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.

Scrambled Eggs and Other Facts

I thought I’d take some time to give further information on a couple comments from yesterday.

what exactly can your dean's office blame on the students? I am confused by that remark, it seems that any blame would reside on the people who make up the curriculum for the students.

Our school started a new curriculum with my class. In fact, we were the class that had to go through everything new – EVERYTHING. Just to let us know that we weren’t forgotten in our last year, they added an additional class late last summer that screwed up a lot of schedules and didn’t know what to do about the extra month’s requirement until January. Because of these road bumps and obstacles our class expressed ourselves regularly. Some of us, me included, were old enough to know when we needed to be in class and when it was just smoke being blown up our ass. The faculty didn’t like people not coming and responded with grades being marred by poor attendance. Because the administration felt we were being recalcitrant the hospital staff was alerted to our disdainful attitudes during our first year. Any form of disagreement we expressed, about anything, began to be viewed with a roll of the eyes and a lecture about what life’s really like in the hospital and as a physician– so we’d better just shut up and take it. That’s what I meant by the school holding it against us – they’ve felt we weren’t properly humble and appreciative of some of the bullshit they’ve laid out before us and have lectured the incoming classes to not listen to our sage advice. It's absurd, since it's they're curriculum and we're providing feedback that should be evaluated, but they've wanted us to fail (I feel) in order to justify to themselves that we were just bad apples.

From an outsider's perspective, what does the "scramble" mean - do they still have a chance of entering into the specialty they want?

Perhaps. Scrambling, or the new PC term “rematching” refers to the chaotic mess that is the Tuesday afternoon that follows Match Monday when everyone finds out their match status. On this day those students who were unlucky enough to not match are allowed to see the residencies that didn’t completely fill their spots and contact them. Naturally it is expected that if a specialty is competitive there is a lot less chance that there are any open spots. The students and the dean’s office have to coordinate information and delivery to various programs that the student called or e-mailed and was asked to submit their application. Sometimes people “rematch” by submitting their ERAS app only, but others have to purchase plane tickets and try to interview between Tuesday and Wednesday. Many times people enter fields they aren’t interested in just to have a job for a year with the intention of entering the match next year. It sucks (from what I’ve heard and seen) and is rather stressful for all involved. Since surgery and OB/Gyn are more competitive it’s likely that people will have less chance of getting into these fields and may end up in Medicine or Peds for a while.

you have to keep in mind that sometimes the scramble rate has nothing to do with the school and a lot to do with the choices people make when they rank...ie where they will live, not giving up on wanting that super competitive spot. and then you have the limitation of the number of interviews you are granted which limits your rank list. scrambling is really just a clusterf**k of many variables.

Correct. I honestly think that some of the people were just not honest with themselves about their chances. Last year a girl had to scramble because she only applied to Derm, wasn’t a great candidate to begin with, and the school has never had a student match in Dermatology. Stupid. If you want to try and get into something highly competitive or into a specific location you need to understand that you’re risking a lot. Suicide matching (trying to get in to only 1 or 2 programs) for whatever reason is also extremely risky and can really screw you. It is worth it to review data from the previous match year on the field you’re entertaining (like the number of places ranked that resulted in higher match rates - Anesthesia was around 10 for a 100% match rate), having frank discussions with people in the field about your chances, and applying to some safety nets to avoid having to scramble - those being a poorer program than you’d like or fields that aren’t as competitive.

I think part of the problem as well is our school’s reputation in certain areas (since I was asked a few times why I was a student there), but more likely bad luck and other factors affected our class. One person with whom I'd talked with had interviewed at enough places, but the programs didn’t take a large number of residents which narrowed the chances. Those are other things that must be considered – 11 programs interviewed with and ranked, but each taking only 5-6 residents, really makes it harder.

Ultimately I think we have a very high unmatched number regardless of a smaller class size (less than a hundred), but I’m really not sure. We’ve only ever been told about the school’s match numbers after everyone scrambled at which point it was nearer the 90th percentile – so maybe we’re not worse. It’s scary as hell though.

4 Nickels and a Penny

21%.

That's the number, people, 21%.

That's the number of my peers who didn't match yesterday. Consider that. Consider the number of years in undergrad, in medical school, and the cost and stress of interviewing only to be told that "Sorry, you didn't match, please 'rematch' tomorrow afternoon!"

