Creating the Godcomplex

Time to Tumble Down - Again

2008-05-27T09:51:00.000-05:00

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

2008-05-27T06:36:00.005-05:00

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

2008-05-26T06:44:00.001-05:00

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

2008-05-23T09:25:00.003-05:00

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

2008-05-22T13:21:00.002-05:00

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

2008-05-20T07:26:00.006-05:00

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

2008-05-19T08:35:00.003-05:00

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

2008-05-17T20:26:00.001-05:00

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

2008-05-16T11:01:00.000-05:00

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

2008-05-15T22:32:00.002-05:00

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

2008-05-13T08:54:00.002-05:00

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?

2008-05-12T14:52:00.002-05:00

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

2008-05-11T10:45:00.002-05:00

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

2008-05-09T08:48:00.000-05:00

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

2008-05-08T12:59:00.001-05:00

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

2008-05-08T06:02:00.000-05:00

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

2008-05-07T12:14:00.001-05:00

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

VIP

2008-05-07T06:20:00.000-05:00

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?

2008-05-06T05:02:00.000-05:00

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

2008-05-05T13:53:00.003-05:00

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

2008-05-03T15:42:00.005-05:00

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

2008-05-02T19:29:00.002-05:00

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

2008-04-28T09:59:00.003-05:00

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)

2008-04-26T11:16:00.001-05:00

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

2008-04-25T10:20:00.004-05:00

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

2008-04-24T05:22:00.000-05:00

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

2008-04-23T03:12:00.000-05:00

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

2008-04-22T20:57:00.000-05:00

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...

2008-04-22T13:59:00.000-05:00

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

2008-04-21T05:04:00.000-05:00

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?

2008-04-17T07:15:00.000-05:00

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

2008-04-16T06:56:00.001-05:00

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

2008-04-15T04:57:00.000-05:00

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?

2008-04-14T19:36:00.004-05:00

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

2008-04-14T14:31:00.002-05:00

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

2008-04-13T12:58:00.000-05:00

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

2008-04-12T07:40:00.002-05:00

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

2008-04-10T22:18:00.002-05:00

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

2008-04-10T15:40:00.002-05:00

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

2008-04-09T06:00:00.003-05:00

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

2008-04-08T12:49:00.002-05:00

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

2008-04-06T13:10:00.003-05:00

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

2008-04-04T15:06:00.002-06:00

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

2008-04-03T13:16:00.002-06:00

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

2008-04-02T14:09:00.002-06:00

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

Just Had to Say It

2008-04-01T14:13:00.002-06:00

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

2008-03-29T16:51:00.002-06:00

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

2008-03-28T07:01:00.001-06:00

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

2008-03-27T10:09:00.004-06:00

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...

2008-03-27T06:49:00.002-06:00

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

2008-03-26T00:39:00.000-06:00

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

2008-03-25T05:53:00.002-06:00

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

2008-03-25T05:09:00.000-06:00

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

2008-03-24T09:00:00.004-06:00

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

2008-03-24T05:18:00.008-06:00

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

2008-03-22T13:01:00.003-06:00

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

2008-03-21T06:35:00.004-06:00

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

2008-03-19T06:27:00.002-06:00

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

2008-03-18T07:51:00.004-06:00

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.

2008-03-17T11:07:00.000-06:00

I matched. That is all.

HELL's YEAH, BABAAAEEEEYY!!!!

Wear Green and Pray

2008-03-17T05:31:00.002-06:00

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!

2008-03-07T12:43:00.003-06:00

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

2008-03-07T05:08:00.003-06:00

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

2008-03-06T06:00:00.003-06:00

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

2008-03-05T15:10:00.000-06:00

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

2008-03-05T06:41:00.002-06:00

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

2008-03-04T06:32:00.002-06:00

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

2008-03-01T08:30:00.001-06:00

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.

Phew!

2008-02-29T07:39:00.002-06:00

I was driving home the other day after taking stepson back to his dad's. I was listening to the radio and looked down at the clock while changing stations. 8:15pm.

Suddenly a cold sweat broke out on my forehead.

"Shit!" I exclaimed. "Did I certify my list?"

You see, it was the 27th of February, the last day to certify and submit rank lists for the match, and I couldn't remember if I'd certified the last time I made a change. The time to get those done was by 8 pm my time. I was already past the time if I hadn't...I cranked up the accelarator and raced home.

As soon as I arrived I checked - and, much to my relief, found that I had indeed certified. If I hadn't I'd have been SOL for this year. Thank god.

Please, Not There

2008-02-28T05:58:00.000-06:00

Wife has talked about getting another tattoo. She’s received a couple since we’ve been together, the first being the day before we got married, but I’m a little hesitant about the location she wants to have one placed.

You see, I’ve seen a lot of trashy people in the hospital where I’ve rotated through the most. Several women have tattoos of hearts, roses, etc. on various parts of their bodies – but the most trashy always had at least one on their ankle or breast (sometimes on both or multiple). I began to associate a tattoo around the ankle or breast as a sign of a white trash ho or a ghetto bitch, regardless of the level of class the person sporting the tattoo evoked.

Wife wants to get one on her ankle. I’ve told her my reason for not wanting her to get one there and she’s laughed at it. Apparently there are many women who get them on their ankles, but it still looks trashy to me. She’s also stated that I shouldn’t be one to talk since my tattoos are all of a rather trashy sort (I guess demons and skulls aren’t the most friendly looking) and I’m being a hypocrite.

Despite that rather sound argument, I've not received any since I was 18 and wouldn't get anything similar now. I've matured...a little.

Sigh…I just wish that she didn’t want to get one there. And if that’s how I think, Lord knows how others view them.

Not A Real "Doctor"

2008-02-27T08:39:00.003-06:00

Dr. Jarvik is not a real doctor - at least in how the Lipitor ads were trying to make him appear.

Although he has a medical degree, Dr. Jarvik is not a cardiologist and is not licensed to practice medicine.

Learning about his history earlier when he began hawking the drug instilled in me the desire to never prescribe it. But at least now Pfizer has pulled the ads and I won't have to look at him talking to "real doctors" in the hospital or running with his goofy looking kid.

Ah, Dr. Jarvik. How you will not be missed.

Too Pretty

2008-02-27T08:23:00.003-06:00

I saw this on one of Wife's celebrity news shows yesterday. It was hilarious to watch - since it was clearly evident that these "pretty" bitches were the trouble. Their pictures that they gave the "news program" to use were rather trashy as well. It was great.

By far the best part was when the blond admitted to starting a yelling match with a passenger after she felt they'd been in the bathroom too long. Another factor against them being singled out for being too pretty? The fact that the FBI had to get involved after they landed. It seems to me they are the problem.

Coddled? Yeah, I think so too. I applaud Southwest for having the guts to actually stick up and deny people like this their "rights".

Campaign 2008

2008-02-27T06:55:00.000-06:00

The reason that Hillary is struggling? Perhaps this hits the nail on the head.

Personally I hate the Clinton machine and her attempt to run on her husband's coat tails (running on 35 years of change my ass). Plus Hillarycare is scary to think about working under. I imagine it would be kinda like Stalinistic - but worse. And yes, I hate her that much.

