Time to Tumble Down - Again

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

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

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



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



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

Well, Okay Then

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

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

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

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

Scary As Hell

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

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

Stay away from the hospitals, people, stay away.

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

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.

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.

Scrambled Eggs and Other Facts

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

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

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

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

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

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

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

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

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

4 Nickels and a Penny

21%.

That's the number, people, 21%.

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

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

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

I know something like that will be said.

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

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.

Perfectly Said

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.

Obligatory Comment Induced Post

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.

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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.

Of Course, Something Else

After all was said and done about knowing what my rank list will be, I was hit with a major obstacle. I showed the presumptive list to Wife, after we had talked about the locations of my top 3-4 programs a week earlier, and she calmly stated that, wait for it…she wouldn’t move to my 3rd choice.

Of course I was rational about the whole event – not. You see, I’ve tried to keep her involved in this decision, let her know where I was thinking about applying, and asked her opinions of the cities and overall locations where we’d potentially be moving. A few cities where I had wanted to apply were lost in this process and I proceeded to interview with the assumption that, despite not wanting to move, she’d be OK with where we ended up.

The other notion that ran through my head was an absolutely selfish one: I’ve sacrificed 7 years for her to be near Stepson, lost a year of undergrad, gained $15,000 in out-of-state debt, and was forced to only interview at 2 medical schools (of which only one actually interviewed and accepted me). I’ve done a lot for her and this was my training: 4 years to become an Anesthesiologist, board certified and all. I felt that, given the fact that I’ve put up with 4 years of bad experiences at my medical school with feelings that I might have been happier at another location, I should be able to rank programs based on where I feel I’d receive the best training.

Selfish.

This argument eventually ended up in discussions by her about going separate ways. Wife feels we’re not on the same path anymore – and all because I got upset about one program. Now, don’t worry too much at this point – she brings this idea up every now and then when we have a heated argument. However, I feel somewhat betrayed at the suggestion that I just went about “interviewing all over without talking to me”.

I felt I had taken a great deal of steps to try and avoid this problem – only to have her start 2nd guessing the whole notion of moving. So now I feel that, unless we end up in the program we both want as our primary choice, she’ll decided that it’s not worth it and stay here.

There is a burden I’ve carried for a while now – the idea that she has sacrificed her aspirations for this process. I also worry about where we’ll end up because Stepson will not be coming with us if we move. I’ve spent more time at home, trying to be helpful in order to assuage these concerns, but I’m getting sick and tired of feeling like I’m the bad guy in this situation. It sucks, yes, but I honestly feel that I attempted to keep her involved throughout.

So I’ll move the program low on the list (despite being an outstanding place) and try to patch things up later today. But you know, residency is not going to be easy – anywhere.

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.

Back at It

Well, after a lovely couple weeks break from interviewing and 5 weeks from medical school I'm back at it. Last weekend (yes, an interview on Saturday - I've got a couple places doing those) I interviewed at a nice enough program, but - and thankfully - I knew that I wouldn't rank it high. I've vacillated enough about my rank list already and I really didn't want some place that I wasn't keen on to begin with to suddenly astound me and fuck things around again.

Today I'm supposed to start my Radiology rotation. Supposed to. But, I'm several thousand miles away for an interview tomorrow. I had to fly out yesterday in order to ensure that I could make it to the dinner and the interview since the weather out in the west has been lovely.

Of course, trying to get information on the rads rotation, the change in our starting date, and attempting to alert the coordinator that I will be out for the next 2-3 days (remember, the last time I flew through this area I had to sleep in an airport for another flight) I have, naturally, not received any reciprocating e-mails from this rotation.

Sigh...

I wonder when the school will realize that I'm paying you to help me here, it's part of your job. Some assistance would be nice - but then again, I'll have a quarter of a million in debt for a study-at-home medical degree. YES!

I'll be glad when interview season is over. It was fun at first, but having time off has made me realize that it's hard to try and kiss ass all the time and appear interested in anything being said.

***Addendum: I received an e-mail from the coordinator regarding my first e-mail, 2 weeks ago. She wants me to call her and explain myself. Hey, I tried to get to you already, now you'll have to wait.

Certainly Not

So I was in Philadelphia the other day and, well, just loved it. That is to say I loved hating the hell out of it. Large cities and me do not mix well at all - I hated being honked at for not trying to run down pedestrians, hated having to hide my GPS so that I wouldn't get jacked while navigating streets around the airport, and hated the dirty look of the city - I mean, how many industrial plants do you have?

During this process of hating this area I had to consider doing a residency there. Certainly you jest. Come on now, if I hated it that much during the brief period I was there, imagine my misery 4 years later. No rank for you.

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.