Home for the holidays

After working my butt off without a full week off since July, I'm looking forward to just hanging out with the fam and being a normal, non-medical student person for a little while.

I almost always enjoy my ride home...until I'm stuck driving on the "clear" day between two snowstorms (it snowed the entire way) on the same day when people from the southern states are all of a sudden trying to drive in the snow for the first time in who knows how many years. I only saw 4 accidents on the way and they only added 45 minutes to the ride, so it could have been alot worse...

I actually miss the Massachusetts winters. There's a routine that happens around a snowstorm, life slows down a little bit and there's a clear priority to the days affairs: get the snow out of the way and go about life. It's almost automatic, ingrained on my soul from my formative years. It could be 3 inches or 3 feet...life goes on as normal. In NY, life pretty much stops for a few inches of snow, everyone on the roads looses their mind. In DC, it takes about half an inch of the white stuff to cripple the nation's seat of power. I came home to about 6 inches on the ground and then we had about 10 more that fell on top of that...so it's a nice wintery change of pace up here. I've already hit the local ski resort up once which was great, though there's something that seems wrong about skiing corduroy the day after 10" of snow fell (but it's the east coast...I can count the number of days I've skiied powder on one hand).

I haven't really been in my usual holiday spirit this year. I think it's the all consuming nature of school coupled with the girlfriend and family being far away, my classmates being spread all over the tri-state area and my roomate being depressed because his girlfriend moved back home for the forseeable future. Despite my case of the Bah-Humbug's, I spent 6 hours of yesterday shopping for everyone with my youngest brother. I'm almost finished, just the girlfriend's mom and niece to shop for. I have to head up for their traditional Christmas Eve Party, which is always interesting since it's the only time that I interact with her massive extended family. Then it's back home for christmas day and then to upstate NY/Canada for a bachelor weekend including the world famous Dinosaur BBQ, a venture into Canada, the Pats-Bills game...and probably lots of heavy drinking in there too. I imagine we'll probably also end up in a canadian strip club at some point (which is always interesting). Then it's back home for new years in Boston with a few of the college buddies and the GF. Then I have 3 days to recover, ski and get ready for OB/GYN to destroy my sleep cycle/personal life.

Merry Christmas to you all! Until 2009...
~Bostonian

A little too close to home...

I had the lovely opportunity to spend 3 days in the NICU of my hospital. Being an ex-30 weeker with APGAR's below 5, I was a little hesitant to begin this rotation to say the least. It brought up a lot of personal feelings that I didn't know were there...like a deep appreciation for the docs and nurses that worked on me...I would have never known that I was such a giant pain in the ass for so long. There's also a sense that all of that is worth it.

It's also immensely sad to see young familes go through that kind of ordeal...I could never imagine the anguish that my parents went through over 25 years ago watching my pediatrician code me in the delivery room...I guess I turned out all right. I feel a deep attachment to the field and a fondness for everyone in the unit. It's truely a wonderful profession that they practice.

At the same time, I had this weird identity crisis thing going on every time that I would reach into an incubator to examine a baby with tubes coming out of everywhere. It was like looking back 25 years ago onto what my life was, and could have been. Rounds for the past three days have been a little too personal of an experience for me to even consider as a career option. I wouldn't be able to deal with it the first time I lost a kid...which happens. Having to code a kid in the delivery room would probably be just too much for me to handle.

But at the same time it has alot of the benefits of EM (proceedures, good lifestyle, portable practice) that I like. I just don't think I could hang through 3 years of gen peds only to have to deal while being emotionally invested in those kids for the rest of my life. It just hits a little too close to home for me.

The rest of the week the Peds ED

So I've nearly had just about every bodily substance pass by my general direction while torturing the kiddies for the past 6 days. I've seen everything from perfectly behaved children who don't even bat an eye while you poke them with needles to 4 year olds that require 5 full-sized adults to hold them down to look in the ears. I've seen parents who would do anything to make sure that their very sick children get healthy to some of the dumbest, drug addicted DNA donors that I've ever met.

What I've learned:
-A thorough H&P will pretty much give you the right diagnosis 9 times out of 10...be thorough and cautious.
-Parent's ideas of what constitutes an emergency and what is an actual medical emergency are two very different things
-Schools and daycares are germ factories. Wash your hands or you'll catch a stupid URI that will suck the life out of you.
-Kids puke for almost anything at all: Strep- puke, PNA-puke, Cold- puke, Flu- puke, AGE-puking alot, intusceception- puke, bad mood-puke, poor self image- puke,
-Not every
-Eyes are disgusting...conjunctivitis is gross, eye herpes is perhaps the scariest thing in the world.

Finally, I love the ED...undifferentiated patients, procedures, trauma, medicine, primary care, decent pace to keep me from slacking, a good lifestyle, near-instant access to resources, being the floodgates...it's awesome. Yeah, it's a shitty field in many other respects but I'll deflate that baloon full of niave optimism when the time comes.

NICU next week, with exams...should be a fun week.

Peds ED Night 1

First night in the Peds ED with my favorite attending and tolerable peds residents...it was great!

Favorite Chief Complaint of the night: "Pain in behind" with photographic evidence that I can't make this crap up. Second favorite was "congestion"...mom wanted her kid suctioned for a runny nose...discharged with reassurance.

Snow!

Being a native New Englander, the first snow is something that I've looked forward to every year since I can remember...it always makes me feel like a kid again.

I went out for my weekly long run yesterday on a quiet out-and-back route that takes me by a local pond. There was a decent chop on the pond and it wasn't even frozen over yet. I watched a few ducks diving below the surface and then popping back up into their ripples a few second later. It was a bit windy but overall a quiet December day with the occasional snowflake that would meander out of the sky and land in my eye...always in my freaking eye. I can just see myself now, running next to traffic with my face all contorted into some sort of demented wink to try and melt the snowflake on my cornea. I no longer wonder why passing motorists give me weird looks...though maybe it's the tights.

Anyway, I cruised through the first half of the run without much of a problem through the turn around point. I passed one other runner in too much pink and she let out a quick "hello" between breaths...I smiled and waved. Most runners are a friendly folks and will acknowledge you unless they're in the midst of a full-on tempo run or sprint. I stopped at the end of the path to check my watch and catch my breath for a moment before turning around. Being the friendly runner that I am, I said "good morning" to the lady crossing the street with her yellow lab. She gave me a look of disgust/"why-the-fuck-did-you-just-acknowledge-me" that is quite prevalent in the greater NY area and continued right by me as I tried to get the tightness out of my left calf and get enough oxygen into my brain to calculate my splits (8:29/mi).

All of a sudden I was hit by a C-O-L-D gust of wind and I looked up to see a wall of white absolutely flying down the hill in front of me. I thought to myself, I've never seen a snow squall come out of nowhere like this one.

The white wall enveloped me and I decided that I should get on my way. I felt like the care-free seven-year-old version of me again as I cruised along the path next to the pond, squinting my eyes to keep the snow out and leaving my footprints in the accumulating dust on the path. For those of you that have never experienced a snowfall, the sound of it is amazing. There's a background of white noise from innumerable snowflakes hitting anything in their path, and a muffled quality to the rest of the sounds that you'd normally expect. It's absolutely other-worldly.

I passed the lady with her lab in silence, as is my NY-bound cultural duty, and continued home in the snow with only the syncopated rhythm of my breathing and footfalls to keep me company.

When the hell did I get 16,000 viewings??

The combination of longer hours in the hospital, getting back into running, some peer-advisory stuff, the return of new TV (TopChef and How I Met Your Mother) and Netflix (TM) have conspired to knock the will to blog out of me lately. I've got a few ideas on the brain that might be interesting to share...but I also have my peds shelf coming up in a few weeks.

Apparently people have started to read by blog for some reason or another. I'm not quite sure why...but thank you for looking at the blog 16,000 times. I was playing around with the new gadgets so please note the addition of the followers gadget and my new countdown to the end of medical school...feel free to stick yourself on there and I'll reciprocate!

I've also started using an add-on for Firefox called Scribefire to write my posts and it's been great so far...just thought I'd share a free utility.

Normal Saline Analgesia

I've been working on the floors of a peds hospital for the past month and I finished up my last call the Saturday before Thanksgiving. I had to cover a new admit with the working diagnosis of "Chest Pain" just admitted last night. Seemed like a strange symptom in a tween, but I'm pretty much open to anything after a few months at the major referral center.

Generally, I like to approach these new patients with an open mind and go through my working differential a kind of slowly since I'm still not the brightest crayon in the box. Her symptoms were refractory to a week of antacids/PPI's and had NO identifiable triggers or patterns. Kid had a normal cardiac workup, normal pulmonary work up, clear films of the chest and abdomen, nothing out of the ordinary on labs. So I go out onto the floors to start the day and I hear what sounds like crying coming from her room...great.