I would like Obama to take her under, but he also worries me as well. The more he gets going the more I see someone who could potentially be dangerous. Little leadership experience running the country? Hmmm. Plus, anyone who believes that universal care is going to "fix" our healthcare system has their head up their ass. Period.

Republicans? God, another lose-lose situation there. Maybe I won't vote this time - then I won't feel bad when one of the godawful choices fucks everything up and messes with medicine even more.

Oh, and today is the deadline to submit the rank order list to the NRMP. I changed a program's location yesterday up one, but other than that I haven't touched my list. 3 weeks to go.

Their Take

2008-02-26T08:50:00.002-06:00

Some bloggers have been posting some great topics recently. Rather than submit you to more of my drudgery, I offer their takes on a couple topics I've spouted off on here and there:

Psychiatry by the Half MD (posted under clinical rotations - you might need to dig a bit).

CRNA and MDA "relationships" by Mitch Keamy over at The Ether Way. *

Enjoy.

*And just so we're clear - I like CRNAs and think they provide a valuable service. But they're not MDAs and shouldn't think that they are as qualified - ever. It's the same problem that occurs in retail clinics - a few thinking they know more than they actually do with no one to tell them differently and believing they're doctors..

Like a First Year

2008-02-25T07:08:00.002-06:00

The last couple days of my mandatory, don’t come and you’ll not graduate, “Doctoring” class are this week. Ah, it’s been an adventure. I’ve learned so much. I’ve come away with a great deal of useful knowledge that wasn’t already learned on the wards or from reading resident’s blogs. I feel like a first year – everything had weight to it, everything was important, and I love being a medical student…but not really.

4 weeks of this class and I really think it could have been condensed into one week. It was very disappointing – it had a great deal of potential, but as usual we’ve been led astray. At least I was able to catch up with some of my classmates and hear about where they’d like to be going.

Despite this farcical educational process, I did learn a couple of important items:

1) Sipping caffeinated drinks over an hour will keep you going longer than if you chug. Caffeine downregulates itself and if consumed in large quantities (as I’m wont to do when on call) it actually diminishes sooner, leaving you dead tired in 1-2 hours. Good to know.

2) Get through the first day and you’ll be OK. Expect to be on call – many interns start out on call.

3) OB/GYN residents (at least here) are very pessimistic.

4) Money scares the hell out of me – at least knowing what to do with it outside of paying off stuff.

5) You will get very depressed – most likely in the winter months.

6) Discharge planning starts at the time of admission – and sucks ass.

7) Government funded healthcare has already suffered from poor resources and funding – so why do we think that we can cover everyone?

And that’s about it. Aside from learning that a couple people are matching into specialties that I didn’t ever think they’d go into and getting the final touches on my case report done so that it can actually get published this month has been a waste. At least I don’t have to take senior Psychiatry!

Revelation

2008-02-24T14:00:00.002-06:00

At a family dinner my uncle asked me a question:

“Would you do it all again?”

Simple question, hard answer. My parents, grandmother, brother, and various other family members were there – all awaiting what, I'm convinved, they were sure they’d hear. Instead I dropped a blow. After refusing to answer at first and being cajoled into answering I replied:

“It’s not that I wouldn’t, but right now I’m not sure. It’s really not been worth it and it’s a helluva lot harder than anyone understands. I don’t know…I don’t think I’d do it again. I know I wouldn't want my kids doing this.”

Almost everyone sat there, rather stunned. I’m sure they thought they’d hear me praise my training and the love that has grown inside me for medicine. Instead I was honest. Honest about the hardship, the frank disappointment, the depression that had set in many times, and just let them know I wasn't sure if I'd made a good decision. My uncle, who is by trade a lawyer, looked at me and shook his in agreement.

He then went on to expound on how he hated being a lawyer for the first 10 years following law school, which his wife agreed completely. This received incredulous replies from my grandmother and mom, to which my uncle and aunt echoed my frustrations - debt, disappointment, pressure, self-doubt, and the feeling of accepting a lie. He explained how the debt, the lack of esteem, and overall bullshit that he had to endure while fresh out of school made him almost quit several times. He expounded on how he hated people assuming he was "rich" because he was a lawyer and that he had originally believed he'd be wealthy when he entered law school. The harsh fact was, that for many years, they barely could afford to live.

He then looked at me directly and proceeded to inform me that it got better. It took time, but once you find what makes you happy it makes the job fantastic. He now loves what he does – though it wasn’t what he initially thought he’d be doing.

That was, for me, the only time that I truly felt that someone in my family understood what I felt. The sad part is that the only reason he understood it was because he had to endure something similar. You just can’t explain this to people who haven’t dealt with the process. They all look at you like you’re crazy and talk about the money, the prestige, and the myths that shroud the professions of medicine and law.

I hope that I'll find the peace and happiness that he has in law. I would really like to wake up most days and want to go to work. Right now I don't.

Power Whore

2008-02-22T08:33:00.003-06:00

There’s something about power that makes people crazy. The other day I had to take a senior OSCE that was supposed to help us get ready for Step 2 CS. However, many of the participants that day had already taken and passed the exam, therefore making this just another useless exercise. To add to this day was the fact that Wife was trying to get seen for an illness and I wanted to be there, but couldn’t.

The day started out on a bad note – those in charge were running around, barking orders, and trying to look organized while they were, in fact, the opposite. Threats of 5 points off the total grade were tossed at us because some students didn’t bring more than a stethoscope. The 10 students in attendance tried to remain in good spirits, regardless of the absurd nature of the requirement, but soon realized that we were dealing with power whores and this would not be fun.

The man in charge of the standardized patients was by far the worst. He actually believes he is a doctor – though I’ve never seen any proof beyond his proclivity to wear long white coats while he yells rules at students. He proceeded to yell at us about everything, claim that we weren’t being “professional” (once again, I completely hate it when anyone uses that as an excuse to blame students for being human), and told us that no one could talk. At all.

“No one should be talking. This is a serious exam and if you fail because you can’t keep quiet and remain professional, well…that’s on you.”

“Excuse me! I’m talking. Table all conversations!”

Various re-utterances were heard of the above for almost 2 hours while we were oriented. Yes, it took them 2 hours to get us through the orientation. We had 10 cases to get through at 25 minutes a piece. Everyone of us knew that it was going to be a long day. Preparation for Step 2 CS? Hardly.

And that’s where I get a little miffed. People in these kinds of positions have lauded their authority over us for the last 3.5 years. We’re close to being done. We’ve passed every examination that’s been required and we’re over the threats. What? You’re going to fail us because we wouldn’t sit in fear while you assaulted us with rules and regulations – all of which we’ve already heard numerous times?

Power corrupts. In this case it made people who have low self worth try to use it to swell their image. I see this quite a bit, but that day it was just a little too much to deal with.

Failure to Communicate

2008-02-21T08:41:00.002-06:00

Wife recently had to get treated for an overwhelming sickness that she couldn’t ignore anymore. Almost 2 months had gone by with her having various URI and a constant shortness of breath or tightness in her chest. These feelings were more marked with cold air, exercise, and exposure to cigarette smoke.

