All of this

80 hours/week on the wards, 30-hour calls every 4-5th night.

If I could make 1/2 the money I'll make in medicine (which might not even be much under Obama-care) playing music, I'd leave you in a heartbeat.

3rd Year in the Can

It's over. 3rd year. It kinda sucked as a whole: you're the lowest on the food-chain, you don't get respect from patients, residents, attendings, or even nurses and NPs. Did I mention that I fucking hate mid-levels? Anyway...reasons why 3rd year sucks:

-You show up as long as any resident, so depending on the rotation, this can be well into the 60s and 70s of hours. I know of several colleagues who had topped out over 80, and then were bitched at by their surgery attendings for complaining that they went over. The thing is that you are not paid, since of course, you are in school. So you get to sit around idle for hours watching everyone around you scurry and get work done, at least getting the money made, while you spiral into debt. An investment for the future? Of course? Tough at times? Yeah.

-No respect: noone respects you, and why should they? You're there to learn, and many patients are reasonable to understand that they are contributing to honing the mind of a future doc, but many people are just frustrated with the extra time it takes to deal with us and the way we can never answer questions or always have to defer thigns to our higher-ups.

-Scutted out. You get all this shit work dumped on you. On one of my surgery rotations, the PA dumped all the services' discharges on me every afternoon. Monotonous hand-written orders for the patients, and this was a busy service, too. What's the utility in this? Where's the education? I guess the argument can be made that we will be residents soon, and that doing anything they do has some educational value. But when you're there, in the hospital, tired because you got up at 4:15am that morning, and terrified of the end-of-rotation exam, you really want to just learn useful information and not be sent on endless missions of scut work.

I'll go over all of my specific rotations in the next posts. Believe me, I could write an entire book on any one rotation.

3rd Year Just About Done

3rd year SUCKED.

I finished my very last clinical day of 3rd year today - YES. I just have the exam on Thursday, then a meeting Friday morning for a few hours and I'm officially a 4th year! So tonight's gripe will just be a quick bitching about how much I hate being in the O.R. Most people who don't go into surgery at least liked being in the O.R., but just didn't want a career in it. Well I hated the O.R., you know why? (Caviat: The OR experience is much different as a med student because you can't really do anything, and anything that you do do is going to be "scut"ish work, like holding retractors for hours on end. Being a resident and doing surgery actively would probably help. Still...)

-Sterile environment. Annoying. You can't scratch your balls if you needed to, or, more commonly, annoying itches on the back of your head. Can't scratch them, you just have to wait it out.
-Standing. Hours of it. Tiring. And you got up at 4:30am that morning on 5 hours of sleep if you were lucky. It hurts.
-Mean attendings. They yell and curse and make you retract for hours...
-Retracting - tiring. Hold your hand out in front of you for 2 minutes straight. Hurt? Do it for 30 minutes, an hour...you'll sweat and panic.
-Mask, gloves, gown, hat - annoying. I feel trapped, hot, and suffocated.

And worst of all...

-Bitchy Nurses. Seriously. Seriously. Get over yourselves. Yeah, I know, the attending surgeons are mean and they dump on you all the time. They berate you, humiliate you, yell at you, and take their anger out on you. You chose this profession, so deal with it. Stop transferring that frustration down to the only people you can: us medical students. Stop actively going out of your way to find something wrong with my sterile technique...I was not standing "too close" to your fucking mayo (instrument) tray.

Stop giving us the 'tude. Changing your tone of voice as soon as we ask you a question or ask you to help us gown isn't going to help anyone. Just shut your trap and treat us like you do everyone else, which usually isn't very nice, anyway.

You who disrespected me when I walked into the room and bitched me out because you had to take my name down to enter into the computer for the records; screw you.

You who made me change out and back in for stepping one step outside of the curtain when everyone else was walking around the entire room for the entire case; screw you.

And this isn't OR related, but to you who bitched me out over the phone because you were to lazy to get information out of the chart that my resident needed; fuck you.

Do your fucking jobs. We all hide behind this facade of professionalism so the patients and others at the hospital think everything's dandy. But behind it all, everyone (even residents and sometimes attendings) can be real big cocks. But most of all I take it from nurses. Some of you are amazing, really, and to that I salute you. But I've experienced a lot of shit, and to those who have been shitty enough to dish it out; go fuck yourself.