Mom comes running out to ask for pain meds. So I eyeball her...and she looks like she's a little uncomfortable, but not in too much distress. She's able to answer my questions clearly through her distress and "8/10" pain. I get the story from mom and it seems like the kid has these paroxisms of stabbing, non-specifically localizable chest pain for about a week. Kid's not in any distress, so I walk away to see the other 10 patients I was covering. Motrin doesn't touch it. Tylenol #3 puts the kid in a comfortable place...problem solved.

So I sit down to write some notes about and about an hour later I hear screaming coming from the room again and mom comes out looking distressed. I stroll on over to check on the kid...10/10 pain, inconsolable, stabbing pain everywhere in her chest. But she still answers my questions and is distractable. Resident writes for some morphine and the nurse goes in a few seconds later to flush the IV and get some fluids running before she pulls the drugs out of the Pyxis.

On the way back over to the room, the nurse notices that it's unusually quiet on that side of the unit...so she palms the morphine while asking the kid how she's feeling. She feels great now, 2/10 pain. Much better!!! I'll file the normal saline analgesia trick away for the finicky attention seekers later in my career.

The difference between kids and adults when they fake:
Adults seek the rush they feel from morphine hitting their neurons,
Kids seek the rush of everyone's attention falling on them for a brief moment

Just an interesting case that I wanted to share.

The Floors

::Beep beep beep::
That's my watch alarm going off at 5:45...what an ungodly hour. There's a little bit of grey in the sky, but it's still mostly dark outside as I drag my sorry ass out of the warmth of my bed and into the coolness of the autumn morning. I slink into for the warmth of the shower and try to suck every last second of freedom out of the warm streams of water. As I turn off the faucet I think to myself: today is going to suck. That's pretty much how every morning goes when I'm on the floors.

It's not that working on the floors is that difficult. I take a walk through the brisk morning air, watching my breath form a cloud infront of my face, grab my cup of black coffee from the cafe, round on my kiddos and make sure that the on call intern and night nurses didn't try to kill them while I slept. Sign-out is at 7. Team rounds are at 9, Heme-onc rounds are at 10, noon conference is at noon. I write my progress notes how the interns like them, and sign out to the intern by 4 after hiding in a conference room for an hour-or-so trying to read up. It's the sheer monotony that wears down on you. The same people, the same patients, the same notes...

How many times did you poop last night?
Ok, I'm going to listen to your heart now.
Deep breath for me.

It gets to be like a yoga routine: calming, precise...boring.
I get into my flow, feel time slowing down around me, feel like I'm one with the living, breathing organism that is the hospital.

I've never liked yoga very much.

My first BIG miss

One of my sicker kids came up to me in the middle of the day yesterday while I was sitting at the nurses station writing a note. He looked pretty relaxed and like he was doing ok, so I talked to him for a bit while I was writing. Then out of the blue he said "My tounge feels funny. Kind of tingly. It just started a little while ago."

OK I thought, probably not a big deal. So I ask him all of the questions that I can think of relating to electrolyte abnormalities, and it doesn't really sound like a big deal to me. So I tell him so and put it in the back of my mind. Well about an hour later, he's told my resident, the nurses and anyone that would listen that he's feeling tingly all over his body and his hands are getting crampy, and it feels like when his K gets lower. Ok not really a big deal, but this is not good!!! Resident orders a BMP and CXR, and we go to sign out for the night.

In the middle of signout the lab calls back with a STAT BMP showing a K+ in the 7's. STAT EKG is showing PVC's. Insulin + Glucose, CaGluconate and Kaoxalte go in and he's transferred to the PICU...OH SHIT THIS IS NOT GOOD. Long story short, he ended up being completely fine once his K+ was brought down to normal levels and he'll be back on the floors tomorrow.

However, the scary thing is that this kid came up to me and directly presented me with a problem. I brushed it off as something not serious...it didn't sound like Ca+ or high K+ to me...but there he is. I could have nipped the issue in the bud and looked like a superstar, but instead I was a space cadet and blew off someone who was SEVERELY sick. We're not talking "ooops, I missed something"...we're talking OOOPS I could have killed a kid by not saying anything. He could have flipped over into VTach or VFib and collapsed infront of me and I wouldn't have known what happened.

I know that I'm a third year student and that seeing the manefestations of disease are what this year is all about. I know there's a saftey net of 10 physicians, nurses, techs and janitors behind me to pick up what I miss. I know this one turned out to be OK...but what about when it isn't OK?

Great article!

Sorry I haven't posted in a while....just haven't been inspired to write and haven't really had anything interesting.

Just to update, the remainder of neuro went well and I had one excellent preceptor and one medicore preceptor. The excellent doc was one of the best educators that I have ever met. He cared about us learning more than the neuro exam...he wanted to be a role model for us and to educate our entire person...what a breath of fresh air. The other guy just didn't want to do work and blew us off...which was good for studying but bad for learning practically. The shelf sucked, but that's what I expected. Now it's onto peds.

Anyway, I was sent this article by a classmate and wanted to post a link to it: Medical Student Burnout

I'm pretty sure this will be me in about 10 years sitting around with my classmate recalling how miserable I was. The years of my life spent isolated from the real world, real people is starting to wear on me. The single persuit of nothing but medical knowledge is eroding who I am...but I'm too in debt now to back out. Today for instance, I finished my work by 4:30 PM and had to sit around waiting to sign out until nearly 7 PM. In that time I wrote 1 note, discharged 1 patient, attended 4 hours of lecture, and 2 sets of teaching rounds.

Was it a fulfilling day? NO!!!
Did anyone get better because of what I did today??? NO!!!
Did anyone get worse because of what I did today??? I certainly hope not, but I'll find out in the morning I guess.

I've said it a few times in the past, but I had no idea what I was getting myself into. I niavely just convinced myself that I would have no problem being a great doctor because I'm a pretty smart guy who listens and cares a whole bunch. HA...if I had only known. Anyway take a gander at the article, it's interesting to see this doc's look back at medical school. I found it to reflect my feelings many times.

Follow the leader

I'm getting kind of sick of this neurology rotation, but it is providing some valuable insight into the nature of what I want to do with my life. Here's today's episode of frustration:

Yestederday, 4:30 PM: Attending says "I'll see you in the morning. I have a meeting that will be over at 10, give me a call after that"

Today,
8:30 AM- Morning report...2 of our patients are presented by the medical residents, I learn a little bit
9:15 AM- Report ends, go to coffee shop to blow off 45 minutes waiting for attending
10:00- Call attending, who doesn't answer, leave voicemail
10:30: Call attending, who still doesn't answer, leave voicemail with pager number because I know he doesn't remember it
Noon: Attending pages and asks us to meet him in Radiology in 5
12:04: medical students and NP arrive at radiology ready to start the day
12:10: No sign of attending
12:15: Attending shows up, talks to radiologist about golf for 5 minutes, radiologist says the patient's scans are fine
12:20: Go to noontime conference
1:15: call attending to meet, he's still eating lunch...call back at 2
2:00: call attending to meet, says to meet at this patient in 5, head up and print out everything needed for a consult and play 'find the chart'
2:30: Attending strolls onto the floor, sees the patient and dictates his note
3:00: Another consult, med students play 'find the chart' for 10 minutes and then attending does the neuro exam
3:30: Another consult, another game of 'find the chart' but we can't find the patient either...he gives a brief lecture on MG and then we BS about the stock market, iPhones, his kids.
4:00: Patient arrives, he does the consult while we watch
4:30: Called for a frequent flier in the ED...he whines about having to go there, we talk him into going to see her, he says that he'd like to keep it less than 20 minutes if possible
4:52: Finishes dictating his note on a silly CYA consult...
4:53: As we walk out of the ED, "Well that wasn't so bad, I'm glad we decided to go see her. Have a nice evening"

Total time in the hospital: 8.5 hours
Total time doing anything productive: 30 minutes playing 'find the chart', 10 minute lecture on MG, 2 minutes removing socks and performing babinski's= 42 minutes of actual educational time towards the specialty of Neurology.
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So I think I've made the 'doing' vs 'thinking' decision in my career decision tree. Thinking sucks...I really don't think I could take 30 years of sitting around and hypothesizing what the hell is wrong with patients...I need to have something going on, I need some sort of end-goal directed activity to get through...not just a bunch of people chilling in beds waiting to get better. I need a stack of charts, or an OR schedule, or a patient schedule...this in-hospital endless rounding thing just isn't my cup of tea.

WTF...

There are just certain times when a neuro exam just isn't going to go smoothly and won't be of much value...I was lucky enough to have TWO of those situations today pawned off on me by my attending. Consequently, as of this morning I had done 1 independant neuro exam...so as you can imagine, it went smoothly.

1) A lovely, demented, non-english speaking Pakistani woman presents to the clinic with her son who claims initially that she can not speak, form new memories or remember much from the distant past. Ok...I'm a fairly bright and patient guy, but patience and creativity have their limits. Son acting as translator, I manage to get about 40% of the neuro exam done and have a slight clue that she does have some functional capability. I go back and give my very disorganized, half completed report to the attending who then feels the need reward my performance by mercilessly pimping me on all of the causes of dementia. Anyway, he gets frustrated while repeating the exam and gets frustrated after extracting about half as much as I did out of the lady and gives up...I felt a little bit satisfied, but only a little.

