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MD School: Year Two

Medical students move from the classroom to the operating room.

By TCU Magazine

August 16^th, 2021

by Lisa Martin

Quinn Losefsky ’19 wanted to catch a baby. The second-year medical student, who has dreamed of becoming a surgeon for nearly half of her life, was assigned to the OB-GYN floor as her first rotation at a Fort Worth hospital in October 2020.

Losefsky bought a pair of black rain boots — the footwear of choice for most people in labor and delivery — then went to work nights at Baylor Scott & White All Saints Medical Center - Fort Worth.

Midway into Losefsky’s first week, she delivered a boy in the company of an attending physician and nurses.

“I actually got a little teary,” she said. “I was the first thing the baby saw.”

Losefsky and the 57 other second-year students at the TCU School of Medicine spent much of last fall in area hospitals, working alongside doctors, nurses, physician assistants and other health care professionals. The students learned while observing and doing.

Most medical students in the U.S. don’t start interacting with real patients until their third year. The TCU School of Medicine, however, takes a patient-centered approach to its curriculum, emphasizing empathy and compassion alongside anatomy and physiology.

The school opened its doors in July 2019 as the first new medical school in Fort Worth in half a century.

“These kinds of hands-on experiences helped prepare us for working with real people,” said Quinn Losefsky, second-year medical student. Photo by Joyce Marshall

From left: Dilan Sunil Shah, Quinn Losefsky, Charna Kinard, Edmundo Esparza, Ive Mota Avila and Jonas Kruse, unlike second-year students at most U.S. medical schools, spent more time doing rotations at local hospitals than learning inside a classroom.

Empathy in Action

Early into his surgery rotation, Losefsky’s housemate Dilan Sunil Shah put his training as an Empathetic Scholar® to use when he encountered a patient he’d known since his first month of medical school.

Shah had seen the woman regularly as part of his family medicine clerkship, the only rotation that begins in the students’ first year. During his surgery rotation, Shah, a big-picture thinker who grew up in nearby McKinney, Texas, participated in all three of the patient’s surgeries for diverticulitis, an infection in the intestines. When the surgeon opened the patient up the final time, he and Shah were shocked to see that the small bowel had died.

They immediately stitched up the woman’s abdomen and went to break the dire news to her family.

Covid-19 restrictions meant only one family member was allowed in the waiting room — in this case the woman’s daughter. Because she had accompanied her mother to clinic visits, Shah knew her too.

After the surgeon left, Shah offered to escort the daughter downstairs to meet with other family members. Through her sobs, she asked if he would share the prognosis with them.

“When you go over bad news, you have to be way more repetitive and intentional, and you have to be slow and kind,” Shah said. “You need to pay attention to how the patient’s family is feeling.”

Shah said the experience made him grateful to attend a medical school that emphasizes communication skills.

Jonas Kruse runs a simulation case with a coding patient in a class on emergency medicine. Photo by Joyce Marshall

The patient died on his last day of the rotation. Shah, whose interests during his second year of medical school shifted from psychiatry to otolaryngology (a specialty that ranges from head and neck surgery to treatment of the ear, nose and throat), stayed in touch with the daughter.

“I am an eager student of medicine, but at the same time it’s sad,” Shah said. “This stuff gets really heavy.”

Almost from the outset of hospital rotations, a gravitas settled on Shah and Losefsky as well as fellow second-year students Edmundo Esparza, Charna Kinard, Jonas Kruse and Ivette “Ive” Mota Avila.

Aspiring OB-GYN Avila said she had a harrowing first week. “I went from delivering a mother’s worst nightmare in one room to another’s dream come true with a perfect delivery in the next room.

“The happy mother loses sleep with her crying baby, and the baby-less mother wishes her baby’s crying kept her awake,” Avila said.

“This week I learned the definition of medicine,” she added. “It means holding her hand, being a friend, being an anything-she-needs.”

Dr. Karen Goff, a Fort Worth pediatrician, coaches Ive Mota Avila as she checks the femoral artery pulse in an electronic baby intended to resemble a 6- to 9-month-old. Photo by Joyce Marshall

The Covid-19 pandemic prevented the class of students from meeting in person from mid-March until Sept. 8, 2020. As a result, the school’s faculty and administrators retooled the second-year curriculum to include five weeks of intensive classroom training to prepare the aspiring doctors to work in hospitals.

