More Truth Than Not

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

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

Oh, and happy mother's day.

Don't Do It

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

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

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

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

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

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

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


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

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

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

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

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

Match, LORs, and Interviews

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

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

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

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

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

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

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

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

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

Match, ERAS, and Other Questions

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

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

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

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

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

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

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

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

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

Picking a Life 2

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

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

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

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

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

Picking a Life 1

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

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

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

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

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

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

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.

New Sidebar Items

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.

Rank Advice

Tomorrow I can enter in my rank list for residency programs. Hurrah, it’s almost there! Even though I have 2 more interviews to undergo, I already know my rank list and plan on entering it just as soon as I can. These interviews are more formalities – I already have seen what they have to offer outside of the dangerous interview day and an extra day isn't going to change anything.

For what it’s worth I found interviewing a struggle. How can you honestly determine a program’s worth for you based around self-aggrandizing statements, sweetened webpages, and residents who tell you that: “It’s awesome here! I would do it again!” Perhaps, but still…something’s not right.

So, with that in mind, here is a list of some items that I’ve come across that tipped me to some redflags which pushed a program low on my list:

1) Residents not being able to get out to their assigned dinner meeting with applicants because there’s no one to cover for them. Hey, if they can't even go meet their potential applicants because they're stuck, how do you think you're going to get treated?

2) Mention of the word “probably” when asking a resident if they’d rank their program #1 or come back as a resident. Yeah, I'd probably want to get reamed again too...if I forgot how bad it was.

3) Program directors or chairs who aren’t at your interview day and never talk to you. Seriously here, if one of them can't be at the interview (expecially the PD) then how likely are they going to be there for you when you're having some issues or need to talk about the program? Major red flag.

4) The feeling that “there’s nothing that needs to be changed” when asking someone where they feel the program will be heading in the next 5 years. Really? Nothing? Just like anything, you can always improve.

5) Students from programs that tell you they hated, or the residents hate, the program. Additionally, if they state that they’ll be placing their own school’s program low on their list – you better dig more. These are the best source of information, but can also be very devious since they're interviewing for the same specialty as you. I was asked about one of my school's residency programs and was honest. Some people will tell you accurate info while others lie. Take it with a grain of salt.

6) Program where you feel a nauseated feeling after leaving – something’s not right, but you’re not sure what…trust that instinct. Unless it's food poisoning from the fish the night before.

7) Less than forthcoming program director when questioned about ACGME troubles or a low cycle year. They should tell you what they were cited for, their improvements, and where they hope to be when they get reevaluated. If they can't, they're hiding something bad.

8) Dirty and run down hospital setting. Look, I know a lot of hospitals aren't pristine, but I’ve already dealt with this for 4 years and I want to work somewhere that I have pride in being at day to day. Worrying whether the ceiling tile will fall on my head is not beneficial.

9) Environment where you’ll work – is it run down, nasty, scary? If you don’t want to work with certain populations (perhaps having to speak ebonics more than english at any one time) come early and watch whose walking around the hospital.

10) Residents who tell you “don’t come here”. Yeah, you might want to avoid that one altogether. Didn't actually hear that, but some people have and I actually cancelled an interview after learning a co-applicant was informed that by the residents.

Just a few hints that I picked up while out on the trail. I personally am grateful to have run into students from various areas in order to get a better appreciation – because I honestly think you get the wool pulled over your eyes a great deal during this process.

Caring For Loved Ones

One of the more frustrating things that come with a medical education is having people expect you to give advice or fix them right away. I’ve had Wife’s friends and coworkers call me, unexpectedly and unacknowledged, to ask me if their doc was crazy, or if they should be doing this for that, etc. I’ve told all of them a very similar message: I don’t give advice over the phone or in person, I’m a medical student, go see your doctor. I have stated and firmly believe that you shouldn’t give advice to people without being their doctor - regardless of the relationship. It can come back and bite you in the ass.

That being said, it’s harder when it’s your family. Both my kids were sick recently (10 days of hacking cough and 2 days of violent food poisoning) and I’ve been trying to take care of them as best I can. Since they’ve been sick with illnesses that would resolve on their own I’ve really just been dolling out comfort care. But it upsets you, to know that you’re looked at to fix them and that being post haste. Plus, on top of that expectation is the very real notion that you're not believed.

“What good is your medical education if you can’t take care of this?”


"I didn't really believe what you were saying, but I guess you were right."