I don't know if I'd have the stomach for it. I also don't know if I'll have the stomach for the school's use of this number to the future classes. They've been waiting for this day since we've been the guinea pigs for the new direction the school's taken.

We warned them, but they didn't listen to us. They wanted to do things their way - and look what happened to them!

I know something like that will be said.

Apparently OB/GYN has become rather competitive since several didn't match in this area; many others were in surgical pursuits. I wish my friends and classmates luck. I wouldn't wish this on anyone, not even my beloved Worst Medical Student Ever.

I matched. That is all.

HELL's YEAH, BABAAAEEEEYY!!!!

Wear Green and Pray

Back from vacation – visited the grandparents and spent a lot of money. It was fun and the kids were glad to see Wife’s parents again…it’s been a while. Can’t say that I’m really rested, but at least I had some time to not think about the match…which is, BTW, today…and I’ll find out about at 11 am.

Wife asked this morning for me to call her when I found out. She asked: “What will you do if you don’t match?”

Of course I instantly and with wide eyes told her to not even think such a thing.

“Are you superstititous?” she asked, incredulously.

“With medicine you have to be. A couple call nights where you discuss how slow it is only to get dumped on will make you change your thinking. Don’t talk about it. Don’t acknowledge that it might happen – then it will.”

Wise words indeed, if not completely based in magical thinking. Personally I think dragons and witches exist and that dwarfs are sissies.

Anyway, let’s stop talking about it. I’m starting to get worried. I'll update with the result later on.

So, after a week in Little Mexico (TONS of Mexicans in the city where grandparents live – about 50% of the signage was Spanish-only) I came home to a dead car. It wouldn’t turn over and I felt it was a battery problem. As I went to get it out of the car I decided to try once more and found that the car started without problem. Hrmmm….

After some detective work over the weekend I found that the battery is fine, but my connector to the negative terminal has cracked and doesn’t form a tight fit anymore. In case you were wondering, Hyundai’s have a combination of clamps for the positive and circular connections for the negative terminal. As of yet I have no idea how to fix this myself. It looks like you could just buy a part and plug it in, but then again you may have to change the entire cable – which I wouldn’t be able to do. Thus far I’ve had to push on the connector or wiggle it a bit to get the car to start more often than not. It’s not been fun.

Later today I’ll go and ask my local car repair store how easy it will be to fix, since I’m not very mechanically inclined. Perhaps I’ll even invest in a repair manual, since I’m sure there are things I can do, but just don’t have the proper guide. What I don’t want, is after spending a lot on that vacation, is to go to a mechanic and pay out the ass. Why can't I barter their price down like insurance companies do for doctors? Hell, only suckers pay what they're asked to pay for services rendered.

Adios Amoebas!

I'll be away on a much needed vacation. I shall not return at the very earliest until the 17th, at which point I will find out if I matched. So posts will not be produced until the 17th, if not later. Please look over the archives if you should so desire or you may go about your daily lives.

Till next time.

Match, LORs, and Interviews

In the last post we discussed various websites and important information regarding Step 2. In continuation of that discussion I would like to delve into letters of recommendation, dean's letters (aka MSPEs), and interviews.

Chossing an author for a letter of recommendation should be considered thoroughly and well before asking. The process of narrowing down potential writers should begin in the 3rd year and carry on into the 4th year with electives and away rotations. It is important to understand that there is verbage that experienced faculty and academicians use to communicate with other program directors, etc. about candidates that are not well known to community physicians.

In fact, an important consideration is to not request letters from non-academic physicians. This is due, once again, to word context, recognition, etc. They may have been great to work with and/ or advisors, but if they’re in private practice they aren’t usually well known in academics or may write a letter that’s viewed differently than they intended. Even more important, even if you have chairs, etc. that are in academic hospitals, but don’t have a residency program, don’t ask. My letter from a department chair who did not have a residency was never discussed in interviews – while those from chairs with residencies were consistently brought up with glowing references.

