Where will we be in 3, 4, 5 years? What is beyond the recommendation letters, the MCAT, and the white coat ceremony? Once admitted into medical school, the first two years are typically dedicated to lecture and laboratory study, followed by Step 1 of the medical licensing boards. The last two years take place almost entirely within the teaching hospitals in a clinical setting. This is where students can test their skills in the field, explore specialties, and really experience what it’s like to be a doctor. In order to give aspiring medical students a better understanding of what these “clinical years” are like, I turned to Benjamin Nguyen, a class of 2017 M.D. candidate at the Keck School of Medicine USC, for thoughts on starting his third year of medical school.
The third year of medical school is, for various reasons, difficult to describe. The breadth of experience is so wide that you feel that you can never do it justice. The depths and heights of emotions are difficult to convey to those who haven’t lived it. I guess I’ll tackle this by talking about recurring themes that I’ve seen in my collective experiences within the past couple of months.
On my first day of surgery, I met my R2 (second year resident) at 6 in the morning, who introduced herself to us amidst blaring ICU alarms. She rolled her eyes and sighed and walked over to the room of her patient, who was coding for the 3rd time that morning. The first two had been in the dead of night, between 1 and 3 AM. She’d been here all night. A small crowd of nurses and other doctors had already begun to work on the patient. After introducing himself, our intern told us to go help with the code. Help with the code? At this point in my training, all I knew was that a code was short for “code blue” – which meant a patient was essentially crashing and dying that very moment. Besides knowing that it was bad (because patients dying is a bad thing), I had no idea what else went into the response to a code. I approached the room dressed in a shirt and tie and nice shoes, watching as drugs were started, CPR was done, and the patient was ventilated. I took my tie off, rolled up my sleeves, and grabbed some gloves. In the midst of the controlled chaos, we got in line for CPR (you have to take turns or you get too exhausted) and I mentally prepared to do chest compressions for the first time in my life on a human being, not a training dummy. Was it 30 compressions to 2 breaths? Or was it a continuous 60 since the patient was ventilated? Damnit, I should know this. But I didn’t so I tried my best to see what the people ahead of me were doing. This was terrifying, to know that I had to perform at this moment, and I might not know how to. Before it was my turn though, the patient returned to sinus rhythm, and a pulse was felt, meaning his heart was functioning again. I was pretty scared at that moment, scared I wouldn’t to the compressions correctly, scared I didn’t know the right pace, that I didn’t know the right count. That was how my first 10 minutes on surgery started. Today, I watched my attending sew up a lacerated artery that was squirting blood 8 inches into the air, soaking our hands as we worked to suction and hold the clamps to slow the flow and give him a clear view. His view was terrible, obstructed by the spraying artery and the fact that the vessel was deep in the abdominal cavity, his hands were slippery with blood and he had to use long awkward instruments to reach the vessel. The tension in the room was palpable as the patient lost more and more blood every second. But the attending placed his sutures, tied the artery off, and stopped the bleed. Every day, when I examine patients, when I watch my residents make decisions, when I see my attending surgeons cut into flesh and bone, I think about how someday, I will be called on to act, to perform, to deliver. And I think back to the fear I felt that moment in that room when I didn’t know how to do something as simple as chest compressions. Every day, exhausted as I am after 14+ hours of working, I’ll go home and I’ll read up on surgery because of that fear that someday, a patient will need me and I won’t be able to help them because I didn’t work hard enough. Fear will drive you to work harder and longer than you ever thought you could.
You mess up a lot in your 3rd year. You’ll write a note the wrong way, forget an important detail, misdiagnose things, accidentally screw up a stitch, etc. If you mess up only once a day, it’s a good day. You really begin to develop a sense of humility. There is much to learn, and the learning curve is steep, so everybody gets chastised at some point by their residents or their chiefs. When that happens the first few times, it feels shitty. But then you work with your residents and chiefs and you see them screwing up every day as well. They too make mistakes and get berated for them. My chief gave me a hard time for taking a long time to stitch one day…and the next day I watched him accidentally perforate the gallbladder twice during a cholecystectomy. The attending wasn’t pleased, to say the least. It sucked for him, but he kept going and he kept functioning and performing for the rest of the day. I’ve come to learn that to have true humility, you need a willingness to face your mistakes and your shortcomings every single day in medicine. You need a willingness to swallow your pride and listen to blunt, direct feedback that many of your superiors will give to you. You have to be willing to tell yourself “I will do better tomorrow” again, and again, and again. You have to have the courage to come back every day, willing to try again despite your failures because you’ll never improve otherwise. Medical school will probably be the most humbling experience of your life.
