From students to doctors

It's the morning before her anatomy final, and Stacie Beck couldn't be calmer.

"Well, if you don't know it by now, when will you?" she said. But she admits she's "so nervous."

Her classmate Noel Hastings agrees. Most people don't study right before the test; it's better to take the time and clear your mind so it is free while you are taking the test, he said.

Half the test is multiple-choice, "just like you would take for any class," Stacie said.

The other half is on cadavers.

There are two labs containing cadavers, four students per body.

The instructors will find a healthy part of the cadaver and stick a pin in it for the students to identify; there are two pins per cadaver and students have one minute with each.

Then come the questions.

"What arteries provide the main blood supply to this tissue?"

"What is the embryological origin of this structure?"

"What is the innervation of this structure?"

This test is on the head and neck and concludes their study of the "trunk" -- everything from the head down through the pubic region. The limbs won't be looked at until second year.

"I had to kind of prepare mentally for a long time," Stacie said, of seeing the cadavers. "Walking in on that first day -- it was surreal to be there with two rows of gurneys holding bodies. I had to gather my wits that first day."

It was Stacie's first experience seeing a dead person, and her first time cutting into one seemed unreal.

"It was very apparent there was no spirit left," she said.

Stacie said before she took the class she never understood what a gift it is to give your body for research. The class took a moment of silence before beginning the first day of the quarter.

"It's a real honor what we've been able to learn," Stacie said.

The cadaver lab is different for every student, because everyone deals with things differently, Noel said.

Noel's group named their cadaver "Ishmael."

"It's a person," he said.

During the first few weeks of class students didn't see the head or hands of the cadaver; seeing the personal aspects might evoke stronger emotional reactions. For Noel, being able to see the head in the last week was a way to say thank you.

Though it's not religious, Noel said the cadavers have been "born again" for med students' use. For five weeks they give everything to the students.

"We have no idea what kind of person they were before, but they made the ultimate sacrifice -- it's complete selflessness," Noel said. "Whatever mistakes they made are completely nullified by this."

As for the smell, it's "just bad," Noel said.

"Not like rotten -- just permeating. I feel like I can smell it on my clothes."

The smell is so bad that some students have stopped eating meat, Noel said, though it hasn't affected his appetite. It just doesn't seem very appetizing to some, he said.

Noel isn't the "traditional" student, though by appearance the med school does have a somewhat broad age range. He's 35 and has already gotten his feet wet in emergency medicine by volunteering as an EMT for a few years in New Mexico and then again on Vashon Island.

He also served as the director for the Emergency Medical System in New Mexico and was a medical assistant in the UW Medical Center emergency room while finishing his pre-med requirements.

Noel's academic background is in physics. With his accomplishments in that field, medicine could be seen as a step back.

"It's hard for some of us that are in a place in life where we certainly have some standing in our field," he said. "I've been published in other fields and now 23-year-olds are kicking my butt."

While serving as a teacher's assistant for a UW undergraduate anatomy course, Noel received his acceptance letter from the Medical School -- a welcome delivery since he had been rejected the year before.

"I know people who applied five times," Noel said.

Stacie was one of the lucky ones to be accepted on the first try.

"Every now and then you have a student who you can identify from the beginning is going to make very significant contributions in medicine -- Stacie is one of those people," said Dr. Raye Maestas, Stacie's assigned mentor and instructor of Introduction to Clinical Medicine.

Stacie has been married for three and a half years. Her husband, James, is a lawyer with Gordon Thomas Honeywell in Tacoma. Between law school and med school, a lot of Stacie and James' time has been spent apart.

They have two residences -- an apartment in Seattle and a house in Olympia. Before she started school, Stacie and James lived together in Olympia. The apartment in Seattle is for Stacie; it's near school so she doesn't have to worry about commuting. She calls it her "study nook," because she only really spends time there during the week. James lives in the house in Olympia and commutes to work from there.

They get together for dinner during the week some nights but mainly see each other on the weekends. They are in the process of looking for a place where they can live together but still each have a reasonable commute.

On the weekends they stay in either Seattle or Olympia, but often take weekend trips. Both are very passionate about outdoor activities including rock climbing, mountaineering, hiking and bicycling, also cross-country skiing and snowshoeing "when it's too wet to climb rocks," Stacie said.

Notoriously known for being the toughest class in med school, anatomy has lived up to its reputation. The schedule is demanding -- four hours in the morning, three hours in the afternoon, rounding out to be a solid 8:30 a.m. to 4:30 p.m. day.

There is no other word to describe anatomy more accurately than "overwhelming," Noel said.