Further delineation between selecting professors to whom you will approach for a letter should also be considered. You should not have more than 2 assistant professors write you a letter with the majority coming from chairs/ vice chairs of departments or associate professors. This is due to the nature of promotion in the academic hospital, the time spent in research and publishing, and the overall name recognition that comes with more senior faculty. It can be hard to do since a lot of assistant professors are more involved with med students, but try to get some time in with the big guns. Letters can also be obtained from chairs while on away rotations and is often viewed favorably. It shows that you did well enough in a program outside of your institution for that chair to write you a letter. Just make sure to ask everyone you're requesting from if they feel that they could write you an outstanding letter (work on that wording so not to offend). It is important to know since some will write for you out of politeness, but don't feel you've been a great student and their letters reflect this thought.

As far as the dean’s letter, aka Medical Student Performance Evaluations (MSPEs), these are usually scheduled to be uploaded to your ERAS application the 1st of November and are essentially a comprehensive record of your time at your school. They invariably contain transcripts, information about any difficulties you’ve encountered (like repeating a class, year, etc.), perceptions of your talents, and may contain your class ranking. As I’ve said earlier, many programs don’t wait for these before offering you an interview, but some will want to see these before they ask. It is in your best interest to talk to the program coordinators at your intended programs (not the program directors mind you) about their policy on interview offers well in advance in order to know who will be offering interviews earlier than November 1. This will save you some hair pulling as you don't receive offers from some of your premiere choices while others are pouring in.

An extremely important, but often overlooked item, is that the coordinators can provide a great deal of information for you about the residency. Their contact information is easily found on the Frieda website. It is wise to be very nice to these coordinators, no matter how stressed you are, as they can make it a lot harder for you to be considered for residency. It was once explained to me that they can't vote you in, but they can sure as hell keep you out.

Interviews themselves range between late October through February, unless you’re early matching or military. As I’ve already said, I don’t know much about those so I won’t be discussing them. Scheduling can be a hassle. Know that now. Interviews may only be held on certain limited dates, interfere with other interviews already scheduled, don't correspond to another interview time in the same area, and should be replied to ASAP to avoid being waitlisted.

Additional concerns relate to those programs that wait until the dean’s letters are out – as you will invariably receive many offers prior to this that may narrow your acceptance time and force you into deciding between two programs. Once again, it is important to know where you think you’d like to go and what their policy is regarding interview offers before dean’s letters are out. This can help you decide where you'll be more willing to request another date or cancel altogether when such problems arise.

Hopefully these couple of posts have been helpful and don't just make you more crazy. I feel that the more you understand and take action now, the less it will hurt in the end.

Match, ERAS, and Other Questions

I wanted to provide my perspective on the match process and tips/ what to avoid for those that will be taking this in a year or two. There is a lot of confusion and misguided advice that can come from everywhere and it certainly can be hard to discern the valuable from the invaluable, especially when everything contradicts each other. Hopefully this will be more helpful than damaging – since I’ve just gone through it and, knock on wood, had a rather benign experience.

First and foremost, what are ERAS, NRMP, and Frieda? If you’ve been thinking about applying to any program you should know about the AMA Frieda website. This site allows you access to basic program specifics, including numbers taken, interviews from last year, dates they have open for interviews, what they require, etc. Very informative and essential to review throughout 3rd and 4th years. You can even create a folder to save your programs that you’d like to look at again without the hassle of searching.

ERAS is the electronic residency application system and is where you’ll enter in all of your data for the residency application. Basically this is where you make your CV for the programs you’ll apply for. You cannot begin to do this until a specific date, but there are places on the webpage that allow you to view important dates and timelines. Essentially most programs use this in order to receive your application for residency and it saves you the trouble of mailing out paper CVs to every program you’re interested in. Some go through other channels – which I won’t discuss here as I’m not experienced in these at all - but most residencies participate. You must pay a fee to use this service.

The actual ERAS application has a deadline each year where submissions must be in by. Keep in mind that these change yearly, but your school should keep you posted as to when they are scheduled to open and when the deadline for submissions falls as well as the timeline on their site. I would strongly advise that you get your letter of recommendation writers to begin writing early and keep up with them so that you can submit you application earlier. I’ve noticed that many interviews seem to be given on a first come first served basis, with fewer and fewer programs waiting for your dean’s letters to be added to your application. That being said, having to wait for a LOR or deciding how you want your personal statement to go, etc. may hurt you. Be careful not to send one out too early that’s not well polished, but don’t take so long getting it ready that you find there are few if any interview dates open.

