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MD School: Year Three

Aspiring doctors juggle a crucial exam and personal challenges.

By TCU Magazine

August 10^th, 2022

by Lisa Martin

In the days leading up to what he considered the most critical exam of his life, Dilan Sunil Shah spent hours meditating in his childhood bedroom, working to tame an anxiety familiar to all third-year students at the Anne Burnett Marion School of Medicine at TCU.

Back in Fort Worth, one of his housemates, Quinn Losefsky ’19, had followed a rigorous study schedule starting in January 2021 to prepare for the make-or-break test.

By the time he took the Step 1 exam in mid-November 2021, Jonas Kruse had a 650-day streak of quizzing himself with online flashcards. This highly disciplined approach to studying became as much a part of his routine, his wife said, as brushing his teeth or walking the dogs.

Charna Kinard and Ive Mota Avila, meanwhile, sat for the daylong exam in December 2021 after devoting more than two months to studying upwards of 14 hours a day. Like every student who wants to practice medicine in this country, they must pass three United States Medical Licensing Examinations.

Third-year students, from left, Charna Kinard, Dilan Sunil Shah, Edmundo Esparza, Quinn Losefsky, Jonas Kruse and Ive Mota Avila have their eyes on their futures as they enter their final year of medical school. Photo by Joyce Marshall

The Step 1 and 2 tests carry the added pressure of helping determine the course of a medical student’s post-graduation education.

For Edmundo Esparza, whose testing site computer froze midway through the November 2021 exam, the grueling process of preparing for the Step 1 had pushed him to the edge of burnout.

“This is the most important test of your career,” Esparza said. “How you score dictates everything from what type of residency program you can apply to, to what kind of hospital and city you’ll end up in.

“It’s that big of a deal.”

Upon beginning their third year of medical school in July 2021, each of these students was acutely aware that the stakes were higher than ever. But diversions ranging from two dramatic resurgences of Covid-19 to various personal issues vied for attention as they sought to focus on their futures, including what specialty to pursue.

Esparza faced a particularly challenging beginning to Year 3 — one that might have had long-term implications.

In 2018, as he was starting an MBA program at the University of Texas at El Paso, Esparza went to the emergency room with searing pain from kidney stones. When he began medical school in July 2019, he still carried debt from that visit plus two others he had made while uninsured.

The Burnett School of Medicine discourages students from working during their four years of undergraduate medical education. On occasion, Esparza would drive for the ride-share services Uber or Lyft when money was especially tight, but he relied on loans to cover his expenses. Though he borrowed the maximum allowed each year — more than $80,000 in 2021 alone — almost all of that went to tuition and living expenses like rent and food.

A $2,500 medical debt almost derailed Edmundo Esparza’s third year of medical education. Photo by Joyce Marshall

Esparza had managed to pay off two outstanding medical debts when unbeknownst to him the remaining unpaid debt was sold to a new collection agency. When the debt hit his credit report as a new loan, Esparza was automatically denied his $40,000 GradPlus Loan for the 2021-22 academic year.

“It’s killing me,” he said in the first few days of Year 3 when his fate was up in the air. “There’s a chance I might have to take a gap year now if it’s not straightened out in time.”

Despite several deans rallying to support him, Esparza’s appeals were denied. In late July, one of his brothers stepped in to pay off the debt. The original total was $2,500, but the Esparzas settled it for $1,400.

Worries about money still swirl in Esparza’s mind. By the end of his third year of medical school, he had amassed $240,000 in student loan debt. He projects that figure will top $300,000 by the time the Class of 2023 graduates.

Family Matters

Not long after Kruse started his second year of medical school, his maternal grandmother died in Orange County, California. Within weeks of taking the Step 1 exam, Kruse flew west for a week to help care for his grandfather.

In January, the family moved his grandfather into an assisted living facility, where the 94-year-old seems to be thriving.