Students learned how to check someone into the hospital and intubate patients during an emergency. They also performed pediatrics exams using replicas of babies.

During the initial class session with the electronic babies in September, Losefsky volunteered to go first. She examined the eyes, heart and lungs before checking the femoral pulse with her fingertips.

“You have to know normal before you know abnormal.” That’s what Dr. Karen Goff, a pediatrician, told her group of five students.

“It’s funny how much of medicine is subjective,” Losefsky said to Kruse after he finished examining “Oliver,” the 6- to 9-month-old manikin. “You know it when you feel it.”

Later that week, Kruse, Losefsky and Shah spent an afternoon suturing fake skin in a lab on the UNTHSC campus under the watchful eye of Dr. Shanna Combs ’01, the school’s obstetrics and gynecology clerkship director.

YouTube videos of suturing played on iPads directly in front of the students as they worked first with yarn, then nylon and different types of needles.

“When you have a uterine artery pulsating at you, your knot-tying is all muscle memory,” said Combs, who majored in ballet as an undergraduate at TCU.

Dr. Karen Goff teaches how to conduct pediatric exams as Jonas Kruse listens. Photo by Joyce Marshall

Out in the Field

A few weeks later, the students began nine weeks of immersions in North Texas hospitals.

“Unless you grew up in the world of a hospital — some students have, but most have not — there’s nothing that can compare to the first day you walk into this large hustling and bustling edifice, which takes your breath away,” said Dr. Stuart Flynn, founding dean of the TCU School of Medicine.

From October to December, the students spent three weeks in internal medicine, a week in pediatrics, two weeks with OB-GYN and three weeks with surgery.

“The energy of the hospital is amazing,” Esparza said. “You feel like you’re part of something a lot larger than you are when you’re there.”

Kruse said he was grateful for the additional training after doing a suture to sew up a cesarian section in November. After the attending physician praised Kruse’s work, the new mother asked from the other side of the drape, “Is one of you teaching the other?”

Hospital shifts might stretch past the 11- or 12-hour mark. Most of the second-years brought textbooks with them to squeeze in study time in the doctors’ lounge, though the amount of downtime they had depended on the day.

“At the hospital when I’m seeing patients and learning, it’s all fires blazing and I have energy,” Kinard said. “But when I get home it hits.”

Kinard wants to focus on either surgery or family medicine but also really enjoyed working alongside Esparza in Cook Children’s pediatric intensive care unit.

“Do I feel like a doctor? No. But I do feel like an effective empathetic scholar,” she said. “I tell every patient that although I don’t have all of the medical knowledge to heal them yet, I am here to be their advocate and make sure they feel heard.”

Charna Kinard, right, practices a pediatric exam on a manikin with Dr. Karen Goff and Connor Rodriguez, one of 11 TCU alumni in the class of second-year medical students. Photo by Joyce Marshall

Jonas Kruse takes control of a simulated emergency room by doing chest compressions on a manikin while coordinating the team's response. Photo by Joyce Marshall

“I tell every patient that although I don’t have all of the medical knowledge to heal them yet, I am here to be their advocate and make sure they feel heard.”

Pandemic Precautions

Though the second-years were not allowed to care for Covid patients and didn’t even work in the areas where infected patients were being treated, the students nonetheless suited up in protective gear before shifts. They had attended a class to learn the proper way to scrub hands and arms, tie surgical masks and make bouffant caps stay put.

“There are all these tricks to putting things on the right way to keep everything sterile,” said Avila, who had never before dressed in full blue surgical garb.

Kinard’s steps for keeping herself safe from Covid-19 included staying in Fort Worth for Thanksgiving and Christmas rather than traveling to her Chicago home to see family.

Despite a negative Covid test before heading to El Paso, Texas, for the holidays, Esparza worried that he might somehow infect his mother or siblings.

“I’ve already lost one parent and need to protect the other,” he said, referring to his father, who died in 2018. “My anxiety was to the max over winter break.”

