In english, please

Me! in my role as the clueless medical student dressed as a real-life doctor! I’d like to thank… all residents honest and humble enough to admit they also don’t always have a clue and for showing me how to admit I don’t have the answer without feeling bad or guilty about it and without losing my professionalism and authority. And I’d like to thank all of the patients who didn’t throw me out of the room after they found out what “PJ” means. Not to mention the laundry service for keeping my appearance sparkling white!

Ok, seriously, I have had some down time this week and realized how far I’ve come. I was so scared to start my final year- I was so scared of what I don’t know yet! I was scared to make a mistake and to not know something! I’ve really learned two things- 1) I know so much less than I initially thought I did and 2) it’s not only ok to not know things and be a beginner- it’s just the way things are, I need to accept it and live it if I am ever to move on.

For example, I got to perform a minor procedure as the “operating surgeon” the other day using local anesthesia. The attending also scrubbed in and explained every step to me. I was embarrassed that the patient heard that I was a beginner and had never done it, I was really nervous. Did I do everything perfectly? No! But I learned a lot and it all turned out well. The best part is, the patient THANKED me when I finished! I felt like a movie star!

The other “Eureka” moment occurred when I was showing a fourth-semester student how to draw blood. She was really nervous and was afraid to look at the patient, afraid of making mistakes, afraid of rejection. Man, I knew exactly how she felt- that’s how I still feel when I am challenged to take it to the next level. I realize that I’ve learned how to mask it more- which not only makes the patient feel better, but it makes me more confident as well.

There may be no yearly awards ceremony and I may not waltz around in chiffon robes, but I’ve decided to be motivated every day to earn the “Oscar for Professionality”.

(isn’t that like the end of a cheesy American sit-com? Aren’t you just waiting for the group hug and the theme song?)

Ok, there’s no repressing it any further- I have to make a gameplan to tackle the USMLE2. I’ve been considering the pros and cons of taking the test right away, or this summer, or after the “Hammer” exam, or next year. I’ve also analyzed the bank account and thought hard about my priorities and job options. Though tempted to bury my face in a pillow and scream, I decided to toughen up and just make a plan and stick to it. (After my dog looked at me strangely and ran away when I tried screaming into a pillow I saw it as a sign).

Ok, I am just going to take advantage of the study power I’m investing into the “Hammer” exam. It will be a great feeling when I finish the German oral exam and I know I am really finished. Well, with one exception. Financially and time-wise I am unable to travel to the U.S. for the Step 2 CS (practical) exam. I am planning a big trip to the States next spring, so I will complete that portion then. I have heard that 98% of American students pass on their first try and that the biggest hurdle for foreign students is the language barrier (and learning the form of American medical documentation). Language certainly won’t be the problem for me and I think after being a doctor, the material won’t be a problem, either. The Kaplan CS book and the First Aid CS book are both highly recommended by American students- I think I will be able to conquer that portion.

Ok, now to the meat of the issue- the CK exam. 8 hours of testing on one day with up to 26 answer possibilites (though there are usually only 5). Deep breath. First the positives – I can speak English, obviously. I am pretty familiar with the American system. I will take the exam during my study phase for the German exam, so I will be used to sitting for 8 hours (which will be a big change from running around in the hospital all day!). I will be covering the same material for the German exam. There are still 3 practice exams left. Ok, so far so good. Now the problem areas- I also need to practice in English and deepen the high yield topics for the American exams- and it can’t cost me a fortune. After long consideration I’ve decided to start by using my study materials in German, focussing on the areas that were shown to be weak by my first practice exam. I will re-take a practice exam in early summer and see how I stand. I will then use First Aid and 1 month of USMLE world to review in English. The second problem is that I may not feel ready in early/mid summer and end up taking the USMLE in september, which could be stressful. There’s no easy answer to that- I just have to accept that it could be stressful. On the other hand, it IS practice for the German exam, so not all is lost.

Strangely I feel better now that I have a plan. Sometimes I think that’s half the battle.