Diagnosis? Asthma with complications related to non-treatment.

Easy enough to see.

But she didn’t believe me, as she’s wont to do, and a few times I got upset and would castigate her for complaining. After all, coughing constantly and complaining about feeling tired/ ill when you could get better from an inhaler just began to wear on me (even more is the idea that she didn’t think I was correct – but that’s a different post).

So the other day, after she developed some night sweats, productive cough, fever, and chills I forced her to go and see a physician. Ironically she couldn’t get in that day and instead went to a retail clinic. I wasn’t with her as I had an obligation to get through in order to graduate (more on that in another post) and only found out about her treatment later.

The NP was very nice, from what Wife says, but it was clear to me that she was a little overwhelmed by Wife’s symptoms. She gave her an antibiotic, an inhaler, and cough suppressants stronger than the OTC variety. I didn’t agree with some of what was done – like giving a very strong antibiotic normally reserved for hospitalized patients or those with community acquired pneumonia, or the suggestion that she go to the ER to “maximize her breathing”, but at least something was accomplished. I was glad to hear that the NP took her time to explain things out to Wife and even told her that she felt she was incredibly sick.

What was funny to me, however, was that Wife was told almost the exact same things that I had for months told her about her asthma. She didn’t want to believe she had it and refused to go to a doctor and “waste her money while they guess”. I find it ironic that a lot of what I try to champion in others and get heated about on this blog has not been instilled into Wife. Somewhere she’s lost her faith in medicine, despite being exposed to it more than ever, and doesn’t trust doctors. Gotta work on that.

Boys and Girls

2008-02-18T05:29:00.001-06:00

Parents. Gotta love ‘em.

Daughter has started T-ball and had her first practice last weekend. We had prepared for this by obtaining various tools that she’d need – like a glove, bat, bat-bag, etc. and hoped that they’d have helmets. When we received her team’s information and met for their first practice we noticed that, to our horror, she was the only girl on the team!

GAHHHHH!!!!

Naturally we were proud to watch her match the boys in many aspects and wallop the ball off the tee just as well as some of the others, but we wanted her to stick out. Like all parents do, I guess. But mostly because she was the only girl and Wife wanted to spread GIRLPOWER all over the field.

So afterwards we went to the sports store and spent a large sum of money on pink and purple gear (helmet since theirs were only blue and black, balls, cleats that have pink accents, and a mitt that was a correct size). So now, when she gets up to hit, play defense, or just hang out with the boys, she’ll be a standout. Because we’re shamelessly promoting that OUR DAUGHTER IS THE BEST!

Where’s that parenting certificate?

Just Go and Read

2008-02-17T17:06:00.002-06:00

You have to read this commentary from the Happy Hospitalist. Dead on.

America has lost her way. We once were a nation of proud people. We were once a nation that took care of itself. Now we're a bunch of freeloaders blaming "the rich" for everything that's wrong.

You want universal healthcare? Then you pay the damn taxes to fund it. I sure as hell won't.

Dead Blogs

2008-02-15T14:05:00.001-06:00

I'm toying with the idea of eliminating some of the blogs on my blogroll for being dead. I prefer to think of a blog as being dead if it hasn't had activity in 2 or more months and have a few on my list that meet or are close to meeting this criteria. Plus I've noticed that there are some blogs that aren't necessarily dead, but I just don't enjoy them as much anymore. We've grown apart, I guess.

So here's a fair warning to those blogs: you know who you are and you need to post something before next week...or off with your head!

Courtship

2008-02-15T09:53:00.003-06:00

There is a fine and delicate game that is played between soon-to-be residents and various programs. It’s akin to a courtship, where each tries to feel out the other while attempting to remain diffident about their desires.

E-mails or phone calls are sent between the two parties, informing the other of the intents, without being completely honest. It’s really quite a lot like dating:

Do they like me? I can’t tell them that I like them that much, but I need to let them know I’m interested – lest they hook up with someone else.

High school politics in a lot of ways are rekindled.

Amidst all of this, the potential for confusion, frustration, and stress accompanies students and programs alike. Woe to the student who matches, but only to a program where they really didn’t want to go. While they have a job, they’re not pleased with the outcome – like getting the uglier of two sisters.

While students can suffer from match diappointments, programs are just as susceptible. My mother once regaled me with a story about a program director who moped around for a long time after discovering whom they had matched. Apparently they were less than stellar candidates, but now he was stuck with them, and he proceeded to let everyone know how disappointed he was in the result.

So now the game is on – over the last few weeks I’ve received several e-mails from programs informing me of their intentions, but not so much that it violated NRMP rules. I've been listed as “favorable”, “strong”, and “well-suited” to subvert the NRMP designation that programs should not tell candidates where they are on their rank list. I’ve been informed, but I still don’t know.

A lot of this courting deals with word-play. Only once have I been so bold as to let any program know where I ranked them – and only because I really want to score (continuing with the dating analogy). However, despite all of the words being passed around, the interview feelings, and some rather overt indications, a student should always be cautious – as you can read about here. Heed the warning.

I Don't Heart Today

2008-02-14T07:58:00.000-06:00

Valentine’s Day. God, what a waste of time and money.

Let’s consider some of the inevitable, if not blatantly stated, perceptions about this “holiday”.

1) If you are a woman you expect to receive some romantic display of affection, even if that display is just a repeat of last years. As such you can expect to be disappointed more often than not.
2) Men don’t know how to be romantic anymore – we wait till the last minute and buy flowers and chocolates from the grocers.
3) Jewelry stores make a killing off stupid, cheap, and unoriginal heart shaped “diamond” necklaces and charms as men try to find something that doesn’t take a lot of time to do, but will get them some points.
4) If you receive said jewelry, expect that the person delivering it wants you to reciprocate physically. It’s the oldest exchange of goods in the book: money or valuables for sex.
5) Relationships on a somewhat rocky ground will be brought down by this one day.
6) Many people think that this day is special and should be used to cherish your loved one. Those of us who have been with their loved one for more than a few months know of much better ways and times to demonstrate their affection than to capitulate to the card gods on 2/14.
7) A lot of people hate Valentine’s Day.

Wife and I are of the #6 variety. We exchange cards, chocolates (since Wife really wants those every year), and will do something out of the ordinary for each other. Tonight I plan on cooking more than my usual spaghetti or hamburger dishes, but I won’t go overboard as I have in the past. I had thought about taking us to a fancy dinner, but Daughter came down with a fever and cough (again) yesterday and would have forced us to stay home anyway.

Personally I hate Valentine’s Day, but I’ll say it anyway – Happy Valentine’s Day everyone!

Enough Already - Please!

2008-02-13T06:35:00.004-06:00

A trend that has started since my class has been mandated to be in attendance at a course similar to our "Doctoring" courses during 1st and 2nd years. Essentially the executive body of the class has taken this opportunity (as they rightfully should) to talk to us about dues, class gifts, monetary "responsibilities", etc. since we're all together - perhaps for the last time before graduation.