I’ve heard those statements before and will most likely hear them again. It’s hard to tell your loved one that they just have to “suck it up” and deal with it for a while – there’s nothing that can be done beyond supportive care. Certainly you feel that you want to be proactive and heal your family, but at the same time you must realize that in order to be a good husband and father you have to distance yourself from your medical training – at least to some extent.


I've had conversations with my mom about my dad's cancer, if it's progressed, and similar topics. She recently asked me, while out for an interview, to come with them to a follow up appointment where a new growth was going to be discussed. Because this subject was well beyond my training, I went and asked only a few pertinent questions. My goal was to be a support while trying to not interfere with the relationship developed between my dad and his doctor. Mostly I was there, I think, to make my mom feel better and certainly not second guess the treatment plan. They were glad I accompanied them, but I understood the hazards that were in place at my being present and tried dutifully to avoid traversing them.

There’s a slippery slope that can develop if we get too involved in caring for our family or friends. Regardless of your experience I feel that we can get too emotionally involved and attempt too much without the guidance of other, perhaps more appropriate, physicians and nurses. I’ve had times where I felt guilty for wanting to take Daughter to her pediatrician because I felt there was something that they could do - anything - just make her happy again. I've also had times where I've felt ashamed for presenting with an illness that, in retrospect, was an easy diagnosis that did not require a sick visit.


Between all of these cases she's been OK, but it still bothers me. Stepson's dad has taken him to their doctor after I've told him there's really not much more they can do - too which I've found some degree of anger directed towards him. Regardless of whether or not I was accurate I have since realized that it's not his job to trust me (nor I him) as I'm not their physician. And because of these understandings, based on pride and shame, I realized that I was too involved in the care of a loved one and could have made mistakes shadowed by emotional attachments.


A perk of medical training is being able to take care of people around you, but it is imperative that all physicians realize there's more undertaken while caring for a family member than a regular patient. Important findings could be minimalized by a desire to avoid a tough discussion or diagnosis and bonds that were once strong can be broken forever. I personally have decided to never provide healthcare for my family that would normally be part of their doctor visits.

Wonderful World of Traveling

Driving over 1500 miles in 4 days for 2 dinners and 2 interviews, followed by a day’s break after which I then will drive a few hundred miles more to take Step 2 CS has made me edgy, dizzy, nauseous, and out-of-sorts. Plus being cooped up in a small rental car for hours and hours on end with no CD player and only the radio is enough to drive anyone crazy! I’ve come to find that I talk to myself a lot while driving – lovely. My advice? If you have more than a 4 hour trip by car - just fly. It's really not worth saving money if you think you'll throw an embolism from sitting so long or have to take hourly breaks to avoid the vertigo you get while driving in a thunderstorm, at night, with large trucks wizzing past you, and only your headlights to see.

In spite of this post-trip funk, the programs that I’ve interviewed with have been tremendous and really are screwing with my previous idea of what I would rank and where. I will have to take a long, hard, and completely honest look at all options and have insight from Wife before making any final commitments – what I thought would be high is being moved around a bit and programs I was a little wary of have been quite impressive. Damn...so tempting, but are they right for me? For us?

The interview trail is actually quite fun since you get to see a new city, meet some interesting people, and hear about interviews they've finished. The other day I heard about a program I'm interviewing at this month with the discussion being between two large city dwellers. Their focus was on the program's small city location and the interesting fact that, at times, it smells like chocolate. These candidates found it to be a tremendous program, but the area was just too small for them to consider it. They need a larger environment and this was more of a family place, I guess, so it might just be perfect for us - plus I've seen that there are lots of places where Wife could work within 30 minutes of the area...so it's all good.

What is the most fun, however, is to observe how people start acting weird once their level of anal-sphincter tightness declines. Sometimes they turn into real jackasses, helping you look a lot better and sometimes they are really cool and easy conversationalists. I'll be glad to have some time to just crash and not feel evaluated all the time, though. I really hate those dinners, not for the food, but for the forced social interaction with people I've never met and are judging me. For all their infamy, the interviews are nothing compared to those dang dinners - at least for me.

I've also had some programs ask me in a rather round-about way to explain why I'm at my school. It's not well known and has a somewhat, um, less then stellar rep in the medical field. I spin it very well, I think, but I find it interesting that I have to explain it at all. Perhaps they're wondering why someone with all of my obvious talent and wisdom wouldn't be at a more prestigious school - yeah right.

Auscultung!

Liana’s post here had a somewhat off topic interest for me: how do you wear your steth?