“He’ll tell anyone who listens that his advice for a long life is ice cream, wine, Fig Newtons and a good marriage,” Kruse said before acknowledging that everything from the Covid-19 pandemic to ongoing grief could have led to a worse outcome.

In early 2022 Jonas Kruse said he felt the time had come to decide which medical field he'd enter. Photo by Joyce Marshall

Losefsky, meanwhile, scheduled her Step 1 exam for Nov. 8, 2021, only to learn in mid-September that her mother would undergo a prophylactic double mastectomy the same day. Both Losefsky and her mother carry the mutation in the BRCA1 gene.

A surgeon told Losefsky’s mother that she had an 85 percent chance of getting breast cancer. Even before entering medical school, the younger Losefsky had also accepted the fact that a double mastectomy was in her future.

“My mom’s surgery was something I didn’t expect to worry about on the most impactful and stressful day of the year,” Losefsky said. Since students can sit for the exam anywhere in the country, Losefsky opted to take Step 1 in Austin, Texas, to be close to her mother.

After finishing the exam in the afternoon, Losefsky headed to the hospital, where she learned that the five-hour surgery, which included the meticulous removal of breast tissue as well as total reconstruction, had gone perfectly.

While most of her classmates were still studying for the critical test, Losefsky put her education to use, changing drains, managing her mom’s pain and cooking nutritious meals.

Any fears about the timing of the surgery evaporated three weeks later when Losefsky received her test results.

Dr. Joshua Trussell demonstrates a surgical procedure to Quinn Losefsky, a third-year student at the Burnett School of Medicine, at Methodist Mansfield Medical Center southeast of Fort Worth. Courtesy of Methodist Mansfield Medical Center | Angel Biasatti

Highs and Lows

In summer 2021, Avila had her own encounters with the medical community in Austin. Right as she was finishing her second year of medical school, her 80-year-old maternal grandmother called to say she was walking to the bathroom and couldn’t feel her legs. Avila, who was nearing the end of her first trimester of pregnancy, phoned her uncle to tell him to rush her grandmother to the emergency room.

Avila’s grandmother had a blood clot. When surgery was scheduled for a week later, Avila successfully lobbied her grandmother’s primary care physician to move up the procedure.

Following surgery, her grandmother, who spoke only Spanish, complained of a terrible headache, which the attending nurse treated with Tylenol.

“We had just been talking about it in school, how Black and Brown people are dying more often in the hospital,” Avila said, “and the whole time my grandmother was in the hospital hemorrhaging.”

The nurse called security on Avila’s family as they begged her to help their beloved matriarch. When the guard arrived in the room, he took one look at the patient and told the nurse that something was very wrong.

Avila’s grandmother lost consciousness and never woke up. The family later learned that one of her arteries had kinked, causing a fatal stroke.

The family was still reeling weeks later when Avila’s mother complained of headaches and vertigo. While visiting her, Avila conducted a brief neurological exam and realized her mother had a serious problem.

A brain scan later revealed that her mother had an aneurysm that was too big to simply monitor, but a surge of Covid-19 meant the surgery was delayed until after Avila’s 30th birthday in August.

Like Losefsky’s mother, Avila’s mom came through her surgery with the best possible results and prognosis.

Ive Mota Avila gave birth to a son while navigating the intense pressures — including a crucial medical licensing exam — of her third year at the Burnett School of Medicine. Photo by Joyce Marshall

New Beginnings

By fall, all six of the TCU medical students had received a Covid booster, but the shots didn’t prevent Avila from falling sick a week before she gave birth to her son, Quentin Samuel Avila, on Jan. 3, 2022.

Avila enjoyed an easy pregnancy, something the aspiring OB-GYN did not take for granted. But “his birth was terrifying,” she said. “Everything was going fine until it wasn’t.”

She and her husband, Sam, arrived at Fort Worth’s Baylor Scott & White All Saints Medical Center on a crisp January morning for a scheduled induction at 39 weeks. Avila had an epidural right away and felt no pain, but she was dilating slowly. Her team hooked her up to an intrauterine monitor to make sure the contractions were OK before giving her medicine to accelerate them.

