Time to Tumble Down - Again

Well, it's time to officially close this blog as the next chapter of my life begins. I realized this after the last post focused on residency issues and had little to do with medical school.

I have ascended to the highest rungs of medical education to this point and can no longer content myself as I look down on those still struggling to make the ascent. I don't even have an ID any more for my school, so it's time to move on.

Unfortunately a new challenge, a new totem pole, a new hurdle awaits and I must, regrettably, begin again at the bottom.



So thanks to everyone who linked me, read my ramblings and bitchiness, and gave support at times when I was down or celebrated as events came and went. It's been a helluva ride so far.



Everyone's welcome to come over to The Chloroform Rag, where I'll start posting from now on. See ya there.

Well, Okay Then

Received my schedule for the ER last night. It's not bad - i.e. no call and nothing more than 12 hours at a time with several days off - but it made Wife make one comment.

"You're sleep schedule is going to be all fucked up. You know that, right?"

She was referring to the accurate identification that I have shifts all over the place - including one that ends at 4am. One day I'll be working in the morning/afternoon then come back to the overnight, then back again. It's easy to see how my body is going to try and revolt over this.

But whatever. It's internship - and this is probably the best schedule I'm going to have all year. Plus everything that I thought would happen hasn't - like starting out on call, in the ICU, and working July 4th weekend. Thinking that these were inevitabilities they haven't happened. Interesting.

Necessary

I've often wondered if the 4th year of medical school is really necessary. Many medstudents spend the majority of this year taking electives in their respective desired fields, easier rotations during interview season, and often have months off with little to no patient interaction leading up to July. It's clearly no wonder that a July syndrome is often seen in many incoming interns.

I've been reviewing over the last few months, but it's hit and miss. There are things that come up and I feel guilty trying to study about diseases and physiology when the family has come home - I won't have this much time with them again in, well, probably ever. So I close the review books (because by now I've admitted that I just really should review the basics again before getting too in depth on anything) and head outside to play one-on-one with my son, teach my daughter how to ride a two-wheel, or take care of wife.

I think that a full year of 4th year, while nice in the time off you often get, really is a hinderance to many students. I knew far more and was multitudes more ready to enter the "real world" of medicine last July, not this one.

Personally I think it would be better for programs to have earlier interview times in the early fall, find out where you matched in December, and then enter your program in January or February. The students would be better prepared, less rusty, and far more capable of handling the first couple weeks of internship. The syndrome would still be in place, but not as pronounced as it is currently.

Hell, if there was a real consideration to drop the 80 hour work week to 56 we could lengthen the residency training based on reducing some of the 4th year requirements and letting med students into training 6 months earlier.

So, is a full 4th year really necessary? I don't think so.

Hoping Beyond Hope

There are several items that I hope don't happen - even though I know there's a very good chance that they'll occur anyway. Like gas stopping its ridiculous and out of control move towards $4 and $5 a gallon.

What I really hope is just merely a rumor mill is this, a cut of work hours from 80 to 56 per week. I found this link from Medschool Hell - who, naturally, is in support of the move.

I've already blogged about this topic in the past, so I will allow you to read over that post and refresh yourselves. Clearly I do not believe cutting the work-hours anymore will lead to significant changes for the better.

What it will do is just lengthen an already long process with residencies adding additional years, create further punch-clock mindsets in residents entering the work-force, and leave a large topic of discussion still on the table: debt repayment.

Hell, as it is the government has been trying to get underpaid residents to pay back on loans by reducing the years that they can defer or forbear or simply removing the option of "economic hardship" from the list of reasons. So adding more years will do what? Create more financial burdens, reduce the chance to moonlight, make residency akin to a 40 hour a week job where-in doctors will become even more hesistant to do anything past 5pm? Is that what we really want?

Think about it before you'd say that working a few less hours isn't that bad.

Oh Yeah Moments

I'm starting to think that the people who designed the home we've moved into had a few "Oh Yeah, we need that." moments.

For instance - both bathrooms are small, lack drawers, and give the impression that the architect suddenly recalled needing to have 2 bathrooms.

Today, after getting a new washer and dryer delivered I tried to run a load of laundry. Unfortunately I couldn't open the dryer door - the hinge-door on the dryer side would not allow the left to right opening that is customary on many, many, many dryers. But, after unhooking the sliding feature on the door I could swing it wide open and, with care, open the dryer. These appliances aren't anything too large, too fancy, or too anything - normal sized.

Ah yes, the Oh Yeah moment hits again.

Purification by Fire

This is the end, my beautiful friend, the end.

The coats burned nicely, soaked with lighter fluid, and a large plume of foul smelling, blackish smoke arose as I exorcised the drug-resistant demons from within. Thanks for the memories, short white coats, I hate you still.

Graduation

So the grad ceremony was nice - if not long - and my family was able to be here to watch Wife hood me. Thankfully my back, which had been acting up the last week and kept me from working out for the last 8 days, did not hurt as much as I had thought - given that we stood for an hour before walking into the arena and then stood again while 100 of us were called, walked across the stage, were hooded, and then recited the Hippocratic Oath (updated version).

I felt a swell of pride as Wife placed the hood on me, I turned and walked down the stairs and kissed her. It felt like we had arrived, but I still don't feel like a doctor. I'm sure that feeling won't come anytime soon until I hear the pager go off endlessly or am asked to assess a patient that I feel completely underprepared to deal with - wait, scratch that, I won't feel like a doctor for a while...if ever.

My parents took tons of pictures and many of the classmates and friends were in the backrooms snapping away while we readied ourselves. It was sad that so many of us had been through so much, and now we're heading off into different cities, different specialties, and different lives. I hope to keep in touch with some, but I'm not optimistic.

So, one more month and then I begin orientation. July 1st is coming fast. I think I'll post some more on this blog until June, then I'll turn the attention to my residency blog. After all, I'm no longer a medstudent.

I am a Doctor

Nothing more needs be said. Well, it will, but just not right now. I've got some partying to do!

Obesity - Dangerous To Your Health

Fat people are a danger to themselves. Health not withstanding (diabetes, hypertension, stroke, cardiac disease, arthritis, etc. are all shown to increase in patients with, um, largess) there are many more practical and truly understated reasons to remain thin:

1) radiology equipment may not be able to accomodate your size (CT or MRI scanners that can't handle the weight/ size)

2) getting any central line placed is much harder due to obliteration of normal anatomical landmarks by fat and once obtained many healthcare workers won't want to remove it even if a "potential" infection is suspected leading to possible catheter related infections

3) peripheral IV's are often obtained only through multiple, painful attempts and frequently are 22 gauge size or smaller, in the fingers or feet, lending them to being subpar for any real utilization if acutely ill

4) intubations are harder, messier, and patient's tend to decompensate faster with larger body habitus - plus bag masking is harder on someone who's chin doesn't really exist anymore

5) lumbar punctures, epidurals, spinals, etc. are much harder to obtain as, once again, normal anatomical layouts are obliterated by fat

6) beds may not be able to support you unless "special" ones are obtained which could leave you waiting in uncomfortable chairs, wheelchairs, or stretchers for prolonged periods while one is obtained

7) moving patients from stretchers to OR tables requires more personnel and once on the table you have a higher chance of falling off due to weight balance being less central

8) when incapacitated, being turned, changed, etc. is harder on the nursing staff, requiring more staff to accomplish the job, and therefore lending to potential reductions in care over time and bedsore formations

9) harder to hear heart and lung sounds - plus radiographs tend to have abnormal shadows and lines from rolls of fat which can impair diagnosis of conditions

10) many drugs are given based on ideal body weights and larger status leads to variable dosage delivery. Fat is also large storage pool for many drugs which can lead to reduced effective concentrations intially only to then have an increase as the drug stored in fat is released and joins the already circulating concentration with resultant overdosing.

Just some things to consider when the current culture tries to tell us to be "happy with yourself just as you are". Be happy, but work towards losing weight - it's best. Humans are not naturally fat.

Scary As Hell

Just found out that I will be starting July 1st in the...wait for it...

EMERGENCY DEPARTMENT! (dramatic, scary music plays as audience gasps and shrieks in horror)

Stay away from the hospitals, people, stay away.

Nothing like starting out in the level 1 trauma center for half your state and portions of bordering states, in July, when the amalgam of drink, warm nights, and fireworks will work itself into a frenzy.

More Political

As noted in the last post, the problem with gas getting this high is that the US is not, and most likely will not be for a very long time, equipped to handle a huge increase in price due to city structure.