For me it’s always been cumbersome and rather weighty around the neck. After 12 or more hours that relatively light piece of equipment begins to bore into the back of my neck, causing stiffness and discomfort. For a while I tried to just keep the ear pieces wrapped around my neck while the heavier piece dangled around my stomach, like a tie. However, apart from feeling like I was being strangled, I found this quite absurd when trying to write and bending over a patient during exams. Swoosh. Careening completely out of control whilst knocking the shit out of a patient or two.

I’ve seen those who favor wrapping their steths around their waists, using the drawstrings of their scrubs as a type of belt. It seems, however, that unless you are a tall, yet petite female, a very effeminate male, or have an instrument that’s so absurdly long you couldn’t hear a train while auscultating this just isn’t feasible.

There has been a resident or two whom I've seen wear a type of device they clip onto their belt or scrub pants that allows you to “holster” your steth. Apart from being a little odd looking I found this a fantastic device; keeping the cumbersome, yet completely necessary tool at one's side without taking up much space. Considering this, I have still not procured one for my own use - yet.

What I currently prefer, based on a surgical resident’s insight that "surgeons don't wear stethoscopes", is to just simply wrap it around itself as demonstrated below, and stuff it into my large white coat pocket. Out of sight, out of mind.


Now there are some disadvantages to this - like getting the ear pieces hooked on a piece of furniture and getting pulled to the floor as you run for that code, or eventual damage to the tubing necessitating another purchase - but for the most part I find it a helluva better alternative than wrapping it around my neck or having an episode of vasovagal syncope from bilateral carotid massages.

Chips

I've noticed that there are a lot of people in health care that take shots at medical students and younger residents while they can. As a resident gains more seniority these people begin to behave differently and almost cower from their gaze. Being one of these students who has received harrassment from various nurses, techs, and assistants I can understand how one might get riled up when you're the object of another's fun.

But that's just how it goes during this process. We have almost no power over anyone, can't really get on someone for being a jerk, and have to simply suck it up. Or get flustered, let the person know they got the best of you, and realize that you've now become the "joke bitch" for that floor.

A friend of mine has been given a rather hard time during her Sub-I from just about everyone. The latest was from a tech who prodded her into anger by insinuating that she wasn't cut out for medicine after a comment she made. My advice, had I given it, would be to just suck it up, ignore the insults, and try to keep the chip on her shoulder from getting bigger.

Because if we were to allow every instance of humiliation at the hands of "lesser people" get to us then we'd be demon asses and bitches by the time we're finished with residency.

Part of training to become a boarded physician is to learn limits. When those above us do it, they do it in hopes of keeping us grounded, well aware of our limitations, and more vigilant the next time. When it's done by those below us (like techs, MA's, and the like) they're doing it while they can, because they know in a few short years they won't be able to say one negative word without being severely castigated.

So let the fuckers make fun and just continue to improve. Reacting simply makes them feel more justified and makes you appear insecure about your level of knowledge.

What's That, Fucker?

Alright...calm down. It's going to be OK.

Really it is.

He's just a fuckwad.

To hell with that shit! He's a damn 2nd year!

What nerve!

I shoulda kicked his bitch ass all over the place is what I shoulda done.

Tardbucket.

Gahhhh!

Well, I just had an interesting run in with a 2nd year while studying. Apparently I was in "his chair" and was asked to leave. The room.

Yes, he actually asked me to leave "[his] room because this is where [he's] getting ready for a major test (didn't they just start) with friends and they always study here. If I wasn't a first year I'd have know that."

Serious. That's what he said.

Of course I was gracious and kind, the absolute picture of calm. Ha!

After 5 minutes of me tearing him a new one, telling him where he can put his study books, and what year I was (after all, being a senior makes me uber cool now, doncha think?) he got the message and left.

I'm not the only one to have a run in like this with the 2nd years either. A classmate apparently had a very similar run in when asking people to be quiet while studying. They told her about the "quiet rooms" for studying and continued to talk - since they thought she was a lowly 1st year.

Fucking underclassmen. Learn to respect your goddamn elders! I know where and how to stick shit in people now that will kill them quickly...Don't. Fuck. With. Me!

Bitter Doc Face

Sometimes people seem to wonder what’s wrong with healthcare professionals. Why do we complain and gripe so much? Aren’t we still considered one of the most respected, well-paid professions out there? What could possibly be so wrong with medical school and residency that causes people to become such inhumane asses who focus a lot of their attention away from their patients?