She was shopping on her phone for a pair of boots when a nurse came in to check progress. When she pulled back the sheets, she found Avila in a pool of blood. The nurse, who discovered blood clots, rushed to find the doctor as the baby’s heartbeat started to drop.

“I have seen enough to know how things can go bad really fast,” Avila said.

The obstetrician suggested a cesarean section, which Avila agreed to upon learning that she had lost a half-liter of blood in 30 minutes and was dilated only 3 centimeters. She began bleeding faster as she was readied for emergency surgery. A few minutes later, Quentin emerged pale, struggling to breathe and not crying as much as he should.

“It was the worst feeling ever,” Avila said. “I told Sam to go with him and talk to him. He started breathing when he heard Dad’s voice.”

The nurse took the baby to the neonatal intensive care unit, where his blood sugar stabilized. Avila, meanwhile, rebounded from the C-section with minimal pain. Hospital Covid-19 restrictions meant mother and baby could have no outside visitors beyond her husband, but fellow medical students Hira Nazim and Kinard, who have hospital privileges, stopped by to admire the infant and congratulate the proud parents.

Ive Mota Avila rejoined her class online a few weeks after Quentin’s birth and kept up with her assignments while taking six weeks off from clinical rotations. Photo by Joyce Marshall

Also around the first of the year, Shah became one of four students at the Burnett School of Medicine to enroll in a nine-credit-hour program with the TCU Neeley School of Business, which will lead to a graduate certificate in health policy and management. A full-tuition scholarship sealed his decision to take one three-hour evening class a week until February 2023.

“My adviser, Dr. [Ken] Hopper, is a psychiatrist who also has an MBA,” Shah said. “We used to have all of these conversations about health care management [and] business, and I know there is theory behind it all, but I was craving a formal education.”

At the same time, Shah wrestled over his future path. In advance of taking the Step 1 in December 2021, he moved back in with his parents, who live in McKinney, Texas, about an hour east of the townhome he shares with Losefsky. He would leave the house at 6 a.m. and study at a shared workspace until 7 p.m. After dinner with his mom and dad, he would hit the books again.

At that point, Shah had spent about a year thinking he would pursue otolaryngology. Head and neck surgery is one of the three most competitive specialties, alongside plastic surgery and dermatology. He needed a strong score.

Dilan Sunil Shah, right, said his parents Sunil and Ila Shah were surprised when he announced his intentions to become a psychiatrist. Photo by Joyce Marshall

Shah, the founding president of the medical student senate, also realized the toll that exam preparation was taking on him and his peers. Many of the 58 third-year students reported feeling lonely while devoting days and nights to test preparation. So he set up a daily Zoom call where students could drop in and study alongside their friends.

“We were all sharing in the misery,” he said. “Studying apart but together seemed to really help.”

Along with classmates Connor Rodriguez ’18 and Nazim, Kinard spearheaded an effort to convince the school to allow students more time to study for the Step 1. After 48 of the school’s 58 students joined in the effort, the school granted their request, giving the aspiring doctors until early January to sit for the seven-hour exam.

The school also had hired learning specialists to prepare individualized study schedules for each student as a strategy to maximize their chances for success.

“I can’t begin to describe how much Dr. Wynn helped me,” Kinard said, noting that the learning specialist, Shavonia Wynn, urged her to move her Step 1 date from mid-November until Dec. 23 to give her extra time to study, given that she’s aspiring to become a surgeon, a competitive specialty.

Kinard said she also felt the ongoing strain of dealing with Covid-19, as the pandemic had affected almost their entire medical school education.

Losefsky described herself as “fatigued with the Covid conversation. As soon as someone knows I’m in med school, the vaccine comes up. I feel duty-bound to make this an educational conversation, but it’s exhausting.”