Pricks

You know what is funny? This happens to everyone in medicine. We come in all doe-eyed and ready to save the world, and by the end of 3rd year our cynicism peaks and we're angry, jaded bastards. It's hard to keep a blog when all you want to do is bitch. I'm nearing the end of my 3rd year...actually 8 days from the end. I'm wrapping up OB/GYN rotation, which is the very last thing in my surgery block. The 4:30am mornings out of bed, the 7:00pm and later arrivals at home, the endless standing in the OR's srcubbed in. I shall write about it at some point, for it has been months of intense madness and often misery. But now I'll just do a random bitching.

Subjective evaluations. They count for most of your grade. It's how the system is set up and it is complete bull-shit. Medical student A works his ass off and because his resident or attending is a jerk, or just has a given style/philosophy of grading, he'll get a harsh evaluation. Student B might mess around all rotation and since his resident is really chill, he might get a far better evaluation. That is the system in a nut-shell.

I've ran into a lot of dick holes. One was a GI doc during my surgery rotation. He wasn't evaluating me, but he was a dick hole nonetheless. One of our patients was status-post gastric bypass, and as you'd expect, had a host of metabolic and nutritional issues from mal-absorption. Yeah, it's kinda hard to absorb Fe and Vitamin B12 without your gastric antrum(?) intact. She was going really anemic during her stay and her hemoglobin was in the range of I think 7.0-7.9.

This asshole asked me, "why do you think she's anemic?"

I'm like, "well...we've been drawing blood from her every single morning and she's also missing her gastric---" he cut me off and replied in a frustrated tone,

"you're supposed to be a medicine doc! What are they teaching you! She's had a gastric bypass surgery, of course she's anemic, she is having trouble with Fe absorption" etc etc and he walks ot of the room.

My attending comes in and I ask him, "Why does [patient] have low hemoglobin?"

"Oh, well its because we've been drawing her blood every day."

Fuck you, shit bag GI fucker.

Fuck.

I'm just fucking sick of this already. Standardized patients' report comes in to the effect of:

-"Student was purely clinical, not personal. Came off as cold and uncaring, only smiled once at end of encounter."
-"Try to build rapport...I didn't feel like I wanted to share any extra information with you."

And my clinical evaluations always fault me for interpersonal skills (or lack thereof). Every time it's that I'm too quiet, or don't develop a good team dynamic. Well fuck. I won't sit here and say that they are wrong...they are right. But I don't know what to do with myself. I honestly believe I just have some traits/elements of Asperger's or something, because I am not able to relate to others fluently and naturally like most people.

So it is. I do what I can and get through the rotations. I'll get my passing score and move on. I'll take my shitty eval time and time again. I'll try to improve and get burned every time. "Student lacks initiative, student is quiet." I've had a number of actual patients complement me on my "bedside manner" for what its worth. I don't know what the truth is, I just think it really sucks. Just fuck it, you stop caring after awhile.

Sucked

So I had a stint on a urology team at the most "intense" hospital on our campus. The way this month works is, I do urology for 10-12 days, then anesthesia for 12, then urology again for 12 days. Thankfully, my 2nd urology stint is at a different hospital. The children's one, even.

But seriously, that team was horrible. The hours were crap as you'd expect: show up at 5:15am to help the intern with pre-rounding scut work, then round at 6:00am until time to hit the OR, watch a bunch of operations all day, then eventually more scut work and afternoon rounds. After fighting evening traffic, I'd get home at maybe 5:30 or 6:00pm and "enjoy" my few hours before I had to think about getting some sleep before another 4:30am awakening.

Ok, fine. Expected hours for this block. I have 3+ more months of hours like this. It's the team specifically that I didn't like. Your typical surgery types: white, sporty, butch-haired males all the way from attending to intern. Even though urology is generally considered the happy-go-lucky lifestyle specialty, it's different in academics and at a huge, tertiary care hospital. It's still surgery residency, and you have residents working 80+ hour weeks and what-not.

I was pretty much blatantly ignored and treated like an uninvited pet dog. Part of it was because they are a busy, busy service. The inpatient roster was around 23-28 with 2-5 consults the whole time, and they had to round and operate and round and call consults and write orders like mad. So I get it. But I felt completely disrespected by some of them, like they didn't even bother to pull me aside 1 minute and say "hey, sorry we're so busy, but you could do this or this". No, it was just irritated glances and "do this" "do that".