The NRMP is where you’ll enter your rank list based on your interviews and where you’d like to wind up. When you hear people talk about “my number one program” or “I got in at my number 2” they are discussing their list they entered on this site and the location of the program in numerical order. It is important to register before the deadline lest you be forced to pay a late fee of $50. There is a regular fee just to register, so being late in registering is quite costly.

Now, let’s talk about Step 2. This is perhaps an area where a tremendous amount of differing information will come to the hopeful applicants. Basically this is because there is not just one or two ways that programs are handling this right now. Unlike Step 1 which is required and you must demonstrate that you passed along with your score, Step 2 has not been required in the past to obtain interviews. Therefore it was suggested as late as last year that those doing well not take either CK or CS until after interview season. The idea was this would assist you to get interviews without having to answer to a low test score.

Well, that line of thinking has begun to go the way of Dodo – at least for some programs and specialties. Many of the more competitive specialties are now asking for/ requiring you to at least show that you have taken and passed Step 2 CK. You don’t have to show a score (at least I still believe that ERAS had that option this year though I couldn’t find it), but be prepared to answer to your clandestine score during interviews. Less competitive specialties (family, internal, etc.) may not require that you’ve taken it for an interview, but the more competitive programs (like top 10's) are starting to request this before an interview is ever offered. Therefore it is best to take this early and avoid losing an interview.

With that being said, Step 2 CS, however, is not required for interviews. Most residencies will require you to have passed this skill exam before starting residency, but they aren't being sticklers on it beforehand. It’s pass/ fail anyway, so schedule it according to when you want – or based on your school’s demands. But don’t wait so long that you risk failing and not being able to start at your program.

Ok, so a lot to digest. I'll post another component to this that will discuss the dean's letters (aka medschool performance evaluations - MSPEs), interviews, letter of recommendation author selections, etc. later this week.

Enigmatic

During a recent discourse on end-of-life care I realized that anesthesia is a very misunderstood specialty. Basically a topic about drug-induced comatosed patients turned to various items related to anesthesia - like paralyzing medications, propofol induced comas, and the need for pain control these situtations.

What I found interesting was that the physician, with many years of experience dealing with dying patients and ICUs, didn't really know a great deal about an anesthestic state produced when one creates a drug coma. He didn't remember what drugs were used to cause muscular paralysis either. A couple students trying to be helpful shouted out succinylcholine.

"Well, yes, that does cause paralysis", I thought, "but for a very limited time (2-10 minutes)". More likely he was referring to the longer acting non-depolarizing muscular antagonist - like vecuronium or even pancuronium (since we're talking about dying ICU patients here). But no one brought these up. Multiple suggestions of a depolarizing blocker, but nothing else. A lot of places don't even use sux anymore because of the side effects, but I'm going off on a tangent here.

He then went on to discuss whether pain meds were needed in these types of comatose patients. What amazed me was that he wasn't sure if they needed them or not. Some of my peers suggested that propofol was useful to prevent pain. Hm, news to me. I thought that opiates and other painkillers were used for this, but maybe, again, they were thinking back on their surgery sub-I and remembered the anesthesiologist giving some propofol when a patient was "awake" and moving - thus the belief that it affects pain. I wanted to talk about the fact that people do respond to pain even when in drug comas, and often anesthesiologists titrate opiates and other pain relievers in based on physiological parameters, but decided it wasn't worth it.

Ultimately I found it interesting that the nature of anesthesia is so misunderstood by many people. "Give some white stuff. Pass some gas. What's so hard about that?" Apparently a helluva lot more than you'd think - since most people involved in care that mimicks anesthesia's induction and maintenance have false notions on what's going on. I don't want to know what a surgeon thinks - I'm sure it's even more basic than that.

Picking a Life 2

Continuing with the theme from before, I should mention that there are tests out there that are supposed to help guide medical students to various specialties. It should be well noted that they should be taken as a suggestion only– as many don’t include some specialties (like anesthesia, as I saw on a few I participated), and can make you myopic in regards to a career. I stopped using them after I kept matching with surgery because they lacked anesthesia related fields.