The lectures have more than 100 PowerPoint slides. Noel misses most of them, but goes back later to fill in the information with what he learns out of the books.

"There's so much to know, no matter how much you try, you will never know it all," he said. "I am barely grasping any of it. It's an overwhelming amount of information to assimilate in a short amount of time."

The competition in class is fierce -- these are students who have always been at the top of the class. But even in a class full of overachievers, someone has to be on the bottom.

The first week, everyone walks around with "giddy, glazed eyes," Noel said. They're thinking that after all the hard work, entrance exams and interviews, they are finally in med school.

"At the beginning I felt like I was on the top, but now I'm at the back end," he said. "Even if you think you are doing great and you are learning tons, it doesn't feel like it's enough. There are definitely people who spend a good amount of time crying because they feel they can't keep up."

To help, the school offers counseling for students and their family members and partners if needed.

Noel said he just trusts that the school administrators didn't make a mistake. They wouldn't let him in if they thought he couldn't do it.

Third-year medical student Anna Shope can relate. She remembers crying a lot during those first few days of her first year, until she realized she had to give up the notion that she could learn it all.

"As soon as I had that realization that I can't know everything, everything fell into place," she said. "I had to give up."

In her class, throughout the year everyone had their own "breakdown" where they would reassess and strategize to take on the task at hand.

The only face-time first-years get with patients is in their Introduction to Clinical Medicine (ICM) course, where they conduct patient interviews. The purpose of the interviews is to obtain the patient's social history and an illness narrative, from which students learn the patient's life story and what is wrong from the patient's point of view.

"Our science classes can sometimes seem far removed from patients. ICM helps me remember what made me want to become a doctor in the first place," Stacie said. "[It] teaches us the art of medicine -- how to communicate with patients and how to listen."

It's still a long way from the patient contact they will have in their third year when they will spend six weeks at a time circulating though pediatrics, surgery, psychiatry, family medicine, obstetrics and gynecology. They also spend 12 weeks in internal medicine -- six weeks of inpatient care and six weeks of outpatient care.

"I know our time in the classroom is necessary to prepare us for third and fourth years, but learning in a hospital or other clinical setting seems like one step closer to being an actual doctor," Stacie said.

They are eager to get into the rotations, where they will gain hands-on experience.

"There is no way to really learn this stuff without getting into the hospitals and putting it into use," Noel said. "Right now my favorite part of medical school is my clinical opportunities. That is where I actually see patients that exhibit all the things I am learning in class, and then I see how the treatments work."

It's 4 a.m. and third-year medical student Steve MacLean wakes up for school. He is on call today so he will serve a regular shift from 5 a.m. to 5 p.m. at Harborview Medical Center. He will still be on call until noon of the next day -- but it doesn't end there.

Steve has lecture today, so after he is done at Harborview he will trek over to the UW to fight sleep in a lecture hall until 5 p.m. Then he is free -- until 5 a.m. the next day, that is.

"Surgery is one of those things that, up front, people fear naively, but in fact the human capacity is much greater than we all give it credit for," said Dr. Hugh Foy, an attending physician on Steve's surgery team. "People can do so much more than 9 [a.m.] to 5 [p.m.]. Steve's holding up under the strain just fine."

Before starting surgery rotation Steve was excited. He thought surgery was what he wanted to pursue for residency and for an eventual career.

But now he's not so certain.

The long hours of surgery wear on Steve; he is thinking of going into another concentration in medicine. So far, he hasn't felt a kinship with any of the rotations he has been assigned to, but he remains optimistic.

After serving a 36-hour shift on Thursday, he was back for more on Monday. He went to bed at 8:30 p.m. to catch up on sleep, not his idea of a fun-filled Sunday night.

"The hours are brutal," he said. "I want a family -- I want to have some fun. I knew it would be time- consuming, but I didn't realize it would affect me as much as it did. This is what [surgeons] live for. I have way too many outside interests."

Steve spends a lot of time with his sister Danielle, who lives in University Park near Tacoma; she's his nearest family tie since his parents live in Arizona. He and Danielle used to get together one night a week for dinner or a movie, but haven't since Steve started the surgery rotation. There's just no time.

Before the rotation is over he has to complete four essays and a final, but the long hours don't leave time for studying, and the surgery final is rumored to be the toughest there is. The redness in his eyes is the most immediate sign of his exhaustion.

"None of us have picked up a book -- we still have to work," he said.

With only two weeks left of the rotation, Steve is looking forward to more free time. He asked his parents to sign him up for a sushi cooking class for Christmas. He's excited, and has already bought all the supplies and a book.