When I took my first night of acute care surgery (ACS) call at LAC+USC General Hospital, I barely knew my team – they were classmates I had been acquainted with but I wasn’t close with them. This did not last long. There is a mutual understanding, a sense of respect that grows between people who have experienced the things we experience in medicine. It is born out of the shared intensity of our lives, the emotional peaks and troughs we feel when we work with the sick and the dying, the tests of our character and fortitude on our long long nights. That first night of my ACS call, we worked alongside each other, alongside the residents, the nurses, the doctors – and we cared for over 10 high level traumas (patients who are hurt so bad that they might die within minutes without intervention), 7 of which arrived within a 90 minute window. It was a bloodbath, a war-zone, and a miracle all at once. We worked as a team for 5 hours straight at one stretch without sitting, taking a drink of water, going to the bathroom, to stabilize our trauma patients when the flood of trauma cases just wouldn’t let up. At 4 in the morning, I watched my attending (the most experienced surgeon on the team) leading her team in an emergency surgery on the gunshot victim we had taken into our care 30 minutes earlier. I knew she was even more tired than I was, but she didn’t show it. She must have known her residents were exhausted too, but none of them complained or indicated that they were tired because they knew she needed them at that moment. They operated for nearly 3 hours, and saved the patient’s life. As I watched the surgery through a glass window pane, my classmates walked up to me. We silently nodded at one another, too exhausted to talk. I saw that some of them had bloodstains on their clothes and all our eyes were bloodshot. It was 6am, and we had been in the hospital caring for patients for 24 hours, but we weren’t done yet. We had 6 hours to go to round out the full 30 hours of call day. Nobody had slept a minute because there was too much work to do, too many patients to care for. There will come a time in your training when you all realize that you need each other not just to save your patients, but to save yourselves. We walked away from the OR and down the hallway, and I looked outside briefly to see the sun rising for the second time during my shift. Together, we rode the elevator back down to the trauma department.
On High Moments
Before I started third year, a 4th year student told me about how rough it could be, and she ended the conversation with: “Remember Ben…this is the path we choose. You wanted this.” Every once in a while, you have a case that reminds you why we do what we do. Once, a 5 year old came in after being hit by a car. I helped take care of him from start to finish – I physically took him down to get his X-rays, which showed that he only had a clavicular fracture, a simple and easily treated injury. I told his dad that he was going to be okay. His dad had been there by the bedside, awake for almost 2 days with worry. A day later, we discharged him and on their way out, the family asked to take a picture with me. I’ve seen patients come into clinic 2 weeks after their surgery, crying and thanking the surgeon. The other week, we performed surgery on a woman who had a botched C-section that left her with only skin to cover her abdominal organs, so they herniated and started to form a large lump below the skin which protruded out her belly. She had to walk around with a protruding, disfiguring pouch because of this. We went in, separated all the components of her abdominal wall, pulled her abs back to midline, sewed them together, and reinforced the suture line with mesh. Her stomach was flat and beautiful again. Last Tuesday, I was elbow deep in a man’s chest cavity, helping to remove a cancerous esophagus. We dissected it out, and cut part of the stomach to turn it into a makeshift esophagus so that he could live a relatively normal life. These are what I call your “high” moments. They can make your entire day, and when I’m in the trenches wondering why I wanted to do this, I just remember that It’s because I’m chasing that high.
It’s a privilege to experience these things that I know most of my friends will never experience – to help patients and be with them at their worst, at their most vulnerable. 3rd year is terrifying, exhausting, emotional, and wonderful all at once. I think I made the right choice.
Benjamin D. Nguyen is an M.D. Candidate at the Keck School of Medicine of USC.