Fine. I would do the same. What's upsetting me, though, is the amount of money that's being asked for and how often I've been asked to give to some charity, event, dues, or other item. It's beginning to get really upsetting as I'm budgeting to make it through July with little to no money to spare.

Thus far I've been asked to pay dues of almost $200, to pay for a dinner for my AOA induction ceremony (which I'll attend of course), to give to various clubs and charities, asked to consider committing to 4-5 years of a monthly donation in regards to a class gift, and have been told about the commencement invitations and cap/ gowns we have to purchase in the very near future. Let's not even consider the fact that I'll have moving expenses, licensing fees, and a host of other forseeable and unforseen costs in a few months that are more pressing and concerning to me than a lot of these "extravagances".

I'm about to lose it.

I haven't graduated yet, received a fucking paycheck yet, or even know if I'll have a job yet and the vultures are already at my door. What I find is that this makes me less inclined to give anything - because I'm freaking out.

***Addendum*** Now, since I just attended an AOA meeting the other day and I was told about the dues, dinner, and other events that are quickly approaching I freaked out a bit. I'm planning on paying for this society since I worked hard to get accepted and know the priviledge that's involved. The other stuff, though, is getting a little ridiculous. It's like they can sense our student fees are slipping out of their grasp and it's a last ditch attempt to get anything from us.

And as far as freaking out about my, ahem, upcoming divorce? Let's not be jerks, shall we?

Confessions

2008-02-11T12:38:00.000-06:00

I read a post where an ER physician “confessed” their likes and dislikes. It received a great deal of feedback, both pro and con, and was a rather powerful post generator amongst several bloggers. Having some time to think while I attend mandatory “Doctoring” lectures left me with a desire to “confess” as well. So, here goes – hopefully it won’t be as negatively viewed by the powers that be…

1) I’m scared. Scared to death to start intern year. I’ve been losing sleep over this, staying up late trying to read on treatments, planning on making flashcards on drug dosages and when to use them, etc. I’ve gone through a few of my reference books trying to find the “golden book” that will house everything I need – and make me a doctor. But I know that one doesn’t exist and it all comes from experience and repetition. But it still doesn’t deter my mind from freaking out about not being able to handle the first day…or week.

2) I’m impressed with how I’ve grown over the last 4 years. I’ve seen slides, talks, and discussions related to certain aspects of medicine that, when I began, were completely foreign and mind blowing that I now understand a great deal. A slide of a surgery was once viewed with complete unfamiliarity that I can now view systematically and understand what’s going on – at least a little. It makes me feel pretty good.

3) I feel a constant guilt about taking my family through medical school. Wife and I fight about things that, normally, wouldn’t cause a great deal of trouble. I get mad quickly about any inference that she’s been betrayed or dragged along in this maddening process – and I lash out. Tax season lends itself to this more often than not – as I want to use the refunds towards future expenses or emergencies, while Wife has ideas of her own. It is, after all, her money. She worked for it, not me, and therefore should be able to use it as she deems fit. I get really upset when stuff like that comes up – I’m working hard too with little more than debt to show for it.

4) I hate the increasing belief that doctors are overpaid and that a great deal of what they do can be done by lower-level providers. Enough said about this topic.

5) Frequently I have fits of jealousy when I look at others. I constantly compare myself to what I don’t have and what I think others have. Living in an apartment, driving a car that looks trashed and lacks a driver’s side door handle, and struggling with mundane financial issues at the age of 30 infuriates me at times.

6) I think nurses are great sometimes and terrible others. When they do their job and understand the gamesmanship between them and the doctors they can rock. Others, either through time, jealousy, or just a bad attitude can be obnoxious and draining – leading to a lot of time spent maneuvering around them. I’ve found that if doctors can’t evaluate or hold a certain level of expectation on the nurses, the worse they are. I hate the fact that they can make life miserable without any fear from the interns/ residents - we are helpless and a bad nurse can really make a rotation godawful. Hopefully there will be less of those and more of the patient, tolerant, and kind nurses.

7) I hate pop culture music – R&B, rap, hip hop, etc. I find it absurd that white people buy a great deal of this music that promotes sexism, racism, and bigotry towards the white population. I find it even more deplorable that the literacy and grammar of the upcoming generation, buying into this cesspool, is becoming increasingly fragmented and acceptable. We pretend like they’ll be OK, using double negatives two or three times in one sentence, while secretly hoping that we’ll be dead before they take power. Our country has lost itself in trying to be PC and allow any form of stupidity to exist.

Like A Fat Big Bird

2008-02-11T06:20:00.000-06:00

Did anyone watch the Grammys last night?

Ok, I know, they always suck and the most pop trendy at the time walks away with awards as if they're the second coming of Christ. Or they applaud the hell out of drug addicted minor talents - because they show "courage" in defying lawful behavior. I get that.

But I wanted to know...did anyone see Aretha Franklin perform? In that yellow dress?

Personally I'd think twice about wearing a color that doesn't hide anything - especially when the only time you put down the fork is to pick up the microphone. God that woman is BIG!

I couldn't find a picture of it - yet - so I picked up this one. Imagine a yellow dress instead of this blue one and that's about what you'd have seen. Damn scary.

Nothing Diet About It

2008-02-08T06:40:00.000-06:00

Thanks be to Lone Coyote for reminding my of an article I had read last week and wanted to post about.

I’ve always been one of those people who refused to drink “diet” sodas. Partly because I had a fear that I’d be branded effeminate, like a guy seen drinking Tab, I steered clear of them. Another part of me, especially when I was in middle school science and my teacher went on a rant about the fact that the body still reacts to the fake sugar like real sugar, knew that they weren’t anymore healthy than a regular drink. The fact that many fat people I've known will eat like crazy, but say they're on a diet because they're drinking Diet Coke also dissuaded me.

Some researchers seem to believe this as well, as I read about from this article. So I guess my crazy ol’ teacher and Diet Dr. Pepper are right – there’s nothing diet about it.

Taking PCPs Out Back

2008-02-07T12:30:00.000-06:00

In a ridiculous turn of events, it appears that Wal-Mart is starting to link their retail clinics with hospitals and other physician offices – in order to have name recognition.

“We have learned that people are willing to receive their health care from the front of a store or the back of a drugstore,” said Dr. John Agwunobi, a medical doctor who is a Wal-Mart senior vice president. “But customers also have said they would rather it be delivered by a trusted name, a local health care practice, a trusted local provider of care.”

Thankfully there are still some people who are actually thinking straight regarding these “trends”:

Medical societies are inclined to be skeptical of the clinics. The American Academy of Pediatrics opposes them, saying they add to fragmentation in the health care system.

The American Academy of Family Physicians and the American Medical Association have set forth principles for clinics to observe, including sending patients’ medical record to their doctors and finding doctors for patients who do not already have them.

It’s a rather interesting read overall, stating that many clinics have yet to even break even and there are a few that have closed down, leaving NPs and patients alike without much to show for it.

What I would like to know is whether people actually think these are the “way of the future” or a “fix to primary care medicine” as often touted. Yes, it increases a patient's ability to get seen that day, but it also increases the amount of interactions, reduces the medical record keeping by spreading it out over many providers, and runs the risk of patients receiving medications that will interact with drugs they're already taking. When I think about how hard it is to just get a hospital to send over the records from a patient's stay or ER visit, I can't even fathom what places like these will do - regardless of their claim to be connected with your doc. I'm not buying.

