as ensured there was more than enough biohazard bags, gauze, heplocks etc. 

The last thing I wanted was to be unprepared in the event a trauma rolled in. I never got to experience a paediatric polytrauma, but following my shift one night, another Physician did and she was more than grateful to us for leaving the area stocked, clean and organised. 

3. Document! Document! DOCUMENT!

Practice proper documentation of everything! 

Some services are riddled with Senior House Officers with inflated egos who have a misguided sense of their duties. If you haven't encountered any as yet, prepare to meet one or two during your time in A&E. 

Get in the habit of documenting when you sent a page for a referral, when that page was answered, by whom and a synopsis of what was said. Document when they showed up and what was done and what was to be done in the future if they failed to document it. The last thing you want is for the next doctor following you to not know what was done or to be done for a particular patient. 

It's best to have some form of documentation (preferably in the patient's file) of the overall management in the event legal matters arise. 

If your hospital has certain policies regarding documentation, familiarise yourself with it. The one thing I wish our hospital was good at is providing Standard Operation Procedures for each department and the common scenarios encountered. Why? Because it would allow for standardised care and something to stand on if someone ever questioned why you did or did not do something. 

4. Do ask for feedback

As you move through the various areas, remember this is all another rung on the ladder of continuous learning. 

Speak to your seniors. Develop a professional relationship where constructive criticism can be given and where you are comfortable growing as a Physician. 

Ask them for advice for improving your histories in the department as A&E focuses more on the abbreviated history. Try to utilise your seniors for your success. These are the big kahuna's of the field, adopt their good practices and forget the rest. 

The Don't's

1. Don't Waste Time!

The main purpose of the A&E department, be it adult or paediatrics is to provide quality care, reduce turnaround time and to ensure overall patient satisfaction. 

Be efficient and try to get the patient in to be consulted, examined and treated in a timely manner and out if possible. 

2. Don't pick fights with Senior House Officers (who aren't aware of their roles or responsibilities)

This may be easier said than done but ensure you approach every Goliath cautiously especially if they are not in the same department as you. 

It is easier to report any issues, document the situation and its outcome and remain professional than to argue with someone whose main goal is to make life difficult for you. 

You will quickly recognise the culture of each specialty and each person based on their position in the hierarchy. 

3. DO NOT CONFORM

Do not be quick to settle. Three months in any place can start to feel normal. Be true to yourself and your morals and the overall purpose of you being there, which is to learn, advance in your career and to provide adequate and professional quality patient care. 

4.  DO NOT vent to everyone

Be wise with whom you confide in. There are lots of 'news toters' lurking around just waiting to start some confusion. 

If you can, start a journal and learn a new skill. Write down your experiences. Be cautious with how you vent on social media as well. 

You may not be aware, but most areas conduct evaluations of their staff, interns included; these evaluations at the end of your internship may work against you or for you. 

Be mindful that what you may mention to someone 'in confidence' may end up hindering your progress. 

5. DO NOT order unnecessary tests

Your patient is your answer book. In A&E, learn to be smart with your diagnosis and your differentials. 

Based on their vitals, the presenting complaint and the history of the presenting complaint you should be able to determine what tests you need to order to confirm your suspicions. 

It's up to you Sherlock to pay attention to the clues. 

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All in all, it's a great experience! 

In summary, be prepared and remember you're going to be faced with patients who you just don't know what's wrong or where to start. But remember, you're not alone. 

Be sure to: 

1. Create lists: they will help you stay on track
2. Keep busy: with purpose, but enjoy the downtime
3. Always be bold enough to ask for feedback and to speak up if you're uncertain why you're doing something or being asked to do something. 
4. Take the initiative but don't overstep your boundaries. 

Growth

"Thinking always ahead, thinking always of trying to do more, brings a state of mind
in which nothing is impossible."- Henry Ford

It's been two weeks since I've been employed as a Medical House Officer. I won't comment on whether they were tough or not, rather I've decided to share some tips for persons who will be rotating through any Paediatric Hospital Clinic, however some things may be more specific for my setting but nonetheless they may hold helpful to others elsewhere.

I recently read a devotional entitled 'Growth' which I would like to share before I delve into the tips, so bare with me a while.