Particularly when interacting with unvaccinated patients, Kruse said, he felt compelled to fight misinformation.

Charna Kinard plans to spend parts of her final year of medical school working at the Mayo Clinic and the University of Chicago. Photo by Joyce Marshall

“This is where our school’s empathy training has really helped. It’s easy to be compassionate when you’re bright-eyed and have had a full night of sleep,” he said. “They’ve given us some really useful tools to have tricky conversations no matter the circumstance.”

During pediatric rotations, Kruse said, he was surprised to encounter teens begging their parents to let them get the shots. “Usually kids hate shots,” he said, “so that’s been a really interesting dynamic to see play out.”

Forward Thinking

By early 2022, Kruse felt the time had come for him to choose a career path. His scores on the Step 1 and the Step 2, which he took in March, meant any option in medicine was within his grasp.

Even before entering medical school, Kruse began working toward the goal of becoming an academic physician, one who can teach and conduct publishable research. In spring 2022, he spoke about his research at a conference in Seattle on the long-term impacts of metformin, which is used to treat high blood sugar levels caused by type 2 diabetes.

The son of a geriatrician, Kruse spent much of his childhood trailing his father around hospitals in Orange County. Thanks to that experience, plus his year working in a nursing home after graduating from Baylor University, he gained a profound awareness of the toll certain specialties can take on both physicians and family members.

Interventional radiologists treat a host of diseases, including cancers, using imaging to help guide catheters and tiny needles through vessels and veins. These specialists also treat stroke patients, one of Kruse’s longtime interests. Among the procedures these specialists do are needle biopsies, stent placements and angioplasties, which open blocked coronary arteries.

While Kruse was deciding on a specialty, Shah continued agonizing over his choice. For much of the year, he vacillated between head and neck surgery and psychiatry, the field he’d thought he would pursue when he entered medical school.

His parents, Ila and Sunil Shah, were taken aback in February when he announced his intention to become a psychiatrist. He had scored so well on the Step 1 exam that he could compete for residency programs in either specialty.

“We always make a decision together as a family,” Sunil Shah said, “so there was a little bit of disappointment because he made a decision on his own this time.”

Shah kept coming back to the idea that he felt he could make a bigger impact in mental health.

“I think I can become a good surgeon,” he said, “but I can be a great psychiatrist.”

Quinn Losefsky cools down after a riding lesson with Reed at Willow Creek Equestrian Center in Joshua, Texas. Photo by Joyce Marshall

Outward Bound

Surgery has been Losefsky’s focus since an eighth grade science teacher complimented her dissection of a cat. She takes weekly horseback riding lessons, another longtime passion, but would choose to spend that time in the operating room if she could. She gives her phone number to the surgeons she works with, asking them to text if they have an interesting case.

In May, Losefsky surprised the staff at New York-Presbyterian Brooklyn Methodist Hospital when she showed up on a Saturday to ask how she could help. She was there on an away rotation, one of several she plans to do in her remaining time in medical school.

The school encourages students to spend a month at hospitals outside Tarrant County to expand educational horizons and possibly gain letters of recommendation. Students also consider doing a stop at a hospital at the top of their potential residency list. Kruse, for instance, plans to do four away rotations.

Quinn Losefsky takes weekly horseback riding lessons, but said she would choose the operating room over the stable. Photo by Joyce Marshall

“If you know the discipline you want to go into and you think you know where you’d like to do this training, it’s very helpful to do an away elective rotation there,” said Dr. Stuart D. Flynn, dean of the Burnett School of Medicine. “It’s used much more strategically than when I was a student, but it’s really valuable to see other perspectives, even to see the same diagnosis but how they address it from different angles and perspectives.”

For many students, away rotations function as auditions. Losefsky, who took the Step 2 in March, is doing a burn surgery rotation at the University of California, San Diego in August. Avila is heading to a hospital in Temple, Texas. Kinard has fall rotations set for the Mayo Clinic in Rochester, Minnesota, as well as the University of Chicago in her hometown.