Yet despite the suggestive nature of these skill exams many students let these guide them, forcing their minds into a predetermined notion of needing to like a rotation because they’ve tested highly on that area consistently. While this may help make a month or two pass blissfully, it will not let 4-5 years pass quickly if you didn’t recognize warnings with your rose colored glasses. Nor will it assuage concerns that rise during residency and afterwards about the choice of specialty. It would be quite sad to spend so much time and money to only hate what you're doing.

Fortunately the 4th year of medical school usually allow some experimentation through 4 or more months of electives and can help shape your thought process. But it also comes at a time when you begin to get worried that you’ll miss the ERAS deadline, won't receive interview offers because you waited too long, or won’t be able to get letters of recommendation since the letter writer already committed to multiple students.

You may also never consider an elective in a specialty that fits you more fully since you never received any exposure. Right off the top of my head I feel that Pathology and Radiology are often those fields where rotations may not be required and are never considered. How can you make a clear decision when you've received little to no information other than bias?

For the stated expectations of medical schools and the LCME many schools meet their agendas. However, this too often leaves students pondering their future and entering residencies they find deplorable within a couple years. They are then forced to decide to continue on or to reenter the match, hoping for a better fit, and losing time. It should be taken with a great deal of warning that the 3rd year is not the ultimate year of decision making. The entire 4 years of medical school needs to be more focused on exposing students to more than the core requirements and students themselves should not enter school with one field already decided upon – as this often changes.

Picking a Life 1

The Lone Coyote recently focused a couple posts on the thought process she underwent towards deciding on a residency. The interesting aspect of the entire post, beyond the rather frightening nature of entering 4th year unsure of where you want to go, dwells around the central, if not clandestine, topic of exposure.

Stated simply, there is just not enough exposure to the many different fields of medicine in the 3rd year of medical school for students to be able to make clear and complete decisions regarding a job. As it is currently, most schools require students to rotate through some form of Peds, OB/GYN, Gen Surg, Family and/or Internal Medicine, and Psych/ Neuro. You may get exposed to a few “subspecialties” – like a Peds ER or anesthesia during surgery in order to increase your experience, but these are often quite limited. The fallacious idea that I've picked up on is that the students get enough exposure to be able to come to a well determined and thoroughly researched conclusion regarding residency choices.

Absolutely incorrect. These "electives" are often only a week to two at a time, frequently limited by the number of students, clerkship schedules, and regularly are not great experiences.

As an example, during Gen Surg I wanted to take the 2 week anesthesia elective offered. Other students wanted to as well - because they thought it was a cake walk and they'd get to slack for a couple weeks. Because their schedules were more accomodating than mine I received one week. One lousy week with a new batch of SRNAs who wouldn't let you do much because they needed all the exposure and I often sat watching them do everything, confused as hell (we don't have a residency which might have made it better). I could have easily walked away with a bad taste and went straight into surgery.

With similar experiences a number of students will make up their minds during or late in the 3rd year. It's an extraordinarily bad idea, but is often a go-to for many as a means of determining where they fit. Of course, it's not hard to understand that a rotation and the joy received vary greatly based on location, personnel, and other factors that the student may not recognize at the time. However the student applies, schedules rotations in this area, and may feel trapped when they realize that it wasn't quite what they wanted and undergo matching anyway.

I will discuss this more in the next post, but I feel this is a topic that's not addressed nearly enough. There are many stories of people changing fields many times, reentering residency after a few years, or forgoing entering the match because they haven't found "the one". It is, I feel, another way that medical education fails those it's meant to help, to educate.

A Lost Opportunity

The student had met her earlier last week. During that time she had been quite charming, quick minded, snarky, but with a compassion beyond belief. She had insisted that the doctor come to her home, once she was discharged, and sample some of her homemade jam recipes. She proudly recalled that she grew her own ingredients and her jars of jams and other treats were the talk of the neighborhood. Her daughter smiled lovingly at her. She was decisively independent in action and thought, but euphoric about her improvement. Traits that endeared her to the student and he hoped that he'd see her again when he returned the next week.

Upon the student’s return he found her in an opposing condition. That Friday she had been planning to go home, doing well and feeling optimistic about her time left, but now she was besieged like a cornered animal, clinging to an oxygen mask as life sustaining gas was pumped through at more than 7 liters a minute. Her eyes were screaming at him: “Help. I can’t breathe. Help!” and he recalled seeing that her oxygen saturations had dropped over the weekend to precariously low levels. The room, once full of euphoria, was now transformed into a dark, humorless, shadow full of dispair and exhaustion. The student felt a unique sense of vertigo, as if his entire world was being lost along with her's.