We have focused on autonomy, little on public transportation, and many people live at least 30 minutes out from their jobs. It's quite rare to have a city that can actually move a tremendous amount of people efficiently during the rush hour and all day. I believe a couple cities on the coasts are the best examples, but not much else.

So then, what are we going to do? Mass influx into the crime-ridden and impoverished inner cities? Nope.

Demand our city planners make transportation miraculously affordable, available throughout the day, and easy to use? Not likely in many areas.

Buy motorcycles and scooters? Dangerous and honestly not a good option.

Hybrids? This should have been done years ago, but was constantly being put off by "Big Oil" influence amongst both parties. The cost of purchasing one currently offsets any savings in gas they might provide as many are pricey. For me, having paid off my car, it's completely ridiculous to even consider for many years.

As was pointed out, some Eurpopean countries are paying almost $8-$10 a gallon. Yet, even though they're paying a lot more we should understand that Europeans have paid more for years (I remember my brother telling me that gas was as high as $6 or $7 a gallon in Switzerland when he was there for a year - 9 years ago), are far more accustomed to other methods of transport (like bikes, trains, etc.), and are much smaller than the US. We're huge - some countries across the pond are the size of Maryland or even Rhode Island.

I listened in yesterday to a debate about "the pain at the pump" as two senators from the Dems and Repubs argued how to help out 'our consituents'. Both raised interesting ideas, that are all doomed to fail. Our leadership in this country has no real good idea to help us - they've been sucking up to the oil companies for too long and little has been done to plan for this inevitability.

In my 30 years, I don't recall a worse time. Thankfully, for all the bitching and whining I do about medical training, I have a rather secure job ahead of me. My wife, however, is seeing the impact on her job as hours are cut, people lose jobs, and more is expected to compensate for declining cash flows.

Whomever the next president is, I hope they understand how important these next 4 years will be for our country. It's make or break time and I'm scared that all involved won't have what it takes to turn us around.

Where Will It Go?

While driving my daughter to preschool today I passed a gas station that, just yesterday, was selling gas for $3.55 a gallon. Today? $3.70. Where did the 15 cents come from?

I'm actually in an area that's not been hit as bad as others - we've yet to reach over $4 for 87 octane, but I'm not holding my breath that it won't happen in the next couple weeks. I wonder, when's it going to end and why is this happening in the first place?

I mean, as I'm sure all Americans are wondering right now, what the fuck is going on here? Are there no more controls? Are we at the mercy of every CEO who controls energy in this country since the Bush-era arrived to pillage the country into extremis?

Before gas would rise based on "situations" that would invarably be used as excuses. Now I don't even hear anything - just expect it to keep going up. Bend over and take it, America, you're fucked and we're getting rich as hell doing it.

A sign I read the other day stated that gas was about $1.50 a gallon in 2000. While looking over some of my daughter's baby book I noted that we had placed gas at $1.75 a gallon. She is 4 years old. More than a 100% increase in over 4 years.

I wonder where it's going to eventually end. If we had better public transportation here (meaning it would leave early enough so that I wouldn't be late getting to the hospital for rounds) I would have ditched driving a long time ago. As it stands I have to budget a certain amount, fill up to that, and hope I don't have to get gas again for another 7 days. Anymore than $4 a gallon and I don't know what's going to happen to a lot of people commuting. Unemployment will surely rise, the economy will continue to falter and fail, investors will be ruined while the companies they invested in will be "saved" by the gob'mint, and the Bushies will thump their chests, smoke their cigars, watch their children get married in lavish ceremonies, and laugh all the way to the bank.

More Truth Than Not

I read this article when a couple blogs posted about its topic. Some were naysayers, stating that it painted a bleaker future than really necessary, others were more open to the advice. I noticed that many of the younger bloggers identified with the article than the "dinos" who, of course, viewed this with a grumpy hurrumph! and went back to their job of trying to keep their investment portfolios from completely going under.

Of course I kid, but there is a lot in this article that I've identified over the last few years, which several physicians warned me about, but I didn't listen. If anything - to those out there not in medical school or medicine, it's really important to review information like this before deciding to go into medical school. Take a look at some of the comments as well, that will give you a good idea what people think of doctors.

Oh, and happy mother's day.

The House of God

The book, The House of God, is one that many medical students, residents, healthcare professionals, and people all over the world have noted as being a standout read regarding the trials of internship. Sure it's dated - since it was first published when I was born - but it's still considered a benchmark against which many medical writers are compared and is often listed as a "must read" for medical students and wannabes.

But I don't see it.

I've been trying to get through this book the last couple days and have just tossed it aside more often than I'd have thought. I find it infantile, neurotic, sloppily constructed with poor transitions, and just not a book that I must finish.

Perhaps I want to understand more what's going on than having a skim-job whereupon the author enters into emotional turmoils over the latest "insult" yet will go into florrid detail about their sexual achievements. I know intern year sucks, but some more information related to the actual crushing process might have been nice rather than learning how nuns teach nurses to deal with erections. Instead I feel that the reader is merely shown a glimpse and then ferried away hurriedly - as though it's more than we could handle.

And another item: was there really that much sex going on in hospitals back then? I can begin to comprehend where some of these TV shows developed the lustful nurse-doctor relationships after reading pages upon pages of bawdy behavior and descriptions. It seems like a pubescent fantasy rather than a beacon of light into the process of medical training.

I don't know if I can finish reading this book. I'm halfway through, but it just grates the nerves to continue. I should be reviewing other items anyway - like movies that I've not seen in a while...and perhaps a medical chapter here and there.

Home Sweet Home

Pics of our new home. Nothing yet related to the white coat burning, as it hasn't happened, but I will post just as soon as it's done.

These are in order:

1) the front of the home with a small view of my car (only the front yard has much grass - like we wanted - so the upkeep will be minimal and mowing is not much more than an hour to do at most)

2) entrance view from the front door with wood-burning fireplace (will be nice in the colder months to save on electricity)

3) kitchen with Daughter's fabulous kitchen magnets all over the fridge - on the left by the wine glasses you can see Geebo our Betta - and in the sink is the larger bowl I'm preparing for him

4) hottub left by previous owners - which is very nice to soak in after some unpacking along with an ice cold beer, but I think it might get a little annoying to keep up with when the shit hits the fan later

Haven't Earned It

A recent conversation that Wife told me about went something like this:

Wouldn't know their ass from a hole in the ground guy: "You know you're husband isn't a doctor yet. Just because he's graduating doesn't mean he's a doctor."

Wife: "Umm, yeah he will be. He's getting an MD in a couple weeks. He'll be called doctor by everyone including patients, nurses, doctors, etc. He will be a doctor."

WKTAFAHITGG: "Well, he'll be called that, but he's not a real doctor. He hasn't put in his time yet. And I don't think they should be allowed to call themselves doctors either - it's like lying to patients."

Wife: "What the hell do you think 4 years of medical school is if not putting in your time? Just because he has to do a residency doesn't mean he can't be called doctor."

WKTAFAHITGG: "I bet he's going to get a real fancy-pants car, isn't he?"

Wife: "No, he doesn't like cars that much and would prefer to drive his for as long as it will allow. Then he might get a truck or something."

WKTAFAHITGG: "Yeah, so he can dump your body after he's found a few nurses to cheat on you with."

This was an actual conversation that Wife told me about while dealing with a vendor at her job. I have no idea why the guy is saying these kinds of things, but I warned her that if I ever run into him we're having it out. He's an ass, has been for too long, and this last bitty broke the camel's back.

It's like he thinks we're fighting over the same woman - who is MARRIED TO ME - and he feels that downplaying any accomplishment we've had will earn him points.

The other fact that just chafes is that he felt I hadn't "earned " the right to be called doctor. Then what the fuck is medical school for? What is the purpose of any post-graduate education that bestows a doctoral degree on someone if they haven't "earned it"? Just because he clearly feels inferior doesn't mean that 8 years of higher education doesn't count for something.

I'm serious - I'm going to have it out with him should I ever see him. Enough's enough already.

Ugly Celebs

Found this recently and think it's kinda funny. Have to agree on most.

VIP

We had a VIP who, even though he was in the ICU, still didn't want to have his beauty sleep disturbed. The following was a message placed on his door:


DO NOT awaken patient between the hours of 11pm and 6am unless absolutely necessary.

Lab techs, nurses, and various personnel didn't know what to do with this and kept waking up the on-call resident to get direction. Keep in mind that, in the ICU, the nurses have to do hourly checks as part of their guidelines and regulations. Most of the night they were concerned about getting in trouble just to give someone their restful sleep.