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Derek and Jordan were neighbours who agreed to plant a small vegetable garden together. They would each help care for it and share the produce with their families. The friends looked forward to spending time together on the project, but neither realised how involved the task would become. 

It took time digging up the soil and breaking up the hard clods. Planting the seeds required precision. Some had to be deeper than others; some were planted side by side; others were planted eight inches apart; and still others were planted three inches apart. As the seeds sprouted, a portion of the plants required stakes to support them. Watering, weeding, fertilising and cultivating took a lot of time, but the guys kept their end goal in mind. 

Finally, they began to see the fruits of their labor-tomatoes, squash, beans, cucumbers and other vegetables. As they harvested their crops, Derek remarked, "Aren't you glad we don't do this for a living? It's fun, but it takes a lot of work."

The time and energy it takes to grow a vegetable garden can be compared to the effort it takes to "grow" your life. You must fill your life with healthy, nourishing influences. Be careful of what you read, what you listen to, whom you talk with, where you go, and whom you choose for friends. Living a fulfilling life requires planning ahead and maintaining your "soil" daily. The value of your life will be measured by the positive impact you have on yourself and others. 

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These two weeks were all about growth. Being able to work alongside other physicians more seasoned than myself and to communicate as a colleague has shown me that in life, we're all given the opportunity to grow. Some of us require more soil and sunlight than others, but that's alright, the goal is to continue to grow.

I started off with nine other colleagues in the Department of Paediatrics. This department has several areas each house officer is required to rotate through during the three month period on the rotation. These areas are: 

1. Community Clinics (of which there are 2)

2. Team 1 (which is a hospital based team consisting of 3 consultants with various specialties in addition to General Paediatrics)

3. Team 2 (same as above)

4. Accident and Emergency Paediatric Department

5. Maternity Nursery 

6. Hospital Clinics (all previously discharged patients and patients with particular needs are seen here)

Today's post will shed light on the intricacies of the Hospital Clinics and what you can expect on each particular day and ways to ensure clinics run smoothly and on time. 

INTERN TIPS

1. BE ON TIME

This pretty much goes without saying. First impressions are lasting impressions and if you're known to be punctual believe you me, everyone will notice. If you're new to the hospital clinic setting and what all it entails, arriving early affords you the opportunity to speak with the nurses in charge, the Senior House Officer or the Physician overseeing the runnings of the clinic so that you can be informed of the functions of each person on the team and how each clinic is run if there are multiple clinics on the same day.

Arriving early also gives you the opportunity to ask the patients whether or not they are attending clinic solely to get results for tests that were done at their last visit since in our setting depending on the result, you would have to walk to or call the laboratory to retrieve them. Once this is done you can attach them to their notes for the day which will expedite their visit.

When you're new to an area, it takes some time to get acquainted with where things are located and where they belong. Being on time or earlier than scheduled particularly on the first day allows you the opportunity to get a tour of where things are stored, where the bathroom is (staff vs. patient), where the supplies are kept because you'll always be in need of an alcohol swab, tongue depressor or gauze as well as those infamous continuation sheets for the patients notes, growth charts (because every child is plotted) and referral forms.

There are other documents that are dedicated to certain things that you will also need to know-headache diary for instance for patients who present with a history of headaches in whom you're trying to rule out migraines.

At our clinic, all of the necessary documents for the various clinics excluding Infectious Diseases clinics are stored in a brown accordion folder which is placed on the desk in each examination room at the start of the day and stored by the nursing staff at the end of the day along with a cylindrical desktop container that houses all of the tongue depressors, alcohol swabs and gauze you'll ever need.

2. INTRODUCE YOURSELF

With changes being made to the schedule in terms of who goes where each month or every other week, it is important that everyone is aware that you are new to the team or service and it also allows you to familiarise yourself with the persons with whom you will be working over the next few days, weeks or month. 

By introducing yourself to everyone, you'll also have the opportunity based on the ranking to know to whom you are to report and who can actually review your consults and ensure your plan is in keeping with protocol and in the best interest of the patient. 

3. KNOW YOUR ROLE

In the Paediatric hospital setting your role as the medical house officer is to frankly, be on time, see patients, don't get on the nurses or any other team members' nerve and to ensure that you complete everything necessary for your patient. 

