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A Letter to Third-Year Medical Students

Dear freshly-crowned MS3s,

Congratulations on making it to the best part of medical school! I hope that it has finally sunk in that classes and labs are over, and most importantly, you are on the other side of Step 1. It is finally time to take all of the facts that you learned from a textbook and apply them to a real-life person. It is the moment we all wait for and the reason we go into medicine.

Indeed, it is a time of excitement. However, it also is a time for change. During the first two years, our sense of responsibility is largely self-imposed. We can perform less than ideally on exams, and as long as we are passing the course, we are the only ones who know the details of our grades. There are no patients to please and no physicians to impress. Essentially, there is almost no opportunity for external judgment and little opportunity for embarrassment; hence, our pride stays relatively intact. However, the game totally changes when we begin our clinical rotations. My own story testifies to the fact that oral presentations provide a rich venue for embarrassment, and so I hope to pass onto you the lesson I learned the hard way: always prepare for your presentation.

On your internal medicine rotation, oral presentations are very important, and it will be the time you will receive the most practice. Often residents will offer to meet with you before rounds to discuss future management with the patient, so you can appear prepared, and maybe even a little intelligent in front of your attending. One morning, I met with one such resident just minutes before we were scheduled to meet the attending doctor to begin rounds. It was very rushed, and I had several patients to run by her. One of our shared patients was a diagnostic mystery to everyone at the hospital. He was undergoing a very extensive work-up for a fever of unknown origin, and almost all of the sub-specialties had been consulted and were involved in his care. Naturally, with his exotic presentation, I was very interested, and as an ambitious medical student, I felt motivated to crack the code. What a hero I would have been!

During my discussion with the resident, she mentioned that perhaps we should consider some infectious disease as a cause for his bizarre combination of symptoms. The patient was from a rural town in the Southwestern United States and owned livestock (including several llamas), so exotic parasites and other uncommon bacterial infections were important considerations. As an example, she mentioned Echinococcus infection. It had been awhile since I had heard of this particular parasite, if indeed I had ever heard of it at all. (As you know, it is often hard to distinguish between what we have forgotten and what we never knew. In any case, this particular infection did not ring a bell.) At the time, I did not ask for any details, but I should have, or at the very least I should have clarified the proper pronunciation. To me, “Echinococcus” sounded a little like “a kind of coccus,” so I assumed I could think about this and figure it out before my presentation.

As we went about our morning rounds, we soon ended up at the bedside of the patient with the mystery ailment. As nervous as bedside rounds made me, I actually delivered my presentation relatively smoothly at first. As I neared the end, I started to outline my plan (really the resident’s plan) to pursue a more extensive infectious disease work-up. “Based on both the fact that he is meeting the criteria for ‘fever of unknown origin’’ and also that infection is part of the primary differential diagnosis, I think we need to look into a … um … a … hmm (What did she say again? Was it “a kind of coccus?” I meant to ponder what she meant by this. Crap, what did she mean? No, she must have said something more specific. Was it gonococcus?) … a … umm … gonococcus infection,” I mumbled almost incoherently. Even if I had perfectly understood her, I did not know much — or really anything — about an Echinococcus infection, but a gonococcus infection is relatively common, and I just assumed that must have been what the resident had mentioned. I hastily went on to talk about a few more diagnostic possibilities and plans for further work-up, and then finished my presentation. I waited expectantly for questions from the team.

My attending nodded encouragingly at the end, but she said, “Okay, good, but I just wanted to clarify one point you mentioned. What type of infection are you concerned about?”

I, still not being exactly sure what infection I was literally having trouble talking about, quickly slurred over it once again, “I don’t know, maybe, a gonococcus infection.” I quickly went onto explain my thought process, “You know, just because he is around livestock a lot, and I guess, you never know — just to cover all of our bases.” I essentially had no idea what I was talking about. I thought I was just relaying everything that the resident told me.