2) There are two consults on the psych ward that the attending wants to avoid: I'm assigned the chronic schitzophrenic found wandering the streets and my classmate gets the lovely, cognitively intact gentleman that's getting discharged in about 10 minutes with a clean bill of health. I'm sort of getting the feeling that I'm not the favorite student on this rotation. My patient's HPI is completely disjointed, his MSE is literally the most painful exercise in futilty that I have every striven to complete...fortunately the rest of the exam was less than painful.

Again...I don't see myself doing this EVER.

Neurology

I'm about 2 weeks into Neuro at this point and I have to honestly say that I could NEVER consider this as a career path. I will admit that my opinion is colored by the service that I'm on (consult based in a private community hospital) and that the two of us on the service have been left waiting for HOURS for the damned attending to show up and pay some attention to us and maybe let us do a consult or two.

I think the most frustrating thing is the thought processes of a neurology attending since the advent of the MRI. In one hand you have the bread and butter Neurological exam: Someone's brain is potentially (whether in reality or not) different from baseline, so you call the neurologist to find out what is functionally wrong with this person's neuraxis, localize the lesion to a level/side/location if possible and then try to figure out what can cause that and devise your treatment plan. On the other hand...you could get an MRI and be done with the logical part.

The scary thing is that the neuro exam can be very wrong...and I've seen it in my short time on the service. We had a lady that came into the ED with what seemed to be unequivocally radiculopathic pain on exam. It looked like classic root compression with some pain and loss of sensory modalities...thanks for the $500 ED copay, do some PT for 6 wks and follow up. Well, within 24 hours she was a paraplegic without control of her bowel or bladder without sensation below the waist, enhancing lesions in the spine consistent with transverse myelitis. What causes it? We don't know 50% of the time. What's the prognosis? We don't know most of the time, but we're hopeful. What are the chances that I won't be bed ridden and incontinent? 60% that you'll improve, we're hopeful. It's tough to sit infront of a family and tell them that you're completely out of control of what is happening to them and you don't exactly know what will happen. I guess this is the most humble and useless that I've felt in a long time.

I don't think that I could walk into the hospital every day for the next 30 years to localize the leison, check to make sure I was right on the MRI and then have a role of the dice as to whether I can affect any change in the patient. Not to take anything away from them, neurologists are some of the most brilliant and logical physicians in the hospital dealing with a very complex system. I just couldn't see myself in their shoes.

The business of family medicine

Every day that I walk into the family medicine office that I'm currently assigned to, I'm smashed over the head by the realities of why I could never go into primary care: the business side of medicine.

On the surface, family medicine conjures up warm-fuzzy images of the iconic practice model of a strong doctor-patient relationship that creates a forum for the patient to address all of their concerns and for the doctor to manage the patient's medical problems and prevent future illnesses from coming up. In reality, the whole enterprise is a bit like speed dating: get the patient/date to talk about themselves for a few minutes, drop some one-liners and patient's/date's , give them your number, tell them to call you soon and move on to the next one. Maybe they call, maybe they don't...who cares because I'm gonna see 30 others today.

To continue my god-aweful dating metaphor, the entire venture of family medicine is a bit like the 20-something bachelor's dating scene. You make your game (practice) as attractive as possible by adding on as many bright-shiny things as possible: the bachelor pad (a pimp office with lots of room), the interesting friends (in house cardiologists and endocrinologists), the stylin' wardrobe (custom embroidered white coat) and the reputation ("You should go see Dr. Bostonian, I hear that his 'practice' is enormous. All of his 'patients' that I've talked to have been extremely 'satisfied', but I hear that he his 'visits' are usually less than 5 minutes.") In the background you've got several other things going on...the cougar (the nursing home gig), the druggie (methadone clinic), the groupies (drug reps/speaking engagements) all vying for your time and energy.

Ok, I'm done with the crappy metaphor.

In reality, I've been studying medicine for the past 2 years and I don't have a lick of business sense. There is little-to-no appeal in spending a decade building a practice after all of the hassle of medical training and residency. A lot of people heading into primary care assume that they'll be able to find some doctor that is on the verge of retiring and will just take over their practice...I'm not willing to gamble my well-being on a capital-venture project or some dude deciding to hang it up. I really don't see myself becoming a savvy business person who battles day in and day out to keep his practice in the black by working 3 other jobs so that I can use that money to cover the practice overhead while I wait for insurance reimbursements. It's simply not what I came to medical school to do. I came to learn to practice medicine, not to run a business.

A life more ordinary...

I received the following comment from one of the 2 people who read my drivel:

"Ahem...remember that time you had a blog??
It's like you have a life or something...
:p"

It's not that I have a life all of a sudden, it's that I can't find anything interesting to write about and I've had a pretty awesome pneumonia going on for the past week...just to put that one to rest.
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So surgery ended last Friday with perhaps the most difficult exam I have ever taken. It was my first clinical shelf exam and being such it was full of long-winded questions with some fairly obvious presentations and lots of medicine questions that were complicated by the fact that I haven't had medicine yet...it was rough to say the least but I passed with all of the mediocrity that has been the hallmark of my medical education
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Anyway, I've been on Family Medicine for the past week and it is pretty sweet to be able to sit down with a patient from start to finish, leave at the end of the day with the sun still shining and focus on my non-hospital life again by doing normal person things like buying groceries, sleeping, meeting people for dinner/drinks, and general human life. I was even able to run a few times...that is until I ended up with a cough and a fever that became productive and included bilateral crackles in the lower lobes (God I feel awful). I -gasp- saw the NP at school and she fixed me up with a really nice macrolide and some mucinex without a co-pay or anything and was very nice about adding a few interesting teaching points while I tried to keep my lungs in my chest.

On the navel gazing front, I've decided that surgery is probably not the right choice for a career for me. Having a life outside of the hospital is an incredible thing...I can read, I can eat properly and I can be a nearly complete human being again! So the status quo of EM will be maintained for now.

That's really it...I wish I had something interesting to say. I'll probably not have anything posted for another week or so becaue girlfriend is coming to visit this weekend if I make it until then...I've got a few interesting posts brewing in the back of my mind.

An education in contrast

I've spent the last week in a small private hospital with a plastic surgery group attached to it. Being over there is like a night and day comparison with hell-hole of a University Medical Center where I spent the previous 6 weeks. Sure the Academic Mecca is great if you want to be the 15th person scrubbed in on a surgery on a patient who is one of 19 people IN THE WORLD to have their specific kind of cancer (true story!), but you could go 2 months without seeing an uncomplicated lap choley in an otherwise healthy individual.

Case in point (which I referred to in my last post): Woman in her 60's with an acute abdomen that hits you over the head with the stigmata of acute appendicitis...CT evidence to back it up. Can't do it laparscopically because she's had 5 previous abdominal surgeries and now has a ventral hernia the size of my head. Try to do it with a LLQ incision...oh wait, there's no way to get the appendix exposed because of the adhesions. Midline incision leads to 2 hours of cutting adhesions, the finding that the cecum and terminal ileum are gangrenous. So a bowel resection, reanastamosis, and ventral hernia repair later, what should have been a 30 minute case turned into 5 hours.

On the other hand, private practice is where I saw my first childish temper tantrum be thrown at the private hospital...hundreds of dollars of instruments were thrown across the room onto the floor to make a point, curses were aimed at the cowering scrub nurses and circulators, stories were told for days afterwards...all because 2 minutes of waiting eats into the bottom line. The cases are more simple, and it's straight forward treatment delivered to the average patient. I feel like that is what has been missing after 6 weeks at the academic Mecca, however now I'm missing the intellectual stimulation and the feeling of being part of something larger.
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Oh, Plastic Surgery, you are so glorious.

No one is sick, no one is dying, no one is grumpy. I get to watch boobs change size, tummies get tucked, big sticky-out ears get pulled back saving years of therapy down the line, and bumpy, crooked noses made straight and feminine. Everyone is there under their own will, everyone is pleasant to work with, no one has scutted me out in a week...I haven't even had to write a note! Oh and I get to leave when cases are over...usually around 3 PM...and cases start at 7:30. Sleep is so awesome.