A potential exposure in November forced Kruse, a Southern Californian, to miss two weeks of surgical rotation, which he elected to make up over the holidays. Also as a precaution, Shah had to forgo the final week of his internal medicine rotation at a Dallas hospital. Neither fell ill.

Not so with Avila and her husband, who bought a home in Fort Worth in the fall. They contracted Covid-19 in December 2020 following his father’s funeral.

Both rebounded without lingering effects but share a respect for the disease.

“It was pretty awful,” said Sam Avila, who works in medical recruiting.

“And could have been so much worse,” added his wife of three years, who had to skip the final week of her surgery rotation.

Nearly all of the students received their first round of Covid vaccines at TCU just before the new year.

“We’ve been dealing with the pandemic since March 2020, and everyone is fatigued,” Kinard said. “Getting the vaccine was about more than just protecting ourselves. It was about leading by example.”

Losefsky interrupted her winter break to drive up for the day from Austin, Texas, to receive her initial dose of the vaccine.

“It was this huge weight off of my shoulders,” she said. “I was actually surprised by how relieved I felt.”

Shah, who met up with nearly a dozen classmates at the Brown-Lupton Health Center earlier that day, said the post-shot atmosphere bordered on festive. “It was a great day for science.”

Nearly all of the 58 second-year medical students volunteered to give the shots to community members in early 2021. Photo by Mark Graham

Taking the Lead

In his role as president of the medical school’s student senate, Shah collaborated with fellow second-years Sophie Wix, Sarah Lyon and Sam Evans to create a flyer explaining the vaccine to the public.

“We’re all worried about misinformation about the vaccine,” said Shah, who grieved the loss of a close family friend to Covid-19 during the winter.

He and fellow students volunteered to vaccinate members of the community on weekends at a Fort Worth hospital and at TCU’s Amon G. Carter Stadium.

One Saturday in February, Esparza spent the morning in Fort Worth’s North Side and Diamond Hill areas registering residents of those largely Hispanic communities for the shot. He proceeded to do a five-hour shift at Baylor Scott & White All Saints, vaccinating those age 16 and older as they wended their way in cars through the parking lot.

“Everyone in my class volunteered because it’s such a unique opportunity at a really unique period of time,” said Esparza, who estimated he could administer 80-100 vaccines during an afternoon.

Community involvement remains a core value of the TCU School of Medicine.

In summer 2020, Esparza spearheaded a back-to-school drive to collect supplies for children living in Fort Worth’s Como and Stop Six neighborhoods, in addition to the North Side and Diamond Hill. Classmates, including Kruse, helped deliver boxes of crayons, paper and glue.

“To get all of these donations during the pandemic was incredible,” Esparza said. “It’s also one of the great things about this school, that they let you run with an idea.”

In their respective roles as vice president and president of the Latino Medical Student Association, Esparza and Avila spent much of the fall working with fellow Hispanic students to create a class in medical Spanish.

Dilan Shah, who presided over the medical school senate for the academic year, administers a Covid vaccine during a drive-thru clinic on the TCU campus. Photo by Mark Graham

“It was like a garage band going pro,” Avila said. “We were really excited when the school agreed to our proposal to make the class an elective for next year.”

Kinard volunteered to co-chair the regional conference of the Minority Association of Pre-Medical Students, an organization that supports members of underrepresented communities in their pursuit of a medical school education. She also mentors undergraduate members of TCU’s association chapter.

Kinard asked the medical school to donate 3D suture pads, which she mailed to participants in advance of the virtual event.

“I really felt a lot of love from our school for giving these students the tools they need to be successful,” she said.

Leadership and service positions beef up the students’ résumés, something particularly important for anyone intent on pursuing competitive specialties such as dermatology or neurosurgery.

Losefsky served as the medical student community administrator for the American College of Surgeons. Holed up at home the week a massive winter storm walloped North Texas in mid-February, she created Jeopardy-style questions for the group’s springtime conference, virtual this year.