I haven't been to this particular hospital at all since I started 3rd year 8+ months ago. I noticed off the bat that it was a more intense, serious place, with frankly ruder staff. It didn't help that I was on one of the busier surgical teams (probably second next to transplant). In the OR, I didn't enjoy the procedures. I would scrub in and stand there for 5 1/2 hours while they did their lymph node dissections and ileal loop thing. I get it, you're all busy, there's no time to deal with the med student. But I've had a great third year up until now, you could at least show some effort.

Anyway, whatever. I start anesthesia tomorrow at a much better place. After that, more urology at the children's hospital, then off to somewhere (I don't know yet) for 5.3 weeks of general surgery. I'll get used to the horrible hours, I only ask that where I'm placed has a bearable atmosphere.

Yukers signin off~

Surgery Clerkship

If any of you clicked on my blog, wondering what's up, then here. I'm in 3rd year of medical school. During that year, you have to "rotate" through all the different major medical specialties...at about a rate of a different one per month. Such as my schedule would have it, all of my surgery specialties have come last in the year. And so, between now and late-May, I'll be dealing with the "worst" of third year, if not the worst of medical school.

So I'm now on surgery. My hours are very, very long, and my days start very, very early. I don't have the luxury of weekends anymore; they will be chopped in half at best. But in general, days are expected to be 12 hours long. In my case right now, this is my expected routine:

4:30am - Wake up
5:15am - Bet at hospital to help intern do scut work (dirty work, paper work)
4:30pm - Supposedly when I get out
6:00pm - Later end of when I get out

Mind you, I don't have a "safe haven" of Saturday and Sunday. I should get one of those two days off a week. This coming weekend I have a feeling I will work straight through, because my team doesn't give a shit that I'm there and they just want me there to do work while they have me.

I will be online as I can be. I'm not sure just yet how waking up at 4:30am will affect my body, but it will surely wreak some amount of havok. I can only imagine that to arrive home 13-14 hours later, I'll be dead-tired, even though it'll only be 6 or 7 in the evening. How I'll deal with sleep and how I distribute sleep is to be seen. But I put friends absolutely first, so I won't be falling out of touch w/anyone; that is my priority.

I can only say that going through this is just as much physical as mental and emotional strain. I will do my best to cope.

Isolation

Families, Health care workers, Patients, PLEASE...

Stop fucking wearing isolation gowns all over the hospital. So much for universal precautions. These gowns were designed to protect your clothes from patient pathogens, and the patient from your pathogens. If agents get on these gowns and you leave the room with them on and masquerade around the hospital like dumb-asses, then you're theoretically stirring diseases around in the general public.

I fucking hate seeing this shit.

Bull Shit

Inpatient Peds Rotation

1) I hate it when you get two different instructions from two different higher-ups (residents). Then, invariably when nobody is around to help you when you need it, you do whatever you think is safest (note-writing procedure, for example). Then you get bitched out by the resident for "doing it wrong." Now you can't argue back or they'll make you out to look like a condescending and haughty med-student.

Too many times, mis-communication. You get mixed signals or incomplete communication and you just do your best. And too many times you get bitched out by some stressed out resident who has noone better to take out their anger on than you.

It's an annoying and long rite of passage and I'm sick of stuffing my pride to bend over and take it from cheese dicks. And I hear this happening all over my institution and at other institutions. It's part of medical education and you learn to let it roll off your back.

Do it over again

3rd year here. In clinical rotations. If I were time-warped back to freshman year of college now, knowing what I know, would I do it all again? No.

I'm not sure what I'd do, but I'd try going into physics or computer science and finding my way to a reasonable job near a big city. I don't know, maybe 75K/year and I'd be plenty happy. Because in that non-medical job...I'd potentially have...

-Colleagues/Co-workers that were actually like me
-Weekends off
-Weekends off
-My 20s
-Did I mention my 20s?
-The freedom to fully explore my hobbies and interests
-An actual time to clock out and go home

I'm not saying medicine gives me no pleasure, or that I won't be a passionate physician that truly cares for his patients and his work. I can do that. But the sacrifices are so much, so great, that it is just barely, barrreeellyy worthit.

Even in medical school, hell all four years, you are asked to give up time and energy that very few your age are also giving up. There's worse...there are those soldiers who put their lives on the line for our country, who leave their families and stay abroad for months and months at a time in dangerous places for their stints. There are many who have to work many jobs to support their families in the hard economy.