At this stage in your medical career, the goal is to gain knowledge, improve certain skills and to ensure that your history taking, physical examination, and overall patient communication is improving and you're asking for help when needed. 

It is imperative that following the review with the consultant, you document everything that was discussed in their presence in the patient's note, you complete all necessary referral forms and fill out any prescriptions they may need and ensure they understand what was discussed BEFORE they leave. In our system, the medical clerk is responsible for making the follow-up appointments, but as the house officer, it is our duty to ensure we inform the patient and/or the clerk of when we're wanting them to return for their next appointment. 

4. KNOW YOUR SCHEDULE

Knowing your schedule allows you to keep track not only of where you're meant to be at a particular time of the day, but also when you have some free time to get other things done. 

If you're like me, a new house officer with some things to follow up in the Human Resources Department then knowing how much free time you may have ahead of time can help you take care of other matters. 

In regards to the hospital clinics, there's usually a clinic every day of the week excluding holidays or during MBBS examination time which is around May/June each year. Here's an idea of our hospital clinic schedule: 

On Monday mornings as you can see, there are three clinics running simultaneously, so on those days it really is a gamble as to which patient you will see. Team 2 patients basically are kids who were admitted on a call when Team 2 was 'on take' or designated to receive the patients on that call. Once they are discharged by the service, they are then scheduled to return to clinic (all at the discretion of the Team) for a follow-up to ensure they haven't had any problems since, or if they did have any medical issues, what they were and whether or not they would need to be readmitted or watched closely before being completely discharged from the clinic. 

The consultants on Team 2 are General Paediatricians with Paediatric subspecialties such as Paediatric Neurology, Endocrinology, and Asthma. 

Like previously mentioned, Monday mornings are a toss-up. The patients needing to be seen in Paediatric Chest Clinic (patients with PTB for example) or the Diabetic Clinic is dependent mainly on the week as these two clinics alternate on a weekly basis. So if this Monday was the week for the Chest clinic then the next week would be the week for the Diabetes clinic. Following the morning clinics which can sometimes run a little late (all depending on the patients needing to be seen and the complexities of their case) is asthma clinic.  

In the asthma clinic, the main goal is to ensure that each patient is controlled on their medications and whether or not they are in need of being stepped up or stepped down based on the severity of their symptoms and their overall diagnosis and assessment. The main questions you must be familiar with asking are mainly based on the symptoms: 

• When were they first diagnosed with asthma?
• How did they initially present when first diagnosed?
• How many hospital admissions or visits to Asthma Bay did they have since being diagnosed? What treatment did they receive?
• What medications are they on?
• Do they take the medications as prescribed? If no, why not? Were they on any medication for asthma before? What was the dose? Please demonstrate how they take their medication and when. Do they use an aero chamber? Do they have an asthma action plan? Do they use a peak flow meter?
• Since their last clinic appointment did they have any asthma attacks? Any nighttime awakenings because they had problems breathing? Any decrease in their activity or exercise levels due to asthma? How often do they have symptoms of asthma such as wheezing or chest tightness? 
• How many times in the year, or since their last clinic visit have they had to use their reliever? 
• How many days of school have they missed due to asthma?
• What are their triggers (change in weather, cold, flu, illness, smoke, dust, pollen, etc)? 

Tuesday mornings there is no Paediatric clinic scheduled. However, all Paediatric interns and Residents have a teaching session at 8:30 a.m. At 12:30 on Tuesday afternoons, there is an Intern presentation session scheduled, from which you are excused by 1:30 in the event the session is running longer than normal so that you can make it to the clinic in time to see patients for Sickle Cell Clinic. 

Be prepared to leave the clinic around 4:30 or 5:00 on a Tuesday. Since there is only one Sickle Cell Clinic per week and one Paediatric Haematologist in The Bahamas, this clinic is one of the well-attended clinics (which translates to sometimes 10+ patients). Punctuality to this clinic is essential mainly because there are so many patients to be seen and sometimes plenty of pathologies to be exposed to which means the teaching opportunities are endless. 