But it feels like something is missing. I have no sense of urgency in my days, no need to get everything done 10 minutes ago because Dr. So-and-so wants to round. I'm not part of a team delivering health care, there are no decisions to be made. Everything runs on autopilot. There is no physiological medical purpose to the majority of these surgeries (except breast reductions) that I have seen, absolutely no pathology to eliminate besides the overly self-critical psyche. Plastics seems, in essence, an exercise in feel-good, preventative psychiatry.
____________________________________

Oh well, one more week until the shelf to go. I started making my first forays back into the library since the boards and I don't miss it very much. I'll take the narsty wound infection smell of the surgical floor at 5AM over that damned carrel any day. I'll be pounding through NMS casefiles, Surgical Recall, Pre-Test Surgery and whatever else I can find. I'm not too sure how the shelf questions are going to be asked, but I'm sure that it won't be too bad. Hope it goes well, until then
~Bostonian

Surgery Experience Redux

As you're all aware, dearest readers, I've pretty much stopped writing over the past 6 weeks because of my awesome surgery schedule, lack of time to do anything but be in the hospital, sleep and read for the next day's cases/rounds. I apologize for the absence, but I am not on a Breast/Plastics 2 weeks that promises to be quite relaxed. Anyway, here comes the post:

On a number of occasions since the beginning of third year, I have attempted to piece together something coherent enough to post in my very limited free time. When I go back and look at those drafts, they reflect what had happened in the previous 12-24 hours, don't really have any direction behind them, and generally are just bad. Now that I'm post 24 hour call for my last time until January and looking back on the bulk of my rotation, I can properly analyze it...I hope.

What I liked:
To be completely honest, I enjoyed Surgery quite a bit despite the downtrodden tone that I adopted when writing about it. I know it's going to sound cliche, but I like the idea of being able to directly intervene in, and usually alter, the course of a patient's illness by surgical management. It was satisfying to see the patients come in sick, get surgery and leave the hospital in a better state! While that's not universally true, it did happen in the majority of cases. I like the fact that there is a continuum of patient care from admission, through discharge for the disease without the 5 hours of teaching rounds per day...just get shit done instead of mentally masturbating over potassium changes of 0.1 while the patient circles the drain. As a surgeon, you're a complete physician who can manage most medical problems on your own without having to have someone talk you down from the roof of the hospital when something isn't going quite right in one of your patients. I like being independent!

I thought understood the need for continuity of care on an intellectual level before this rotation, but to see the management of patients with a night float system is somewhat horrifying. You could get legitimately sick overnight/weekend and no one would fully understand your entire clinical picture and some 26 year old kid with an MD comes to the rescue and has no idea what to do because they have a 10 word blurb on what's going on with you on a sheet of paper with 40-90+ other patients. Medications fall off the list because they're not renewed, innocent nurses call about seemingly emergent issues that are trivial, seemingly trivial events go unnoticed despite their far-reaching implications. So while the hours are inhumane, they are necessary to actually ensure proper care for sick patients overnight so that they not just stuffed in the corner to heal on their own accord/die!

Of all of the specialties that I had the opportunity to see, I think Trauma/Critical Care appealed to me the most.

For Trauma: patients come in the door with whatever is going on and very limited information, you figure it out with a very logical algorithm and intervene by addressing threats to life and everything after that. If they need surgery they're in the OR ASAP, if they don't you manage them conservatively. The patients generally tend to be younger healthy people with fewer comorbidities than the general patient census, from all walks of life and they generally appreciate the fact that you have helped them.

For the Critical Care end of things: the approach is very evidence/data based, which appeals to the repressed scientist in me...everything is based on trends in the patient's physiologic functions (which are continuously monitored) and directly acted upon in a monitored fashion. Instant results that usually make the patient better!!! Everything is continuously monitored, the staff is extremely competent in dealing with VERY sick patients, there are lots of other docs around to talk your plans over with before you implement them...it's the safest place in the world next to the OR. What could be more satisfying???


What I disliked:
The hours/isolation: I can now honestly say that I have worked 114 hours in one week, albeit in the capacity of a medical student with only 4-5 patients to follow in an ultra-supervised manner. The sleep deprivation isn't that bad once you get used to it. My problem comes in that I have had no semblance of a life outside the hospital for the past 7 days save one quick dinner outing with a friend who happened to be around.

If I had someone to come home to and to assist in keeping my home life somewhat on track and to talk about non-surgical issues with every night before I became unconscious, I feel like I could make a 110 hour week work for me. But to go through this endeavour alone would be the most isolating experience ever. The other issue that I'm coming across is that I couldn't imagine putting children through life with their father not being around on a consistent basis to do normal family things. Running can be squeezed in around shifts, hiking/skiing/outdoorsy stuff can be crammed into vacation months...raising kids takes a lot of work and time that I wouldn't have as a surgeon...something to think about.


The people:
Surgeons are a unique breed: cantankerous and crotchety on a good day, downright malignant and vindictive on a bad. There is not a whole lot of respect for anything not going according to plan, and when there is a SNAFU everyone knows about it from the temper tantrum. That's not me! I'm too laid back to be like that...I don't know if I could deal with people like that 24/7 for the rest of my life.

Altering my life plan:
I guess that I never really saw myself as surgeon in the past. I have always loved my life outside of medicine so much more than my life within it. The thought of working 80+ hours a week for the rest of my life makes me sad for the plans I once had in my life. I like going to the beach on weekends, meeting up with friends for drinks/dinner randomly and spending my free time doing absoutely nothing at all of purpose. I met up with one of my good friends a few weeks ago to hit up the rock climbing gym and I had forgotten how good it felt to do something with absolutely no real purpose other than fun. I'm not sure that I can/am willing to live my life that way for the 7 years following medical school and to wake up and suddenly be 35 before making my first paycheck and holding a real job.

The REALLY sick patients:
My training hospital is reknowned for how sick the patients are. Our beds have been shown to hold some of the sickest patients in the nation. What looks like a simple 20 minute open appendectomy on CT can turn into an overnight 5 hour suffer-fest (lysis of adhesions for 2 hours, exploratory laparotomy, resection of terminal ileum and cecum with reanastamosis, ventral hernia repair). There are some people that you can't do anything for...they're just going to die because their disease process is so advanced. It still makes me sad because I haven't had to deal with it directly, so I haven't become desensitized to it completely.

The really sick doctors:
I've felt like absolute crap for the past 5 days and nearly passed out in the OR a couple times, but I don't have a choice...I just have to keep on trucking through it. My residents have been sick to the point of needing to fluid resuscitate themselves, but they've stayed in the hospital through it and kept on working/operating. There are no sick days...
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I guess what I'm getting at is that it's time for the Bostonian in NY to reassess his life and what he values within it...it should be a fun, whiskey/scotch sodden adventure full deep thought, navel gazing and long talks with the GF, friends and parents.

My next week will be AWESOME

Fortunately, there is no hour limit for medical students...otherwise my school might be in trouble:
-On for the next 7 days in a row
-42 hours of call (18 on Sunday, 24 next Saturday)
-70 hours of regular work week
-1 midway evaluation meeting with the clerkship director who will be getting an ear full about how disorganized his program, his residents and his secretary are, my 112 hour work week.
-1 sleepy Bostonian who is working nearly 3 normal person work weeks in the span of one and will be living off of nothing but caffeine, crappy cafeteria food and sarcasm come Friday evening.

By far, this may be the longest week of my life.

But, if I make it out alive I'm rewarded with 2 weeks at the Private-yuppie Hospital in the breast/plastics practice. Should be a nice change from the hellish County Hospital that has eroded my sanity/personal life/sleep hygiene for the past 5 weeks.

Catch ya'll on the flip side next week if I'm not in 4 point restraints by the end of the week.

Surgery Experience part deux

So far I've been in the hospital for 75 hours this week, and I still need to toss in another 18 this Sunday for a total of 93.

I have dreams about doing scut. I wake up ready to go do the scut, but then I realize that I'm in my room and go back to bed.

I have no life outside of the hospital except for consulting Dr. Google on my patients and ten minutes of talking to either mom and/or girlfriend before bed.

I still have about 5 people pulling me 5 different ways and I've reached the point where writing notes is no longer educational, just routine.

What have I learned thus far?
There is a hierarchy of surgery that revolves around the black hole of time known as the surgical floor.
Attendings: spend about an occasional hour rounding on their patients with a train of people paying attention to everything they say.
Chief Residents: Tell the senior residents to work their asses off and send everyone home or to another service, then go to surgery.
Senior Residents: Try to act like chiefs and spend as little time on the floor as possible
Middle Residents: Still occasionally help out and write notes.
Interns: Spend life on the floor taking care of everyone on the service 18-20 hours a day. Take care of everyone else when on call in addition.
Medical students: Stay out of the way, help where you can on your assigned patients, go to the OR when you finish, don't piss anyone off, make the chief look good during attending rounds and in the OR.
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Ok so maybe it seems like I'm completely ruling out surgery from my life because it sucks. While it does suck, I have a deep respect for anyone that would sacrifice their life to that enterprise. But there is something about surgery that is appealing to me. You get to do something other than waiting for your patient to get better...you can intervene, change their course with a direct correction of the pathology. Anyway, Trauma/Critical Care/Burn has gone on my short list because of what I have seen in the residents/attendings. It's pretty far down the list because of life style/length of training. We'll see though
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Anyway just wanted to toss up a post in my spare time because I haven't vented in a while. Peace out

25 years ago...

25 years ago, there was a child born in Massachusetts that would become the Bostonian in NY. 2lb, 8 oz of premature, grade A baby.

He promptly urinated on his new pediatrician within 5 seconds of birth...classy.