"If I was stranded on a desert island, and I could only eat one thing, it'd be sushi," he said. "Even though it would be sick, because it would get all warm and shit."

Steve said his social life has been non-existent; he went from being someone who went out every Friday and Saturday night to someone who can barely remember the last time he spent a night out.

He doesn't even have much time for the basic necessities. He just went to Costco to get new contacts. He had the last pair in for a month, and he is only supposed to wear each pair for a week.

Two weeks before his surgery rotation ends, Steve considered general surgery for residency again. He changes his mind almost by the day.

"I just don't know what I want to do," he said. "I've never been so lost."

After ruling out OB-GYN, psychiatry, family medicine and maybe even surgery, Steve thinks he might pursue anesthesiology, emergency medicine or pediatrics, his original interest upon entering med school.

"I need to make sure I'm happy," he said. "If you're not happy, you're not going to be as good of a doctor and your patients will suffer. I know I'll find something that fits my personality and interests."

Steve spent six weeks living in Powell, Wyo., a "friendly spot," according to the Chamber of Commerce's Web site. He completed his first rotation in family medicine at Powell Valley Hospital.

Powell is an agricultural town of less than 6,000 people that prides itself on its sugar beets, malt barley, seed beans and cattle production.

"It was a huge culture shock -- small town USA," he said.

After moving back to Seattle, Steve served his rotation at Madigan Hospital at Fort Lewis in OB-GYN and then moved on to psychiatry at Harborview.

Partway through his psychiatry rotation, Steve came in contact with a female patient who showed him the human side of medicine. Steve was able to put a face to problems he had previously only read about in textbooks.

The patient had been diagnosed with depression and psychosis, which means on top of depression she heard voices. The medication wasn't having much of an effect, and the doctors chose to administer electroconvulsive therapy (ECT).

Steve said the procedure is by no means inhumane or as intrusive as it is generally thought to be. The patient is given succinyl choline to paralyze them so when they get the seizure they don't feel it, he said.

"It's not very painful -- some people complain of headaches, but it has [fewer] side-effects than anti-depressants," he said.

The change in the patient was profound, due to the ECT treatment.

"Now she is happy and joking around all the time," said Steve. "Before she would break into crying mid-sentence -- she was almost catatonic. It felt really good. To be honest, she was making me depressed. Just to talk to her."

The woman felt she was a bad mother and couldn't care for her children before treatment, Steve said.

"Now she's like a completely different person -- it's almost surreal," Steve said. "To see someone who couldn't hold a job or take care of her kids [become] someone who could hold a job and is excited to get her kids back."

Anna remembers her first week in pediatric rotation as being "really hard."

She was placed at Portneuf Medical Center in Pocatello, Idaho, a city in the western foothills of the Rocky Mountains.

The night after her first day, a newborn died. Anna said the infant never really took a breath on its own, but the doctors tried to resuscitate it for three hours. She wasn't there that night, but went to the autopsy the next day.

On her fourth day, a 19-year-old suffering from cystic fibrosis passed away. The girl had been in and out of the hospital her whole life, and everyone felt connected to her. Anna said the nurses were like her second mothers.

"I don't know if I could have handled that every week," Anna said. "There's something very wrong about pediatric death."

Luckily for Anna, there were no more deaths in the remaining weeks of her rotation.

Anna is now completing a rotation in family practice at a primarily Spanish-speaking facility in Seattle's South Park neighborhood. She is fluent in Spanish due to extensive language courses and traveling in Spanish-speaking regions, but she still had to brush up on medical Spanish.

"There is so much need for Spanish-speaking health care providers, so if I can, I'd like to get it down," she said.

Anna said when doctors use translators, part of the meaning can be lost. Patients don't always get the same quality of care.

But in a patient interview at Sea Mar Community Health Center, Anna's medical Spanish was almost flawless. She paused only a few times to ask the attending physician, Dr. Julio Jimenez, how to say certain words.

Even after completing rotations in general surgery, psychiatry, pediatrics and now family medicine, Anna said she still feels she is meant for a career in women's health.

Though she hasn't had her OB-GYN rotation yet, she anticipates it will be a good fit. She said in college she was the student sporting the book Our Bodies, Ourselves. She would help her peers whenever health-related issues would arise.

"I've always been really comfortable talking about more intimate issues," Anna said. "I've always been the person my friends would talk to if they had a question on a sexual issue. I work well with women -- making them feel comfortable."

Anna sees a need in women's health due to a "neglect" of women in health care in years past.

"I'm really interested in working with and serving women in a sense, because historically they haven't had great health care," she said. "Part of me feels there's a lot that's unknown."

