The Path Through Penn Medicine

Seven students. Four years. Though some travel together, the path through medical school is a different journey for everyone.

By Rachel Ewing and MaryKate Wust

It is the fall of 2015, a time of both reflection and new beginnings. The Perelman School of Medicine is celebrating its 250^th anniversary, while the bright, new Henry A. Jordan M’62 Medical Education Center (JMEC) opens and welcomes medical students for the first time. The incoming class this year is the first to study in the midst of this newly interconnected hub of medical education, clinical care, and research on Penn Medicine’s West Philadelphia campus. Included in this fresh-eyed cohort are a cellist, a health policy analyst, and a wilderness first responder, among other new first-year medical students who are profiled in a Fall 2015 Penn Medicine magazine story called “The Path to Penn Medicine.” Arriving from distinct origins, these students converge onto a shared new beginning at Penn in a milestone year.

What follows is the story of the next four years of that journey, related by the students themselves as it unfolds.

“You Will Never Have More Free Time”

When a fourth-year medical student imparts advice to the MS1 class—You will never have more free time than you do during the first year, but later on, your academic and clinical obligations will become more fulfilling—Miami native and Brown University graduate Amanda Labora inwardly scoffs. “I couldn’t possibly have less free time,” she thinks.

During the preclinical curriculum—classroom learning, first in modules focused on basic science and gross anatomy, then in modules organized around organ systems—the amount of knowledge she must absorb hits Labora and her classmates as a deluge. It threatens to drown students who felt confident as the best and brightest among their undergraduate peers.

“It’s a huge learning curve,” says Mariah Owusu-Agyei, who majored in economics at Penn, worked as a financial analyst, and later completed pre-med studies at Bryn Mawr. “You don’t know the most efficient way to use your time. You also just don’t have enough time.”

As she begins medical school, Katie McDermott intends to be “the sort of student who attends every lecture and prepares thoroughly for every small group, studies early and eats well, and sleeps enough and reads for pleasure.” Immediately after describing this goal, she admits she never consistently maintained those habits before as an undergraduate at Fordham University or post-bac student at Bryn Mawr. Things don’t work out that way during her preclinical studies, either. Some subjects come very easily. Others don’t. She comes to rely heavily on her learning team, a small group of classmates assigned to work together, for both academic and personal support. This group creates “a safe place to learn, a safe place to come and say, ‘I don’t know this,’ or to say, ‘I do know this,’ and then to hear that I’m wrong. And to have a really good time,” she says. Finding a love for collaborative learning makes intuitive sense to her, as she’s discovering that medicine is “inherently team-based at every level.”

Despite the hardships, there is a feeling of arriving on the right path. “Once I get into the books, I love it so much,” Owusu-Agyei says, bubbly even at the end of a long day. “Even though I’m probably the most miserable I’ve ever been in life, I’ve almost never been as happy as I am now. That’s the weird thing about it. It’s very challenging. It takes a lot out of you. But at the same time, I just love waking up and going to do this. I feel like I definitely made the right decision.”

Extracurricular Pursuits

Gina Chang, a Washington University graduate and classically trained cellist, studies a lot in her first year, but finds time to spend with old and new friends, too. “Part of the reason I chose to go to Penn was that the students I met seemed well-balanced, able to study hard but also maintain other interests and relax, and I was happy to find that that was the case.”

Sabrina Layne, a Stanford alum from Long Island, finds that, perhaps for the first time in her life, she has a hard time concentrating on studying; basic science just isn’t as motivating as learning about real patients, the real people she wants to help. She fills that void by volunteering with a student-run community clinic, the University City Hospitality Coalition (UCHC), as does Michael Stephens, a Thomas More College graduate who also pursues a clinical interest during this time by co-chairing the student Dermatology Interest Group. Working with UCHC to provide care to underserved patients represents these students’ first foray into clinical medicine, a first lesson into how to take a history and do a physical.

“Being able to provide health care for our clients, many of whom are homeless and would not have access to care otherwise, is an affirmation of why I decided to pursue medicine in the first place,” Stephens says.