So I am not saying medical students' lots in life are particularly difficult or unfortunate, not at all. I'm just saying man...we made a choice and we really do give up a lot for that choice. For the hope and promise of job security, prestige, financial security, and a great job, we go through so much.

Cuz you know what sets physicians...a "profession"...apart from "jobs"? The fact that we don't clock out and go home at 5pm. We are beyond the basic "job" where you come and do your work and go home. We are professionals...we do our jobs as doctors and care for patients. We don't watch the clock. In this profession, 60 hour work-weeks are touted as "nice", "light", "easy", and to some older docs, even as lazy. Especially when in training, a 60 hour week is considered extremely easy, and even 80 hour work weeks are considered normal and people lie about their hours to exceed even that. Weekends are never to be had off and families are rarely seen for many.

It's ridiculous. I'm getting so jaded already. I'm on an inpatient peds rotation, it's asking a lot of hours, weekends, staying until 10pm when I came in at 7am. And this is nothing compared to my up-coming surgery rotation...or actual internship.

It's so easy for kids in college to sit there and say "yeah, I want to be a doctor. I want to help people and save lives. I'll go through whatever it takes to get there, I really want to do it."

Do you really? Really? I'm amazed that as many accepted med students follow through and graduate, but I suspect a large number are disappointed, and "held hostage" by their mountain of debt, and knowledge of the time they invested.

PMnR

Doing a month elective in PM&R (it's an actual board medical specialty, look it up) this month.

I should have taken a vacation month instead, it sucks.

I'm getting up at 6:30am stuff like that and getting home at past 5:00pm.

The attendings really haven't been nice at all; I can't imagine soliciting a letter from them at all, let alone if I wanted to do this field.

Ugh, screw this shit. I should have really taken a vacay.

Rant Blog

I'm starting to think this is becoming a rant blog. I really am enjoying medicine and med school overall. I still affirm my decision to become an MD and I have no regrets. That said, there is a lot of bull shit that goes on.

I hate...

1) Asshole nurses. There are way too many of them. Fucking nurses with a chip on their shoulder who think that as soon as they see the short, white coat, they can whip out their God complex of sorts and act like the shit. I'm here to learn and get through my rotation. You don't have to brush me off, act rude, or talk down to me just because you've been working your job for 2 decades and I'm still a doe-eyed student. Show some respect; we show you guys respect. I know it's hard work, we students don't have it much easier and we sure as hell don't have an easy path ahead of us.

Not all nurses are dicks. But I've had enough ass-holery that I'm honestly surprised and ashamed about them. Don't get me wrong. My dear Mother is a nurse and I honestly believe she's the best nurse there is. Many of them are good people. But the ones who are total fuck offs (and there's way too many like this) are the ones who need to be handed the fucking slip and booted out the front door. These shit bags don't deserve to be anywhere near patients. But then again, half the patients I've seen have been fuck offs, too.

2) White coat break-down. Not trying to be an elitist, but what ever happened to the days when doctors wore long, white coats? They still do. But...so do Physician Assistants (PAs), Nurse Practitioners (NPs), Pharmacists, Pharmacy techs, Dietitians, Nutritionists..... Anyone who thinks they "went through" something and ends up working in healthcare thinks they're entitled to wear a goddamned white coat.

You ass holes try going through organic chemistry and fighting your way through college, brown-nosing every fucking Ph.D you run across in order to squeeze another A out of them for your GPA. Then volunteer, join clubs, do w/e you can to get in med school. Then go through 4 years of hell, do a 3-6 year residency. Now put on a white coat. Then walk out into the hospital ward and just wait....oh! There goes some numb-nuts in a white coat, and SHE just took a year of school after college. See where I'm going?

I'm sick of seeing it. Every fucking person and their aunt wears one, and many even throw a stethoscope on just to look even more toolish. If you went to college and thought that made you magically some mystic, professional doctor person, then go wear your white coat. I'm sick of seeing that shit on everyone.

3) Asshole residents. I had some residents during my medicine rotation who were complete shits. No surprise right? Well, I can still bitch about it. It sucks.

4) People. Patients demand drugs, procedures for every little thing. People go out and spend $150/week on "alternative" bullshit like chiropractors, herbal horse-shit, and god knows what. Then they bitch when their insurance makes them pay $40 on a PAP SMEAR. I'm SORRY we're saving your life from cervical cancer, ma'am.

