The Rookies

New grads have mastered the books, but it could take years to cope with the pressure of professional life when reputations and lives are on the line

Nestled on a foam mattress with blankets draped over her frail, 60-pound frame, Tulip, a 3-week old premature filly, struggled to take each breath. Patches of chocolate-brown fur were missing from her bony flanks while feeding and oxygen tubes jutted from her nostrils. The rhythmic drip … drip … drip of intravenous lines delivered a laundry list of medications throughout her body.

As she lay in the neonatal intensive care unit at the University of Georgia’s Large Animal Hospital, battling symptoms from a blood infection, seizures and diarrhea, some veterinary interns caring for the filly saw a heart-wrenching but inevitable death. Amanda House, D.V.M., saw an opportunity to save a young life.

“At one point, she had such severe acidosis and hypernatremia (a condition where blood pH is too low and sodium is too high) that she was blind,” says House, a UF assistant professor of equine extension in large animal clinical science in the College of Veterinary Medicine, who was the senior clinician handling the case in 2005. “Many students, and probably a couple of veterinarians, thought she should be euthanized.”

After using the drug tris-hydroxymethyl aminomethane, a product used in human intensive care cases to help improve blood pH without increasing sodium levels in the body, and nearly four months of seesawing in and out of treatment at the hospital, Tulip slowly improved, eventually making a full recovery.

“If I was at the beginning of my career, I may not have been inclined to give the foal a chance,” House says. “Today she’s doing great, galloping around in a beautiful pasture and having a great life.”

Like House, most health-care professionals do not walk off the stage at graduation with Zen-like patience and the ability to solve every medical crisis with the skill and ease of Doogie Howser, M.D. — if it was that easy, the medical industry would be inundated with physicians and there wouldn’t be a nursing shortage. Rather, students and recent grads will learn that it can take years to feel comfortable in their professional skin and that real-life lessons begin beyond the confines of a 2,000-page medical textbook. It’s the sleepless nights spent drafting detailed nursing care plans. The 18-hour marathon shifts in the ER and the beaming smile from a pediatric patient who learns she is cancer-free.

"You get a lot of practice as a senior resident,” says Sarosh “Shawn” Batlivala, a third-year pediatrics resident. “You get to see how everything you do helps kids get better.”

Training Day

Kendyl Atkinson’s living room looks more like a science library than a place to watch “American Idol.” Her coffee table holds pharmacology reference books, while a 5-inch thick text about nursing care management rests on top of a school-bus yellow beanbag across the room. Her laptop has become a permanent extension of her body as she stays up for hours at night writing detailed nursing care plans. This has been life for the past nine months since she started classes as a first-year student in the College of Nursing.

“I thought my first semester of undergrad was hard, but when I went into nursing school it was more difficult than anything I had ever done before,” Atkinson says. “The first shot I ever gave I was shaking because I was so nervous. But the more patients I see, and the more experiences I have, I learn that there are so many areas I might want to go into. Right now, I like the Neuro ICU.”

In 2007, UF awarded nearly 1,700 degrees to students from its six professional colleges, where future nurses, physicians, pharmacists and physical therapists receive intense, hands-on training from day one. As incoming health-care hopefuls begin classes, these students are more likely to look patients in the eye and ask how they’re feeling earlier on in their educational experience than students 30 years ago.

“That’s something I never had,” says Richard Davidson, M.D., M.P.H., chair of the College of Medicine curriculum committee who was a medical student at Vanderbilt University in the late 1960s. “We started to see patients in our second semester of our second year. The way we now introduce clinical medicine on the first day of medical school hopefully helps (students) get a lot of practice from day one.”

First-year students complete three-week preceptorships where they are linked with community-based primary care doctors. In another course, students visit families in their homes along with other health professions students to help foster interdisciplinary work early on. The Harrell Professional Development and Assessment Center also offers an opportunity for students to train, allowing them to interact with standardized patients, individuals trained to simulate symptoms of ailments or who have stable abnormal physical findings.

Students across the health-education spectrum climb a carefully structured ladder of increasing responsibility. They begin by teetering on the bottom rung, slowly building a solid foundation of knowledge from course plans largely based on objective exams and carefully supervised clinical experiences. In the College of Medicine, third-year students edge closer to the top when they are assigned to monitor two to three patients under the supervision of an attending physician. As a culminating experience in their fourth year, students serve as sub-interns, an experience that Davidson describes as “Internship 101.” Students take on duties similar to first-year interns, ordering nutrition plans, medications, lab tests and other treatments under the supervision of attending physicians.

“I didn’t know what it meant to be an intern until my fourth year,” Batlivala says. “I had two really great senior residents who took me under their wing.”

Davidson says he agrees that most students don’t open their eyes to the reality of the resident lifestyle until their last couple of years of school.

“The first two years of medical school is traditionally similar to college,” he says. “Sometime during their third year they realize they’re really going to have to take care of very sick patients in the middle of the night, and that it’s really not negotiable. That can be sobering.”