Claire Hirschmann, a Yale graduate and experienced educator, begins volunteering as a coordinator at the Germantown youth and adolescent homeless shelter Covenant House. Regularly clad in her characteristic bright, outdoorsy plaid—matching her personality—she runs weekly activity nights and begins working in their health clinic, helping to take histories and beginning to glimpse what medicine looks like in low-resource settings.

Owusu-Agyei continues to volunteer at the Seventh-Day Adventist church in Philadelphia that she and her family have attended with other local Ghanaian immigrant families since her youth. As an undergrad, she coordinated activities for children, including helping the kids produce a play centered on helping those in need. As a medical student, she leads two classes built around camping skills, fundraisers, and community outreach. “It’s like Boy Scouts and Girl Scouts with a religious twist,” she says.

Summertime

As one of the community outreach coordinators for the United Community Clinic (UCC), another student-run clinic serving West Philadelphia, Chang helps plan the Bike Rodeo, UCC’s annual health fair, in the summer after her first year. She also teams up with a classmate, Dan Zhang, to establish the Penn Med Symphony Orchestra. More than 40 medical students, other graduate students, physicians, and nurses answer their call and find time to attend regular rehearsals.

This summer—12 months into the 18-month preclinical curriculum—is the one truly independent summer Penn medical students get. Next year, and likely for the rest of their careers, they’ll spend summers in the clinic.

Layne begins exploring an interest in quality improvement and patient safety research as a summer intern, and she loves it. She’s working on data analysis for a project that aims to improve the rate at which eligible surgical patients receive blood thinners to prevent venous thromboembolism.

Owusu-Agyei, meanwhile, travels to Ghana—where she was born—and begins working on a research project assessing stroke risk and interventions for young children with sickle cell disease.

Hirschmann spends the summer of 2016 interning in Washington, D.C. under the Assistant Secretary for Preparedness and Response, building on her interest in disaster relief and emergency medicine through a bird’s eye view of preparedness efforts for the Democratic and Republican conventions.

The class’s preclinical studies resume in the fall; it’s back to the books and a deep immersion in the body’s organ systems.

In December, the Penn Med Symphony Orchestra holds its first concert and earns a standing ovation.

Into the Clinic

The start of clinical clerkships, for Layne and many others, is a thrill. “By engaging with patients directly—understanding their history, what kinds of symptoms they are having, and how those symptoms affect their lives—I feel like I’m learning so much more medicine than I ever did during the pre-clinical year and a half,” she says.

Clerkship is a time when medical students learn to appreciate thinking about what a patient says and what their symptoms show, and to diagnose and develop treatment plans.

As rewarding as it is, clerkship year is also incredibly hard. Long hours compound the challenges of learning new skills.

“As you go through the different rotations you’re essentially learning a totally different thing in medicine,” Owusu-Agyei says. “Say you have rotation for a month. At the end of the month is when you feel most comfortable, but then you’re starting something new!”

Then there are the inevitable “med student moments,” such as the time that Labora accidentally calls an attending general surgeon by his first name.

These struggles are just the beginning. Hardship and fatigue will be part of the job for years into the future as a resident and as an attending physician, Layne realizes. And so, as she spends more time in the clinic, she also periodically reflects on what has kept her energized along the way. She tells the story of her last day on rotation in the ICU when she almost teared up saying goodbye to an elderly patient and his wife, whom she often joined at the bedside and who’d told her how meaningful their interactions had been. “That happened on more than one patient interaction,” she says. “Those were the little golden nuggets that get you through the worst parts. Those were my most fulfilling moments that I would go home and talk about, that motivated me to be more efficient or to learn other things upfront so I could make time for that.”

Yet some challenges can’t be addressed during a single exam, or even a single hospitalization. “Listening to patients’ stories and realizing there’s not much that can be done to help them because their medical issues are a very small portion of their overall problem has been a hard part of the year,” Chang says. She has already been contemplating getting a master’s in public health to broaden the perspective she will get with a medical degree. The scales begin to tip toward applying for the program.

Mastery and Differentiation

Clerkship is a sample platter of many of the major clinical specialties. From January of their second year through December, medical students are not just learning, but also evaluating their preferences and fit in each area, and with each type of task.