Even better for me was the fact that this patient was a still practicing physician, but had no idea what his meds were for, and had to have everything explained to him plainly - akin to layman's terms. Watching this scene play out you realize how the CME requirements are a good thing - because there are people who're practicing medicine circa 1970's.

What's the Deal?

Graduation is looming close. The frenzied e-mails are rocketing across the web alerting the seniors to their "week" and all the party atmosphere that befits a graduating medical student. A multitude of official people are hosting lunches, brunches, dinners, and the ever popular gala in our honor - all expenses paid (I believe in part by the class dues).

It reminds me of the events surrounding my undergrad when I was allowed to finally leave without having to harass another dean about credits. And once again I'm filled with the enormous feeling of, ah, what's that word? ah yes...triviosity.

Graduating is a big deal - I guess - but I'm really not looking forward to the splendor, the hullabaloo, and the party. After all, it's just another accomplishment in one's life that, while young and fresh, seemed quite splendid, but now reeks of "tradition" and disappointment.

I feel that, if not for my family coming in to town to witness this miraculous transformation, I'd prefer to not even be there. It's going to be long, boring, and filled with self-congratulatory diatribes and praise. Shudder.

Plus we get the extra pleasure of witnessing both the dental and graduate studies schools graduate at the same time. Like I care about people I've never, or rarely ever, dealt with. Let's just get it over with already.

Step Back

I decided after posting earlier today that, despite taking a few days and rehashing the topic a few times, it was just not a good post to have published and needed to be taken down. So I did just that.

I understand the couple commenters opinions - but still think it was blown out of proportion. I won't go any further than that here.

Race is a touchy subject to write around and I realized only too late that this published post would not be viewed well by many simply based on its subject matter. I wish that we could get beyond our differences, stop addressing "offenses" that are little more than naive opinion, and allow racial harmony to happen. Because at the moment, when we segegrate so many people in our society purposefully (award shows, TV channels, reality TV gimicks, magazines, etc, etc, etc) we not only focus on the color of people's skin or their ethinicity, we also perpetuate stereotypes and hatred. That was the meaning I was trying to derive from the afforementioned post which I saw was quickly being lost by the subject.

Oi

Moving sucks. Even if you're moving just a few miles down the road and have a trio of men lifting your heavier items, it still sucks. I find that I'm more lethargic than I'd have imagined and trying to mentally put anything together is murder. Study? Ha.

Yesterday was a day to relax as our internet and TV service was installed. We switched internet from DSL to cable and we added a local cable connection in lieu of landline phone service so that we can actually see the people on TV and not just their snowy shadows. The cable guy hooked us up - we get basic in any room we want without any extra charge. I didn't even realize he was letting us in on the goods while he was talking to me. I found out an hour later when I was channel surfing (now I just hope that someone from the cable company doesn't come out and demands that we turn it off or pay for the extra rooms).

When I was surfing the web I had tons of e-mails that needed to be responded to days earlier. God, since when did graduating become such a big deal? And why do we have 3-4 different meals during "senior week"? With gas being as high as it is, I'm most likely not going to be driving that far just to get some food.

I finally put together the lawn mower we purchased from Lowe's a month ago and got around to mowing our field this morning. I call it a field as the "real grass" is few and far between the numerous patches of crab grass and weeds. I think we also have some hay sprinkled in there as well - so we won't call it a lawn, just the field.

I've also hand washed both cars (something that gets really hard to do when living in an apartment) and actually waxed my car (never done in the last 6 years I've owned it). I'm tired, but it's a good kind of tired that's not associated with the whole process of moving. I'm really over that fatigue.

A Look Back

I thought that it would be a good idea to publish a little post about my accomplishments in the last 4 years. I don't think of this as self-aggrandizement; rather it's more like self-stimulation of the mind. But anyway...read on if you care to, but if you think this is a load of tripe, then don't - I'd rather not receive nasty comments about my boastfulness.

1) 3.9 GPA

2) >240 step 1 and 2 scores

3) AOA inductee 2007 - 08

4) Award received for being in the top 4 of my class after freshman year (I believe I'm still in this range, though the school makes a large to-do about not ranking us)

5) Highest performance on shelf exam in pharmacology; shared in pathology and physiology

6) Matched at number one choice of residency at a program that historically has not been too keen on students from my school

7) Persevered in 3rd year despite the death of my sister and close cousin within 2 weeks of each other while finding out that my dad had cancer

8) Didn't get divorced

9) Out of the 4 in my gross anatomy group that began medical school, 2 of us matched into residencies, and 3 of us will graduate. I'm quite amazed at the attrition from this group.

10) Started med school wanting to be an Orthopod with a smidgeon of interest in anesthesia. Had varying interests in internal medicine, pediatrics, emergency medicine, and surgery during this time. Ultimately came to love Anesthesiology once I understood what the hell was involved (not well taught in pharm and hardly any exposure in clerkships until 4th year).

11) No one died from my actions

12) Started at 205 pounds 7/2004. Gained 15 pounds over 3 years to an all-time high of 221 pounds. Lost 20 in 4th year to 201 - hoping to get to 190 before residency starts.

13) My pre-entrance physical demonstrated 20/20 vision. Beginning of 4th year my vision was 20/60, requiring me to get glasses.

14) Pre-entrance lab work: total cholesterol of 299 despite being on low fat diet. Total cholesterol checked in family med clinic 10/2008: 201. No drugs were ever used.

Taking Time to Smell the Flowers

NOT!

We move this week. A large moving van will be here Thursday morning and we're trying to get a lot accomplished in the last few days - like getting all of the kids toys and minutia over to the new place to help decrease the time it will take the movers (money saved for my program). We spent most of the weekend hauling crap over and getting it organized, taking it out of the boxes so that we can reuse them again and won't have a ton of trash at the end and so forth.

And yes, you read that right - we're staying in the area where I'm attending medical school, but I'll be a few miles away at the larger, "why are you going there - we don't like them", hospital than at the one I've toiled at and bitched about for a couple years. And yes again, a lot of the residents and faculty have a bad impression of the other place, often wondering why I wanted to go there in the first place - because they're larger, fancier, more equipped, do tons of grounds breaking research, and have a lot more money than our county hospital...and they have a residency that kicks ass. That's why.

Well anyway, we've gotten a little sidetracked here...I was just letting you know that we're turning off our internet connection and going with another once we move in. Plus with moving and stuff I'm going to be rather busy. Therefore posts are not going to be every day or every other like I've been aiming to do the last few months. Stay tuned as I'm sure I'll post a pic or two of our new place (maybe) and the white coat incendiations!

Getting It (No, not that...perv)

There were times during my last rotation where I began to understand the need to be at the hospital for extended periods even when one could leave. Not only for the training purposes - as most procedures happened later in the afternoon than earlier - but also for the overall educational quality and responsibility felt towards knowing your patient.

Interestingly, I found it remarkably unnerving to walk onto the unit the next morning after leaving the previous day. I invariably felt completely out of touch with what has happened overnight and scrambled to get the goods before rounds began. Worse still were the weekends were I had 2 straight days off and absolutely dreaded coming back in - not for the work, but entirely from the fear of not knowing what had occurred, who was there, etc, etc, etc. Part of me felt guilty at having time away from the patients I was following as though I was abandoning my role as their "physician". One woman that I covered for over a week recovered enormously overnight and was confused, but talking. We'd never held a conversation and when I went to examine her and see how she was handling the situation she asked, "Where's my doctor?" She was referring to the on-call resident, despite the fact that I was the person who knew her the best and it felt like a shot.

You weren't here, so why should I think you give a damn about me?

This was, for me, the first time that I had really ever felt guilty about leaving. It was also one of the rare times in medical school where I would find myself hanging around longer than necessary just to keep abreast of the situation. Nothing overly dramatic or anywhere near the hours my residents were putting in, but I knew that there was value to be there. I never felt more prepared for rounds and understanding my patient's situation than when I had been on call.

With my rotation officially over today, I feel good that I got a little understanding what the big concern is with residency training and hour restrictions. You learn a lot more doing than reading; and you learn a helluva lot more when you see, do, and read about a procedure, illness, condition that is presented to you in the form of a patient and follow the progression.

Now this is not saying that I completely feel that residents should go back to the insanely long hours they pulled a decade ago - I saw more than enough post-call delirium in my residents to see that sleep deprivation is scary for patient care. What I am implying, though, is that I get the dinosaur's bemoaning the current state, if only just a little more than before.