This year he's celebrating with a quarter life crisis-of-self: wondering why he's spending over 80 hours a week in the hospital doing NOTHING, why he has conceeded his entire third decade of life to medicine, and why he has lost all semblance of fun in his life for the past month.

Not quite dead yet

Surgery is going OK entering the 4th week. I've come to realize that I've had my head up my ass for the past 3 weeks and was putting my energy into the wrong areas. Now I get to spend the next 5 weeks trying to make up for that...hooray. I've got a few half finished posts that I'll finish and put up some time in september...but for now the beatings will continue until morale improves.

For the unofficial Blogger record, I was in the hospital for about 90 hours last week as a medical student...you can imagine what the resident's lives are like!

Oh and I'm probably colonized by VRE, MRSA, TB and C. diff at this point. If I don't post in the next week or so, no worries...i'm in the ICU with IV abx.

The hidden curriculum of medical education

On the surface, medical education appears to be a fairly simple venture: with deductive reasoning, apply a heap of basic/clinical science in the venture of diagnosing and treating disease. Sounds easy enough once you have 6 years of post-secondary education under your belt, and have been selected from the heap of bright people throwing their applications at American medical schools, right???

Like so many things in life, numerous other things get in the way of that plan. Like chief residents who are too busy to acknowledge your existence because they are busy holding the hospital together. Like interns who disappear half way through the day because they're post call and have to attend to the human weakness of sleep. Like clerkship coordinators who are too disorganized to schedule a doctor to run a mandatory lecture and leave you sitting around for 45 minutes while they "work on it". Like having to break scrub in the middle of closing a patient for a BS preceptor meeting that you skipped the day before and having the resident you were assisting give you crap because of it for the second day in a row. Like having to make 3 different people aware of the intimate comings and goings of your every second of every day with the reprisal of a dirty look and sarcastic comment during a 10 minute lunch break before having to wait for the mandatory conference.

There is a hidden curriculum within third year medical education, where you are the lowest
person on the totem pole. Where you are wrong, almost no matter what you do. Where happenings that are beyond your control are assumed to be your fault. Where you must ask to ask a question, and then ask your question. Where you have no true goals defined for you, no defined schedule, no defined role, but have a series of unwritten expectations that are being continuously evaluated silently by your superiors...to be placed in your record and follow you around for the remainder of your life.

If you couldn't guess from my sunny disposition, I had a rough day where I stood around for too long, probably made some bad impressions with my actions and have fucked my evals up. Nothing bad happened, no one said anything to me, but I just feel like I'm making an ass out of myself while I stand around in the hospital and do nothing for hours on end. But when I'm busy and have a required activity, I get crap for having to go to it. Firmly planting my foot into my mouth at least twice this week with one of the chief residents didn't help...so when he informs everyone in the program that I'm an ass, that's probably not going to be good for my grades either. Working around miserable, tired people without a lick of positive feedback has sapped my energy and made me more critical of myself...but guess who gets to spend another 13 hours in the hospital again tomorrow with a smile on his face and a positive attitude? Yours truely.

Board scores came out today...I was at the national average, which is what I expected. It would be nice to make myself stand out this year, but it's probably not going to happen.

PM&R in Alabama is looking like a true possibility... here I come!

Surgery Experience- Week 1

I'm post call right now and have an ENTIRE weekend to sleep, read about my patient (singular) and every other patient on my team's census and possibly even meet up with my family for a few hours!!! I had the first 24 hour call of my hospital's surgical clerkship for the year. I got to see some pretty complicated surgical cases down in the ED and to watch one BS trauma work up, but then I got to watch the residents on call yell at peds nurses, and then sat around reading Surgical Recall from about 2-4:45. I slept for about half an hour and got permission to leave half an hour early since NOTHING was happening in the entirety of the hospital.

As I alluded to a few days ago, I'm discovering that the hospital is a horrible place to learn how to be a doctor. I say this for a number of reasons:

1. I was given a set of expectations from my clerkship director that apparently only I know about.
   
2. My clerkship director's expectations differ from my preceptor's expectations, which differ from my chief resident's expectations, which differ from my intern's expectations, which differ from the expectations on other teams as well as from that of the teaching resident on call. I have approximately 20 bosses and no defined job description!!
   
3. The words "educational opportunity" is loosely defined as "get the fuck out of my way and go watch X with Dr.Y in the Z" where X, Y, and Z are unknown variables. By the way, if you have not defined X, Y and Z on your own, you are worthless. Thank you janitor for pointing me to OR10...you saved my self esteem for the next 10 minutes until I was pimped again...by the anesthesiologist.
   
4. Trying to get caught up on your work as a surgical intern is a lot like being a dog trying to chase it's own amputated tail. You go around and around and around and around but you'll fall over from exhaustion before you catch it.
   
5. I don't want to be an intern...but it's about $180,000 too late for that one. I've been asked exactly 5 times if I'm sure that I still want to be a doctor...how's that for job satisfaction
   
6. Being pimped in the OR or on rounds is rather benign because it serves a purpose. Unless you're the intern presenting morning sign out at your 24th hour in the hospital with 6 more hours of catch-up work before you can go home and your chief resident is angry at life.
7. My feet hurt.
8. It is possible to wash your hands for 5 minutes straight.
   
9. Don't fuck with the pancreas.
   
10. Eat, sleep, pee and blog when you can.

I don't want to like surgery, but surprisingly I'm having a good deal of fun on surgery...but the novelty is starting to be tarnished more than a little bit. I've scrubbed on 3 cases and gotten to do some fun stuff on my service, but I've never felt more useless in my life. All I can really do is try to be enthusiastic and work hard enough to live up to the expectations of everyone above me, which again are rather nebulous. I've only been scolded like a child once in the past four days, so I'm doing better than I thought I would.

My plan is to get up to speed this weekend on what I should know for my service and then to actually define my place next week, if I'm not reshuffled onto a different team again by one of the chiefs. For now...my bed is calling

Figured out where I stand...

Tuition to east coast medical school: $45,000/year
Inflated NY cost of living: $20,000/year
Books, supplies, etc: $ 1,000/year
Years of higher education: 4 undergraduate, 2 medical

Realizing that you're at the absolute bottom of the totem because meticulous details laid out in your your orientation were wrong thrice, you were ignored by every nurse in the hospital while trying to remedy the SNAFUs and it took one attending about 10 calls to various residents to find someone to teach us to scrub in after a nurse reamed him a new one:
Priceless

Some things in life money can buy, for everything else there's surgery.

And so it begins

In about T-8 hours, I'll officially begin third year. Not going to lie...I'm a little nervous because it's surgery and I'm still a bit hazy on exactly what I'm supposed to do on a daily basis. It seems to be a learn as you go sort of thing, so that looks like the plan for now.

Anyway, I celebrated my nation's independence from the land-grubbing Brits with copious amounts of alcohol, unhealthy food and precious little sleep. I'm quite relaxed, but about 3/4's of the way to my first MI...I think my cholesterol is pushing 400 right now.

I'll let you know tomorrow how orientation goes

No one really gets it

I found myself sitting across the table from my engineer father and brothers, trying to explain what I'll actually be doing over the next couple of years in school:

Dad: So what are you doing next year?
Bostonian: I'm in the hospital learning how to diagnose patients and manage their medical problems.
D: But what about classes?
B: There are a couple...but only for the really important stuff
D: What about books and tests?
B: Yeah, still have lots of reading to do and a big final at the end...but I'm in the hospital for like 12 hours every day talking to patients, standing around in surgery and chasing down information.
D: So you get your own patients?
B: Nope, the residents and attendings check and redo everything that I do. I can't do anything on my own.
D: Why are you there again?
B: ...!?!?!

I guess the point of this post is that I'm not exactly sure how to explain to the average lay person what my role as a third year medical student is because I haven't conceptualized it myself.

Within the context of the delivery of health care, I am at best a leech on the scrotum of everyone on my medical team; a painless annoyance that just sits there sucking up resources, time and attention. At worst, I'm a stumbling block; everything that I'll be doing, someone will have to double check in excruciating detail and probably correct. Everything that I don't understand will have to be drilled into my head. I'll be the pain in the ass at 2 in the morning that needs to get in his delivery before the end of his OB rotation, the speed bump in the trauma room after an 18 hour day, the poor kid with the deer in the headlights look on his face who accidentally scrubs out when the attending pimps him across the sterile blueness of the operating field. The only schmuck in the hospital willingly paying out of pocket to be there, not out of necessity.

On the other hand, I''ll probably be the first one on the wards in the morning collecting labs and scurrying around to not look like a schmuck on rounds and piece together what happened over night with my patients while I slept soundly feverisly prepared passed out at my desk trying to prepare for teaching rounds. I'll be the one sitting with the patients for hours on end making sure that every detail of their history is documented. I'll be writing up the most complete notes and admits because I have extra time to wrap my head around the case. I'll be the one making the nurses', interns' and residents' lives easier by running the mid-level scut at a financial profit to the hospital.