Quinn Losefsky draws maps of procedures. Photo by Joyce Marshall

Edmundo Esparza practices suturing and knot-tying. Photo by Joyce Marshall

Charna Kinard works in Anton Naumov's lab at TCU. The second-year medical student and the assistant professor of physics are researching cancer treatment. Photo by Joyce Marshall

Medical student Jonas Kruse studies a holographic anatomical model in mixed reality using a HoloLens 2 headset equipped with the HoloAnatomy software suite developed by Case Western Reserve University and the Cleveland Clinic. Photo by Johnathan Babirak

Marathon Days

Like most of her fellow second-year students, Losefsky felt the toll of long days and fast weeks while going from January to June without a break. She regularly volunteered for extra surgical shifts, meaning she might work at the hospital or clinics for 11 days straight.

Losefsky spent hours with surgeons in the operating room holding their instruments in the role of first assist. She became adept at closing, sewing up incisions with tiny and precise stitches.

Afterward, she and the surgeon would round on their patients, hospital-speak for checking on them. While walking in the hallways, faculty doctors quiz students on how they might approach a case. They ask other relevant questions, from anatomy to what medications to prescribe.

Physicians such as Rohan Jeyarajah emphasized the importance of broad learning that extends outside students’ intended area of specialty. Medical school is the only time doctors in the U.S. work in a range of disciplines.

Dilan Shah and roommate Quinn Losefsky take a break from a virtual class on how to admit patients to the hospital. Photo by Joyce Marshall

“I also tell my students that whatever field they go into they’ll end up seeing surgical patients,” said Jeyarajah, who chairs the medical school’s surgery department. “If you’re a psychiatrist working in the psych ward, one of your patients will have appendicitis at some point.”

Jeyarajah and his colleagues also share an appreciation for medical school’s demands, which increased significantly during the second year.

If, for instance, Losefsky planned to scrub in on surgeries, she typically devoted the evening before to reviewing gross anatomy, studying the charts of the upcoming cases and even sketching out procedures on paper to help her prepare.

In the absence of an impending surgery, she and fellow students would study for upcoming exams, often using online flash cards.

“As a second-year, there is this press of time that I definitely didn’t feel last year,” she said. “I am always busy and always feeling like I could and should be doing more.”

For nearly Losefsky’s entire time in medical school, she and other leaders of the surgery interest group have recruited area physicians to speak at meetings.

These kinds of interactions with physicians who can provide networking, coaching and research opportunities can prove critical to the students’ futures.

“So much of medicine you can’t learn from a book,” said Losefsky, who organized the surgery interest group. “Medicine is all about mentorship, especially once you transition to becoming a clinical med student.”

Shah devoted time and head space to overhauling the organization of the medical school’s clubs and communication models during a monthlong break in August 2020.

Quinn Losefsky and Jonas Kruse participate in a lesson on pediatric exams. Photo by Joyce Marshall

The creation of a council with a representative from each club helped ensure that multiple events weren’t booked for the same day. The council also kept students in the loop about all clubs’ activities to encourage wider attendance.

The first Monday in October, Shah convened a schoolwide Zoom meeting to present a new way of categorizing these groups.

Shah, alongside Esparza and a few other student senators, divided the groups into three categories: professional (anesthesiology, cardiology), advocacy (Pride, Latino) and recreational (medical ethics, performing arts).

Communication among student organizations became critical when the medical school doubled its population by welcoming a new class of first-year students in July 2020.

“My goal is to build a system that people will follow for a very long time with everyone doing their part,” Shah said. “The burden is on all of us to make this school great.”

“The burden is on all of us to make this school great.”

Next Steps

Some of the reputation of the new medical school will hinge on where members of this inaugural class wind up doing their residencies, which they will apply for during their fourth year of medical school.

After graduating in May 2023, the newly minted doctors should begin the next phase of their education, which could take them anywhere in the country.

As of 2020, there are not enough spaces in residency programs to accommodate every medical school graduate in the U.S., the Association of American Medical Colleges reports. Knowing this adds another layer of pressure to the undergraduate medical school experience.

“Residency is something you’re always thinking about,” said Kruse, the founding president of the student interest group in neurology.

Some of the students worry they could miss out on certain residency programs because they didn’t pick that lane during the first half of medical school.

Flynn, however, said that second-year and even third-year students still have time to decide on specialties. “This is where their coaches and career advising can come in.”

Also weighing on the students is their make-or-break United States Medical Licensing Examination. Third-year medical students at the TCU School of Medicine will take the critical Step 1 test in the fall or winter.