We keep dumbing down our healthcare delivery systems all for the sake of convenience, reducing costs, and providing more access. The problem is, when you pay peanuts, you get monkeys.

If I were a physician and the hospital or clinic I was considering working for showed this level of concern related to medical care, I’d walk right out the door. They're getting ready to take you out behind the dumpsters and shoot you in the head...just as soon as you're not beneficial.

A Little Too Calm During the Storm

2008-02-07T06:41:00.001-06:00

So apparently the storms that came through here the other day were actually a huge deal. I heard that they were some of the worst seen in the last decade or so…which makes me kinda puzzled.

You see, I was at my apartment’s gym, working out, and could see the lightening flashes, the downpour of rain, and hear the gusts of wind – but didn’t think anything about it despite normal programming being interrupted to warn about the twister formations. Didn't consider that I should go into a room that wasn't lined with large windows, or that I probably shouldn't have walked back home when the red from the doppler radar was centered around where we live. Even though I know the warmth that day would surely lead to tornado conditions and the storm was definitely making some trouble, I didn’t seem to care.

Since moving to this area I've had some history with severe weather, but have been less than concerned about it.

When I was in undergrad I apparently wasn’t aware of the tornado siren and walked to class while one was within a few miles. Some of my classmates yelled at me when I walked into the building for being an idiot and witnessed the proximity of the destruction later as I drove home.

Another time the store where I was a security manager* had the roof severely damaged by hail and high winds while a tornado ripped through a rural area 5 miles away. When it began to rain the water poured through into our building, causing some of the lights to spark and forcing us to use tarps and turn off all but the most essential lights. Maybe my calmness resulted from the fact that we were ordered by the district manager to stay open – despite the water coming in everywhere and lights shooting off sparks. I’m surprised no one was hurt.

So what I’m saying, I guess, is that I might want to take these warnings a little more seriously. My family and everyone we know are OK, but jeez. After all, it’s people like me who end up getting carried away, into Munchkin Land, because we’re walking around like idiots.

* Call me rent-a-cop and I'll kick your ass!

Oh Dear

2008-02-05T06:43:00.000-06:00

Consider this:

This is my local grocery store, where I am waiting in line*, observing a brand new addition – a retail clinic. In a grocery store. WTF?

They call this little shack “The Little Clinic”. Clearly. What makes me laugh though, is the signs in the background stating that this is a “perfect compliment to your primary care provider”. My question, of course, is: How?

How is this complimentary in the least? Do you actually think that the doctor will be informed of the “diagnosis” arrived at by the provider? Neither do I.

What I do know, however, is that the CVS store next door recently opened a retail clinic and was apparently taking too much business away from this store’s pharmacy – located just off camera to the left. I’m sure we’re all much happier knowing that this little shack is taking care of patient complaints.

In case you're interested, the AAFP has a quick tidbit about what these "complimentary" services should actually deliver - to be complimentary. Personally I wonder if this actually happens much at all.

*And yes, I did need chocolate milk. It's quite tasty.

** For more on my thoughts on retail medicine (like you don't already know), please check these posts.

More About Balancing Life and Medicine

2008-02-04T06:45:00.000-06:00

Yet another comment has fueled some need to post within me. Essentially the comments from my last discourse were interesting. Receiving a hint of disdain for my belief that a medical career is just a...gasp... J.O.B. I wanted to touch a little more on what makes my day (and maybe not disdain, but a certain level of disbelief that a medical student didn’t want to put medicine first was clearly evident).

The other night I was in Daughter’s bedroom, reading a couple bedtime stories to her. While I was leaning against her bed reading, she lovingly placed her head on my shoulders, stroked my hair, and kissed me several times on the head. After I finished she rolled over and said sleepily: “I love you Daddy”. My heart melted.

This happens on a regular basis when I’m home. I have memories that make me smile, laugh, and occasionally make me sad. I relish them, but realize that almost all of them are from the 3rd and 4th years, where, after spending most of my time in the school studying during the first couple years, I decided that I needed to spend a lot more time at home. I’ve done well throughout, but I certainly have more fond recollections of my times at home than freaking out over some quiz or test.

Now this being said, let me explain that at the same time I have always been committed to the patients I’ve worked with. I read a lot at home, about diagnoses and treatment plans that related to diseases I’ve seen or will see the next day, and never abandoned my duties in order to get home sooner. However, I do not have a great deal of memories from the hospital that would make me want to replace anytime spent with the wife and kids. I’m sorry, but patients just don’t fill a need in me the way my family does.

Other physicians and medical students may find that they have no better times than being in the hospital. While I applaud them and thank them for their dedication, I feel sorry for those who sacrifice their family life in order to obtain this satisfaction. I won’t state that I feel certain careers shouldn’t have families involved, but I think they’re more apt to be strained and the relationships more miserable regardless of the persona involved. I didn’t want that…that’s where my decision came into place that ultimately steered me away from a surgical career and into the anesthesia field. Others may decide that medicine is their priority and they’ll sacrifice everything else towards that end. So be it.

Yet, despite my understanding that some people love being at work, I find the most pleasure, solace, and love when I’m home, not amongst the sick. My favorite place in the world is not in the hospital, that in and of itself is proof enough that a career as a surgeon should not be attempted, but with my family. A quote I heard during interviews described my situation perfectly:

“If your favorite place in the hospital is the OR, then anesthesia is the right path for you; if your favorite place in the world is the OR, then be a surgeon.”

Perfectly Said

2008-02-03T08:16:00.000-06:00

A comment on OB/GYN really hit the nail on the head for me. From Agraphia:

I divorced my husband during the third year of obstetric residency, which was a second residency. My daughter and I hardly missed him by then. He never made it to her school functions, recitals, science fairs, ever. But, I think that was just him. He found time for things he wanted, like on the phone and hanging out rehashing the political garbage of residency with his “family” of residents. He was rarely home when he was there. He was chronically exhausted, mean, and self-focused. He became obsessed with malpractice issues and how to keep everyone from getting his money. I started the first residency “with him” and my focus was appreciating him when he was there, not bitching like I heard so many wives. Our lives were on hold all of the time … at age fourteen his daughter doesn’t know him and doesn’t want to. Nothing is more sad or tragic. I know it would be that way either way. The system of training, indoctrination, and expectations beyond what is humane is the cause. Why do people go along with it … and lose their loved ones/families? It is so unnecessary .. it is about control of money and litigation. He went from being disturbed about the way women and babies were treated and wanting to get a journalist to cover it in his first year, to becoming shut-down and numb so he would become stuck in the financial obligations that keep them there.

If the system would allow real midwifery, the load of the care needed could be divided between doctor, nurse, and midwife. A midwife is glad to be a woman’s primary caregiver and be there throughout, which is really important emotional support. Doctors have to be in the office doing monthly exams, available for surgery and births night and day. It’s crazy-making for everyone except the hospital coffers. If nurses and midwives helped play a part in the care of pregnant women, it would be acceptable for the doctor to just show up at the last minute, do the medical deeds and move on.