Dr. Stuart D. Flynn, dean of the Burnett School of Medicine, calls the first cohort of students trailblazers. Photo by Joyce Marshall

In May, Kinard did a rotation at Cook Children’s Medical Center in Fort Worth, where some days she spent as much as 14 hours in surgery. There, for the first time, she scrubbed in with a Black female surgeon, assisting in removing a portion of a dead bowel from a 1-day-old patient who weighed less than 6 pounds.

Working with that surgeon, Dr. Kanika Bowen-Jallow — the reason Kinard signed on for that rotation — was reaffirming, she said.

“These are significant experiences shaping who I will be as a surgeon,” said Kinard, whose Step 1 score puts her well on the path toward a career in her chosen field. In addition, Kinard has been involved in community outreach, as well as a number of school and national organizations, including the Association of American Medical Colleges, where she has served as a student representative since 2020 and is currently a national delegate. As such, she acts as a liaison between the medical school and the organization, which seeks in part to make patient care safe, more affordable and more equitable.

All the while, she studied for the Step 2, which she took in August. She devoted the month of July — a month that welcomed the fourth class of students to the Burnett School of Medicine — to preparing for the exam.

Charna Kinard said working with a Black female surgeon during rotations was reaffirming. Photo by Joyce Marshall

Empathy in Action

Aspiring OB-GYN Avila, meanwhile, draws on personal experience with two pregnancies when working with patients in various clinical settings. She did well enough on her Step 1 exam in December that she feels confident about earning a spot in a competitive residency program. She took the Step 2 in August.

During the massive storm in February 2021, Avila’s husband drove her to the hospital in blizzard conditions as she was miscarrying their first pregnancy. She continued her studies without missing a beat and was soon expecting again, but the sorrow of the miscarriage returned during those first few weeks of motherhood.

In the days after her son’s birth, Avila “couldn’t even look at his baby blankets, his bottle or pacifier without feeling this intense panic. I do remember thinking, ‘Here I am holding this baby, and there’s another baby I should be holding and I’ll never get that opportunity.’

“I’ve seen patients come in with postpartum depression, but I think a lot more women get it and don’t talk about it,” Avila said. “Why doesn’t this get talked about?”

She rejoined the class online a few weeks after Quentin’s birth and kept up with her assignments while taking six weeks off from clinical rotations.

“There’s something to be said about allowing a mother and child to have that time uninterrupted,” she said. “I really think we have a lot of work to do in giving medical professionals the time they need with their babies.”

When Avila does rotations, other medical students come into her Fort Worth home to babysit her boy, who is long, slender and all smiles.

Ive Mota Avila comforts her newborn, Quentin, at her Fort Worth home. Photo by Joyce Marshall

Esparza, who took the Step 2 in late June, had something to smile about in early May, when he was named an ElevateMeD Scholar, a program for physician leaders from historically underrepresented racial and ethnic groups. The award came with a $10,000 scholarship, mentoring and financial planning education.

Like Kinard and Kruse, Esparza aspires to work at a medical school someday but in the meantime thrives on the pulse of hospital culture. With his Step 1 score now in hand, he intends to pursue a residency in internal medicine.

Aspiring internal medicine doctor Edmundo Esparza treats patient Gisele Paviani. Photo by Joyce Marshall

Shah spoke about his research at an April conference on psychiatry in Washington, D.C., in the company of his mentor, Hopper. Deepening crises in the U.S., including the gun violence epidemic, affirmed his commitment to mental health.

He also credited his experience at the TCU Neeley School of Business with helping him reflect on the motivations and rewards of a career as a physician.

“I know my intentions for entering medicine are altruistic at their core, but somewhere over the last grueling year I have shifted to a more cynical mindset that wants acknowledgment for my acumen and retribution for the hundreds of thousands of dollars I am spending on my medical education,” he wrote in a paper for one of his business classes, Health Care in the U.S.

