Time to Tumble Down - Again

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

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

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



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



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

Necessary

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

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

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

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

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

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

Purification by Fire

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

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

Graduation

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

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

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

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

I am a Doctor

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

The House of God

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

But I don't see it.

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

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

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

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

Home Sweet Home

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

These are in order:

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

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

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

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

What's the Deal?

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

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

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

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

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

A Look Back

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

1) 3.9 GPA

2) >240 step 1 and 2 scores

3) AOA inductee 2007 - 08

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

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

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

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

8) Didn't get divorced

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

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

11) No one died from my actions

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

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

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

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

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

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

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

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

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

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

Luxury

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

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

Do You Have This View?

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

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

Respect II

Overheard while performing the babysitting duty:


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


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


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


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


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


Nurse 2: "Shut up, bitch!"


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

Death Rattled

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

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

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

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

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

The Sitter

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

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

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

Lessons

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

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

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

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

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

Tired

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

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

Match Stats

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

Anesthesiology, 3
Total offered: 666, unfilled: 17

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

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

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

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

Neurology,1
Total offered: 177, unfilled: 12

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

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

Pathology, 2
Total offered: 508, unfilled: 41

Pediatrics, 8
Total offered: 2382, unfilled: 87

Psychiatry, 4
Total offered: 1069, unfilled: 56

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

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

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

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

Surgery, 9
Total offered: 1069, unfilled: 2

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

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

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

Hysterical Blindness

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

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

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

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

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

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

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

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

*****

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

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

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

Courtship

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.