Of what service is the current system to women? They are forced to accept only the care of an OB, that when all is said and done is so inadequate and minimal. The tragedy from my perspective is seeing a man turn into someone so nasty to women. Why do we expect them to be all to everyone … so that end up tragically giving such poor quality to all?

The reasons that I feel surgery wasn’t for me drew along very similar concerns. Having a family, who doesn’t want you home, being completely consumed by your job and having nothing to do with people outside of the hospital are absurd events that many residents go through when entering demanding fields. To me, it’s just not worth it. I feel, and hopefully will always feel this way, is that there is no failure more complete and absolute than to fail as a parent.

Trust in Pain

2008-01-29T11:00:00.000-06:00

A comment recently received caught my attention. And not so for it’s questioning of my patient attitudeness, but more for this first portion:

I think it is interesting that you have chosen anesthesia as your specialty - the management of pain issues being one of the few areas of medicine where the physician has to simply trust the patient to report their pain since there is no objective test to prove it. Have you thought about how you will manage when a patient reports pain (and i'm not speaking of one of the flat out easy to spot drug seekers) but you feel you have treated them adequately? If you, using your prior experience and all of your knowledge don't feel they need more meds despite what they are telling you - what will you do?

Fortunately I received a great lecture on this topic early in my 3rd year that has stuck with me. Yes, there are those people out there who abuse the system and want to have narcs up the wazoo just because they want to get high. However, in anesthesia we do have to be more receptive to the idea that someone’s pain is a 10/10 even though they are sleepy.

The lecture to which I referred earlier was by a doctor who worked with the old and terminally ill. She often gave dosages of pain killers that many other doctors thought would surely kill the patient. Her advice was that pain should never be uncontrolled just to remain within the “standards” of the pharmacopeia.

“The patient will let you know when they’ve received enough. You just titrate out the amount until they are pain free or close to sleep. Then you’re at your boundary.”

In most patient encounters this wouldn’t work too well – not enough staff to watch carefully over the patient as the drugs reach their peak effect. However, in the PACU, where we have nurses who carefully observe and manage patients, we can adjust more readily. They are given orders for pain management by the anesthesiologist, who, by way of observing the patient’s narcotic need intraoperatively, will have a better understanding of how tolerant or labile the patient is towards pain control measures. These can then be adjusted based on pain scales and overall patient physical characteristics.

Addressing the notion that we lack objective tests, certainly during the operation there are physiological parameters that anesthesiologists look for when controlling pain: increases in blood pressure, heart rate, breathing, perspiration, etc. are all items that alert them to a need for increased pain management (this being said, it is important to realize that even though the “body” is responding by reflexive physiological measures, the patient very rarely has any recall). This is a form of acute pain control, often a direct result of a noxious stimulus. Many patients present with similar findings, even when conscious, and allow for more visual confirmation of pain. While easier to understand and treat, we still have people with chronic pain, vague and mysterious, that's often at the heart of these controversies between physician and patient.

Rather than label a patient as a "malingerer" or "druggie" who presents multiple times for low back pain, neuropathic pain, or "flares" we must trust them. And that’s were the catch comes. That’s were so many healthcare providers, who entered medicine wanting to help only to be burned time and again, are now skeptical of most pain complaints. The abuse they've seen and endured, at the hands of addicts and malingerers, hurts more than just the patient - we all suffer to some degree.

Considering the notion that people report pain even after receiving large amounts of highly potent narcotics, you can easily expect providers to write the patient off as an addict. Unfortunately, while true in many cases, some pain cannot be well controlled with medications or is completely untouchable. This leaves the sufferer searching for assistance, help, and relief from the constant agony. Pain specialists are often useful for these kinds of patients, using advanced pain management, through invasive procedures, to help in these cases. A rather lucrative field, I personally have no desire to entertain such thoughts, as pain patients are some of the hardest people to treat, having been "mistreated" so many times.

Many forms of pain are hard to diagnose, treat, or even moderately control regardless of level of therapy. Asking for a quantification (the best known is the 0-10 scale) is often hard to deem accurate as pain is patient specific, based on psychological, emotional, and environmental cues. Someone claiming 10/10 pain may actually have the worst pain they've ever experienced. Just because we've seen people in worse situations shouldn't cause us to feel they're lying to us - it's completely subjective.

A theory postulated by some neurologists and others has suggested that the brain “makes up” pain in order to elicit stress responses that were once normally found – we’ve just become too comfortable and it’s a fall-back mechanism gone awry, kind of like the increased incidence of allergies. I kinda like that idea and understand it – after all, many of the harder to “trust” diseases like Fibromyalgia are more receptive towards medications targeting brain chemistry and function*. Whether I believe it to be a real disease is not the question, the patient believes it and therefore they suffer from it. We need to understand that more.

I honestly feel that we must listen to a patient and assess them truthfully while at the same time the patient must also listen and adhere to physician advice. An overdose of pain medications results in decreases in many aspects important for body funtions, including breathing and cerebral consciousness. If patients are found to be sleepy, lethargic, hard to arouse, disoriented, or having some trouble breathing at a normal rate they shouldn’t receive anything more - regardless of additional complaints. That's were the education comes into play. The physician must acknowledge the limit and be in control of the situation, without allowing emotions or a concern for legal action to influence their decision.

Despite the fact that there is some evidence that pain exists regardless of conscious level (i.e a sleepy patient can still have 7/10 pain) we need to accept that the limits have been met or breached and inform the patient as best as possible. I might still trust that the patient has pain, but my ability to help with more narcotics has been limited. My hands are tied.

*Is it just me, or do those commercials have the crazy patient look down? I look at those ladies, talking about their pain, and just shudder.

New Sidebar Items

2008-01-28T15:19:00.001-06:00

Just wanted to put some emphasis on the new sidebar items I've added: MDCalc, MedCalc, Intern Survival Guide, Learning Radiology, and the EKG Library. These are extremely useful items for all med students, interns, and residents. Perhaps even a higher level might even find these useful.

The Intern Survival Guide is from the U. of Michigan and therefore has items on it that are hospital specific. With that being said, I think it's a wonderful site with a plenty of useful information - especially for me as I begin to sweat thinking about July 1st.

Kids Are to Placebos as Patients Are to...

2008-01-28T06:19:00.000-06:00

Little children are placebo happy. If they have a small scratch, bump, or bruise that they can see they want a band-aid and a kiss. As soon as the band-aid is applied, the kiss given, they suddenly feel an instantaneous relief. If they’ve received medicine in the past for an illness they want something for their cough – or just to be like mommy and daddy. As soon as they get it, they’re happy. They're cured.

Patients are a lot like little children - at least the ones who use primary care services or the ER for minor complaints and an overt sense of entitlement. If you tell them that they’re going to be OK and try to send them along their way they get all upset.