After hearing my response, such as it was, the attending doctor looked even more alarmed, “Wait, I am sorry … what are you saying? Gonococcus?”

I do not think she was trying to be overly critical, and still less do I think she was trying to embarrass me. She was just trying to tease out what I had said.

I shrugged my shoulders and sheepishly answered, “I don’t know, maybe?” I quickly followed up with, “but I know that is probably stupid and pretty unlikely.” I truly did not understand her skepticism. I thought maybe she was incredulous because this bacteria was so rare that she could not believe I would suggest it. It would not be the first time (nor the last time) that I would suggest something so implausible that it provoked this type of mystified response.

It was the first “kind of coccus” and the only “kind of coccus” I could think of in the moment. I thought that there must be more than just the type associated with the venereal disease. But, as I am sure you are gathering, there I was, earnestly suggesting to my team of interns, residents, attendings, and to the patient and his family, that I thought he had gotten gonorrhea … from having intercourse … with his livestock.

The attending had the horribly strained expression of someone who is trying to mask a baffled smirk. (Looking back, I almost feel sorry for her. As entertained as I am by my ignorance, I am sure she was twice as amused.) In a calm, and noticeably quieter voice, the attending continued to press my opinion. “So, I am sorry. I am just trying to clarify what you think is going on. You think he might have a gonorrheal infection … from his livestock?” (In hindsight, I think she was doing her best to genuinely decipher my thought process while at the same time keeping the discussion vague enough to protect the patient’s pride.)

When she finally used the term “gonorrheal,” my mistake dawned on me and the reason for her confusion became very clear. At this point, I was, to put it mildly, profoundly embarrassed. I looked desperately at my resident for help, believing she had gotten me into this mess, with the hope that she would explain herself quickly.

The resident chuckled, fighting back more uproarious laugher. (As you can imagine, it’s generally not appropriate to be laughing hysterically at the bedside of a sick person with an undiagnosed ailment. In this case, however, some laughter was warranted, and essentially unavoidable.) “No, not gonococcus, Echinococcus.” All along she had assumed I had been trying to talk about the parasite infection she had proposed earlier. She had no reason to believe I was not saying what she told me to say, so she did not notice the difference in my pronunciation. Obviously, “gono” and “echino” don’t sound especially alike, but when this part is slurred, and the rest of the word, “coccus,” is the same, there is room for confusion. Apparently, I am a master of incoherence (this time on purpose).

Now the attending and the rest of the team were laughing. I finally had the nerve to glance at the patient. Unfortunately, now he was the one confused. I was still utterly humiliated. I could not believe that I had been confidently giving my presentation while all the while my attending thought I was implying that our patient had intimate relations with his livestock. Luckily, the attending took over the conversation and explained the amusement to the patient and his family. Now they were laughing, and the patient swore his undying love for his wife, although he did admit to owning some very charming goats.

We all “enjoyed” a chuckle at the miscommunication, but my eye was glued on the door, wishing I could make a beeline out of the room. I felt like I had long overstayed my welcome, and besides, I had to go figure out what the hell Echinococcus was.

I am using this story at my expense, not to scare you, but to both encourage diligent preparation on rounds, and, far more importantly, to demonstrate that things happen. We mess up. Everyone shares a good laugh (albeit at your expense), but at the end of the day, the medical team appreciates medical students for exactly this reason. Therefore, my ultimate piece of advice to new third year students is to preserve your sense of humor. It will undoubtedly serve you well, and it will keep others smiling around you. Good luck!


Emilee Sandsmark, an “all-knowing” MS4

Emilee Sandsmark Emilee Sandsmark (1 Posts)

Contributing Writer Emeritus

University of Colorado Denver School of Medicine

I am currently a Class of 2015 medical student at the University of Colorado. I am a CU student through and through, and went to CU Boulder for undergraduate. I grew up in various parts of Colorado, but consider Summit County, CO to be home. I have decided to pursue OB/GYN for my career, and can't wait to spend my life delivering babies and advocating for women's health.