Well I think, at least what I've seen thus far, it that it's really a few things: 1) huge debt to income load; 2) increasingly diminishing returns with an increasing CYA workload; 3) administrators and insurers who know nothing about medicine, but dictate policy and procedure regardless.

Personally a lot of my own bitterness these last couple years has come from the unforeseen future for something I've fought hard and sacrificed for. Medicine is on shaky grounds right now and I’m not sure where it will be in 10-20 years. What I envision, when looking at the current state, is a system where no one thinks anymore and all decisions are run through an administrative system - but the culpability remains squarely on the heavily burdened shoulders of the "white coat" - and malpractice reform is defunct.

The concerns of this generation of doctors are completely different from any other – which may be part of the rift between the old and new. It's very hard to dedicate oneself entirely to the practice of medicine when so much of it seems to be a time and money sink. The idea that one might not be able to afford to practice after 12 years or more of school and training is depressing. The thought of being “insecure” within your profession – beyond financially – causes a lot of grief and anxiety in residents and medical students. Simply looking at the state of primary care medicine is evidence enough that monetary concerns (i.e. being able to pay off your loans and still be able to feed your family) is a huge consideration when considering specialities.

The fact that patients continue to want perfection without paying for services; who, in the same instant, will run to the nearest phone book, ambulance-chaser for any complications (regardless if explained to the Nth degree or not), who, by virtue of their bottom-feeding existence, will then stop at nothing to destroy a career obtained through blood, sweat, and tears - all in the name of “justice” - leaves many docs and students wondering why in the hell they’re still around.

It’s a stark contrast to the dreams held during the early years of my medical training – polar opposites almost. If we, as a nation, want our health care to survive and not become a government run entity with bitter, angry providers who want nothing else but to leave when 5pm rolls around, we’d better realize that there’s only so much hemorrhaging that can occur before someone dies.

Questionable Admit

***This is a letter that I'd like to write to the various e-mails I receive from would-be medical students wanting to get an "advantage" before applying to med school.***

Would you do it all over if you knew then what you know now?

Seriously ask yourself this question about anything and I believe you’ll find yourself struggling with the answer more than you’d have thought. What if you didn’t take that job? What if you never had kids or married? What if you didn’t let that smooth talking guy/ girl get into your pants? And so forth.

Now imagine that you've spent the last 3 years thinking this, about one choice, that ultimately has decided your entire future, complete with ridiculously hazy details, complicated directions, and unknown outcome. Imagine that you know that the next 4-5 years (at least) will be filled with "mentors" like this *who hold you in nothing short of complete contempt and abhorrence for being weak and lazy because you don't work 24/7/365. Would you do it again or still continue?

What does the future hold for me once all this is complete? Will I be able to make a living while paying off my insane debt, have a decent life (being a lazy bastard and all), and take care of my patients without burning out? Did I have a better job and opportunity prior to entering medicine? These are all questions that I, personally, consider before drawing any conclusions about entering medical school. My reasons are varied and differ greatly with peers based on life experiences, situations, etc. I cannot tell you whether or not you’ve made the right choice by deciding to become a physician because my own basis is entirely personal and based solely on the immediate and unforeseen circumstances that plague me at that time.

And because my conclusion changes I find it hilarious and rather absurd that pre-med students often seek advice from medical students. Yet they're told that we're the beacons of light on this subject since we're knee-deep in and that true understanding of medical school can only come from a medical student. Questionable philosophy at best.


What can I honestly tell you about medical training that will truly benefit your own decision? That it’s hard? That during the first couple years I had short periods of tremendous exultation intermixed with long episodes of utter hopelessness; all while getting no more than 4 hours of sleep? That I can count the number of times I've almost been divorced on 2 hands? What about the panic-inducing debt that I've accumulated from loans, upcoming away rotations and interviews, and "emergency" car repairs? Believe me, I had people tell me all these things prior to my entrance and I still had no idea what to expect.

Simply put, no one can make a decision like this for you nor can they truly prepare you for what's to come. You have to do your homework, spend time with people who are in the thick of it all (and not just volunteer for simple shifts or work for uncle Larry's office), and evaluate the true reason you desire to become an MD or DO.

If I’m miserable I’d have opted out long ago. Sure I spend a great deal of time complaining about the process, but the fact that I can see some light ahead, have witnessed the transformation in myself from this process, and understand more than ever that medicine is not the utopian environment I’d believed so long ago and needs people to make a change keeps me going. You need to figure this out for yourself.

* Thanks to Panda Bear's recent post for this editorial.