Finding their Future

An intense third year is comprised of clinical rotations — and decisions that form students’ future

By Rick Krupinski

It’s two degrees below zero late in February, and Fasika Aberra, shivering in spite of a hooded parka and heavy scarf, makes her way to the U-M C.S. Mott Children’s Hospital, floor 5 West, for a 6:30 a.m. arrival. Having volunteered at Mott as an undergraduate, she navigates the place with ease. She pre-rounds with each of the three patients under her charge to see how they did overnight, checking vital signs, completing brief physical exams, reviewing lab reports and charting treatment plans for the day.

It’s the second month of her two-month pediatrics rotation, the first having been spent in outpatient specialty and subspecialty pediatrics clinics. Sounding far less like a medical student and more like the budding physician she is, Aberra admits that she thought working with such young patients was going to be a very sad experience. “But the wonderful thing is that many of these patients get better quickly, and it’s inspiring to see that happen and to be part of it. And you can always do something to make them smile — maybe it’s the gleam on your stethoscope, or a funny face you make …”

Later in the morning, rounding with a team that includes her attending physician, senior resident, a second medical student and an intern, Aberra presents her assessment of each of her patients, as does the other medical student on the team. At Mott, rounds are “family centered,” taking place with family members present at the patient’s bedside, giving them the chance to ask questions and contribute information about the patient, and to have input in planning subsequent steps in their child’s care.

The group places a silver flag high on the doorway of the patient room to identify their team and signal that rounds are taking place. Medical staff on the floor seeing the color-coded flags — nurses, for instance — can listen in on rounds if they choose. The rounding team enters the room in hierarchical array: attending physician first, then senior resident, resident, intern and students. Discussion ensues briefly in the hallway after the patient visit — questions are asked and answered — and the group moves on to the next. Halfway there, Aberra dashes back to retrieve the silver flag and places it on the next patient’s doorway.

After rounds, Aberra and the rest of the team discuss each case in a small staff room on 5 West. Black and white photos of past pediatrics house officers line the walls, along with a child’s colored picture of a princess, charts indicating the prednisone tapering regimen for IBD patients, the electrolyte composition of various body fluids, and a day-prior-to-discharge to-do list. The team reviews and confirms the courses of patient treatment, medications, and plans for the day. Then, at a small work station, Aberra and her student teammate enter notes on a computer.

“In general,” Aberra says of her pediatrics rotation, “I saw quite a few cases of bronchiolitis from respiratory syncytial virus, which is very common in winter months. There were also several cases of failure to thrive — kids falling off their growth curve — skin infections, inflammatory bowel disease, type 1 diabetes, and rare cases too, like Kawasaki’s disease and Duchenne muscular dystrophy.”

Though she gave serious thought to a combined internal medicine and pediatrics specialty, Aberra now plans to pursue residency in internal medicine, working mostly with hospitalized adult patients. “I just feel I can do more good with adults,” she says, “and I like the inpatient practice of medicine — caring for patients with multiple medical problems, utilizing evidence-based guidelines, team discussion, bedside and teaching rounds.”

The third year of medical school — from May to May — is almost exclusively about clinical rotations, punctuated weekly with Friday afternoon all-class seminars. There are seven rotations: pediatrics, surgery, neurology, family medicine, internal medicine, psychiatry, and obstetrics and gynecology. Inpatient rotations include on-call duty — 30 hours at a stretch spent in the hospital. While the frequency of being on call varies with the rotation (internal medicine has the most frequent, at every four days), and there’s no on-call activity with the outpatient specialties, it’s readily apparent that with the early morning starts and long days, year three couldn’t be much more different from the first two years.

“Third year has been amazing,” Aberra says. “It has given me all I hoped for from medical school.”

It’s an assessment shared by Ron Romero. “I loved M3 year!” Engaging with patients made studying medicine meaningful, Romero says, and was invigorating after the first two years of lectures and exams. “Even on the hardest days, or when I was tired, it was always rewarding.

“We had more autonomy than you might think in connecting with the patient right from the start,” he says. If the emergency room calls for admission to an inpatient service, it’s typically the medical student who goes down to see the patient first, take the history, and do the physical exam. “The student often has the opportunity to bond with the patient before anyone else on the team.”

Romero’s favorite rotation, true to his foremost interest from the beginning, was family medicine because of its patient-centered approach and the continuity of seeing patients repeatedly over time. Equally important to Romero is the ability to get involved in psychosocial issues that can impact a patient’s health. He recalls taking a young patient’s history at the Ypsilanti Health Center and seeing signs of such issues, perhaps even sexual abuse. He was able to connect the patient and her family with the appropriate support and resources. “It allowed me to have an impact beyond the immediate reason she was there, to perhaps make some long-term changes.

“I really responded to the family medicine environment,” he says. “I loved the patients — Ypsilanti has a diverse population, and some patients were disadvantaged, which I could relate to from my own background in Miami as the son of a single parent struggling to get by.” Though he considered pursuing obstetrics and gynecology as a specialty, he ultimately was drawn to the diverse range of patients and holistic approach of family medicine. His commitment is solid. “Every time I think it through,” Romero says with his trademark smile, “I come to the same place.” Romero’s wife, Jen, is currently pursuing a master’s degree in social work at the U-M.

In year three of medical study, grading becomes more structured than the pass/fail system of the first two years. Did that result in competitiveness? Romero saw little to none. “I think the students did a great job of continuing to work together throughout the year.” For Romero, grading didn’t add a significant amount of stress to the year: “I tried to maintain perspective,” he says. “You do the best you can and learn as much as you can. Ultimately, I tried to focus on the patient interactions, not the external evaluation. I think that helped me enjoy the year more.”