Docs. Selfish and greedy, specialists want more pay, less hours. Everyone has something to gain and there's no such thing as truly "caring" for anyone.

I'd get sick to my stomach reading pre-med application essays. I can't believe the shit I spewed in mine. It makes me sick remembering the crap I wrote.

Dammit.

I'm so sick of the bull-shit. And asshole personalities. I'm aware that there are rude, inconsiderate people in any field. And that medicine is also full of very kind and great people. I know all this and take it into consideration. But I'm done being Mr. Nice-Blog. I'm going to speak my fucking mind and I don't really care because this is here for me and if anyone wants to read it, it's their time lost. Things that annoy the hell out of me:

-One of my team-mates, a fellow medical student, really proved himself to be a rat today. We were doing walking-rounds. He started bitching about the fact that someone had erroneously placed my name on his patient's chart as the responsible medical student. "Who's in charge of putting our names on the patient's charts?", he asked. I just replied, "I'm not sure, maybe our interns?" Then he said it. I thought he was a nice kid, I really did, but he pulled a bombshell of assholery out of nowhere and it floored me and changed my opinion of him in an instant.

"I'll get in trouble."
"What?"
"I'll get in trouble, they need to change it back to my name. I don't want them mixing us up. You're going to get a bad evaluation." [the implication being that since he thinks I will, he doesn't want that on himself]

Excuse me? Since when do you have the right to judge me? You're not my resident or attending. You are entitled to your own opinions, but please don't push them on me, especially when you've been sitting there all month regarding me as an incompetent fool.

He had no grounds on which to base that accusation. I've received positive feedback from my "superiors" all month. Sure, points have been brought up of things to work on, but they're no different from what I've heard anyone else go through. No glaring deficits, not by any stretch. And how could my classmate know, anyway? He had no right to think that, no right to tell me that, and his smug attitude just served as a last straw in shattering my hope of there being reasonable people around this place. Damn. Ya know? Ridiculous.

-Bitch interns. Had one for the first half of the 4-week rotation. She wanted to get her work done and didn't care about our education one bit. She would repeat to me every time I went to go interview a new admit patient..."Oh sorry, I tend to not let the med-students do the interview. I kind of like to get it done myself and then they can go do what they need to after." She never smiled one the whole time I saw her, I don't think.

-Time ambiguity. It's about a daily occurrence. I'll be sitting in the team room in the late-afternoon. The other students are often in there, too. We don't know where our higher-ups are, and it'd be a rude idea to page them for no reason. We're not sure if we can leave yet, even though we could have easily left hours earlier, with no loss to patients or our own learning. Yet, the way it works, you just sit there. You hate being there because you've done your errands for the day. Yet you can't just leave, for there are constant fear of repercussions. The slightest misstep no matter how late into the game can tarnish your otherwise decent record in the eyes of a disgruntled resident.

-Brown-nosing. Our aforementioned male team-mate hero does this. He'll do anything to look good for the higher-ups. Anyone who will have a say in his grade will get the special treatment from him. He's even taken initiative on my patients at a few points, so he can interject his efforts during rounds. I don't know if its just him being a hard-working fellow, trying to undercut me, or a mixture of both (I'm going to go with the mixture idea).

The point of this point? In the pre-clinical years, the gunners simply fade into the background and study to get their high-scores. But now, when actions count, they become painfully obvious as they play the game of sucking-up, over-achieving, and trying to look good. Yes, there is a component of doing well that everyone should achieve. I'm not saying you shouldn't work hard and respect your higher-ups. But don't undercut your class-mates, don't insult them, and don't look down on them and pass smug judgments. That just makes you a tool in life.

You know what. In the end, I'm not the guy who's going to go 100 miles out of his way to get that top score, publish that paper, and rub the boss' balls. I'm proud of who I am and I'm in this to get through it and become the best doc I can be. I probably won't land a coveted plastic surgery or urology residency, but I don't care. If I wanted to be super-competitive and sacrifice my vital 20s for that, I would have. But then I wouldn't be who I am.

Medicine

I'm in the last week (week 8 out of 8) of my internal medicine rotation. The first month was out-patient which was really helpful and nice. This month has been inpatient, which has been really educational as well...very, very important, but also it has sucked on a lifestyle perspective.