In the midst of clerkships, McDermott finds surprises. Talking with patients about routine, clinically mundane health maintenance issues like eating right, exercising, and blood pressure, hadn’t initially seemed particularly appealing to her: “This feels selfish to say, but there’s not much instant gratification for a physician in that kind of counseling.” She rethinks that attitude at the end of her family medicine rotation when she sees some patients return for a second visit. One woman, a recent immigrant who spoke little English, had initially come in with her daughter. She had high blood pressure. McDermott spoke with her about daily walking for exercise with her daughter, eating steamed vegetables, and eating less salt. Three and a half weeks later, she had lost almost 10 pounds and her blood pressure was lower. “She was so happy, proud of and excited by her progress,” McDermott says, “and I was proud and excited, too.”

But McDermott is at least as surprised to love surgery, surprised to see the continuity of care in surgery and the quality of doctor-patient relationships. And she’s impressed by the speed with which a surgical procedure can turn a dire clinical situation around, as she recounts in the story of a woman who arrived at Penn terrified and barely able to breathe because of a large mass in her airway. “Within an hour and a half, she was taken to the operating room, the mass was removed, and she woke up breathing, talking, thinking, like none of it had ever happened. And she was so, so relieved.”

That rotation clinches McDermott’s decision: “From my first day in the OR, I felt there wasn’t anything else for me.”

As clerkships draw to a close, bewilderment slowly fades into mastery.

“It’s remarkable how much you learn in the context of a year,” Stephens reflects, in his characteristic soft-spoken and thoughtful manner. “It’s not a perceptible moment when you suddenly feel comfortable in your shoes, but over time you start to feel like, ‘I can do this.’ I’m not going to be able to do it tomorrow or next week, but there will come a point in time when I can do this. This isn’t this ethereal concept of being a physician anymore, it’s actually something that I can reach. It’s actually kind of incredible.”

Impact, Autonomy, Exploration

“There’s nothing quite like the end of a person’s hospitalization when they are thanking you for being there for them,” Owusu-Agyei says, in the midst of a sub-internship in internal medicine at the Corporal Michael J. Crescenz VA Medical Center. “Just yesterday, I called my patient’s daughter, his power of attorney. She said she was very happy to tell other people that this was the first time [in many hospitalizations] her father had a black female doctor. It made her feel so proud, it made her want to tell her kids, and she has other people in her family who are thinking of going into medicine. That really touched me.”

The VA sub-internship, or “sub-I,” is a popular choice, as post-clerkship students take electives in specialties they haven’t experienced before, or seek more hands-on experience in broadly applicable disciplines like internal medicine. It’s the time to make a choice—or to strengthen one’s preparation for choices already made—for a future specialty.

As he sets sights on a dermatology specialty, Stephens crafts his sequence of electives to build the strengths he’ll need. He follows the sub-I with a dermatology elective, a pediatric dermatology rotation, and electives exposing him to conditions that overlap with dermatology including rheumatology, hematology/oncology, and infectious disease.

The eight-hour test that constitutes “Step 1” of the U.S. medical licensing exam is a major hurdle after clerkship year; each student has a strategy for when to take it. Layne and Owusu-Agyei are among those who opt to take it early, studying in the fall, then turning their attention to clinical electives, which both are relying on to help them narrow their broad interests in a lot of specialties. McDermott takes it later, disappearing into a self-described “Step 1 hole” of intense studying the following spring.

Hirschmann enjoys electives in adolescent medicine and family medicine. She later takes an elective in family planning and an away rotation in emergency medicine at the renowned program at Highland, in Oakland, Calif. It’s a county program focused on the safety net hospital for Alameda County, and Hirschmann starts thinking about how reproductive health can be addressed in the context of emergency care.

Scholarly Pursuits

The fourth year of medical school not only offers a continuation of elective rotations; it’s also the time when students at the Perelman School of Medicine must branch out into a so-called Scholarly Pursuit—at least three months spent on a hypothesis-driven project under the guidance of a mentor.