The medical school will give the students six weeks off in the fall to prepare for the Step 1.

Those opting to sit for the daylong exam in October or November may be the last group ever to receive scores.

Jonas Kruse practices intubating a manikin programmed to resemble a coding patient. “It was actually easier to intubate in real life,” he said. Photo by Joyce Marshall

“We’ve been studying hard with that on the horizon since Day 1, with the hope of capitalizing on a good score before it goes pass/fail,” said Kruse, who intends to take the test in November.

High marks will further their goals.

Residency programs also look at applicants’ scientific research, something all of these students must do throughout their four years as part of the Scholarly Pursuit and Thesis.

Students choose areas of interest and work with mentors. Graduation requirements include a capstone thesis and a presentation at a research symposium.

To that end, a windowless lab on the first floor of TCU’s Sid W. Richardson Physical Sciences Building became Kinard’s second home in Fort Worth. There she performs experiments with graphene quantum dots. The nanomaterial delivers chemotherapy drugs directly to cells.

She is the only medical student on a team led by Anton Naumov, an assistant professor of physics whom she describes as a powerhouse in the field.

“The more effective the delivery system, the smaller amount of drugs that can be used,” said Kinard, who had experience researching cancer cell response to pharmaceutical drugs prior to entering medical school.

By early spring, Kinard had gathered enough data to begin writing up her findings with an eye toward publication in a scholarly journal, something that can also help with residency placement.

Avila, meanwhile, is studying how rape and sexual assault impact patterns of gynecological use.

Her thesis research delves into whether survivors go to fewer well-woman and other gynecological appointments throughout their lives because of a traumatic history with a rape exam in a hospital setting.

She is seeking to discover whether higher numbers of these women die of cervical, ovarian and breast cancer because they delayed or skipped routine tests that might have detected the disease when it was treatable.

“This is work that I want to do past medical school,” she said.

Charna Kinard studies nanomaterial used to deliver chemotherapy drugs directly to cells. She partnered with Anton Naumov, an assistant professor of physics at TCU, to work on her required capstone thesis project. Photo by Joyce Marshall

Second-year students at the TCU School of Medicine Jonas Kruse, Dilan Shah, Quinn Losefsky, Edmundo Esparza and Charna Kinard moved from the classroom into the operating room. Photo by Joyce Marshall

Feeling the Stress

Following the winter holidays, the medical students balanced research with working in a clinic or hospital, depending on the day. They continued seeing patients in pediatrics, internal medicine, surgery, psychiatry and other areas.

Many of the students encountered something akin to the sophomore slump. The relentless pace of school, coupled with gloomy bouts of weather, seemed to affect the collective mood of the class.

Ongoing worries about money likewise exacted a toll. Many of the students took out $80,000 in loans for their second year. Tuition for the 2020-21 academic year was $60,318, though a grant from the medical school and a scholarship from a donor trimmed some of that cost.

“A lot of us have fallen into a pit of despair because of how hard this has been,” Shah said.

He did feel reinvigorated in April after a Zoom meeting with some Harvard medical students. The school organized the session as a way to give the second-years encouragement from upperclassmen. That mentorship continued with another panel session in June.

Throughout the year, Shah and his peers also mentored the class below them, who started online in July 2020. (The Class of 2024 remained mostly virtual the entire year, with only some coursework and exams in person.)

Kinard, Losefsky and others have made themselves available to the newest class of 60 as well. In July, the school expanded yet again with the arrival of students in the Class of 2025.

Upon hearing that many of the second-years felt fatigued, Flynn expressed little surprise.

“Covid sapped a lot of energy, though I don’t want to use that as a scapegoat,” the dean said. “Clerkship is the toughest year for medical students because of the pressure. You have to be evaluated, and you want to excel.”

Dilan Shah is learning about hospital admissions. Photo by Joyce Marshall

“I don’t ever worry about going into a patient room now and talking to someone. I know how to communicate with empathy and compassion.”

Competence Meets Confidence

Esparza, who continues to weigh his options about specialties, found himself rebounding from the emotionally rough spring thanks in part to frequent vigorous workouts at the TCU gym. He also began focusing on how far he’s come in his medical education.