With this remarkable uneasiness that assailed him from every corner of the room, he examined her. He instantly recongnized the revulsion that had grown up in him and stood as a palpable lump in his throat. He found it hard to talk, even when just telling her what he was doing.

As the student arrived at the abdomen he discovered that the once soft, obese stomach was now a massively enlarged, rock hard, mound with discernible peaks and valleys. He could not appreciate any bowel sounds – an ominous sign. She had stopped producing urine and her eyes were no longer white, but were markedly yellow. His horror magnified as he examined these eyes, noting the distinct despair and cries that were manifested there within.

He knew from last week that she had undergone a major surgery to remove cancerous tissues. They had hoped that there hadn’t been any spread, but clearly the truth was here for the student to behold: The tumor had survived and was assaulting the woman from within; taking control of her body, plaguing her kidneys and liver, and making breathing an incredibly laborious effort. She was drenched with sweat from the effort of living. The student felt the sudden need to leave. He did not know what to do.

The morning rounds consisted of lengthy discussions between the doctor and her residents as well as with the family and the patient. The main topic focused on her sudden and clearly unexpected change. He found somewhere during this time that a party had been for her return and the banners still hung in her living room. "I doubt she'll see them" he had thought.

Radiographic films were viewed with the family in the physician’s lounge and the doctor explained the findings. The student already knew – large amounts of a homogenous, grey material obscured large amounts of the normal anatomy, interspersed with tumor. Her abdominal wall was caked in oppressive and magnificent abnormal cellular reproduction that constricted her diaphragm and reduced the patient's ability to move air.

“Metastasis. Outcome looks bad. Kidneys have begun to stop working”.

The family received these messages with stunned silence; then the daughter, the loving woman whom had been at the patient’s side when he initially met her, began to cry. The student looked away. He was surprised to find that he was fighting back tears as well – tears for a patient he’d only met once. Yet he knew what all of this meant.

In the span of 3 days she had fallen down the potential abyss that many patients navigate unscathed. She had “decompensated” and he knew there was nothing more to be done. She was going to die and he felt the acutely ironic scenarios play out before him.

****

She died later that week - a full code despite the attempts to obtain a DNR. He had avoided talking with the family or seeing the patient since that day unless he absolutely must. The situation was uncomfortable and the interrogations he received or perceived frustrated and confused the student. He didn’t know what to do, nor what to say. The doctor should be doing that. He was angry at the situation and the distinct perception that he was absolutely and completely ignorant of how to proceed. "How is it that after all this time I have no idea what to do"? he would often find himself asking aloud. His mind swam with guilt.

Now, as the student surveyed her lifeless body, tracheal tube still in place, eyes fixed and staring, chest exposed with the disproportions of her abdomen starkly evident, he was disgusted. A sudden and uncontrollable compulsion welled up within him. “I must get out of here!” he thought and he looked longingly at the door and the sanctuary of the nurses station. There he would be safe from the woman’s gaze, from his guilt.

Fighting off this instinct, the student stayed. He stayed when the doctor and residents lefts, he stayed when they cleaned up the woman. He even stayed when the family came in and burst forth in tremendous sobs. He persisted, in spite of himself. He had not been there for them before, but he wanted to be there now. Not so much for them, but for himself. If the student ran from this, then he had utterly failed in his duty.

The day culminated in a total of 20 hours. He had not needed to stay and had been released earlier. Yet he persisted. Wanting to stay and learn from his mistakes he remained and accompanied her to the morgue. He had avoided Death, but clearly it could not be brushed aside. It must be faced, and he had not performed admirably during the patient’s transition.

Though he desired to view her autopsy, he knew that this was an intrusion he could not perform. He had not been there with her during life, surely he should not be there when she was dissected and the tense abdomen exposed - it felt too intimate. He heard the next day that when the pathologist intially began she gushed liters of fluid. Metastatic ovarian cancer with mets all over her body.

At least she’s at peace, he thought. If there is a heaven, then surely she’s making her famous jams. The student smiled, and went about the rest of his day.