As Stephens works toward a career in dermatology, he finds multiple research projects that pique his interest. For one, he teams up with pediatric dermatologists at CHOP to better understand the clinical context—and potential impact—of a new teledermatology platform they are piloting. For another, he partners with melanoma researchers working to better predict which patients will respond best to immunotherapy drugs.

Labora, long committed to health equity and compassionate care for women’s health, has a “totally out of left field” experience beginning a basic science project this year investigating how statin drugs for cholesterol management impact the immune system. She has never held a pipette before this.

For Hirschmann, a scholarly pursuit dovetails with working on a certificate in medical education. A devoted educator since before medical school, her journey at Penn has included working as a teaching assistant for anatomy, doctoring, and microbiology and infectious disease courses. This work with first-year students encourages her to create an elective for all class years focused on leadership—a skill she recognizes is vitally important in medicine, yet is not overtly built into the core curriculum at Penn or most other medical schools. It’s a way of sharing what she sees as her own strength as a leader: “One of my favorite things is watching people do things they’re good at, and telling them that, and trying to find specific things to identify about who they are and why they are wonderful in the world.”

Empowered Students Empower Others

While Chang continues to play in the orchestra, she also partners with a community organization called Play On, Philly! that provides free music education to students in Philadelphia who are not otherwise able to receive music lessons. Through the partnership, the students get to play in a Penn Med Symphony Orchestra concert.

Chang is also a coordinator at UCC after two years of volunteering, helping to organize other upperclassmen volunteers and sending them teaching materials to use in mentoring younger students. At UCHC, Stephens is now the mentor. As a volunteer and an educator, Stephens applies the skills he has developed and his advanced perspective to help first- and second-year students make their own leap into clinical care.

“It’s a neat experience to still be involved in patient care, but also have that added component of mentoring first- and second-year students and helping them learn lung sounds and how to take a history,” he says. “It comes full circle—you start off relying on others to find your way through, and then you eventually get to a point where you have some knowledge that you can pay forward what’s been invested in you.”

Stephens also embraces other opportunities to educate, including by serving as a chief anatomy TA for first-year students during his fourth year.

After excelling in a bedside ultrasound elective, Labora is invited to teach first and second-year students how to perform right upper quadrant ultrasounds, echoes, and first trimester pregnancy scans. Developing a broader perspective of how ultrasound is applied outside of OB/GYN in specialties such as emergency medicine, and getting the opportunity to share it with her younger peers, are things Labora knows she will carry throughout her career. She also begins volunteering with a women’s refugee clinic.

McDermott, embracing her interest in surgery, finds opportunities to lead at the Agnew Surgery Clinic, a community clinic that provides patients—many of whom are uninsured, underinsured, undocumented, or homeless—with easier access to surgical triage on a monthly basis. As the clinic’s community outreach coordinator, McDermott works to increase referrals, communicates with other student-run clinics and ED residents, and liaises with the community to make sure populations who could benefit from the clinic’s services know it exists. McDermott is deliberative in her word choice—she wants to be sure that what she says is what she truly means. So her comment is emphatic: “This clinic has definitely been the most meaningful extracurricular in which I’ve been involved during medical school.”

The experience inspires her to pursue an additional degree during her residency, potentially in public policy or health systems.

Global Ventures

Chang returns to campus in the fall of 2018 after spending her final third-year clinical elective rotation in Botswana. Then she begins her own additional degree right away—a master’s of public health. While many of her original classmates are now beginning their fourth year of med school, she is diverging on a different path. “I’ve always wanted to practice clinically while also doing public health research,” she says. “I wanted to learn how to design projects and run them from the beginning, how policy works, how health systems fit into the larger public health realm… It gives me the chance to practice thinking in different ways.”

Owusu-Agyei, too, follows a unique path this year—back to Ghana on a research fellowship. After spending a year out, like Chang, she will graduate from medical school in 2020. She divides her time between clinical work at the HopeXchange Medical Center in Kumasi and nonstop research, with projects on sickle cell disease, on compliance with malaria treatment guidelines, and on skin bleaching. The latter topic lines up with a specialty she’s now seriously considering: dermatology. “A lack of access to dermatology clinics can mean physicians don’t see many black patients, and that leads to a lack of knowledge of how to treat their conditions,” she says. “I’m interested in getting that exposure, diving deeper into this issue, and seeing more black skin pathologies.”