Shah said that the business classes reminded him of his true purpose in pursuing a medical degree.

“No matter what specialty I choose,” said Shah, who took the Step 2 in July, “I am absolutely dedicated to giving my patients the very best care.”

“This hasn’t been an easy journey,” Flynn said of the third-year students. “They are the trailblazers for our school, and we are indebted to these young people who have put confidence in us.”

With a year to go until they receive diplomas, the students no longer assemble as a class for formal academic training.

They will have no more tests administered by the Burnett School of Medicine. Didactics — the academic part of medical school — has come to an end for the Class of 2023.

In the days leading up to the Step 1 exam, Dilan Sunil Shah spent hours meditating. Photo by Joyce Marshall

“As a third-year medical student, it felt like life was speeding by me,” Losefsky said one afternoon as she walked to her short-term rental from the hospital in Brooklyn.

“It’s sometimes really hard to believe that medical school is almost over.”

A New Name, a New Home

TCU and the University of North Texas Health Science Center began collaborating in 2015 on what would become the first new medical school to open its doors in Fort Worth in 50 years.

The medical school became the TCU School of Medicine following a split from the Health Science Center in January.

In July, it became the Anne Burnett Marion School of Medicine at TCU in honor of the late philanthropist and supporter of the university.

“The great thing,” said Chancellor Victor J. Boschini, Jr., “is that we have not changed our philosophy of empowering future doctors to view themselves as part of a team of medical professionals all centered on the patient.”

As a practical matter, the medical students attended most of their classes on the UNTHSC campus, located in Fort Worth’s Cultural District about 3 miles north of the TCU campus.

TCU announced in February that it would build a medical campus in Fort Worth’s Near Southside. The neighborhood is home to the Medical District, which includes Baylor Scott & White All Saints Medical Center, Texas Health Harris Methodist Hospital Southwest Fort Worth, the Moncrief Cancer Institute and Cook Children’s Medical Center.

The state-of-the-art, 100,000-square-foot medical education building will stand at the corner of South Henderson and West Rosedale streets. The medical school’s founding dean, Dr. Stuart D. Flynn, said he hopes the building will open in July 2024, in time to welcome the sixth class of future doctors.

“Just as you don’t build an ice rink for tennis players, we have worked to design the building to our curriculum,” Flynn said, noting the floor that will house anatomy, simulation and clinical skills “is 100 percent patient-centered with everything high-tech and forward-looking. You are training for a patient in your future, which gives the students purpose and drives our curriculum.”

Over the summer, the medical school moved to an interim building in International Plaza, which is at Chisholm Trail Parkway and Interstate 20 in southwest Fort Worth.

“Even though we will have graduated before the building is finished, it still feels like an important milestone not only for the school but also for our class,” said fourth-year medical student Jonas Kruse, who had joked about the length of the school’s old name (“The TCU and UNTHSC School of Medicine”) during a speech to family, friends and faculty back in July 2019.

Kruse said he and his fellow medical students from the start encountered some confusion while working in local hospitals and clinics. Area medical professionals often asked if they were part of UNTHSC’s Texas College of Osteopathic Medicine. Those students receive Doctor of Osteopathic degrees rather than the MD degree that the first class of TCU medical students will earn in May 2023.

“The Burnett School of Medicine gives us a distinct identity, something uniquely ours,” Kruse said. “I think there’s nothing but positives in having our own campus, our own community and being in the hospital district where we’re around our own patients.”

The city of Fort Worth has also embraced the new campus. In a statement, Mayor Mattie Parker described the expansion as representing “a significant contribution to the Fort Worth economy and job growth. This — paired with the Burnett School of Medicine’s transformational impact on health care — ensures that Fort Worth’s future remains vital and bright.”

Parker said she hopes the talent pipeline will translate into many of the new physicians remaining in Fort Worth for residencies or postgraduate medical education and ultimately choosing to establish their practices in the city after they complete their training.

— Lisa Martin

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