When seeing patients in the Sickle Cell clinic it is vital to ask the following questions: 

• Since their last clinic visit have they ever had the following: fever? chest pain? dyspnea? cough? 
• Age of diagnosis? 
• Last date of crisis? 
• The number of hospitalizations and the reason (acute chest vs. vaso-occlusive crisis)? treatment while in hospital
• Number of transfusions if any
• Steady-state
• Immunization history
• Current medications their on and whether or not it was changed at any point
• Any symptoms of anemia (fatigue, lethargy, pallor, etc)?
• Abdominal distension or pain recently or in the past? Any surgeries in the past?
• Dehydration status (water intake)
• History of jaundice
• Any exercise intolerance or cold intolerance or history of swollen joints? hands or feet?

When you're assessing them, be sure to look in their mouth and refer if needed to a dentist if you happen to see a number of dental caries or poor dentition. Also, be sure to review the tanner staging and comment on the Tanner stage. The consultant in our clinics loves to ask about the tanner staging as well as the surgical history and the conditions sicklers are prone to which would result in them needing to undergo surgery. 

Wednesday morning clinics are dedicated to Infectious Disease clinics. Be sure to speak to the Senior Registrar or the head nurse in charge of this clinic as this clinic runs differently compared to the others. They will be the ones to advise you on which patient they would prefer you see and how to go about conducting your consultation. This clinic runs fairly smoothly because the nurses are so efficient.  Once this clinic is done, be sure to get a bite to eat in between. Technically afternoon clinics are scheduled to begin at 12:00 p.m. however, the team may decide to work through a break so clinics can end a few minutes earlier. 

Neurology clinics can be long as well but they are filled with learning opportunities so be sure to make the most of your time there. Wednesday afternoons are usually for follow-up patients so reviewing their drug levels and reading EEGs to determine if medications are to be adjusted. Sometimes though, you may have one or two new patients who were referred to the Neurology clinic that is seen on a Wednesday afternoon as opposed to a Thursday. One main tip for the Neurology clinic in addition to a detailed CNS and MSK examination, be sure to complete a mini-mental status examination where needed. For example, if the patient has some developmental delays and during the exam appears to be cognitively impaired. It will help in your assessment when you're presenting to the consultant.

Thursday- all day- you'll be stationed in the Neurology clinic. Team, 1 clinic patients are usually seen by the senior house officers and more seasoned members of the Paediatrics department. The physicians in charge of the Neurology clinic will be the ones with whom you are to report and who will be responsible for dismissing you from the clinic. 

Friday's are usually interesting clinic days where you don't really know what to expect. The neonatology clinic sees patients who were admitted to the Neonatal Intensive Care Unit at the hospital and discharged. Some patients may be in the clinic for results of a karyotyping study that was done or just to know whether or not they will be discharged from the clinic altogether.  Fridays can be an early day depending on what needs to be done for a patient and how many patients the Consultant has to see. 

Although our schedule says Cardiology clinic and consults, since there is no Paediatric Cardiologist in the public setting of the hospital this clinic, unfortunately, doesn't exist. 

5. BE PREPARED

Nothing beats preparation. 

That said, prepare yourself each day for the worse. Pack your bag with snacks, water, lotion, hand sanitizers, extra gauze, alcohol swabs and don't forget your diagnostic kit (since clinics aren't furnished with them). By preparing yourself for anything you'll ensure that you aren't loosing anytime from your consultation with a patient because you're either looking for something or dying for a bite to eat. 

I forgot a few times to pack my bag the night before with snacks that I eat and had to wait until the clinic was over to get something. Let me tell you, the last thing I wanted to eat was peanuts. 

By knowing what clinic you're to attend the following day, you're able to read up on common topics so that you can take advantage of having a consultant present to discuss topics with and why certain things were suggested for a patient's management. 

6. BE WILLING TO LEARN AND TO TEACH

It's all up to you to make the most out of this year of internship. Although you've successfully completed all requirements of medical school and attained a degree in Medicine, it is important to remember that learning is lifelong. 

The clinic settings afford you the time and opportunity to learn. You are in a setting with persons at different levels in a particular specialty who are still learning themselves. Most times they're excited to discuss something with you and to guide your thinking. 

Once you've been taught, it's important to pass that knowledge on to the medical students who may be present in the clinic as well. Remember you were literally months ago a student, continue to be kind and willing to teach. After a while you'll realize you won't need to ask all the time the dosage of certain medications and why you're checking the levels of Tegretol in a month as oppose to a couple of weeks (remember autoinduction?) and you'll be now able to store new information. 