Ready to Dust Myself Off

Even though a few hours remain, I think it's safe to assume that the 65% of you who voted for me starting a new blog won't suddenly change you minds and try to sway the results. With that being said, I decided to start a new blog (for the record I find it interesting that those who felt I shouldn't start a new one were more likely to comment rather than just vote). Therefore I grabbed one under a new name that I will link with this one and vice versa.

In deciding to not keep with the God-complex/ delusion/ whatever-you-want-to-make-of-it persona I've created in the last 3 years of pathetic self-indulgence I shall be known, upon graduating May 17th, as Resident Anesthesiologist Guy (RAG)*. Cool, huh?

Now that you've had time to get over the awesomeness of this name and have picked your jaw off the floor, the blog shall be called The Chloroform Rag (get it, R.A.G.?) in reference to the infantile days of anesthesia when chloroform soaked rags were used as general anesthetics. I plan on using it as a tool to increase both awareness of anesthesia as a medical specialty as well as the process involved from being first called "Doctor" to that where it is not just a fascietious designation.

I hope that you'll make the trip to review my random postings and complaints as I finish one arduous climb only to get knocked off my high-horse into the dry and dusty dirt to begin another, harder trek.

*Actually I think RAG would work better if I where entering OB/Gyn, but whateva...

YEEOUCH

2 hours of Stepson's baseball. 1.5 hours of Daughter's T-ball. 1 hour in between. New haircut (shorter, obviously) and poor sunscreen control. You get the idea.

Note the distinctly attractive demarcation on my receding hairline where I applied the most sunscreen and where, somehow, I failed.

Almost There

In two days I'll officially be done with medical school. Oh the glory, the fame, the wonderment I see in people's eyes as I pass them.

Wait? What's that? I'm not as great as I think and my first week of internship will absolutely, no doubt about it, kick me off the top rungs of medical school heirarchy into the dregs of the lowest denominators of the hospital peasantry?!

Dammit.

But at least for now I can relax, read some, review some, and just enjoy the last moments of freedom before my life is completely taken away. Despite the generally intense nature of the ICU I've been more relaxed with issues as my time approaches. I've taken the notion that I'm still learning and really applied it to my patients, learning as much as I can from each rather than just trying to impress but not understanding what's truly going on.

Another one is the baring of arms and the tattoo concerns I've dealt with for the last 4 years. Only recently have I been more apt to wear short sleeves around peers. Now I'm frequently removing my grisled white coat in favor of bearing my arms, tats and all. This will most likely be something I shun again when residency starts, but for now I don't fear the repercussions a couple partially removed tattoos might inflict as I dispense of my cumbersome coat.

And speaking of those bastions of med school - the white coat burning is going to be kick ass! Grab a beer, throw a burger on the ol' grill, and light those short, stupid looking, monstrosities up! Pics to follow - of course.

Luxury

Hello from the one call room with a working TV! As you can see I've gotten myself comfortably aligned to view the best in television sitcoms while awaiting the page for another ICU admission. Sometimes getting to the call room early is the best - as you may not get to take a nap later in the evening.

Truth be told, though, I spent most of this time reading about HIV and metabolic alkalosis - this was a break (if you believe that).

Sex, Drugs, and...

I knew that most drug reps were full of it before I started rotations. Working in an outpatient clinic as my first exposure to real patients during 3rd year was not completely eye-opening to their ploys despite this being an first interaction with them as well. I was shocked to see, though, that the office regularly received anywhere from 3-10 a day with the majority of female reps wearing outfits that were intended to attract the eyes in “sublime” locations (some were guys dressed to the nine's who didn't exude as much sexuality as their female counterparts). Additional interest developed from observing those who would regularly purchase lunches wherein they'd give "lectures" to their captive audience. It seemed like a Hollywood cliche gone awry.

This was, in all actuality, one of the worst I've seen in the last 2 years, but variations are regularly presented - and in all specialities.

Yet, until a few days ago, I was a little murky on their education.

That was until a rotund, bleached-blonde, large-breasted woman who, while wearing an overly-tight blouse to accentuate her natural gifts of adiposity, tried to hock a statin. She began by introducing herself, her aspirations, and educational background. I can tell you that a BS in biology and an MA in liberal arts do not impress me when it comes to pharmacology and her credentials didn't extend beyond. Since I graduated with a BS in bio and could have graduated with that liberal art degree as well – damn near minored in it from a community college before deciding to go pre-med – I thought it mildly amusing that she was here to "educate".

But that’s OK – because rather than muddle her way through a memorized market campaign, she brought a video to deliver the information! A room full of residents, watching some hacky, 3-D video that was clearly marketed for the public. Embarrassing. But at least the food was good.

So now, armed with more than enough information about drug reps, I feel very little sympathy when I purposefully evade their handshakes, avert my eyes from their amply laden bosoms, phony smiles, and well-tailored suits, and eat their free lunches guilt free. All the while completely ignoring the rhetoric they spiel so blithely.

Tragic Realization

Picking through a Civil War book of which I'm quite fond I came across an atrocious image: masses of ravaged arms and legs, piled waist deep, gathering flies and rotting as a surgeon and his staff, covered in stinking, blood soaked leather and cotton aprons, began again on another poor soul.

The anesthetic being delivered came woefully from a single chloroform soaked rag and a prior heavy drink of whiskey. In the picture one of the men held the soldier’s head with that rag, covering his nose and mouth. This was the extent of anesthesia – and that being rarer as the war raged – that many a man received after having their limbs decimated by Minie balls, canon shrapnel, and grape-shot.

Surviving this extreme assault on an already destraught, damaged mind and body, the soldier faced the inevitable infection that would arise and hope, praying pitifully, that God would spare their lives. Many prayers were not answered and thousands died from postop complications.

We’ve made leaps and bounds in 140 years, people. As much as people don't understand anesthesia, I'm sure they're grateful that they don't have to undergo such horrors.

What Savior?

Where will all of the primary doctors come from? Serious question – not rhetorical. Despite the assuagements from various people that the PCP is and will be filled by foreign medical graduates who’ll be more than happy to work in rural environments, I’m concerned.

For instance, many of the senior foreign residents in the Medicine program at my hospital are talking about taking hospitalist jobs when they finish. I’ve yet to hear one who has discussed going into private practice.

Not one.

And why is that? Because docs are greedy, money-grubbing, unethical whores, worshipping the almighty dollar in a gluttonous orgy of padding profits and ordering unncessary exams while Rome burns (or something)? Or is it because the government, that same government that plans on swooping in and “saving” American healthcare, is actually the etiology behind all of this?

Think about it. Medicare is the main stimulus for insurance reimbursements for everything from major to minor insurance companies. “Do as I’m doing, follow, follow, me” should be the mantra of Medicare as they cut payments and dare docs to retaliate. Private insurance companies take heed, and follow similar cut backs in payment - rather than acknowledging that their reimbursement schedules are messed up.

So congress, rather than being smart about cost-effectiveness, believes that in order to balance their budgets (oxymoronic term if ever there was) they have to pay hard working doctors – who've spent more than a decade getting an education – less and less. We're now seeing the deliterious effects that years of this foolhardy maneuvering has caused; removing office-based, primary care out of resident’s minds.

Further insult comes from beauracratic nonsense that, while not completely government controlled, is basically just a few votes shy of becoming part of the FDA or some other monolithic entity. Of course I’m speaking of the idiocy known as JCAHO and all of the ridiculous limits and strangleholds they place on patient care disguised as “safety measures” which only leaves the physician spending hours digging through minutia and dead-ends in order to "meet standards".

Bullshit.

Yet, millions of Americans are being dupped into believing that they must have universal coverage in order to get healthcare – and they’re buying it hook, line, and sinker. It has taken center stage over most every other consideration during the recent campaign speeches. The economy? Iraq? Ha, mere annoyances compared to this impending "disaster".

It infuriates me to see people who are highly qualified physicians avoiding the work that their residency was initially designed towards. I don’t bemoan them. Hell, I’d being doing the same thing. What I find sickening is the idea that the government will fix this. That the good ol’ US of A can be saved by lawyers and career politicians who know as much about medicine as they’re able to maintain party neutrality and an open mind. Ha.

Junior Mints

Hrrm.

Watching 3rd years brings back memories of surgery clerkship – walking around in groups, thinking you’re a bad ass while the residents do everything, and not knowing what the hell you’re doing but acting like you do – yeah, I remember those days well.

