Transitions Driving Lifelong Learning

The transition from the pre-clinical years of M1 and M2 to third-year clerkships is a stark change. Gone is the flexibility of setting your own schedule, watching lectures from coffee shops and taking an organ-by-organ approach to clinical reasoning. Gone is the relative stability and sameness; this all gets thrown out the window once you embark on your M3 journey. Suddenly, schedules are at the mercy of the particular service you are assigned to, clinical reasoning no longer occurs in multiple-choice questions, and once you get comfortable in a particular rotation your time there is up and you are on to the next team. You see a lot, do a lot, learn a lot as a third year, and while it might be feel a bit more rigorous than the prior two years, you are rewarded with the privilege of direct involvement in patient care. You can’t help but pause and think that this finally is what you came to medical school to do – but of course you don’t pause too long because there are shelf exams to stud for and residency choices to figure out.

 

Having had little exposure to clinical settings beyond being a patient myself prior to medical school, adjusting to clerkships was far from seamless. Unexpectedly, one problem I struggled with most early in this transition was wondering where on Earth to find information to answer the clinical questions I had. My first two years of medical school were spent internalizing a multitude of PowerPoint lectures with clearly defined objectives. Information was presented in a particular, predictable order: “here is an antibiotic, it can cover these bugs, and is contraindicated here. Here is another antibiotic, which covers similar, but different bugs, and can’t be used in these situations.” Now in a primary care clinic, I found myself caring for a patient with a simple bacterial sinusitis. “What antibiotic do you want to give them, Rebecca?” The order was all off, and I struggled to invert the information I learned in the lecture hall. “Vancomycin?” I suggested. My attending’s facial expression told me that this patient wouldn’t be getting vanc. “Well sure that would cure it all right, but it’s only IV and a really heavy drug for this. How about… amoxicillin?” Yikes, I had a lot to learn.

Thanks to enthusiastic residents, patient attendings, and supportive classmates I soon got the hang of being a third year. I had enjoyed the success of mostly glowing evaluations, passing shelf exam scores, and even academic “honors” in several specialties, and therefore approached fourth year without trepidation. Again, however, I was met with unexpected challenges in making this next transition. I spent July filling a new role as “sub-I” on a hospital peds team, where I first struggled finding balance in straddling the line between medical student and intern. The team had a brand-new senior, a guest rotator intern, myself, and several M3’s, all trying to navigate unfamiliar roles for the first time. I struggled to figure out where to fit in this team dynamic; with a low summer patient census I worried about taking patients away from the M3’s. I struggled asking for more practice with placing orders, knowing that my inefficiency would slow our team down. Finally, amidst this chaos of learning how to be a sub-I on the busy, ever-revolving door of a hospital peds service, I was told by an attending for the first time in my medical training that my medical knowledge was not at the level where it needed to be. This was crushing. This was unexpected. This was not how I planned this month to go.

This feedback rocked me, so what came next was a lot of introspective re-evaluating. I went over and over in my mind what I felt wasn’t working, and belabored the issue with my fiancé at home. Things started to turn around when I started using down-time on service to talk to my senior resident. It was helpful to get an external perspective of how I could improve. I started similar conversations with my two attendings, revisiting the goals I had set at the beginning of the rotation. My senior and I came up with ways that would both help my learning and reduce his workload while maintaining team efficiency. From one attending I learned of pediatric review resources to get quick information on some of the most common pediatric illnesses. The other attending and I developed quick, small goals to work on overall confidence. Finally, I had a plan, and in that plan I no longer felt lost in my role as a sub-I. Slowly, the month started looking more like what I expected going in.

 

It was an uncomfortable month, but one where I felt a lot of growth. Before medical school I ran the 800m on my college track team; between sets of repeats on the track my coach often preached the concept of “learning to be comfortable being uncomfortable.” I see this translating now into my medical training, as new rotations, new responsibilities, and maybe even living in a new city for residency will continue to push me into the realm of “uncomfortable.” But these opportunities are how I grow as a physician, and these struggles are what I will someday draw on as I teach future trainees as a resident and attending. As a resident I will work to meet these challenging transitions by being patient with myself when I’m not achieving at the level I expected for myself, and communicating with those around me when I feel like I need help or advice. I will set small, measurable goals to help me achieve overarching milestones. Similarly, when I someday work with students and interns as a resident I will remember to give targeted feedback with specific things to work on or address, because I saw how that has helped me develop a plan for improvement during last July. And because everyone’s progress looks differently, I will avoid comparing myself and my experience to that of my peers.  I was relieved when my sub-I month came to a close, but then it was just on to the next month.