7. BE WILLING TO HELP

Regardless of your position on the medical totem pole, you always find that you're in a position to help. A colleague may be in with a difficult patient and in need of a radiological report but they're unable to move at the moment if you're free to, why not offer to run and retrieve it? 

What I've found over the last two weeks in clinics is that a little goes a long way, especially if persons were on call the night before and weren't able to get a night's rest. 

8. COMPLEMENT SOMEONE EVERY DAY

Compliments go a long way! 

From a simple "you look nice today" to "the way you handled that situation was impressive, you did a great job with that" can create an environment that is comfortable to work in and to grow in. Once people realize that you're teachable, genuinely nice and have great work ethics, your daily experiences -despite the unforeseen circumstances that may arise (i..e that close call with explosive diarrhea or having kids pee on your lap) will be so rewarding. They may even have a ripple effect that changes the culture. 

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My very good friend Dr. M was so kind as to send a video of his tips based on his two weeks in the Hospital in Scarborough Tobago. I've posted it below. 

If you're a new House Officer or an experienced one please share in the comments section your tips and tricks on how you survived your initial weeks of internship. 

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Quit Faking IT!

“All the world's a stage.” ― William Shakespeare, As You Like It

The elephant in the room needs to be addressed. The time has come to shed some light on what some may have heard throughout the first three years of medical school, and what others may be told when they begin their journey.

There is nothing greater to the person whose passion is medicine and whose desire it is to be at the service of others, than to be given the title of "Doctor."

Before I started my journey as a medical student, I never fully grasped what so many medical bloggers meant when they wrote "the easy part is getting into medical school, the hardest part is staying in." How dare they? I thought as I sat in my apartment on my night off, with my Pomeranian on my lap, working diligently to complete as many tasks on my medical school application 'to do' list. The most daunting being completion of my personal statement or the autobiography sketch as some schools may call it. At that point in time, trying to convince a committee of admissions directors to grant me acceptance, was far from easy. Studying for the Medical College Acceptance Test (MCAT) in and of itself while working full-time appeared an even greater challenge-not impossible, just challenging-and here I was reading that this was the easy part.

Makes you wonder whether or not those medical bloggers had a high threshold for challenges or if they were simply crazy. Now that I've completed most of my medical school training, I now understand what they meant and I'll admit they weren't exaggerating either.

As you sit probably with your rough draft of your personal statement either on your lap or rolled up and tossed on the floor, once you soar over this hurdle, you will be well on your way to gaining acceptance and entry into the medical society.

You see, with each passing day, the challenges we face intensify and our ability to face our obstacles and fears and to supersede them not only become easy, but more bearable. We are strengthened in our capacity to overcome our challenges and fears; we become more resilient and sooner (rather than later, hopefully) what use to have us down for the count, won't even knock us over.

With my acceptance to medical school, came excitement as well as fear. Fear of failure, fear of not being able to stay in medical school, not to complete the courses on time and the list goes on. Mixed with the fear there was some excitement, mainly due to the fact that here I was with a youthful appearance but years older than my teenaged counterparts who were just as intrigued by the mechanics of the human body as was I. We were all ignorant and in it together.

Due to the large class size, we were alphabetically categorised into smaller groups for just about everything from laboratory classes to clinical skills sessions. This allowed the laboratory directors and clinical skills instructors to teach in a less intimidating manner and also afforded us the  opportunity to "network" and to get to experience medical learning in a different way. It was in these sessions where we were told how OSCE's were all a 'big show' and that in order to pass all we had to do was 'to fake it' until we made it.

You may have heard how competitive medical school is. It's true. But it doesn't have to be. What I believe most students fail to realise is that regardless of how many persons are accepted into your graduating class, the last thing any school wants to do is to see you fail.

There aren't shortages of medical degrees that can be awarded per year or per class. However, this is how medical students act. Rather than perfecting skills that will ensure their success in the long run they limit themselves to faking it and doing all that they can to hoard material and preserve themselves whatever the cost.

QUIT FAKING IT!