I’m still living them.

But in all seriousness, the juniors have been putting in some serious work this week. Many of the ICU patients are surgical, sicker than snot, and require a lot of interventions/ management/ follow up, leaving the juniors arriving throughout the day trying to find some data that's needed. Most are here well past 6 pm on a regular basis.

Yet, despite these hours and the conditions they've been launched into in the last 1.5 weeks, I still can’t fathom why anyone would walk into a patient’s room whose on contact precautions, touch them with their bare hands, and get huffy at the nurse who tries to stop you. I get that you’re tired, man, but is the extra few minutes of putting on a cover and gloves really worth risking infection? Plus snapping at the nurse will only get you on a shit list that you don’t want to be on. Trust me.

Overall though, the thing that bothers me the most about them (not that they bother me in and of themselves) is the fact that they have to change into nice clothes as soon as they leave the OR. One girl had to leave and change before she could help out with a chest tube the other day (which was subsequently completed while she was gone). It floored me.

Gone are the days of walking around in scrubs – like I was allowed – and being able to deal with the fluids and contaminates since you could just get another clean pair from the OR. That was one of the great things about the surgery clerkship – not having to wear a tie and iron your damn clothes or worry about destroying them.

And there were great days on that clerkship. But I mean, do you really have to avoid wearing the scrubs altogether? The residents still walk around in theirs, why can' t the students?

Question Y'all

I've been toying with a few ideas for when residency begins as to what to do with this blog. I began it as a memoir of medical school and a place to vent frustrations during those times. I wish I still had my posts before the "delete" incident, but they're gone and there's nothing I can do about that - so let's not worry.

Instead what I've been pondering is whether to keep writing on this forum (since many of you have come to know MSG without the full name being spelled out) or keep it linked, but start anew - fresh and free from my monicker's shackles.

After all, I've several posts under the title of Medstudentgod and I honestly don't want to have an archive list a mile long dealing with med school and then residency. Perhaps it's time to get a new blog, to chronicle the next phase in my journey. Who knows.

So, I'm asking...should I keep writing on this forum, or start a new blog; a template that's clean from all the hate and bitterness that encompasses much of the posts herein. I've added a poll for the next couple weeks. Please let me know. I value your input.

Do You Have This View?

Even though call sucks - mostly because I can't do much and sit on my hands all damn night long, waiting for something to do, ergo the 2 posts in one day!- I have to revel at the beauty I'm awarded from my call room's window on the 9th floor as twilight descends.

Taken from my cell-phone, so it's not the best pic, but this encompasses the older parts of the hospital, the dental school (building on the far upper left), and a portion of a university that is across the street (not affiliated with us). It is far more breath taking than this crappy shot demonstrates - trust me.

Reading Rainbow

So I hinted earlier about my uptake in pleasurable activities during this semester and the slip in my medical knowledge because of it. I was thinking about the amount of literature that I’ve read through and, while not epic in any sense, it is rather astonishing to regard the amount of reading I’ve undertaken in the last 6 weeks. My list of fiction that I’ve gulped down with child-like glee includes:

1) Cutting Remarks by Dr. Sid Schwab
2) Odd Thomas by Dean Koontz
3) The Face by Dean Koontz
4) False Memory by Dean Koontz
5) The Shining by Stephen King
6) ‘Salem’s Lot by Stephen King
7) Nobody True by James herbert
8) Mary Shelley’s Frankenstein
9) The Killer Angels by Michael Shaara
10) First, Do No Harm by Dr. Derrick Beech

Most of these have been excellent reads, but it staggers the mind to think how much time I’ve spent absorbing fiction. No wonder I’ve gotten a little rusty. Up next? Carrie.

Respect II

Overheard while performing the babysitting duty:


Nurse 1: "They went and ordered for [some test] on your patient".


Nurse 2: "Well, I told them that they needed to get that test...3 DAYS AGO!"


Nurse 1: "I guess they didn't feel it was needed at the time?"


Nurse 2: "Who knows what these docs are thinking? But, whateva...I'm just a lowly nurse anyway...don't know shit."


Nurse 3: "Who ever said you knew anything to begin with?"


Nurse 2: "Shut up, bitch!"


They then all proceeded to start laughing hysterically. I didn't get the joke, but the innuendo from the critical care nurses that they know more about how to take care of patients than the doctors (surgical, medical, attending, resident, or otherwise) is more than covertly spoken. But only when the docs aren't around - I apparently don't count.

Respect

A note from the ICU in which the impression on the residents and attendings is clearly manifest. Sometimes you just have to laugh. I personally enjoyed the grammatical errors that are rampant throughout.

Death Rattled

A face to face encounter with death is something not normally undertaken by most people. I’ve begun to see enough of the haggard face of Death that I’m getting slightly immune – slightly, not completely.

It used to transfix me, watching someone die – especially in the ICU where so much seemed to be happening. Now I go about my business, still checking in to see if Death, with his icy, skeletal fingers, has deposed a soul of their body, but I no longer hang around and wait.

Gasping for breaths, eyes lolling absently within the skull, chest and abdomen heaving from the physiological desire to increase the body's blood-oxygen - not normally a pleasant view to observe. I think I’ve seen enough to remain interested, but not morbidly fascinated - as if I'm witnessing my own mortality through another life’s culmination.

I do know that the exposure has solidified any unnecessary desire in me to seek heroic interventions for own life. Do what you can, without going overboard - that's my take on it. These people who spend days to weeks in the hospital are, for the most part, already door nails (if you get my drift) – we just fool ourselves while the machine works.

To further these considerations I have decided that I should attend an autopsy - offered at certain times for those students/ nurses interested to which I was heretofore unawares - while on this rotation to finally deal with Death's throes over life. Seeing the completeness of a body emptied, lifeless, being quickly but systematically cut open in an attempt to understand the "flawed defect" that resulted in death should be riveting. And an experience that teaches how fragile life is - in spite of our societal denial that death is the inevitability of life.

The Sitter

Today I figured I'd cury some favor from the nurses and spent about 2-3 hours babysitting a patient. They were there for several days while we attempted valiantly to wean them off some sedatives and get them up to the floors secondary to severe alcohol abuse. Unfortunately there were an infinite number of sick patients (it is the ICU after all) and the nurses had not been able to keep their attention on this patient when they were out of bed – so they sedated more and kept asking for restraint orders. It's easier if they can't move, ain't it?

Finally today the attending asked for us to take shifts and watch. And since they were mine, I took first shift – which showed a very coachable, easily manageable patient who needed to get the hell out of the ICU and go to the floor.

I try to not think about the cost to me in dollars for an education where I babysit patients, but then again, I had nothing else to be doing at that time anyway. I should appreciate these times more. Plus I looked good in the eyes of the nursing staff - which will mean that they'll watch out for me for the next couple weeks - hopefully.

News From the Front

Medical students are useless. We just are - adding extra work to resident's daily to do lists, getting in the way during procedures and rounds, and having to be accounted for on a regular basis all leads to a rather mundane and useless person.

Yet for all the tomfoolery that goes on with training med students the majority of residents/ attendings/ nurses are nice and considerate to make you not feel completely ridiculous. Most. A nurse from the L&D ward was down in the ICU yesterday and she brought with her the mentality that I hated on that floor: get out of my way you useless piece of shit!

Twice I was attacked by her for just looking in a patient's chart (which I had to defend by stating it was my patient, so back off), I witnessed her badger the radiology tech for HIPPA violations since she was walking around with patient labels on her sleeves (which most people do when they're actually, you know, up and moving to get their work done and not sitting behind a PC all day), and several times this behemoth of a woman got after the residents. Once she even went so far as to tell my senior "You need to get off my computer and get back onto yours!" The resident yielded, laughing outwardly at the farce this woman was making of her position, and I smiled as the nurse pulled up her important work - shoe shopping online.

Good Times

It’s nice to find out that you’re going to have a moving company work on moving you from a 3rd floor apartment into a home with stairs and a fairly steep driveway – all paid for by your program.

It’s wonderful to have signed on a home and know where you’ll be living for the next few years.

It’s fun to roll in the grass with my kids, despite the dangers of doggy poop landmines.

It’s exciting to complete items needed by your residency program – it makes it seem like you’re already there.

It’s fun to have sloppy joes for dinner when everyone is tired but starving. It reminds you of how simple life actually is and how complicated we tend to want to make it.

Lessons

My considerations regarding the embarassment I felt during a pimp session have ultimately led to an inevitable truth: I should have known this material.