We're sitting in orientation this week, and everyone tells us how amazing of an experience we're in for during third year and spends 5 minutes of their talk blowing sunshine and rainbows up our asses. But at the same time, I'm about to be one of the few people that even the night-shift janitor knows has no real business being on the wards.

How do you make the average person understand what you do without making their head explode in confusion/horror/pity?

Year 2 in review and Now What?

Well, I guess that I am now officially a third year medical student. How the time flies when your head is buried in Robbins for a year. I really mean that it flew by. It feels like just yesterday that I was hanging out in the ER and looking back on first year and getting geared up for second year.

It was a struggle for me at times. Sitting around reading a book, memorizing minutiae of diseases for the sole purpose of regurgitating it on an exam felt like an exercise in futility most of the time. That passive style of learning about as far outside of the context where the knowledge will be used as you can get. I think it's a pretty big oversight in the curriculum design, I'd say 90% of us just memgurgitated through the year without trying to integrate the knowledge into something that is applicable to the wards. But then again, it was better than the integrated Problem-Based format that several schools have initiated. I could see sitting around a conference table with a bunch of unprepared students getting on my nerves pretty quickly. From the rather limited small group stuff that we did do, I can say that the majority of my classmates are F'd when it comes to rounds and pimping. Sure they can regurgitate the 25 different translocations for each type of leukemia, but can they form a differential for someone who has abdominal pain??? NO! I feel completely unprepared for what is coming...thanks over-priced medical education. Way to set me up to be useless next year!

Don't even get me started on Step 1 and the debacle that is. While it was somewhat nice to review everything that I've learned so far in a fairly coherent manner, do you really need to charge me 400 dollars and pin my hopes and dreams and future income on it???
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So now that Step 1 is on the books, I keep asking myself "now what?"

There is a ton of information and misinformation floating around about third year clerkships. We had a few forth years come talk about the clinical sites and they weren't able to come up with any clearly discernible differences between them. Our dean of student affairs talked about the sites as well, and without mincing words said that they are all the same. I even took some initiative and talked to older students to try to get a taste of what's expected at my clinical sites and to be honest, they've given me very little to go on in terms of what the expectations are/who the better attendings are to work with, etc. Thanks guys. I guess I'll just have to figure it out as I go.

I hopped on SDN's clinical forum....which is always a huge mistake. Between the posts talking about shoes, PDA's, resident horror stories, pissing matches and generalized gunner behavior, I decided it was a warped perspective that was better to ignore. So I bought myself a copy of the 250 Biggest Mistakes that 3rd Year Medical Students Make to try to get my head wrapped around what I'm in for in two weeks. The overarching theme of the book is to be a neurotic pain in the ass to everyone in the hospital from housekeeping up to the department chairs!!! It instructs me to make sure that I chase down every evaluator and have them clearly define how they'll be evaluating me, how they want write ups, notes, oral presentations, their coffee and their ass kissing. My complaint is that for every helpful nugget in the book (how to write up a new admission/progress notes, how to present a patient), I had to wade through the waste deep gunner advice ("Here's every question to ask your resident on the day you start") and stupidly obvious advice for those medical students with an IQ of 36 or below (Read your orientation packet before orientation). It came with a free Maxwell's (a $15 value), so I can't complain too much.

Anyway, here's my major concern:
In the span of about a week, I'm going to be tossed in way over my head (during the second week of July no less) onto what is rumored to be one of the more malignant Surgery services in the country. There's a bit of a nagging feeling that the preparation that I've received thus far may have been inadequate for what's expected. While that seems the norm for most medical students...so at least I'm not alone.

But in all seriousness: I've never presented a patient orally, I've done 2 complete physicals, I've written up half a dozen patients, I've stabbed a couple veins and I've spent maybe a total of 6 weeks working in a hospital setting...this is going to be a rough transition.

Oh well, the dude abides I guess...

STEP 1...done

Well that was fun...NOT.

Between waking up with "The Final Countdown" stuck in my head and the feeling of impending doom, I knew it was going to be a craptastic day from the get go. I woke up at 6:15 and couldn't get back to sleep for 20 minutes. So I said f*ck it, took a shower ate some breakfast and got on the road a bit early so that I didn't have to deal with traffic. I chilled in the parking lot of the test center for about an hour with a cup of coffee my first aid and the rest of the OCD folks there for their various tests. Of course the girls running the test center were a bit late, and it was raining, so we didn't get registered until after 9.

While I was sitting there in my car, the sky opened up and there was a torrential downpour with lightning striking a couple hundred yards away from the test center. It didn't stop all day, and at one point you could even here hail pinging off of the roof through the soundproof headphones. I figured it's probably a sign of things to come. It would be just my luck to die in a Prometric test center taking the USMLE...I wonder if my scores would still count????

I think the highlight of my day was seeing the little 3D metal chatski in the waiting room that said "Relax". I want to smack whoever put that there...asshole, it's not like this is going to have a bearing on the REST OF MY LIFE. Apparently there isn't an 8 hour exam for assholes who decorate waiting rooms at Prometric centers. It was an ironic contrast to the palpable despair that hanging over that room. I kind of wanted to take a picture of it to post...but after the deep cavity search, retinal scan, blood sample, buccal swab and finger printing it slipped my mind. Ok, so the security wasn't that bad, but it would have been nice if I could have put my sweatshirt on during the middle of the section or maybe a bottle of water to sip from.

Regardless, I finished it up in a little under 6 hours and I have no idea how it went except for the fact that I had 2 easy sections, 2 medium sections, 2 harder sections and I don't really remember the first section because I was still waiting for my second cup of coffee to hit my brain. I'm figuring that it will probably be around the national average.

I took it easy last night because I've had the sensation that I swallowed a mix of broken glass, rusty razor blades and lava. I figured drinking my face off would probably put me into a sorry state of affairs (right before surgery starts up...just what I need), so just had a beer with dinner.

I have an entire 6 days of freedom so I'm going to do what I can to enjoy it while the sun is out and my life is under my own control. I'm thinking a beach day, some shopping for my new apartment, reading a book that isn't step 1 related and sleep...lots and lots of sleep.

HE's BAAAAAAAAAACK

I placed a self imposed moratorium on the Bostonian Blog so that I would actually study...it lasted all of maybe 30 hours, but I just decided that it would be more fun to put it into a word document and then post once the shit-storm was over. It did do wonders for my Qbank/NBME scores. Anyway, if you'd like to follow the progression of my dispair read on.

Day 25-
YES!!!!…best QBank day yet! See what I can do when I put my mind to it! I’ve never seen so many bars hitting 100%!! I’ll take the fucker tomorrow and put it in its place! Decent residency, here I come! Might as well start the apartment hunt in Boston right now! On a less stuck up note, the weather finally cooled down, so I got in a decent run. I’m feeling pretty damned good about life all around!

Day 26-
Trouble sleeping last night, tired all day. Surprise…I dropped back into mediocrity on the Qbank front. I went to write a post on how I have the self restraint of Keith Richards at a hookers and heroin party (God he looks awful), but I restrained and decided to chronicle myself offline in less than 100 words per day. I’ve decided that I’ll post my QBank graph to prove that I’m not losing my mind. 10 days left…AHHHHHHHHH.

Day 27-
I swear that my QBank abilities are a combination of how awake I am, what I ate for lunch, and which direction the wind is blowing. I was back above average today again. This bipolar, daily up and down crap is soooooo frustrating, although I extended my up/down trend out to the actual exam day and it happens to fall on an up day…take it for what it’s worth (nothing). On a completely different note, the GF has to run home for the weekend for some family stuff, but at least that will give me some time to freak out without her thinking that I’m mad at her.

And now for something completely different: Tim Russert passed away today. He gave the commencement address at my graduation, my mother published the story of her father in one of his books and had a few occasions to meet him and speak to him personally. He did what so few in the media do in these days of partisan coverage on Fox News and MSNBC, and the ridiculously short blurbs on CNN; Mr. Russert took a guest onto his program every Sunday, sat them down and forced them to display their view points in a thought out manner, and even challenged them at times, but always in a cordial manner. We have lost one of the great journalists of our time, and a good man. My heart goes out to his family in their loss, especially so close to father’s day.

Day 28-
Strange things are happening. I grabbed my ritual cup of coffee on the way over this morning, and started right into Qbank (after a half hour of procrastination). For some reason, the up and down pattern has seemed to cease for some inexplicable reason. I stayed above average for the second day in a row…Perhaps it’s a sign that some of this crap is starting to stick! Lone Coyote said that her score mysteriously jumped up around 85% complete, but I’m only at 71%. I’m not going to hold my breath though…

Anyway, it’s one of those lazy feeling days because it’s kind of humid out and the sky is intermittently overcast, and no one else is out and about. Apparently Saturday brings the crazy law students out of hiding, you know, the ones that like to talk about Jessica Simpson’s hair out-loud while you’re trying to study or who suddenly sprint across the entire length of the library for no apparent reason in their heels (it’s VERMONT people, no need to wear heels to the library). Anyway, I’m going to keep on trucking through Neuro for the rest of the afternoon/evening and break things up a bit with my long run for the week and some dinner.