Still, she is also eager for the project be wrapped up after months of hard work so she can take some time to explore. Joining a local church is her major extracurricular venture. It helps her feel connected to the community.

“Honestly, I don’t miss medical school at all,” she says, laughing. “It sounds bad, but it’s true. My experience here has been more than rewarding, and I’m really happy that I took the time to come here and continue the journey in a different way. I still feel like I haven’t had the chance to explore everything or definitively pick my specialty, so this extra time has been really valuable to me.”

Applying and Interviewing

For the rest of the class, residency applications loom as a dominant concern as the fourth year begins—along with Step 2 of the medical licensing exam. Applications submitted, they wait. Then the interview opportunities come in—and it’s time to act.

Layne is sitting in the dentist’s chair when she receives her invitation to interview at Penn—where she is eager to stay. Luckily, she has set up a dedicated email account for her residency applications and set it to forward all messages to her boyfriend, just in case she doesn’t see them quickly. He calls her as soon as he sees it. “The sucker is in my mouth, and I’m saying, ‘Sorry, I have to take this,’ and I pick up the phone and it’s still in my mouth and I’m drooling all over myself,” she recounts.

By now, Layne has an eye toward later specializing in either cardiology or gastroenterology after a residency in internal medicine. She wants to find a program with opportunities for residents to do QI work, and she wants to stay in or near Philadelphia; the boyfriend who so helpfully called her at the dentist’s office is a PhD student who is committed to staying here for at least another three years. Layne trusts her parents as a vital sounding board throughout her application and interviewing process. Both physicians, they listen to Layne’s thoughts about the pros and cons of each program where she interviews. They also urge her to take the hardships of a potential long-distance relationship seriously: They know them well, having matched for residency in different cities before Layne’s mother transferred programs after her intern year.

Still, as Layne interviews at a number of programs across the northeast, she finds there are many where she could be happy to continue her training.

For many, the process is also grueling. Labora spends only two nights in Philadelphia during November—but thanks to the Perelman School of Medicine’s alumni host program, she only stays at a hotel once and relies on loans less than she’d expected to finance her interview travel. When interviewing at UCSF in San Francisco, a stay with the school’s vice dean for medical education, who is a Penn alumna, is a powerful and meaningful experience for Labora to connect with a potential mentor. “She welcomed me into her home and shared her own interesting career path,” she says.

For Hirschmann, applying in emergency medicine, people are the most important ingredient. “You could be crawling out of your sleeping bag to adjust a tent in the middle of a rainstorm, and it could be the most fun activity you’ve ever done in your life,” she says. “Even if it’s pouring, even if it’s midnight, doing it with someone who sees the fun in it can make a miserable experience extraordinary. Similarly, in whatever residency program I end up, I’m looking for a place where I feel like the people are going to make me excited to be where I am. Even when it’s really hard, even when I make a mistake, even when I feel like I’m the worst doctor in the world, there are going to be people around me who know me and trust me enough to make me see and become the best version of myself.”

She is excited about the relative newness of emergency medicine as a specialty; it’s something she sees as “permeable” and infused with creativity, as clinicians map new ground for addressing the opioid epidemic and other challenges that intersect with emergency care. Hirschmann herself wants to explore how the specialty can address reproductive health issues. “I want to be at a place where the outlook of the program is that there is a lot of possibility in what we do,” she says. “The world is big, and we have so many opportunities to effect change within it.”

Make Me a Match

On March 15, 2019, anticipation is in the air at JMEC.

Layne has kept her nerves at bay up until this point by planning for an event last night honoring her best friend; today she is trying to have only happy thoughts. Today is the day she will learn if she can stay in Philadelphia to train in internal medicine.

Stephens arrives at JMEC moments before the ceremony and is absorbed into the swarm of excited friends, eager to know where he will go for dermatology.

At noon, it begins.

“Class of 2019, we are so proud of you!” Senior Vice Dean for Medical Education Suzanne Rose, MD, MSEd, says to the cheering crowd.