Whether it resulted from my not reading as much as necessary (I had been reading about this the night before, but fell asleep with my CMDT lying fitfully on my stomach and didn't get it in the ol' brain) or the reduction in patient and floor-type care contact, I don't know. I believe, however, that the atrophy of my knowledge was a direct result of various interactions.

For one, I have not had to deal with heart care in more than a year except in the OR - where the care is decidely more acute, with different drugs and algorithms being employed. In fact, I, along with hundreds of 4th years, haven't had much to do with medicine at all in many months. No matter how much you read something, if you're not involved to some degree beyond printed text you get stale.

Another factor is that I have been taking some time for leisure: reading fiction, music, working out, etc. Medicine has been at a back burner for a few weeks and it's hard to dust off the cobwebs sometimes.

Yet, in this humiliating and seemingly frustrating week I've learned something profound that has, until now, not been fully realized: You need residency training to become a doctor. Simple, right? But it's often so easy to think that we're coasting, doing well, and that residency is too hard and too long just to get a little ahead of where you're at now, so why do we really need it? Then you have moments like this and think "Not so" - the nature of trying to do something, failing, being called out, and then going over the scenario and reading about the current treatments helps create an impression in your brain that wasn't there before and would never have existed except through experience. And that's what it's all about.

Suck

Today was not a good day. I've forgotten a lot of floor patient management and certain things have just leaked out of my brain - leaving me helpless in front of pimp happy critical care docs. When the resident looks at you and tells you that, as a 4th year, you should know that in and out you feel like dragging your beat-down ass out of the ICU - you've no business being there.

Tired

Just got home from being on call. I'd forgotten how tiring this process can be, even with 4 hours of solid sleep. The hospital wears me out...plus trying to find a bed when the previous med student call rooms were completely full/ locked/ or under repairs didn't add to the fun.

I don't know what is about being on call that makes you eat horribly, but about 9pm I began craving like mad and broke down, getting some serious candy munching - only to regret it.

Stoked

Psych note: Patient noted to be in chain stoking respirations. Ah, yes, stoking the chain while breathing - classic.

Just Had to Say It

It actually irritated me a little that someone would, anonymously – like a troll, suggest that I was second guessing my choice for residency. In part because they completely missed what I was trying to write about, but more from the idea that I was having some kind of reaction formation about choosing anesthesia over surgery.

I made the decision early in 4th year. Up to that point it wasn’t that clear – since I’d only ever had very minute experiences with anesthesia, but had multiple and impressionably profound moments of surgery throughout the previous 3 years. It’s always easier to believe that you’re fit for something when you get more knowledge about a field – plain and simple. Once I had a month of anesthesia under me my choice was not that hard.

But it is true that I also made the choice based on a desire to be with my family. An desire that didn't seem as feasible the more I was able to perceive resident and attending surgeons doing very little with their kids and spending countless hours at the hospital. Yet someone feels that I am trying to create a negative attitude about surgery simply to remind myself why anesthesia was the better choice. I tried to ignore this absurdity for a time, but it’s just gotten under my skin and I feel the need to just say "fuck off"! And that’s enough about that topic.

****

On a different note – I have realized that I will suck starting July 1st. Two days in the ICU have taught me that I unquestionably know dick. 4 years of med school and I still suck my thumb when confronted with sick-as-hell patients.

Hours Violations: in which I state the obvious

I've been reading a book by a fairly well known surgeon -at least in the blog realm and whose webpage helped guide me to his accounts of residency training. I have been amazed at his descriptions of the quantity of time he spent in the hospital including a 2 month stint where he never left. What's more is the distinct void I perceive in his life during this time and how he viewed the demands then and now, despite the sheer exhaustion, as necessary to produce a qualified and competent surgeon. In his introduction he bemoans the work-hour reductions, calling them a "pathetic, embarrasing, and paltry 80 hours..." implying overtly that in a few years he expects more deaths to occur due to reduced skill levels and knowledge than ever occurred from fatigue. I might just agree.

It's not hard to believe that the work hour restrictions have upset a lot of the older docs out there who view their interruptive nature as ample fodder for shift mentality and weak residents - both mentally and physically. I've been on the fence about the benefits - since I'm quite sure that having overly exhausted residents invariably leads to poor patient care, but also am quick to acknowledge that the sign out process absolutely results in less knowledge and poorer patient care. Despite this duality, I continue to hold the belief that some of the older docs see the restrictions as an aggregious afront merely because of bitterness at having lost several years in their training while we, the apparent coddled and weak heirs, talk about our social lives, families, and aspirations beyond the hospital-tiled walls. I don't have a definitive answer on whether the restrictions are a blessing or curse, but I have enough sense to comprehend the concerns that attendings and residents have alike when dealing with patient care and violations.

With all that being said, it's important to understand that since 2000 the rule to average 80 hours over 4 weeks has been in place. Not just brought up in vague armchair discussions, but fully implemented and, though weakly, enforced. It's lost it's virtuous shine long ago and hospitals should have made the adjustments by now. Yet we still find various programs continuing to ignore them, risking not only their accredidation but their resident's well-being. Imagine having to work a year or more where your program wasn't accredited - you may even have to try and sign on elsewhere and you'll understand some of the concern residents have when they're over hours regularly. It is prudent of the residency program to understand the serious nature of the regulations and do what they can to turn out highly qualified physicians while regularly meeting the hours.

Yet, I don't know why every residency must meet the same criteria. For instance: anesthesia and emergency medicine have long held their residents to a 24 hour limit while on call. This was done based on the nature of the work - critically ill patients, highly lethal drug combinations being given, and the distinct truth that a patient can die quicker in these professions from a slip of the drug needle than from a slip of the hand. The nature of surgery, on the other hand, demands that the resident be in the hospital more often for both exposure and endurance - all necessary for a truly capable surgeon beyond resident training.

When I was on the floor for surgery we had one resident and two interns - one of which was a family med intern doing their month for the year. They were in charge of the ICU, the floor, ER coverage, and running codes - all while still getting in the OR. I know for a fact that the surgery resident and intern never met 80 hours. They were there nearly everyday, all day, for 2 months as this was mandatory to get through the work. In other institutions I've seen residents in the OR as long or longer than my anesthesia residents and still had the duty to pre-round each morning and round on post-ops. I know for a fact they weren't meeting the hours restrictions either.

Surgery training itself is longer than many others - 5 years or more during which you're required to take care of patients both in the OR and in the hospital. A lot different from medical docs who don't have the burden of fitting in an 8-10 hour OR schedule into their patient to-do lists.

Surgeons were training at 120-140 hours a week just a decade ago as they felt this immersion was requisite in obtaining highly skilled physicians. Would it not be more feasible for them to meet their training goals and still meet work hour regulations if specialties that generally need more time were alotted 100 hour weeks? The writer's assertion, mentioned earlier, of an impending increase in mortalities if we don't recognize the fallacy in the 80 hours for surgical training is quite insightful.

Let me be more blunt - would you want a surgeon who hasn't seen as much OR time taking care of you? Would you want any doctor for that matter whose training was abreviated for any reason taking care of you? No one needs to be there 24/7, but I think we can admit there's a need for those who, just by the nature of the work, demand more hands-on experience to receive more training before they go at it alone.

Slowest Loser

Remember this topic? 221 pound male, 6'1"?

Yeah that was me and I can say that, as of this morning, I've lost about 15 pounds! It feels awesome to have been able to accomplish at least some weight reduction in the months that I've been toiling in our workout center.

My goal is to try and get around 190 pounds before residency starts. I don't think that will happen, but it's good to have a goal in mind. Since I've had some time off I've been working out for 1.5-2 hours a day, have been eating better, have stuck with my plan to avoid soft drinks, and reduced my caloric intake by about 500 calories a day.

I also try to workout before eating breakfast or lunch since you burn more calories this way. Wife commented that she thinks I've lost too much weight and that my clothes don't fit well anymore, but I've still got some more to go. I've just been wearing baggier clothing to hide the bulge for so long that it looks too baggy on me now.

The program where I've been accepted has a fairly good gym with several elliptical machines and lots of free and machine weights, but it's used by the entire campus. I'm thinking about finding out how much they'd charge with me being a resident and then comparing that with purchasing a home gym like Bowflex along with a treadmill. It would be easier to workout at home since I wouldn't feel guilty with the extra 1-2 hours spent away, so it might be worth a little bit more each month just to vanquish the guilt.