One interesting admission last week got me really thinking about the social history part of the history and physical. A patient came to the outpatient clinic for his pre-admission workup, meaning getting all of the anesthesiology workup and release forms, lab tests, etc. so he only has to show up on his operation day – on an empty stomach (the German term for which, as we all know, can also mean “sober”, which is quite fitting in this case). You see – let’s call our patient Mr. Jones- Mr. Jones showed up drunk! Trendelenburg’s sign positive? Not sure! Patient is swaying due to alcohol. Tender to palpation? Have to move his flask of whisky first. Oh wait, there it is. He was nice enough to offer me a swig (don’t worry, I declined). So can he sign release forms when he’s drunk?

(Pandora’s box creaks as it opens).

Sometimes I do a double-take when I read “chronic C2 abuse” on my patient list under diagnoses- sometimes you really just can’t tell! Some alcoholics function well after several drinks- does a blood alcohol level determine whether someone is fit to sign something or is it psychological testing? How often do patients sign forms when they are drunk but no one notices? Even if the release form isn’t the problem, I’m on trauma surgery. Does it really “matter” if someone has an alcohol problem? Sending someone into withdraw can’t be any better for the healing process than letting them put schnaps on their cornflakes. But I digress…

I wanted to originally explain that I find it really hard to take that part of the history. I feel as if no matter how I phrase the question I evoke the reaction in people that they need to be ashamed of drinking alcohol at all. I also have to admit that I don’t always ask old grandmas if they take illicit drugs or smoke some Mary J. I only made that mistake once in L.A., though- there I felt it wasn’t a question of “whether” they smoked marijuana but “how much”? (Yes, even grandma. Yes, I know, I was shocked too). Not to mention that many patients in L.A. requested it for either chronic cancer pain (I will boldly say I could potentially get on board for that) or even for common low back pain (are you kidding me?). Maybe it’s because I personally have never tried drugs- heck, I’ve never even had a cigarette. Does my face always reveal me?

It’s just amazing how many cultural differences there are in relation to drugs and alcohol use- even within the same country. In the Old South, for example, there are many Methodists and Mormons who are very anti- alcohol. I sometimes felt I had to ask twice to get the real story- it had to be on record once that they said “no”. Not to say that all Methodists and Mormons are secret drunks- I’m just saying it made me, as an American, realize that there are “subcultures” that need to be treated differently when it comes to those kinds of issues. I’m just starting to learn about them in Germany.

What are your thoughts and experiences?

I was really excited to see the snow finally melting until I realized that it turned into dangerous patches of ice overnight, causing hundreds of accidents! The emergency room was busier than Starbucks on a Monday lunch- in fact, many doctors at the hospital said they hadn’t seen as many accidents at once in over 15 years!

We kept work on the wards to a minimum- we were told that every free hand was needed in the emergency room and the O.R. The head physician told us PJ students that we were “very important” at morning report. We all looked at each other excitedly! I was actually a little nervous- I knew I wouldn’t have time to think about what questions I wanted to ask, and if someone is screaming in pain I certainly wouldn’t have 3 tries to start an i.v. But I was excited!

So after rounds I asked if I was needed in the O.R. first. I saw that all elective patients had been cancelled and they had one O.R. booked for distal radius fractures! Unfortunately, three’s a crowd when it comes to radius fractures. With one attending and one resident already allotted for every operation, there was no room for students. I guess the residents were excited to get in O.R. time, too. Ok, I thought, I’ll go down to the E.R. and make a difference!

What a chaotic experience- my rotations in other E.R.s in Germany and America were much different. This hospital doesn’t seem to have a good organized system. The other problem was that none of the E.R. attendings really knew me, so even if I did a history and physical on a patient, they would end up repeating most of it before ordering any tests or therapy, since I’m only a student. That was not really time effective. The nurses were extremely stressed- understandably- and had no time to show me how to help, when they saw that I had little experience with casts they just sent me off. Sigh. I guess I have to go back to being a “waitress” in the E.R.