“We know you’re anxious, super excited, but we also want you to be present,” says Dean J. Larry Jameson, MD, PhD. “Be present because this is a day you’ll remember for a very long time. We prepared you well at the Perelman School of Medicine for this next phase, and you’re going to represent us incredibly well as you go on to your internship and residency.”

Hundreds of students and their families and friends fill the rows of chairs facing the atrium stage overlooking the Philadelphia skyline. Hundreds more crush together in the space behind, as far back as the elevators. In this packed zone, too far back to see even if she were taller, Layne waits with her parents and boyfriend.

Chang, taking a break from her MPH studies, stands a short distance behind, cheering for her classmates. She and Owusu-Agyei will be back here in a year’s time when both will finally meet their own matches—Chang’s in pediatric neurology, Owusu-Agyei’s perhaps in dermatology, but for now she’s still in Ghana and glad to have some extra time to decide.

Hirschmann is a short distance away, dressed in her “nice plaid” for the occasion. She’s feeling nervous excitement she compares to a track meet. Each person may be running individual races, but the whole team is there, anxious to see how they’ll all do. She’ll find out today where she will hone her chops in emergency medicine. The day has personal implications, too. She’s couples matching with a Penn classmate, Billy Maes, who will specialize in family medicine.

McDermott is couples matching, too—but she isn’t here today. Her partner attends medical school hundreds of miles away, at Brown University in Providence, so she has joined his Match Day ceremony there to find out where they will go together.

Soon Layne weaves her way up to the stage to get her envelope, knock-kneed with nerves. Once she has the envelope, it hits her that the answer is in her hand, and she begins shaking. She navigates back to her family through a gauntlet of hugs from excited friends—even though none of them know what is inside that envelope yet.

One by one, Hirschmann, Layne, and Labora—each with their respective partners—dash down a hallway to quiet corners in JMEC to open the envelopes. Hirschmann and Maes open theirs simultaneously. In Rhode Island, McDermott and her partner do the same. As he opens his envelope, Stephens’s hands are shaking so much it takes him about 30 seconds to break the seal.

When Labora sees her match, tears start streaming down her face from the release of all the emotion; when her parents catch up, they can’t tell: “Good tears or bad tears?”

Next Stop: Everywhere

 

They are good tears. She is incredibly happy to have matched at UCSF.

Stephens, McDermott, and Hirschmann each feel the same about their matches.

Stephens, who had no idea where he’d end up (“The way I ranked my list, you really could throw a dart at a map of the United States and that’s where I would be going”) will move to Boston for residency. A bonus: Even though dermatology programs are commonly split between the intern year and specialized dermatology training, he doesn’t have to move twice. He’ll do his preliminary year at Brigham and Women’s Hospital, followed by the combined Harvard dermatology program.

McDermott is going to Johns Hopkins for her surgery residency. Her boyfriend matched at Hopkins, too, for pediatrics, so they will finally get to be together after four years apart. (They met during their post-bac program and began dating in the year after that, but weren’t accepted to any of the same medical schools.)

Hirschmann is beaming and seems grounded and calm. She’s headed back to Highland Emergency Medicine, the renowned program in Oakland where she did an away rotation in her third year and clinched her choice of specialty. “I love it because the providers I met there are dedicated to the population they serve in a way that felt real and genuine, and felt like the kind of people I wanted to be around, to learn from, as I train,” she says. “It was the ethos of the place and the sense of camaraderie and community they have. I felt like I was home when I was there, and so I’m really excited to call that home now.”

When Layne unfolds her letter, she immediately starts bawling. It’s her top choice. She’s staying at Penn. When she returns to the crowd, she can barely move for all the hugs she receives from friends at every turn—some lifting her up to spin her around.

Later in the day, Layne reflects. “The more that I talk to people, the more I hear that amazing people are staying. That’s one of the most exciting parts. Because Penn is our home program, and so many departments are great, so many people across specialties stay. It feels so comforting to know that when I’m calling an ENT consult, it’s going to be my friend picking up the phone. Even walking down the hospital halls when you’re super tired and stressed, when you see people you know and they wave and smile, it makes your work environment feel friendly and like home.”