1. Invest in Your Career

It is easy to become distracted by the idle talk and lose sight of your overall goal. Especially if you're surrounded by persons who have already graduated who want to offer their "advice". You must remember that not all advice is good advice and in regards to decisions you have to make for yourself that relate to your career and your overall happiness, the experience of others should be taken with a grain of salt, especially if you realise that advice is coming from a bitter vessel. 

Once you enter medical school, make the decision to utilise every resource available to you and never stop exploring your options as your interests may change or evolve as you advance in your schooling. Be sure to reach out to persons who are in your field of interest and have a conversation with them regarding opportunities that are available in that field that would allow you exposure you would otherwise not be exposed to. 

Do your own research into programs that you can sign up for during your summer months, that would allow you the opportunity to practice your speaking and to exercise your medical vocabulary as much as possible. By investing in your career, your medical education becomes more than an education but the catapult for your future success. 

2. Consider yourself as more than just a Medical Student

Sometimes as students we find ourselves limited in what we can do but doing more than our licensed medical counterparts. The minute you start referring to yourself as just a medical student, you're short-changing your reality. 

When you graduate and take on the role of an intern, you'll then find yourself, walking away from things or referring to yourself as "just the intern". The time you're spending in medical school is the time you are to grow as a medical professional. This is your time to use the platform to exercise your muscles by becoming involved in humanitarian organisations and giving back to the community in which you reside. This is the time to be present in the hospital and to make your face a familiar one to the nurses and other staff on the wards and in different departments. Why? Well because the way in which you will learn, will begin to shift, you'll start to transition from the library to the radiology department, the emergency room etc piecing together the basics in order to construct a sensible assessment and treatment plan that you can discuss with your seniors. 

By doing this you're now allowing yourself to grow and believe it or not becoming more than prepared for your final exams. 

3. Learn to Practice

As a child, I grew up in a home where expressing oneself was expected. I can recall standing at the foot of my parents bed reciting from memory a book report I wrote hours before to my father who was listening to every word. He offered constructive criticism based on what I said and from these exercises it was easy to speak in front of anyone on anything. 

With lack of practice, I do find it hard to eloquently express myself as I once was able to, but like anything, once time is dedicated to doing something, I'll be back to where I was in no time. 

As students, we often become fixated on studying in the library, reading all of the books, watching all of the videos and then find it hard to convey all that we spent time reading to our peers or seniors. So I would encourage you as you study, get in the habit of studying in groups early on in medical school and take the time to verbally review what you learnt as you covered a topic. Come up with a system that you can follow that would make it easy for you to cover the salient points on any topic in ten minutes or less. 

4. Learn to be a Motivator

There are few people in medicine who are motivators. It saddens me whenever I read posts from other medical bloggers about their day on ward rounds and how their attending belittled them, or how after a day of ward work, rather than receiving words of affirmation, they were criticised and as a result felt as if they were unworthy of becoming a doctor. 

In a field where empathy and respect are core principles, they often don't exist. The culture has now become one where tearing someone down to get a foot ahead is commonplace and expected and teamwork although it is spoken of, is lacking. 

The culture is so superficial and sadly with this comes patient negligence and a lack of accountability but a whole lot of blame. 

Learn to motivate your peers. You don't have to be their friend or go out of your way to make friends with persons you just aren't compatible with, but once you learn to accept the fact that the people who fill the seats of the lecture hall with whom you may have to interact with will eventually become your colleague and at some point your paths may cross in the form of a consultation. At the end of the day, you're learning to be a practitioner that is capable of respecting others, building them up in the process and placing the needs of the patient first. 

5. Be Consistent

Learning to be consistent from the beginning makes it hard to fake anything. By adhering to a study schedule where you incorporate practicing your physical examination skills, summarising your findings following your examinations and reviewing past papers, you will find that medicine and all that it entails is now second nature. You will become fluent in the language and when placed on the spot to perform an exam, rather than breaking out in a sweat and panicking, you'll confidently step to the plate. You'll be more open to constructive criticism and comfortable with things that once were foreign. 

Consistency is key in your overall success as a student. That is if you're consistently practicing good habits. If you're consistently procrastinating then you can see how that would just lead to you being a consistent fake and unreliable in the end. 

The goal is to be consistent, intentional and bold with good habits from the inception and to learn to grow with each semester that starts and finishes. By doing this you'll find that you're no longer faking it, but evolving into a Physician patients will be wanting to see.