Sure enough, an attending found me and told me to start an i.v. for a man with a hip fracture who was in severe pain. I’m not bad at starting i.v.s, but I never had to do it under such pressure. Luckily, I got it on my first try. The man wiped off his tears and said “thank you”- his wife did the same. I happily hooked up his pain medication, wished him well and moved on. I still feel pretty useless- though I’m glad I could help. I was a little frustrated that I know very little about the diagnostics and procedures in the E.R. and wasn’t really learning anything.

Then a nurse found me- she needed me to apply narcotics as needed for a patient with a dislocated fracture they were going to reposition. The patient, a middle-aged woman, had lines of mascara running down her face and could barely keep up with wiping away her tears. I handed her a tissue and gave her 1 ml of the “happy juice”. I asked her how she was feeling. “I’m high” she giggled. Then she saw the attending arrive and grabbed my hand. “I’m scared. What’s going to happen?”. So I held her hand, explained what we were doing, and gave her more happy juice. When it was time for her to be transported to her ward, she grabbed my hand again and said “thank you so much”.

Maybe I’m not so useless after all.

So- another day in the O.R. Yes! Time to make a good impression on the one attending so he takes me to the O.R. much more often. I am careful to not make anything unsterile as I make my way to my chair (yay for operations you can sit at, by the way!) Normally, the chair falls down when you sit on it, but for some reason it went up higher when I pushed one cheek onto it. I tried to gracefully- and sterile-ly – push my tush all the way onto the seat (I probably looked like I have a bladder infection or a seizure), and then I pushed my foot onto the footpedal to let the seat down… My clog got stuck in the chair and I nearly fell off trying to pull it out. I tried to play it off- but the OR nurse asked the springer to help “Frau Doktor” get her shoe out of the chair and her foot back in the shoe. I swear the attending was laughing under his mask.

Later, on afternoon rounds, I was pondering why the attending alternately uses the formal and familiar forms of “you” – and got totally sidetracked. I ended up saying “Sie” to a 6-year-old kid, who immediately started crying and ran to his mom. I got so flustered I headed towards the patient room door to escape to the hall and promptly knocked before I left. Neat.

Ok, one more thing to do before I go home- we had so many emergencies today I had to cancel one of our elective patients for the next day. I finally found her phone number and dialled up the sweet old lady. Well either she’s a smoker or I had auditory hallucinations- I thought I had the patient’s husband on the phone. No no, she assured me, it was her. Whoops.

I half-expected a whoopee cushion on the bus ride home or a pie-in-the-face. No, I was just the girl daydreaming in the bus who realized at the last second that she had already arrived at her stop… and forcefully tried to open the doors while pounding and yelling in English. Not so smooth…

“After all, tomorrow is another day” – Gone with the Wind

So two things are stressing me out.

First of all, I just calculated the costs for the USMLE 2. Pretty upsetting- so here’s the breakdown. For the written part (Clinical Knowledge), there is a $740 examination fee plus a $190 fee for taking the exam in Europe (I don’t plan on taking it in the States!).

The exam fee for the practical exam (clinical skills) is $1295 – and that is only offered in 5 centers in the U.S. So I have to fly to the States, which, of course, is great, but expensive. I don’t happen to know anyone in one of the test center cities (and even if I did, I would be too busy catching up and hanging out to concentrate) so that means hotel costs…

Ok, then there’s study material: The First Aid Series are a “must” according to my American med school friends (and some American chat rooms). They cost approximately €35 each- so €70 total. *Kudos to me*: I requested these books at my university library (something most people don’t realize they can do) – and they ordered them! I saved €70!

Ok, we don’t have the MediScript CD- the USMLE questions aren’t published. There is a website called USMLEworld that most people use to do practice questions- that costs $99 for a one-month subscription or $185 for 3 months. Some people also use the Kaplan course materials- but I think that’s much more expensive. Though I’ve heard some of the case books are good- and flashcards.

Last but not least, there are four  NBME exams for $45 each that give you a score range- or approximate score (there are questions similar to the USMLE).