Update: Ever have one of those “I just made a bad choice” moments? I had one about 3 miles into my run. It was an out and back 6+ mile loop. I was stripped down to nothing but short in the first quarter mile because the air was so saturated with moisture that my sweat wasn’t evaporating and my sunglasses were fogging up…seriously, it sucked. Anyway, I was determined to get my milage in after the brief shower this afternoon. The sun had peaked through the clouds and everything was looking great despite the lack of cooling. So I hit the midway marker and turn around, and then I see the big black thunderstorm clouds about to swallow the sun. We’re talking lightning and thunder, the whole nine yards. So I’m sitting there 3 miles away from home, with the GF 2 hours away, wondering what I’m going to do if I get stuck in one of the violent thunderstorms predicted for the evening. So I started my run back at as fast a pace as I could maintain while pondering which barn/abandoned house I would hide in while the storms passed, counting the seconds by mississippi’s between lightning and thunder, and trying to remember that silly guestimation of how far the storm is that my dad taught me back when I was a kid. Anyway, it was a long way off and I managed to make it home safely without incident, but about 10 minutes after I got through the door there was torrential rain and thunder and lightning and wind. PHEW…good thing I made it home before that started. Note to self- don’t die while running…it’s bad for your career/life plans.

Day 29-
I’m behind AGAIN…spending most of the day catching up on reading for neuro (which I loathe…btw. That should make for a happy string of posts come October.) I jumped into an argument on the Runner’s World website under the “Ask the Running Doc” blog talking about hydration and high fructose corn syrup in hydration beverages. Big mistake. Apparently the risk of obesity caused by HFCS outweighs the potential harm of dehydration that comes with running for a long time on a hot summer day. It BOGGLES THE MIND that these people would rather risk death than consume a slightly higher fraction of fructose. It’s like they think that fructose is a virus that suddenly causes obesity in someone that is running 30+ miles a week…it’s just not a realistic fear. The more I think about it, the more I want to open a boutique runner specific practice on the side. These people are OBSESSED with their health and horrible misinformed at times by incredulous sources, and if I can make a little bit of money doing it, so be it. At least it’s not sticking BOTOX into yuppies and doing microderm abrasions/laser hair removal.

Day 30-
…just make it end already

A freaking month into this stupid process, I took a little thing called NBME form 3. I’ll begin by saying that I’m sick of having my false confidence built up, and then crushed. Instead, I’m taking a new approach. I’m going to be pissed off while I take questions because that seems to work better…especially with Qbank. So where did I end up? Dead average…How did it feel? Like I was going to rip out a 230!!! Instead I’m in the 2teens. Yeah yeah yeah…I know, quit your bitching and go study.

Day 31-
Kill me. Less than a week left and I just don’t have the energy to do much more.

100 more Qbank questions- again, I’m still all over the place…first 50 were crappy, second 50 were above average. My last 300 questions have been pretty good, but it doesn’t replace the fact that I’ve been miserably mediocre on some and less miserably mediocre on others. I find that when I scare the crap out of myself, with a performance, I do better on the next session…so I think it’s just a matter of remaining focused…for 8 hours…without the ability to drink coffee during the exam…crap.

Day 34-
I left the GF up in Vermont and headed for the parental abode in the burbs…it was nice to see everyone, but they don’t really get the level of stress. My mom kind of understands because one of the fellows that she works with explained to her that the USMLE is a form of torture designed to break the souls of all those who take it. So now she gets sort of where I’m coming from, but still not entirely. They still want me to go to a graduation party tomorrow…2 days before my freaking exam.

Anyway, the Qbank scores have spiked up into the 70’s and I take NBME 4 tomorrow for a final crushing defeat to encourage me to cram some pharm and micro and other cramable stuff for the final 36 hours…song of the moment is a tie between “The final countdown” and the free credit report dot com jingle about buying a car…they are alternately stuck in my head. I hope that isn’t a sign of my impending psychotic breakdown!!!

Day 35-
NBME 4 down! My score mysteriously hopped up above 230, which was completely unexpected with T minus 2 days to the exam. If that’s reflective of my actual performance, great! Of course, I’m still not sure exactly how to take these things and quite hesitant to allow myself even the slightest glimmer of confidence, so I’ll be sitting in front of First Aid cramming the bugs, drugs, labs, and whatever else hasn’t been sticking so far (Neuro, Heme and GU/GYN tumors-I really hate cancer).

My dad convinced me to stop by the graduation party just to say hi to everyone. Hopefully I can keep it under 2 hours. My brother also took a trip to the ED…apparently no one told him not to put his fingers near the blades of pruning sheers…he damn near pruned his finger off as well as the shrub’s branches.

Day 36-
CRAP…it’s tomorrow. I just want to get it over with at this point. I’m just barely able to pay attention to what I’m cramming (Bugs and Drugs)…maybe it’ll help, maybe it wont. I’m not going to even bother with Qbank today…I don’t want to see that damned program until step 2…and I’ll probably go with USMLE World.

Anway, as soon as I get through these last few drugs, I’m going to get my stuff together and chill out for a bit. FREEDOM IS SO CLOSE, yet so far…catch ya on the flip side.

Day 24...going into hibernation

NBME 2 was today...I went down significantly today.

Less than thrilled that I've gone from above average to below average in the course of a week. To add insult to injury, pretty much every section that I had done well on in NBME 1 (Cardio, Neuro, Heme/Lymph) was marginal for NBME 2, and some of the marginal NBME 1 subjects (Musculoskeletal, Behavioral and Genetics) I did well in for NBME 2. The big one (Path) and my most loathed subjects (Renal and GU/GYN/Breast) stayed consistent.

All I know is that at this point my former shreds of self-confidence are completely gone and I once again have no idea where I stand. On that note Bostonian will be taking a little hiatus from everything but cramming his face off for the next 12 days.

Catch ya on the flip side, wish me luck if you feel like it...it's seeming like I'll need it.

Day 23...

It wasn't until I looked at the countdown in the upper right hand corner that realized that I have less than 2 weeks left in this slog. HOLY CRAP... LESS THAN TWO WEEKS!!! I better start studying harder!

I cracked the halfway point of Qbank a little bit ago...1200 questions down so far! Only another 1100 to go. I'm still pretty burnt out from the combo of studying and the ungodly heat+humidity is conspiring to rob me of my sleep and mental outlet of running. It went from a lovely seasonable 65-70F to 95F (typical of the mid-Atlantic in August) over the course of a few hours. Thankfully the Valley we're in cools down to the 60's at night so it's tolerable after 10PM, but it still takes a couple hours to cool down/ventilate the apartment.

I tried to get a run in nice and early yesterday so I would avoid the heat. Fat chance...even though I was out on the road at 8AM (I'm not much of a morning person, mind you) I realized that it was going to be a crappy run within the first 20 steps. On the run out, I kept my pace about 30 seconds/mile lower than usual and ran shirtless to keep cool enough to move (I normally avoid it out of modesty/how nerdtastic I look with my HR strap on). I thought I was going to die, I haven't sweat that much ever! I decided to I cut a mile off the total distance to save the GF a drive to find my lifeless body on the side of the road. The run back was absolute torture. I had expected to drop the pace a bit more to keep from dying on the way back, but I could barely maintain a jog...it was only like 80 at that point, but the humidity combined with my stupid decision not to eat anything before I ran knocked me on my butt. I finished the run alive, and didn't stop sweating until I took a nice cold shower...

Lessons learned:
1) The Library has free AC, I should have been studying instead
2) It really does take 7-10 days to acclimate to gnarly heat like this...
3) Wake up earlier, eat something and don't push it too hard on hot days!
4) Cold showers are a good stand in for AC...for about 10 minutes.

Day 20...is it over yet?

Studying for these types of exams feels like one of the most mundane tasks in the world. Here's a sample run through of any of my previous 20 days:

6:30 AM- GF's alarm goes off and she's off to the gym. Grumble, grumble, grumble, pillow over face and back to sleep. Why do people mow their lawns at 6:30AM on a week day? SOMEONE MAKE THOSE DAMNED BIRDS SHUT UP!
8:00- Alarm goes off. I think about getting out of bed. GF puts the news on. I bury my face into the pillow even deeper, hoping to grasp a last few precious moments of sweet-sweet REM.
8:05- Snooze 1
8:10- Snooze 2
8:14:58- "If you hit that snooze button one more time..."
8:15- Snooze 3
8:15:03- "Get up lazy ass!"
8:17- Into shower
8:25- Breakfast/TV/Dishes
8:55- Walk over to the coffee shop and procure sweet, sweet liquid productivity, chat with proprietor lady who is super nice.
9:00- Get set up in the Carrel. Law students are EVERYWHERE...they can smell fear, hide your First aid, try to look hard at work. Open laptop, procrastinate.
10:00- Crap, it's 10 already! Open QBank- 50 random questions...go!
10:49:41- Hold breath, end test, yes i'm sure! Yes I'm still sure! Still holding breath. Stare at results with utter amazement (either good or bad). I'm still that dumb?
10:50- Review questions, log Qbank performance in OCD performance tracking spread sheet. .
11:30- Curse at myself for procrastinating so much, open books
11:31- Procrastinate...who am I kidding, there's only 30 minutes til lunch anyway, how much am I really going to get done?
12:00- Lunch!
12:30- Check email, facebook, blogs, blog comments (occasionally...thanks guys).
1:00- Shut off computer. Hide it. Actually start studying for the day.
1:04- Bored already, stare at the wall, more reading.
5:00- Decide it's time for a run and dinner.
7:00- Back to the libs to finish stuff up.
9:00- CANT TAKE MUCH MORE OF THIS CRAP...pack up and leave.
11:00- Bed

Total studying: maybe 8.5 hours
Total procrastination- well over 5 hours

The past 3 weeks have almost made me look forward to starting my surgery clerkship next month. I imagine that actually seeing patients/being in the hospital/not sitting in front of First Aid for 8 hours a day will be nice for the first 10 minutes. Then the novelty will wear off, 3 people will berate me for being in the way/being stupid, and I'll remember that it's 5:30 AM and rounds haven't even started!