“What, you’re not giving me an antibiotic? But I WASTED $25 for my stupid copayment! I didn’t come here to waste my money!” (as if taking up a professionals time and utilizing many years of education and training could be considered a "waste")

So, some doctors give in and prescribe the antibiotic, only reinforcing the patient’s misplaced sense of entitlement. Unlike a band-aid or kiss, this practice is dangerous as every drug has side effects and also increases resistance of normal residential bacteria.

Essentially the patient has thrown an adult temper tantrum, demanding to receive their placebo. Hell, we could give them sugar water with red food coloring and call it an antibiotic and they’d swear that they only get better with drugs.

In fact, my grandmother once told me about one of her friends who will purchase a large bottle of penicillin whenever they travel to Mexico. He then uses them with every subsequent cold he gets. I can't even begin to describe how irresponsible that practice is - I'm surprised he hasn't gotten a severe infection yet. But I'm sure he believes he improves only as a direct result of the antibiotics he takes and thinks his doctor's an idiot.

2008 Meme

2008-01-23T13:11:00.000-06:00

Thanks, DG!

All right, in 2008:

1. Will you be looking for a new job? Yes, of course. Haven't you been paying attention to all of the residency talk around this place? Basically it will be the first job in almost 4 years - at least that I receive a paycheck for.

2. Will you be looking for a new relationship? Um, no. At least I sure as hell shouldn't be - what with being married with kids and all.

3. New house? Hopefully. Even if we stay in the same place we'll be looking at purchasing a home for the 1st time since we've been together. It's exciting to know that at most of the places were looking at we can actually afford to purchase on a resident's salary!

4. What will you do differently in 08? Try to exercise more, eat a little better, study the treatments for more diseases, and be more willing to help out medical students. I will also try to be more loving and listen better to my family.

5. New Years resolution? Stop drinking sodas (have only had one thus far), tell my wife I love her daily, and live by the motto: "Live and let live".

6. What will you NOT be doing in 08? Watching a lot of movies, sleeping more than 7 hours a night, and generally being able to live outside of the hospital (at least when July starts).

7. Any trips planned? No - other than residency interviews and a house hunting venture if it's needed. We need the money.

8. Wedding? Already been there, done that...happy with it.

9. Major things on your calendar? Hells yeah! March 18th I find out if I matched and the 20th we find out where we're matched. Residency will start in July or late June, and a potential major change in our lives will transpire.

10. What can't you wait for? Finding out where in the hell we'll be at. I'm really over all of this already...let's get on with the process.

11. What would you like to see happen differently? I'd like to be more fiscally responsible and be able to manage my budget with more efficacy. I had far too many overdrafts this last year and I hate paying out $30 a pop per transaction.

12. What about yourself will you be changing? Hopefully my body fat percentage will be around 10% or less. I also hope to try and relax more often and not get stressed over everything. I imagine that the entire process of internship will leave me with a great deal of medical knowledge that I thought I'd had, but didn't understand.

13. What happened in 07 that you didn't think would ever happen? That we'd sell Wife's car and purchase another, relatively new, one. I had planned on having both cars go through residency - but sometimes it's better having cars that work well than hoping you don't have to pay for more repairs. Another was the death of my cousin and sister (12/24/06). Both died suddenly and unexpectedly. My father was also diagnosed with renal cell carcinoma and had two operations where he lost one kidney and 25% of the other. I finally realized that I had to get glasses and now wear them readily - even if they make me look older than I really am.

14. Will you be nicer to the people you care about? That's part of my resolution for this year.

15. Will you dress differently this year than you did in 07? I'll still be dressing in work related attire: scrubs, slacks and shirt and tie. So, no.

16. Will you start or quit drinking? What are you, nuts? I love beer. I'm not stopping any time now. A good beer with a football game or after a hard days work is wonderful.

17. Will you better your relationship with your family? Hope to. Losing some family abruptly and having cancer spring up made me realize that I need to keep in contact more often.

18. Will you be nice to people you don't know? I will try. The fact that some of these people will be the nursing staff who can make my year a living hell or nice might play into my affability. Plus it's always nice to have a cool intern when you're starting out the clinics as a med student.

19. Do you expect '08 to be a good year for you? Sure, why not.

20. How much did you change from this time last year till now? I finally know what I want to do in medicine, I'm focused, and I'm less likely to lose my sanity. Other than that, not a whole lot.

21. Do you plan on having a child? I'm not sure...we're kinda in a weird place in the marriage where anything could happen. So another child might not be the best thing right now.

22. What are your plans for new year's eve? Stay at home, celebrate with my family, and drink some wine as the ball drops.

23. Will you have someone to kiss at midnight? Yes, Wife.

24. One wish for 08? That I don't kill anyone when I start my intern year.

No one will be tagged - I don't do that.

Sexual Harassment

2008-01-23T06:27:00.001-06:00

An interesting topic was generated by Hoover over at MedSchoolHell. It discusses some of the sexual harassment that many medical students have to endure during their clinical years. While I've seen some forms myself (and been a victim once) I don't recall anyone reporting the events. All too often I've found that surgeons tend to be the greatest offenders (lots of inuendos during surgical cases - what with the "suck this" and all), but many other professions are also culpable. What I find interesting is the SDN feed that he links - the mindset of many students is to just let it go and be "professional".

You know what? I'm really sick of that catch-phrase being tossed around to shame medical students into submission.

I agree with the suggestions of going to the legal department and risk management. Your dean's office or coordinators are not going to be able to help you. They'll sweep the incident under the rug.

Obligatory Comment Induced Post

2008-01-22T13:38:00.000-06:00

In reflection on my post dealing with Psychiatry I found the responses completely perceptable. Of course, having dealt with similar forms of misunderstanding or degrees of complete arrogant ignorance directed towards my chosen specialty I can understand the knee-jerk reaction towards my apparently incendiary comments.

They were expected. I anticipate more, perhaps as others are directed towards the jerk med student who knows nothing about psychiatry. Imagine if I’d bashed acupuncturists or homotherapeutics – we’d be swimming in the assaultive commentations.

Yet the fact remains – my experiences, my teachings in a school of medicine by residents, attendings, and social workers demonstrated a very sad state of affairs. The social workers were more involved in talking with patients than the doctors who, instead, spent a great deal of their time reading or leaving early. Patients improved here and there, but there were very rare circumstances where a physician actually worked hard at understanding the patient’s needs or point of view. Unfortunately, this is all too common in other areas of medicine, but damnable from a psych perspective. If my exposure has been insufficient to truly warrant a degree of opinion, I am aware.

Yet, even friends entering the psychiatric field have expounded on the degree of psychiatric training they've tried to avoid. They agreed with my perceptions of the residency we rotated through and noted some others where they'd interviewed whose residents actually would state: "we need to get a real doctor's opinion". That's where my concern for Psychiatry lies - in the apparent loss in some training programs in keeping their residents grounded in their medical school knowledge.

****

There have been discussions regarding the desire of psychologists to receive training to begin prescribing medications. If what I’ve heard, that being drug management is more lucrative than couch talk, I can understand their wishes. However, and let me be clear on this, I do not think that psychologists should be giving out drugs, regardless of my perception of the state of Psychiatry. If for what little medical treatment and disease pathophysiology psychiatrists actually recall, they received 4 years of post-graduate training revolving around the medical needs of patients in all arenas. Their understanding of pharmacology, side effect profiles, and dosing have been inculcated during this process and they are, therefore, more likely to be able to understand the toxic-therapeutic ratios, effective dose over lethal dose, and other nuances that a physician must evaluate when prescribing medication.