So that’s the second thing that’s stressing me. I mean the scores are approximate, but I just took one and I would have failed by one point. Ok, I haven’t started my study phase yet, and the questions are a little different than in Germany- in style and partly in content (for example, we have a larger African-American population in the States- there are more detailed questions about sickle cell anemia and all that). I’m just a little bummed cuz I thought I would have passed… looks like I have more work ahead of me than I thought…

Today was a good day. Time passes much more quickly when you get to go to the O.R. Plus, I always feel like I’m really doing something- even if I am just holding a retractor or in charge of suction. Today I also realized that I’ve officially put in more O.R. time in Germany than in the U.S.! In fact, in contrast to the preclinical years, in which I spent a lot of time reading English books, I’m so submerged in German literature that I often don’t know American terms for things! I really need to get some English review books for the USMLE- the First Aid series is supposed to be really good. I figure I have enough literature in order to really understand the material in German, there’s no point in getting all of the literature in English all over again.

But more about the USMLE another day- I digress… I wanted to share some differences I noticed in my experiences in the O.R. in the USA versus Germany. One of my first clinical electives was plastic surgery at a university hospital in America. Right before that I had completed my very first elective in neurosurgery at a university hospital in Germany. Talk about a contrast!

First of all, the Americans were much more lax on being sterile in the O.R. – everyone had on street shoes, not OR clogs, and most people remembered to cover up their sneakers with “footsies” (like the shower caps but for your feet). If not, they would just walk aroundwith blood-stained sneakers all day. That’s another point- a lot of residents stayed in scrubs all day, whereas attendings at that hospital (and everyone at another hospital I was at) changed back into their “business” attire with white coats to see patients. In addition, many people brought backpacks and even water bottles into the O.R. in the States. Not very hygenic, I’m with the Germans on that one!

One thing I do miss is the Anesthesiologist- DJ- persona. Most anesthesiologists in the states packed out their iPOD speakers and even had playlists for different doctors. Awesome. I understand that AC/DC might not be appropriate for delicate brain surgery- but Mozart and Vivaldi can strengthen anyone’s game! I’ve unfortunately only rarely encountered music in the O.R. in Germany- and I miss it!

Bottom line, is though, that most things vary according to the hospital just as much in the US as in Germany. I’ve encountered the “I don’t need food, I’m a surgeon-god and don’t you dare take a lunch break, sissy”- type on both continents- as well as the “let’s have lunch together and I’ll buy you coffee afterwards”- alterego. Same goes for “I will pimp you until you can recite all of the anatomy backwards and then I’ll let you scrub in” vs. “you’re awake! 10 stars for you! have you ever drilled a hole in someone’s head before”? -type educational environment.

Truth be told- I don’t care what country I’m in. I just like to hear the “beep, beep, beep” in the O.R.

So today was pretty annoying.  Time was literally going backwards. Ok, not literally. It’s just ironic that there is so much to do with all of the ice and accidents and broken bones- but we students sit around all day! I don’t exactly understand why- and I had a lot of time to think about that question today. Yes, we all just started next week, so we all have to get used to new computer systems, hallways that all look alike, the rhythm of the wards we’re on… I understand all of that. And yes, all students are different- we all have different interests and strengths and experiences. Got it. I still feel like that’s not the core of the problem.

Now, please don’t take this as a “everything-is-better-in-America” tirade, because the American medical system has it’s own problems- but we can talk about all that later. My dad was a professor at an American med school and I completed 3 rotations in 3 very different places in America- so I feel like I can speak with some authority on medical student education in the States. The biggest difference I notice between my rotations in the USA and here is the team integration.  My first rotation was right after my first German board exam- so I had basically no clinically knowledge. I feel like – although a bit confused about the German system- the American docs accepted me where I was and tried to get me to think independently. Asked me how I should manage patients- questioned my thought patterns. I had a clearly defined role.