Additional Match Data

More information on the 2008 match for all interested. I would take interest in checking out the matched % by US grads. It will be revelatory on the where primary care is in this country. Larger link here.

Hello, I'm Med Student, Er, Doctor...

So I've received some of the information from my program including orientation dates, ACLS/ PALS certification requirements, vacation request form (really? I have to decide that now?), and information on how to obtain my IDs. I'm excited and scared all at once. I'm amped but pertrified. I'll be a medical student, but a doctor. Oh dear...it's so close.

Wife made a comment about our president's speech wherein he discussed days that will stay with you forever; included was the first time when you hear someone calling "doctor" and you look around - only to realize they're calling you. She didn't think it would be that memorable since I've been called doctor in the past by various hospital employees and wondered whether it would really make that much difference in May.

"Yeah it will." I said. "Because this time I can't tell them I'm just the medical student and get out of being responsible. I'm actually the doctor they're wanting".

I get seriously puckered just thinking about that.

Don't Do It

Ok, to buy or not to buy, that is the question.

This bastardized version of a famous, if not overly quoted, Shakespearean line (in fact I don’t even know which play it’s from – I’m that shallow) is a question many medical students face at one time or another during their education and training. Even before medical school begins there are corporations and entities out there trying to obtain signatures from the would-be doctor, playing the hand of a stable 4 years, good investment, and why throw you’re money away? I’ve heard ‘em and don’t buy ‘em. Here’s why.

As a medical student, I must ask, why on earth are you buying a home? Unless your spouse or significant other is the one making the purchase and has the money to cover the mortgage without getting you into significant financial distress, you shouldn’t borrow money with borrowed money. Plain and simple. It’s like paying off a credit card with loans – we do it, but it doesn’t make a great deal of sense, does it?

4 years of medical school sans PhD or other pursuits, is obviously not enough time to obtain a good amount of equity in a home to ensure you won’t owe once you sell. Trusting that you can stay in the area and do a residency? Don’t – it’s hard as hell to do and unless you’ve got some serious cajones and won't interview anywhere else you probably will have to move. Getting a job is great, but worrying about selling your home before you can move can cause a lot of stress at a time when you should be celebrating. Let’s not even consider that you’re responsible for taxes, upkeep, insurance, etc. etc. etc. with owning a home that won’t affect the selling price or value.

As a resident you’ll find there are more people trying to get you to buy a home. After all, you’re finally making some BIG money (which is almost anything since you’ve been unemployed for 4 years!) and you’re a doctor. Treat yourself good. But that’s the trick– assuming you should have something when, really, you’re in the same boat you were during medical school.

Look, most residencies are 3-5 years. Because you’ve likely not been able to save a tremendous amount many residents obtain 100%, nothing down loans covering the cost of everything. Any fee that comes about from the purchase of the home will go into this loan. Now, once signed, the purchased home is now more expensive than what they bought it for. 3-5 years is not a lot of time to pay off that extra money that was accrued, gain equity, and be able to sell the home once residency is completed. You’ll most likely owe and have to write out a check just to be clear of “your home”. Plus your loans are only deferrable for certain period of time and they’ll be coming due at the time or before you finish residency - leaving you owing essentially two mortgages.

And let’s not kid ourselves, many of us believe we’ll be attendings in the area we did residency, at least for a few years while we stabilize. Can we guarantee it? Can we be sure that we’ll be offered jobs by the hospitals or groups in the area? No, we can’t. Once again you’re assuming something that you can’t control. Having a house that you can’t sell, that limits your ability to accept offers in other states or cities, and that now controls what you can and can’t do will make you miserable.


Plus the obvious factor coming into play is the status of economy. 3 or 4 years ago the housing market was doing well - now people can't sell to save their lives. Do you want to risk that?

To further explore the benefits of delaying instant gratification, let's consider what renting could offer. Are you throwing money out the door when you rent? Well, for the insurance, taxes, upkeep, housing association fees, utilities, etc. that come with home ownership you can see how, after 4 years, renters are more likely to come out on top. They’ve not been forced to pay for appliances that break, broken water heaters, home owner’s insurance and possibly mortgage insurance. Every increase in property taxes doesn’t instantly affect them or -god forbid - having entered into a variable rate mortgage, every swing of the interest pendulum won’t suddenly double or triple their monthly payment.

Instead they pay their rent, utilities, renter’s insurance and not much else. Something breaks? Call the landlord. Broken water main? That sucks, but they aren’t paying. Appliances? Unless you’re a shmuck and rent a home where you have to provide the fridge, stove, and dishwasher you’re not paying to replace these or fix them either. An increase in rent can occur, but you’re not stuck having to pay something that you don’t accept. Once your contract is over you can move to a cheaper place if the monthly payments become too much – you aren’t suddenly crippled if the landlord wants another $500 each month.

And if you’re considering the tax deduction that comes with a home – the savings overall per year from a renter are often similar, if not more than those deductions even with a higher monthly payment.

Sure there’s the pride of ownership, but it can wait. It’s just not worth it to get in over your head simply because of pressure to fit a persona, a lifestyle, that you can’t meet anyway. Yes you’re a doctor, but you’re really not - so don't behave like you're set and secure. You’re still a student and it would be wise to think that way.

Exit Interviews

We received an abundance of financial information yesterday – enough to cause some mass confusion amongst the graduates. Perhaps the revelation that a couple loans came from the school and we were going to be paying them – or the group that purchased these loans from them – and they wanted lots of information and repayment options at that moment caused a great deal of alarm. The discussion was further muddied by the combination of dental and medical students, with loans being discussed that were only for dents or meds. Chaotic mess.

Really anytime you get medical students together and start talking about money, debt, and loan repayment we cringe. I hate the topic, because there’s really not much I can pay back and the idea of all the debt out there that needs to be repayed, well, scares the bejesus out of me.

There was some helpful information from a couple financial groups and I appreciated their time. It was extremely nice to learn that there’s an option for private loan consolidation that can reduce payments or provide some deferment time and that I'd most likely be able to take advantage. I had been laboring under the assumption I would have to pay back through the nose starting in 2009.

It was also nice to hear that a financial group that had beseeched us during the first week of med school to avoid purchasing a home* also advocated the same during residency. You just don’t know where the market will be and you can lose out on good opportunities since you’re stuck with a mortgage. Wife and I decided a few weeks ago to forgo purchasing and continue renting.

Money, money, money – it never stops. I wallow in repressed anxiety whenever the topic comes about or I review my loans.

There were some representatives from the US Army who wanted to talk to anyone about loan repayment through service. No thanks…I’ve seen what happened to a couple people who entered the military during med school. It occurs to me that you lose a lot of options and freedom for money – almost like you’ve sold your soul.

* I will discuss this in an upcoming post to more clarity. I think it is extremely important to consider why buying a home can lead to so much stress and possible loss of assets.

Update on Match Stats

I realized that you weren't able to view the match data I provided earlier on this post. Therefore, if you're interested, I've added some of the data to those specialties - in case you were interested to see how competitive various programs can be.

A Story

This is just a story. I’ve been considering a writing project and have come up with some ideas. Do not fear, this is not based on my life. Enjoy.

Occasionally there are moments when we find ourselves in unfamiliar or distressing situations. The Holmes and Rahe stress scales are useful, if you want to acknowledge that what you’re about to undertake is one of the most stressful events a person can do. Death of a spouse, divorce, moving, starting a new job or school, losing one’s sense of self or societal position are considered some of the most vexing on the human ego and psyche. Taken singularly, they can cause depression, but amalgamated, suicidal ideations may flow serenely from the unconscious mind.

By my nature, I prefer to ignore these scales, inasmuch as reading them leads inevitably towards the very notion planted therein. Subconsciously we begin to feel that we must abide the expectations, open the chasm of depression, wallow in the briny filth of morose feelings, and sponge ourselves with latent self deprecations as each event is sampled. Therefore it is neither beneficial nor prudent to tempt such acts.

Finding myself at the age of 26, having forgone the comfort of the business world and regular income, sitting between the legs of a cachetic and jaundiced cadaver, trying to not inhale fully the formaldehyde redolence of room, I was certainly high on the suicide scale.

As I carved at the withered genitalia and nether regions, I surveyed the room. Other students were elbows deep in bodily fluids and preserving solutions while they cleaned out the pelvis. Others were still toiling away at the prodigious amount of fat that their cadavers held, waiting until the last week before they would dissect the privates. The months of arduous labor had turned our lab coats from a starched white to a waxy, oily yellow, reeking of Death. Every fiber of our being had begun to take on this stench, regardless of the time or place. Showers were always welcome, but the morbid perfume was inexorably lodged deep in hair, skin, and soul.

