The summer between the first and second year is pretty much the last free summer. After second year, students have to take Step 1 of the USMLE exam. Then third year begins in July. There is also no summer break between the third and fourth year. I do keep hearing of some extra time during 4th year, but in theory, that’s supposed to be used to interview and different residency sites.

Anyways, this is my last free summer. Quite a few of my classmates are doing mission work. One has blogged about a trip to Africa. If you’re interested, you can read about it at doctajay.com. Other classmates are doing research to pad their CVs for those ultra-competitive residencies.

I had applied for an externship and my first choice was Chicago. Unfortunately I received an email stating that there was so much interest in the program and that they were sorry I couldn’t be offered a spot in the program.

I didn’t really have any backup plans. And because I really wanted to go to Chicago, I didn’t apply for any of the research projects on campus. So now my summer vacation has really become my summer vacation.

But I think I should do something. So I’ve told myself I’d review the material from this year. I think Anatomy is tested on Step 1 and there won’t be any Anatomy lectures next school year. Besides, a review never hurt, right?

So that’s the plan for the summer. Since I’m on vacation, I’ll probably have to draw from first-year experiences I haven’t previously written about.

I had the chance to attend a meeting in which the famous Dr. Leonard Bailey spoke. For those who don’t know, Dr. Bailey performed the first infant heart transplant surgery in 1984 at Loma Linda University Medical Center. (By the way, I really don’t intend this to be a discussion on the ethics of that operation…) Each week during winter quarter my school invited a speaker to speak on one of the values of Loma Linda University. Dr. Bailey spoke about excellence. It was a good speech. I’d even call it inspiring.

During his presentation he read something that Vince Lombardi said to his Packers team many years ago:

Gentlemen, we are going to relentlessly chase perfection, knowing full well we will not catch it, because nothing is perfect. But we are going to relentlessly chase it, because in the process we will catch excellence.

He proposed that each of us sitting there had experienced excellence at one point or another. After all, we had all been accepted into our respective programs. I sat in my seat wondering about a pursuit of perfection — a pursuit with the hope of catching excellence.

And I wondered: can I be excellent?

This year one of my year long classes has been a course called Physical Diagnosis (PDX). In short, the class is all about the physical exam. We learn normal “human morphology” as well as the skills needed to carry out a physical exam, starting with the patient history. We have been learning to auscultate for heart sounds and lung sounds, percuss the lungs and even liver, and palpate an abdominal. In one of the PDX Labs, we learned how to perform a funduscopic exam (eye exam with the shiny light).

At the end of the year we are given a skills test, frequently referred to as the Freshman OSCE. The exam is approximately one hour long, and all the students are paired up with a partner. The examiner, one of the PDX staff members, will announce which exam to perform and one student will perform the exam on his or her partner.

Because of its difficulty, the funduscopic exam is one that all students have to perform. I received a tip from an upperclassman. He said that since we will have had plenty of time to practice with our partners, we should just remember how many times to we need to turn the dial in order to focus in on the cup and disc of the eye. That way, in the exam, we can fall back on just counting how many clicks we need. If necessary, we can just fake the exam and pretend to look in the right areas even if we don’t see anything. The tip seemed really useful. Obviously one cannot do that with a real patient because every eye is different and counting the number of clicks will not work in that scenario. But I can see how this can really make things easier when the stress levels are high.

And then I wonder to myself, “Can I be excellent if I ‘help’ myself by counting?” Am I cheating myself out of perfect opportunities to practice my funduscopic skills on a healthy patient, when the only thing at stake is my grade and not someone else’s health? More importantly, am I cheating my future patients?

If I wanted to be selfish about it, I could probably conclude that I can’t afford (financially and professionally) to be careless with patients. But medicine is all about the patients, isn’t it? So maybe it is the patient that cannot afford for me to be careless. In one PDX Lab session the instructor, a pediatrician, said, “Your patients’ lives depend on you not screwing up. Don’t do it. Don’t do it!”

That was it. That was the pep-talk in less than fifteen words. That was her encouraging us to aim excellence in our clinical skills.

Throughout this school year I have witnessed numerous examples of excellence:

• A blind doctor who needs a seeing-eye-dog and walking stick is able to “see” patients and remember details about each one. His memory and hearing constantly amazed me. If he can get through medical school without sight, what do I have to complain about?
• A psychiatrist is able to deftly negotiate peace between an angry young lady and her mother. Only moments before, a resident struggled with how to deal with them. But the attending came in, took charge, and diffused a volatile situation.
• A surgeon speaks to an old patient who is terrified about chemotherapy. He comments that he has fought in three wars, but “this” freaks him out. She (the surgeon) took his hand, told him the pros and cons of treatment, and told him that no matter what his choice was, she would not care for him any less. It was absolutely amazing the way she addressed the patient. Clearly, there was a solid doctor-patient relationship there. A textbook example of “bedside manner.”

Since I heard that speech I have wondered if I can be excellent. That may not be the right question for me to ask of myself. There shouldn’t be a question of whether I can or cannot relentlessly pursue excellence. Because in the end, when a patient’s life could be on the line, excellence is the only choice. There can be no other alternatives. That’s a lot of pressure. And that’s scary. But if I can’t handle that, I probably don’t belong here.

Oh, and by the way, I passed my OSCE. And I didn’t use the counting method.

*Image of funduscopic exam from Merck Frosst