Barely four hours into his on-call duties in Harborview's ER, Steve and team member Matt Lyons, also a third-year student, heard of a surgery to remove an abscess coming into the operating room (OR).

The surgical team, including at least one attending physician, a chief resident, a third-year resident and two interns, along with Steve and Matt, have been working together for four weeks now, and it shows.

"Do you want to scrub in on this?" Matt asked. Since they are on surgery rotation, either Steve or Matt will assist in the operation. In the OR they are mainly responsible for holding retractors, which pull back the skin. Occasionally they get to staple or cut string.

The majority of time is spent waiting around and then completing small tasks. The students are there to observe and are not given as much responsibility as in years past.

Foy said when he was in medical school about 30 years ago, residents and students were in charge of patient management, particularly after-hours. The physicians rarely came in to perform after-hours surgery.

Now, attending physicians are there all the time, and after-hours they will come in to perform operations if they are not already on-site, Foy said.

"On the one hand, students and residents don't have as much direct responsibility. They have much more supervision now, which may be the negative part," he said. "But the positive part is, they are taught by people who have much more experience, it's not the blind leading the blind."

The student's main responsibility while in surgery is to know about the patient, the disease and the anatomy. They get "pimped" while in surgery, meaning the physician will quiz them on all the information.

"It's the worst part," Steve said. "It's so stressful if you don't know an answer."

Steve has seen abscess surgery three or four times. It's not the most exciting surgery; an incision is made and the abscess is drained, but one of them still has to help out.

"We're going to fight, and I'll most likely lose," Matt joked, adding that he could lose an arm and still have to scrub in.

"I'll go," Steve said.

They usually rotate, and whoever scrubs in on this one will most likely miss out on the next procedure. Steve said instead of rotating, they shouldn't count the abscess in their running tally; that way he doesn't risk missing out on "cool" procedures. Matt offered to pull Steve out of the abscess surgery if something better came in.

"No, don't pull me out," Steve said. "We'll just rock, paper, scissors for the next one."

Surgery is far in the future for first-years, who are still concentrating on things such as mapping the nervous system and understanding the inner-workings of the human heart. This year's anatomy class had a different experience than in past years. Anatomy is usually taught concurrently with four other classes that last the entire quarter.

This year the school is trying a different model. The first-years take anatomy by itself for five weeks, and for the remainder of the quarter the students take four classes at once.

For the last nine weeks of the first quarter, first-year students take systems of human behavior, Intro to Clinical Medicine, histology and biochemistry.

The course load is a lot lighter, especially after the rigors of anatomy.

"I feel like I'm an undergrad again," Noel said. The lack of coursework is stressing Noel out, more so than when he had too much to do in anatomy class.

Noel described the quarter as the "bipolar" quarter because of the difference between the extreme demands in the first five weeks as compared with the "severe" lack of demand in the last seven weeks.

"Don't get me wrong. The material is challenging, but there is a lot of time to deal with it," he said. "In anatomy we would get truckloads [of material] everyday and few hours to deal with it before the next truckload came along."

But the lack of rigorous coursework has led to positives; the class has an interest group for students looking into emergency medicine.

The group met one evening to prepare for when they were scheduled to train with the Bellevue Fire Department to learn preliminary information about advanced cardiac life support.

As a former EMT, Noel had all kinds of tools and books to show off at the meeting. Noel said he just threw everything in a bag at the last minute.

One neatly organized bag contains all the makings of a "jump kit," or portable medical kit, including splints, gauze, a stethoscope and a pulse oximeter among other things. He also had a retractable neck brace. "If you get to the ER you will be embarrassed if you don't know how to take one of these off," said one attendee.

"These little bags are great for people vomiting," Noel said to a classmate, adding that these are things only fellow EMTs would get a kick out of.

"Oh, wow, those are great," his classmate replied.

Noel was disappointed more people didn't come to the meeting. "I really thought people would want to play more" (with the supplies he brought).

In the Bellevue Fire Department's training facility "Kelly" is sprawled out across the floor. He can moan, cough and make vomiting sounds. Kelly is a training dummy that costs between $8,000 and $9,000. Students can practice starting IVs, taking blood pressure and inserting chest tubes on the "patient."

Noel joked about how loud the dummy's sounds are compared with those of an actual patient as he inserts the chest tube and listens for "lung sounds," signs that the dummy is breathing. The dummy squeaked and he had his answer.

"He seems to be breathing," he said, while lying on his stomach, propped up by his elbows. "Love those lung sounds, I can hear them from here."

"These don't look like the lungs did in the cadavers," he added with a smile.