The Contenders

It was late at night in April when most students in Gainesville — with the exception of some procrastinators typing last-minute papers in a caffeinated buzz — were sleeping under a blanket of darkness. But Melanie Wexel, D.D.S., a third-year orthodontics resident, didn’t have that luxury. Under the glow of her office lamp at the UF College of Dentistry, Wexel was busy compiling her patient review, a written summary of the progress and outcomes of many of the patients she has treated over the past two to three years.

Spending extra time on important projects comes with the territory of being a senior resident, where some days are spent going beyond the call of duty. But when she first moved to Gainesville in 2005 to begin her residency, Wexel dealt with more than adjusting to fluctuating schedules during her transition from dental school to a residency program in an unfamiliar place.

“It took time to get adjusted because I had no family or friends here,” says Wexel, who attended dental school at Virginia Commonwealth University in Richmond, Va. “In the beginning you’re overwhelmed. Orthodontics was like learning a whole new language for me because in my dental school orthodontics was not the primary focus.”

For Wexel, time and experience was the best prescription to become adjusted. As a third-year resident, she said she enjoys how faculty members place their trust in the senior residents’ hands, allowing them to have a large level of independence. Just three years ago, she would treat four to six patients a day. Today, she sees between 10 and 20 patients, while delegating tasks to orthodontic assistants and juggling more than one complex case at a time. Now, she says she is finally seeing the results of patient cases she began two years ago.

“You see (patients) at age 11 and then, all of a sudden, the little boy you’re treating is suddenly taller than you,” says Wexel, who completes her training in May. “It’s a major source of accomplishment in my life right now.”

Relationships between senior faculty mentors and residents help increase the new professionals’ confidence, allowing them to feel more comfortable as they become more independent. This is at the heart of many of UF’s professional residency programs, where new physicians, dentists and veterinarians practice medicine alongside pioneers in their fields and specialties.

Pointing at his office wall plastered with more than a dozen framed photographs, Timothy Flynn, M.D., associate dean of graduate medical education for the college’s 650 residents, rattles off the names of young surgeons he has mentored throughout his 24-year career, never missing a beat. Some have gone on to positions at Brown, University of Tennessee and Vanderbilt, while others have forged careers where they began, at UF. But they all share one common mentor.

“You develop a strong bond with these people,” Flynn says of his former students. “You’re spending so much time with them, and they’re there because they want to be just like you one day.”

As much as medical students want to end up as successful as their mentors, it takes several years to get there, constantly practicing and building relationships with patients. Six months ago, Batlivala, a pediatrics resident, used a calm, soothing voice to coax a 2-year-old with a cut above his eye to remain still. With the reassurance of his mother, the toddler didn’t cry or struggle as Batlivala moved toward him with a needle to suture his wound, something that probably wouldn’t have gone so smoothly in his days as a medical student.

“Medical school is designed so it gives you the basis to jump,” Flynn adds. “You don’t learn to be a healer there. That’s the beauty of residency.”

The Champions

So, how long does it really take for a nurse to feel like a nurse and a pharmacist to feel like a pharmacist? The truth is it all depends on the individual.

For Hannah Palmer, Pharm. D., a 2006 College of Pharmacy alumna, the compilation of the lessons she learned at UF hit her in a series of “Ah-ha” moments she later shared in an e-mail she sent to Paul Doering, M.S., a distinguished service professor in the department of pharmacy practice, in May 2007.

“I was the one who you may remember making a bit of a scene one time in the middle of our literature review class,” writes Palmer, who was completing a pharmacy practice residency in Charlottesville, Va., last year. “At the time, I could not understand why we took so much time reviewing these studies. I have learned many a thing this year, but if I could pinpoint one thing I have truly perfected it would be my ability to evaluate literature. I wanted to personally thank you for not reprimanding me at the time of my outrage. I now truly understand the importance of this and often think back to my attack of literature evaluation and wonder how I was so naïve.”

It’s moments of clarity, like Palmer’s, where residents and newly christened professionals realize that when they’re on their own, the white coat or stethoscope are much more than symbols of a profession.

For Flynn, a veteran vascular surgeon, it took about six to eight months after completing residency to feel like an expert confident in his ability to handle the cases that came his way.

“It might take 10,000 hours to learn to play the violin,” he says. “It can take 10 times as long to learn how to be an expert in your field.”

Remembering Tulip, one of the more intense cases of her postresidency professional career, House said she feels there will always be cases that surprise doctors, whether they are in their third or 30th year of professional practice.

“I think all of us can relate to a time when we were stressed or panicked about a critically ill case,” she says. “Even as a faculty member, that case taught me a lot. Early on in my career, I wanted to jump to conclusions and know the answer right away. Now I realize how essential it is to keep an open mind and investigate all of the possible diagnoses and options for treatment.”