He says one of his most memorable patients was part of his pediatrics rotation. “Many of the children I met left a really big impression.” A one-month-old infant impaired by a heart defect, the patient Romero remembers had already undergone surgery and was likely to be blind. “It was very sad,” he says, “that this kid wouldn’t have a chance to have the kind of life you hope for a baby.” Because of the many tubes and wires connecting infant to equipment, Romero couldn’t hold her. “So every morning when I saw her I tried to provide some sense of human connection, holding her hand, speaking to her in a soothing voice,” he says. “It was all I could do.”

Of the seven clinical rotations in year three, surgery was the toughest, according to Shaun Patel, but also the one he loved most. In addition to a full day on the feet, and long stretches of time observing operations — punctuated by sudden questions from the surgeon — there is also, after scrubbing, the need to stay clean. Sterile from waist to neck, students cannot scratch an itch on the nose or touch anything that could compromise their clean state. Despite the rigors, Patel’s specialty likely will be orthopedic surgery. His active lifestyle has generated a desire to treat disorders of the musculoskeletal system, and to improve patient quality of life through the return of form and function.

“You may be hungry, but you can’t eat. You may have to go to the bathroom, but you have to stay in the OR. These urges might be there, but I found that once I got involved — like when I sutured the surface layer when an operation was completed — I forgot all about them,” Patel says. While other rotations offer some opportunity for a bite to eat, the surgical schedule doesn’t always allow time for healthy eating. He often grabbed quick prepared food at the hospital cafeteria, since the many fresh lunchtime options aren’t available after 2 p.m.

While emphasizing the need to limit significant emotional attachment to patients in the interest of providing good, objective medical care, Patel says that he tries to find something in common with his patients to help strengthen the patient-physician relationship. “There was one patient who, anytime I explained my physical exam findings, the treatment plan or next steps, would reply ’Heck, yeah!’ to anything I said. It reminded me how much trust patients place in their physicians, whom they may have just met, to do what’s best for them and their health, a process that’s particularly unique to medicine. It reinforced my goal to always be the best advocate I can for all of my patients.” The patient, when younger, had turned down an offer to play hockey with the Detroit Red Wings since the pay was poor back then. Patel, a devoted Red Wings fan, found their “something in common.”

Patel also emphasizes the need to communicate not just with the patient, but family members too. “In many instances, the family members are the ones who actually have more questions and concerns.” He says this was especially true with non-responsive patients on the neurology and surgery services. “While we may not have been able to communicate directly with those patients during their care, it was very important to have an effective communication line with their families during a difficult time. It’s important to take care of not only the patient, but also their family.”

Keeping emotional attachments in check isn’t always possible, as Patel saw. “When I was on the pediatric cardiology service, there was a baby who was born with a congenital heart defect,” Patel recalls. “I was on service for only a couple days before the baby died, but the resident on service was particularly shaken by the death, to the point of tears.”

While choosing a residency field has been fairly clear for Aberra, Romero and Patel, it’s not always so straightforward. All along, Lindsay Kennedy Brown has weighed surgery against family medicine, but very late in her third year, she began to think of ob/gyn as a choice that could allow her to combine both surgery and primary care, while also pursuing her public health interests in women’s health and preventive medicine.

“The hardest part of third year, in my opinion, was not the rigors of the year itself, but rather the decisions we are faced with afterwards,” Brown says. “It’s been incredibly difficult to walk away from a particularly amazing experience, like my time on pediatric hematology-oncology, and think that I will never work with that patient population again. I could say the same about my experiences on inpatient psychiatry, infectious disease clinic and adult oncology. For me, this decision has not been an easy one.

“For the rotations I loved, I’m left wondering if I truly loved the field, or simply the serendipitous combination of teammates and faculty mentors,” she says. As for the rotations she didn’t gravitate to, she wonders if she might fit nicely into the field in another setting. Weighty questions, to be sure.

Brown is not idly wringing her hands over the dilemma. Instead, she’s exploring further by taking a representative mix of early fourth-year electives to help her decide, as well as weighing the advice of as many people as possible in each field, including her attendings, residents and recently graduated classmates.

“I think I’m still processing third year itself,” Brown says. It was an adjustment at first, she admits, and she says it wasn’t until the new third-year students joined her service this spring that she realized she had adjusted after all. “As I helped guide them through the first few days, it astonished me how much I’d truly learned, which is easy to lose sight of while still in the midst of the commotion of third year.”

That commotion of third year has a lot to do with week-to-week schedules that often aren’t known until Friday of the week before. “It’s hard to plan life,” Ron Romero says. “How do you schedule a dental appointment, for instance?”

Active involvement in organizations from the U-M to the national arena has been a hallmark of Patel’s time in medical school, and indeed before that, as an undergraduate. With the week-to-week scheduling involved with clinical rotations, Patel found planning trips to meetings and conferences “a bit more complicated than the first two years.” He identified when travel would be necessary, then worked with advisors, residents and the M3 coordinator on his hospital schedule. Only once was he told he couldn’t go. “That day turned out to be slow and I was sent home early,” he laughs.

But this past year was, as Romero says, a glimpse of residency — now just a year away for all four. Though not mandated, most students will have chosen a specialty by July in order to begin the process of exploring and applying to residency programs, a key focus in year four. Aberra has a method in place for that. “I’m going to draw a line across the country and not cross north of it,” says the Ethiopia native. “Minus two degrees in the morning, well, I’ve had enough!”