As little of the understanding of psychologist training I do know I don’t feel that they are as well prepared to be able to understand, nor be able to review, drug interactions and potential dangers as a psychiatrist. And perhaps it is the 4 years of residency training that I bemoaned earlier, focusing on the drug management more than psychoanalytical jargon, which further qualifies the psychiatrist from those who want to be included.

But what of the additional year or two that psychologists have suggested that will enable them to understand these concepts? They still lack the fundamentals, ingrained throughout 4 arduous years of medical school, that all physicians rely upon. Rather than being on the same footing they've already started behind and, worse yet, have years of training that have narrowed their mental process towards what they studied.

Overall, medical training allows the students and residents more capacity to understand where, when, and how to obtain vital information – regardless of specialty. What's more is the fact that these same students and physicians have a less focused perspective as they've been trained in broad strokes from the getgo.

Yes, we all forget how to manage certain diseases (I can’t for the life of me recall how to classify Salter fractures from surgery nor what the management would be), but we have studied them before and understand enough to be able to review with better efficacy. It's like riding a bike - you never really forget, but it's harder to teach an old dog new tricks.

What’s more is that through this process we’ve been able to interpret more readily what we don’t know. I’ve felt that a PhD enables someone a great deal of knowledge about a very precise and minute area of science. Truly they are experts in a small area. The problem that occurs is all too often someone with a specific focus begins to believe that they can do more without realizing their limits. I do not agree that a PhD enables anyone the option of performing as a physician – the training is to myopic. In fact, I find it disturbing to know that some professions are actively trying to erase or blur the fine line between the physician title of “doctor” and their own within medical settings. Because, unlike a rose, a doctor by any other name is not the same.

Single Payer Naysayer

2008-01-22T05:06:00.000-06:00

Want a single-payer system? Sure, we all do – right? Free healthcare for everyone and we all live happily ever after.

Wrong.

One of the most basic reasons that single-payer will not work is that it’s controlled by government. I don’t need to point out the troubles that are staring the NHS and Canadian systems in the face to make this point (and therefore did not provide links – you can get them yourself if so inclined).

Instead, imagine why patients are scared of the VA. Put yourself in their place – having to be seen by government paid healthcare providers who do “only what’s in their job description” and nothing more. A friend of mine has yet to receive adequate care for his illnesses and has begun to utilize homeotherapy - he's sick and tired of being "treated like shit by dumbass docs". I’ve seen some awful events, terrible care, and a complete lack of responsibility for patients at the VA during my few rotations. All perpetrated because the government employee mentality sinks in and once caring people become clock-punchers.

Beyond that, think of the military heroes whose medical care is being taken care of by places such as Walter Reed and other embarrassments of governmental medical care. Having spent 2 months in an army base I can tell you that more often than not the patients, doctors, nurses, and techs were more than frustrated by the ridiculous administration set in place to hinder movement through the system. What’s even more outlandish are the wait times in order to even see a doctor – months. Would you want to wait months for care? Months to receive surgery?

You can already see the impact imparted upon the medical field by beaurocracy crazy pencil pushers (regardless of association). If you haven't read or seen the images of nurses waiting to clock in and out in order to avoid infringements I can tell you it's completely absurd - patient care suffers. JCAHO is another entity who seems hell bent on making ridiculous mandates in the name of "patient safety". Do you really think that a single-payer system wouldn't be frought with these forms of "suit abuse"?

Then consider that your choice of doctor will be limited. Your care, paid for by your hard work and budgeting, will be reduced to “equalize” the care between poor and “rich” alike. Now consider whether you still really want a single-payer system. What's more, have you ever had or knew someone who had an HMO medical plan? Right.

That's government healthcare, clearly not "the answer" as preached by idealists all over the US.

Personally I feel that I and my family should be able to get the care that we work for, pay for, and earn through responsible actions. I do not want to receive mediocrity in order to help those who are less fortunate, immature, drug-addicted, slothful, and polybabydadics be spoon-fed more than they already receive.

Wouldn't Know the First Thing

2008-01-21T07:41:00.000-06:00

Rather than post about the continuing discussion regarding my rank list with Wife I will instead post about some other topics until I feel I can discuss the situation with more perspective.

With that being said...

A post from T at Anesthesiobiost (a rather interesting blog about an Anesthesiologist living in, I think, Philly, who is trying to learn the Oboe) illustrated a point that I’ve made to some of my colleagues regarding Psychiatry.*

Unlike Kris Kringle in Miracle on 34th Street who holds a great deal of respect for Psychiatry, I do not. Perhaps my experiences have been dominated with poor understanding or observation of the absolute worst form of practice, but I truly don’t feel Psychiatrists should be held in the same realm as physicians.

For that matter I don’t understand why they need to attend medical school in order to become head shrinkers.

Consider the experiences I’ve seen:

- Patients in an acute Psych ward were treated only by the nurse practitioner for diseases like high blood pressure, diabetes, and headaches. The psych residents and attending were unable to treat these diseases and frequently asked for “med consults” when these “problems” arose. They would then ask the students about the medications and what they did as they didn't know.

- During an ECT day while on an Anesthesia rotation, we were forced to wait for the Psychiatrist to arrive 30 minutes late for the last ECT (consider that we were scheduled in another room after we finished). Once he arrived we were once again appalled to see him spend another 30 minutes talking to the patient about why they were happy having not eaten that morning (as per OR guidelines – NPO after midnight). Then, without alerting the OR team or anesthesia team, this guy allowed the patient’s family to enter the room and observe the procedure. Afterwards he described what they had done and feebly tried to recall the reason for the anesthesia team’s involvement. He fucked up the basic physiology and pharmacology so badly I lost absolute respect for him.

- Whenever a Psych consult was requested at my main teaching hospital additional measures had to be taken in order to get a resident or attending to see the patient within the week. On OB/GYN we had to personally track them down and walk them to the patient floor in order to see mothers before they were discharged. They always acted put out and asked ridiculous questions about the patient’s disease or status (like did they look tired when they delivered – of course they did!).

- An attending stated that psychologists are better talkers than psychiatrists. The job of the psychiatrist had moved from “the couch” to the pharmacy. “Let the psychologists handle the psychoanalytical discussions with the patients, they’re better trained at doing that now than we are anyway. We deliver the drugs that help people”. No, really, he actually said that.

- I spent 2 days being lectured on Freud despite many of his ideas being disproved. They guy was a fucking coke addict with a major sexual compulsion – why are we still being taught about him?

I completely agree with T’s anger over the issue she describes. I don’t understand psychiatrist’s need to attend medical college – because they sure as hell forget about disease processes when they enter residency and apparently are just glorified drug pushers.

* I am not sure what T's opinion of Psychiatry is and am not trying to make any references to the like. Her post only allowed me a moment to reflect on the level of absurdity I feel with Psychiatry.