Most medical schools will have 3 months of medicine rotation. We have just as much, but spread out. The difference with us is that we take a "sub-internship" in medicine during 4th year. Meaning I'll get to do this month again next year, only with more responsibility. For now, I'm really glad to have been through it, but I'm really glad to get it done with in a few days. Goodness.

Hierarchy

I had my first day of out-patient (ambulatory) Internal Medicine today. Before I divulge into that, I wanted to relay to you my new status...at the bottom of the medical teaching hierarchy. Like a private in the army, I get to be the MS3 (Medical Student 3rd Year). The chain of command goes as such, in descending order.

Attending
Resident
Intern (1st year resident)
Sub-Intern (4th year)
MS4
MS3

Woo! The climb begins! The basic philosophy of training at this early stage is exposure, exposure, exposure, and do, do, do. Then do some more. We've taken our pre-clinical basic science courses and consolidated our "knowledge" in USMLE step 1. Now its time to see it all literally come to life. I'll just say for now that this is a very exciting time in training, and it is where you make leaps and bounds towards becoming an actual physician.

Oriented

Now I'm ready to begin. I guess.

Got my pager...my PDA is on the way in the mail. I have several "pocket guides" ready to stuff in my short white coat.

Today I heard that the nurses know full and well what our short, white coats mean. They mean that we're doctors in training. We are clinically very incompetent. I hope the nurses are respectful and kind to us...because I know we are to them. In a matter of a number of years, I look forward to the day when I really know what I am doing. Until then, it is in the bowels of medical education that I shall dwell, where I will, like every other physician, slowly and steadily climb my way up, day after day.

It begins!

I feel a lot of similarities between now and (almost) 2 years ago. I'm starting 3rd year now...I was starting 1st year then. I'd much rather be where I am now, mind you.

We got the emails just a day or two ago that we are now officially considered MS3s. We, the class of 2011. It is a seemingly small matter, but to me it means a whole lot.

Later today (it is 1AM), I have a sort of survival skills workshop at school for getting transitioned into 3rd year. Skills like writing "SOAP" notes, presenting patients, and integrating into the teaching-hospital hierarchy. It shall be awesome.

In other news. I'm upgrading my computer tomorrow...by tomorrow at this time, I should have 1.5 TB more hard-drive space, and a vastly superior video card! For now...more cleaning as I just moved back to my place.

I Return! ...as an MS3

Wow.

Well that was fun. I kind of fell out of blogging for awhile there as I realized the the first two years (plus boards) were a real bear to tackle.

So I did.

And now I'm finally, finally here, staring 3rd year in the face.

I absolutely love writing, regardless of how my writing is perceived. I was going to start a brand new blog, but I logged in here and noticed that this thing had been sitting here for years with all my old posts and writings in it. So I took the easy route and decided to simply pick up where I had left off. I will post about the glorious pre-clinical years and boards, as I must express my thoughts on them!

The Trick.

The trick to medical school (the first two, class-room based, boring, pre-clinical years) is simple. It's not about being good at biochemistry, anatomy, or even histology. It's all about

RECALL.

If you can memorize X, Y, and the relationship between them, then spit it back out on test day, you're golden.

Now, just learn to deal with 10,000 Xs and Ys and you're really set. Again. Recall.

Specialty

And so, you mature with age. You mature in many different ways - as a student, as an automobile driver, as a member of an intimate relationship, as an engineer/lawyer, anything.

I have realized that your perspective of medicine changes so rapidly from day to day, that it's a waste of energy to funnel yourself down into a given specialty any earlier on than mid-late 3rd year or even later.

It's great to read up on everything you can, shadow, ask questions, and learn. But keep an open mind! I realized that I cannot possibly know the first thing about any specialty until I've at least spent considerable time in the hospital during oh say...3rd year and 4th year. And even then, you're only seeing a small slice of the pie (academic setting, given hospital in given state, etc). It's fine to think you're "leaning towards" one thing or another as you move through the system...

But my advice, which I'm following, is to just freaking focus on getting through years 1-2 and doing your best on Step I. Do that first. Then worry about the next step. Don't even think about pigeon-holing yourself into anything right now.

A few kids in my class know with fair certainty what they want to do. One example is an older gentleman (mid-30s) who has spent considerable time as a paramedic. He wants to go Emergency Med. and will probably stick to it.

Anyway, I just tell myself "keep your mind open, don't think about it too much."