“I don’t ever worry about going into a patient room now and talking to someone,” he said. “I know how to communicate with empathy and compassion.”

Esparza — along with many of his peers — also believes the staff in hospitals and clinics treated them more like fourth-year medical students, another confidence booster.

The students are pushing to forge relationships with mentors, some of whom will likely have an outsized impact on their professional lives.

In Losefsky’s case, she knew a number of the physicians she’s currently working with from her three years of scribing as a TCU undergraduate. Starting in 2017, she documented information in the emergency room at Texas Health Harris Methodist Hospital Fort Worth.

As a medical student, she learned that “the more time you spend in the OR with a doctor, the more you can anticipate their needs.” Losefsky also spent hours practicing the use of both of her hands during a surgery. She mastered tying knots while wearing two layers of gloves covered in blood.

“I’m at a point now where I can grab instruments for the surgeons before they ask,” she said. “I always want to make myself as useful to them as I can.”

Over the course of the year, physicians have asked the students to take on more responsibilities like interviewing patients, writing up chart notes and doing supervised procedures.

“This is the hardest I’ve ever worked,” Kruse said, “but working with patients is definitely better than sitting in a lecture hall.”

Edmundo Esparza practices suturing and knot-tying before heading into surgical rotations, where he would sometimes help close a patient’s incision following a procedure. Photo by Joyce Marshall

Confidence grew as the pressure increased for second-year medical students Charna Kinard, Edmundo Esparza, Jonas Kruse, Dilan Shah and Quinn Losefsky. Photo by Joyce Marshall

Challenges in Care

Dealing with patients can present its own set of challenges, as Avila discovered.

“I’ve experienced more full-on direct racism in the past two years than I have in my entire life,” she said.

One day in the spring, as the nation focused on the crisis at the border with Mexico, a patient locked eyes with Avila and said, “I know you people need somewhere to go” before unleashing a rant about immigrants.

“It baffles me that there are people who truly think it’s OK to verbalize these things to someone’s face and be that offensive,” she said.

Kinard once feared she might be subjected to overt racism in Texas. While that hadn’t transpired by the end of her second year, she does encounter microaggressions, subtle actions or comments directed at people of color.

She has also been asked “What are you?” or “Where are you really from?” “Sometimes I’m assumed to be other races because I look ‘ambiguous,’ ” she said.

She has learned to look beyond such behavior. “Sometimes it feels like death by a thousand paper cuts, but I work hard to put it out of my mind,” she said. “If I’m upset, then I can’t study for the rest of the night.”

In response to Avila’s stories, one of her mentors counseled her that she always has the right to walk away.

Charna Kinard is the regional conference co-chair of the Minority Association of Pre-Medical Students, an organization that supports members of underrepresented communities in their pursuit of a medical school education. Photo by Joyce Marshall

“That was very empowering, the idea I could find someone else to treat the patient,” Avila said. “They can choose to be nasty, and I can choose not to take it.”

Avila intends to make delivering babies her career. She’s excited about experiencing the process firsthand, as she and her husband will welcome a son in January.

Losefsky, meanwhile, gained new appreciation for patients who trust their surgeons to inflict harm on their bodies in the service of healing them.“I’m literally manipulating their unconscious body, something that’s so personal and so intimate,” she said. “I always feel like I need to work to earn that.”

She has suctioned clots off brains and kept a liter of blood from blocking a surgeon’s view of the spine for 6½ hours. She’s seen more hernias and infected gallbladders than she can count. She has watched patients die.

“There’s a gravity and weight because I’m not just learning something that’s rhetorical or theoretical anymore,” she said. “This is someone’s life, and that settles on your soul.”

Some of the patients and procedures have kept her up at night, but an abiding passion for the work — plus the promise of Starbucks — makes her bound out of bed before dawn, ready to greet whatever the day holds.

“It can be exhausting,” she said, “but I truly feel like this is what I was born to do.”

From left: Jonas Kruse, Quinn Losefsky, Edmundo Esparza, Ive Mota Avila, Dilan Sunil Shah and Charna Kinard just rounded the midpoint of their time as students at the TCU School of Medicine. Photo by Joyce Marshall

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