Here in Germany, I feel I am at the mercy of other’s kindness. It is usually the young resident who remembers how confusing it is to be a student and who remembers what a leap it was from PJ to your first call as a doctor. They try to teach me “real things” for clinical management- when they have the time, when they remember. When they know me, I get to do more than just close during an operation- if they have time and feel like it. I’ve been lucky, really, I’ve had some really nice residents. I’m just tired of hoping the “nice ones” are on call that day and have time for me. I’m sick of trying to make sense of rounds instead of them testing me how I would manage the patient- them asking ME questions. I’m sick of not having a defined role except for drawing blood and admitting patients.  Plus, if I have a question about a finding on physical exam, someone just rechecks it and writes their own note instead of explaining it to me and showing me!

I think that’s the problem- Germans are not organized. I know, people, I was just as shocked as you are to discover it. C’mon- there’s a stamp and administrative office for everything! But there are no defined roles for PJ students- nor for residents! I’ve also heard them complain that their education is based on luck and how well they get along with certain attendings. Don’t get me wrong, flexibility can be a great thing- the fact that you aren’t bound by contract to a program for 6 years (which is the case in the US) is great if you have to move for a partner, or for your own education. The ability to take maternity leave up to 3 years (also not the case in the US- you can take 6 weeks, then it’s back to full-time!) is also great. But there is a definite lack of organization! Give me a pager and responsibility and clearly defined jobs! I will gladly draw blood!

Can I hear an “Amen”?

So today I got to see my “own” patients in the outpatient clinic and then present them to the attending. It was such a cool feeling to grab a chart, walk into a full waiting room in gleaming white gear and announce “Mr. Schmidt, please”. And the best part is- the patients actually FOLLOWED me into the room, told me their stories, listened to what I have to say! Of course I know ridiculously little and pretty much just try to summarize their history and chief complaint(s) for the attending. I just had a flashback to one of my first history and physicals during my very first rotation. I apologetically explained I was a med student, scratched my head, shrugged and said I would have to talk to another doctor about the case, and pretty much felt completely incapable. Though I have gained much more knowledge and a little more experience- I still have so much to learn! It just doesn’t stop me anymore from presenting a professional appearance, I can say with confidence that we will talk to the attending instead of sheepishly admitting I haven’t got a clue. I don’t know when the transition happened- I suddenly feel “the part”. It’s highly motivational. A true “Oprah” moment.

I used to be worried that it seemed so awkward to “act” like a doctor because I was in Germany instead of in my home country. After talking to my American friends in med school I realized it was a big transition for them, too- a brand-new role they had to learn. I am sure there are things that are more difficult for me because they are different. Take all of the paperwork and the social system here, for example- things like 10 copays per quarter, “Scheine” for everything except permission to go to the bathroom, emergency copays, accident insurance… Germans grow up with these concepts and I had to learn every single one in detail as an outsider.

It gives me a unique perspective, though- stay tuned, I’m happy to share!

So today was my first day in the O.R.- finally! (Ok, my fourth day, but whatever). My experience has shown me that even the nicest of surgeons can get testy when things go awry in the O.R. I was curious how the environment would be. I was pleasantly surprised. The team is SO nice- the nurses, the anesthesiologists and the surgeons all got along, kidded each other, and were really nice to me. It was so much easier to concentrate on the operation since I was so relaxed. I even got to close!

So I’m really enjoying myself- and time is flying! Which makes me start to think about the upcoming exams…. Yes, exams, plural. I have already taken Step I of the USMLE and am planning on taking Step 2 soon. Some people think I’m crazy for taking both the German and American exams in the same year, but I figure, why study twice? In fact, I’m planning on taking Step 2 as a “warm-up” for the German exam. I just want to be sure that I’m really prepared (it’s too expensive to take twice!) but I don’t want to take it too close to the German exam so I am either burned out and/or stressed about getting all the studying done for the Hammer-exam. Some have suggested that I take the USMLE after the Hammer-exam, but  I have no idea when my oral exam will be- and after the 100 day study marathon, plus up to 8 weeks of studying for the oral exam, the LAST thing I want is to sit down another couple of weeks for the American exam.

So I will keep you posted on my study plan, financing plan and study progress. (deep breath). No need to stress out- I just need to take it one day at a time.