The ignominy was deeply palpable. Here and there we would look at our classmates and smirk as we worked assiduously on our bodies. Each was a mirror unto ourselves and the haggard appearance my eyes met at each turn had begun to frighten me.

The fetid stench had overwhelmed the senses at times and various groups had forgone the dissection of their bodies, electing to use sloppy prosections - previously dissected body parts removed from their bodies - that would allow the students the chance to learn the anatomy without the time necessitated by dissection. My group had democratically elected to cut.

Bastards.

In spite of my attempts to ignore the stress scale's warnings, thoughts of suicide had entered my exhausted brain on various occasions. While disturbing, these were never contemplated long enough for me to consider it a startling change. I was troubled, however, by the increasing domination of one bizarre idea - being annihilated as I drove home.

A two-lane highway lead to my residency. This highly frequented road was traveled regularly by large 18 wheel behemoths as they took supplies and inventory to the metropolis down the road. Since the freeway did not connect, these leviathans were forced to navigate the twisted highway. Often times the noise brought upon my home by these monsters was enough to drown out the television and awake me in the night. I hadn't been able to sleep well in months.

On many nights, long awake and fighting off sleep, I’d found myself drifting into oncoming traffic as I returned from a night of study or dissection. Staring at the glare of an oncoming truck I found a beauty in the pure brightness. I had always veered back into my lane, sometimes moments before Death gripped me, but the idea of allowing myself to die in such a fashion had begun to invade all suicidal consideration.

More and more I ruminated over this nihilistic fantasy, slowly talking myself out of an attempt as I would drive home. It was getting harder to not think of those lights as ethereal in nature, as though they were two angels welcoming me and Truth was moments away.

Nightmares began to fill what dreams I had. I wondered how much longer I could last.

Match Stats

I've seen the statistics for our school, including those that didn't come to the match ceremony. I thought that I'd post those along with some information from the NRMP website. Thus far there are only some numbers from the match provided by the NRMP (hopefully this opens since I had to sign in to access), but as more is available I'll link it (link doesn't work unless you have NRMP access - I've added the US total positions being offered and the number that went unfilled for further clarification).

Anesthesiology, 3
Total offered: 666, unfilled: 17

Emergency medicine, 7
Total offered: 1399, unfilled: 29

Family medicine, 11
Total offered: 2636, unfilled: 249

Internal medicine, 20
Total offered: 4858, unfilled: 107

Medicine/pediatrics, 2
Total offered: 362, unfilled: 36

Neurology,1
Total offered: 177, unfilled: 12

Obstetrics/gynecology, 11
Total offered: 1163 , unfilled: 12

Orthopaedic surgery, 1
Total offered: 636, unfilled: 1

Pathology, 2
Total offered: 508, unfilled: 41

Pediatrics, 8
Total offered: 2382, unfilled: 87

Psychiatry, 4
Total offered: 1069, unfilled: 56

Physical medicine & rehabilitation, 1
Total offered: 83, unfilled: 3

Preliminary internal medicine, 1
Total offered: 1901, unfilled: 127

Preliminary surgery, 6
Total offered: 1263, unfilled: 455

Radiology - Diagnostic, 3
Total offered: 157, unfilled: 3

Surgery, 9
Total offered: 1069, unfilled: 2

Overall 90 matched with 59 entering primary care fields (IM, OB, Peds, FM, and EM - even though EM doesn't want to think of itself being primary care, it is for many). Unlike last year where many matched into Radiology and Ortho, we didn't have many get into these fields - though I know a few tried.

I was glad to see a couple getting into Peds/ IM and more than a few matched into highly competitive positions at prestigious programs. Overall we did well. I also thought the number of anesthesia positions offered in total per the NRMP data resulting in the number of the beast was a little distressing. Can't we offer one more just to avoid Beezlebub's blessing?

I matched into the southeast again at a program that's well known. While it's not thought to be in the top 10 (as far as the SDN convos went), it is often discussed in conversations as being one of the top 20 programs in the country for Anesthesia. I couldn't be happier.

Super Nasty

Something that I’ve gotten used to is the idea that hospital’s are gross. People believe that they get the best care and won’t get sick there, but often they end up with more virulent strains of bacteria and other fun pathogens than are out there in the world if they stay for more than a couple days. Patients want to stay, we want them out – before they catch a hospital acquired anything and Medicare refuses to treat an inevitability.

I’ve also realized just how dirty the white coats, scrubs, and other materials healthcare workers wear or use regularly can get. Therefore, my indignation and abhorrence at the following situation has nothing to do with me being a pompous, self-righteous, gym freak, but more from an appreciation of the nastiness being spread.

I ran into a guy in hospital scrubs the other night who looked every bit a male nurse. He was sweating over everything, through the scrubs, and onto the benches, chairs, etc. I hoped that 45 minutes of cardio would be sufficiently long enough for me to not have to associate with him and his profuse secretions. Unfortunately a comely female joined him 30 minutes into my workout and they proceeded to regale each other with stories from the hospital. Evidently they work in the same hospital, if not the same unit, and were bullshitting while they went through perfunctory maneuvers. During this time I learned he'd worked earlier that day.

After finishing my cardio, wiping off my own sweaty brow, I proceeded to the bench and performed some dumbbell chest exercises. I draped a towel over the bench in order to catch my perspiration and avoid contaminating myself from anyone else (like disgusting Bob over there).

Halfway through I got a drink and watched, to my absolute horror, as the sweaty male nurse, still perspiring profusely, got on the bench and proceeded to do some work – while my towel remained! I waited for him to conclude and let him know the proper etiquette for gyms. I then told him about the obscene display he was creating working out with his scrubs and most likely the transfer of serious bacteria throughout the room. He was offended, told me to chill, and received another tongue lashing from me regarding the erroneous impression he had about his behavior. These are, I reminded him, the very conditions needed for MRSA and other infections to be acquired - humid environment with physical activity and potential skin breakage.

Had I not been keen to the notion of transmitting disease pathogens from clothing I might have just asked him to not use the bench when I was still clearly in possession. However, I can’t get past the purely abhorrent nature of what he did. To further let him know just how upset about the situation I was I threw the towel in the trash.

Hysterical Blindness

Visibly shaking, the envelope in hand, he tried to muster up something to say as he fumbled with the tape sealing his future. Some snarky comment arose, followed by the crowd’s mixed laughter and sighs, all of which he didn’t appreciate as he finally opened the envelope without mutilation and removed the contents.

Folded lengthwise in two places making three equal compartments, the paper was ironically non-distinct. He trembled, struggling to remain calm, but realizing the sudden finality and enormity of what he was holding.

Seconds ticked by as he stared at the bolded writing, unreadable in his current state. He vaguely recalled a condition in which people lose their vision when confronted with a stressful event. He read the first part.

“Anesthesiology” was written on the middle portion of the paper. The line directly underneath slowly came into focus. He wondered why the seemingly mundane and simple task he had witnessed the year before was proving to be so arduous.

Finally, after what seemed to him to be an eternity, where the crowd, he felt, grew concerned, whispering and murmuring about the delay, his cognitive abilities returned enough to comprehend.

“It’s a good day.” he finally managed to say. More grains of sand fell as a wave of absolute relief and gratitude overcame him, bringing water to his eyes. He held them back.

“I’m going into Anesthesiology at my first choice…Major Academic Center of Excellence!” Applause resounded in the auditorium which was rendered indistinct by his euphoria.

Refolding the paper and stuffing it awkwardly back into the envelope he proceeded with the ceremonial ritual. His hands still shook, but this time from pure and unmitigated joy.

*****

Yes, that’s right. I matched into my first choice. Once I returned to my seat and watched others of my class go through the traumatic opening of our letters in front of hundreds of people I had to reread my letter, just to make sure. I’ve never been so nervous and I didn’t understand why.

And while we rejoiced I was saddened to learn of those who didn’t match even after scrambling. One of my good friends was amongst these unfortunates and I couldn’t express my sorrow fully enough.

We matched at 85% overall. We were told that the US average was around 73%. When the NRMP comes out with the data I will delineate a little further with our results and the numbers going into each specialty – but it was very Medicine, OB/GYN, and Gen Surg heavy. We only had 3 enter Anesthesia, though I know that another two matched at preliminaries and will have to try and match to a PGY-2 anesthesia position next year.