Day 18: QBank can suck my nuts 2

Two words come to mind at this moment: F**K QBank

Why??? For pouring aviation grade fuel onto the growing pyre of my academic insecurity. I took my first NBME today and I did better than I thought I would. Granted, the rumor is that Form 1 is much easier than the actual exam. Then again, half of what I'm going off of is conjecture cooked up by the nut-jobs over on SDN who toss around their 120 hour study schedules, 260/99 scores, and junior AOA nominations like they're the second coming of MSG (just kidding RAG). The other half is being cooked up as I go.

At the half way point of this joyous process:

• I can say that I'm going to pass the exam...with a 95% confidence interval
  
• I have no idea where I actually stand...I cold barely pass I could do above average!
  
• I'm forgetting things that I've already studied...which doesn't bode well for the day before the exam.
  
• My self-confidence has wavered to a new low as you could probably tell by yesterday's post
• The undermining of my self-confidence is causing me to lose sleep
  
• Running, crappy TV, blogging, the Red Sox, and my girlfriend are the only things keeping me sane at this point
• June 23rd is going to cause more gray hair than it's worth. June 24th is going to be the best day of medical school...unless I tank
  

18 days of the suck left...

DAY 17: QBank and NBME can suck my nuts

The trusty ol' self confidence meter has bottomed out burst into flames, fallen off the wall and set my entire psyche on fire. I've gone through over 900 QBank questions over the past 2 weeks and I can only say four things for sure:

1. I have absolutely no idea of how I'm doing overall. I might as well be sitting in a Viet Cong outpost on the Mei Kong river, blindfolded and forced to play Russian Roulette against Robert DeNiro when I take these exams. Hopefully I don't end up like Walken in the end of the movie...I doubt that QBank Roulette in a warehouse would draw the same crowd of screaming Vietnamese people throwing money around. I'm probably going to end up with a similar case of PTSD, which promises for some good self-loathing induced blogging in the future.
   
   
   
2. My performance varies by 10% in a matter of hours. Morning questions will be way below the average on an easier exam and the afternoon's will be above on a much harder exam...WTF??? To make it better, I can't even tell when the exams are harder or easier!!! I'll think that some of the 22% questions are easy and not have a clue about some of the 78% questions.
   
   
3. Qbank has caused me to develop persecutory delusions of becoming a PM&R resident on Podunk County Hospital's hospice service tending to bed sores, diabetic feet, and terminal pain management with a non-English speaking FMG as my only friend. Ship me off to the 7th circle of hell why don't you?
   
   
4. The NBME has a Kung-Fu death grip on the collective genitalia of all medical students...$45 fucking dollars a pop to put my mind at ease. It's ok, it's not like I needed to buy groceries this week or anything. $45 for 4 hours of sitting there and clicking fucking buttons to simulate the most anxiety inducing experience of my young life! I bought 4 of them!!! I probably need to have my head examined.
   

Tomorrow marks the half way point if this incredibly frustrating and demoralizing process. There's only 19 days of this crap to go...better get back to studying so that I can try to end up near a coast in a profession that might interest me.

Up tomorrow: NBME 1

DAY 16

The roller coaster ride of QBank continues. I bounce up and down every day never straying more than 5 points from a mean of 54% (predicting a 217). On the positive side: there is an upward trend for my average scores between weeks one and two, I haven't seen below a 50% in about a week and I finally hit 60% correct for the first time last friday. Some people recommend tracking your previous 300 questions as a marker of how you're coming along (I've pretty much stayed the same since the beginning).

I'm starting to become somewhat concerned with Kaplan's QBank score estimator. I don't quite know if I trust medical students to report their scores honestly. Bolstering that distrust is the +/- 16 point standard deviation that Kaplan tacked on it's disclaimer to account for the many ways that people use it. Basically, they're telling me that I'll score anywhere between barely passing to a legitimately good score depending on the alignment of Mars in the house of Jupiter.

Just to put my mind at ease a bit, I'm going to take one of the NBME exams this week to get a better idea of how things are really going. My goal is 225-230. I've got 3 weeks left to bring up my scores...seems pretty reasonable to me!!

To all those out there slaving away in the libraries for the step 1: good luck.
To all those about to start their residencies: enjoy the nice weather while you can.
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Day 17 update: Dipped below 50% again today! Karmic retribution I tell you...or maybe the fact that I apparently don't read the questions.
Day 17 update 2: Now I bounced back above 50% on my second set of questions...I hate Qbank

Day 11

Now I don't want to sound too positive here, since there have been karmic rebound effects when I have done so in the past. After locking my books in the library for the weekend, I've realized that my answers actually reflect my knowledge when I'm not completely freaking exhausted taking the questions at the end of a day of studying. I caught myself blatantly not reading questions and blankly staring at the screen...it was pretty awesome.

Since that realization, I've had a string of better performances in a row and have even managed to do(slightly) better than the Kaplan averages a few times, which is marginally positive news to me...we'll see if I can keep up the positive trend!

____________________________________
Anyway, I've been tagged by Dragonfly for a meme.

7 songs I like right now:

O Fortuna- Carmina Burana, Carl Orff: I sang it in college and it's been in that series of Gatorade commercials during the Celts games...it sometimes pops into my head.

School's Out for Summer- Alice Cooper: Because it's almost summer and I'm not stuck in NY going to mandatory classes...even though I'll be spending most of my summer stealing the free AC in OR.

Son of a Sailor-Jimmy Buffett: just an awesome song...

Charlie-RHCP: One of my all time favorite bands, just saw the video on You Tube a few days ago and it's a good song.

Damn it Feels Good to Be a Gangster- Geto Boys: Makes me want to commit violent acts against office equipment...and it gets stuck in my head sometimes despite the fact that I don't know most of the lyrics.

Boston- Augustana: They did a pretty sweet live acoustic version on NPR this weekend that you can stream for free along with some of their new stuff. I liked it before it was all over TV too.

The Bluegrass Sessions- Bela Fleck and the Flecktones: Banjo music rocks...

And pretty much anything by Altan or Danu...I've been getting into Celtic music lately because it's subdued enough to put on in the background while I study.

Day 8....I'm a dumbass

I had a rather unproductive day reviewing pharmacology yesterday, and decided to pack it in early and finish up my daily QBank questions at home. I neatly stacked my books up and put them on the shelf of my reserved carrel in the library, plunked the lappy into it's case and took my nice little walk home through the center of town. I did my questions, had some dinner and went for a run.

I was laying in bed watching the Celts game and I all of a sudden had a sinking feeling. In the nexus of time that is studying for the boards, I failed to remember that it's Memorial Day weekend and that the library is closed until TUESDAY, locked up tight with my books inside. Smooth move DUMBASS. Now I'm stuck with only a copy of HY Neuro and a BRS Biochem, royally screwing up my schedule. Oh well, looks like I'm taking my catch-up day a bit early and starting Neuro 2 weeks before I planned on it.

On a more annoying note, QBank is still kicking my ass. I had one bright day of performance where I almost broke 60%, and then dipped back down to the depths of craptastic with my worst performance to date. Not to make excuses, but the GF did have the TV on in the background, and I was pretty tired at that point too. How I can study for an entire week and do worse than taking the exam cold, I'll never understand. At least there's still a month of studying left....
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On the bright side, I had a nice run down a new road yesterday. The route follows the river through the outskirts of town and turns into a quiet pine-lined dirt road and ends at a pretty sweet steel-truss bridge (my great grandfather was a bridge engineer...it's in the blood) leading to the downtown of the next village across the river. I was feeling great on the way out, but kind of wanted to toss my cookies a various points on the way back.

I'll have to post some pictures of my new favorite running routes...having a nice view makes the run more tolerable.
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UPDATE: So about 2 hours after posting the above, I somehow bounced up to my highest performance yet. This yo-yo performance is pretty aggravating...I just hope I can drag both extremes up.

Day 5...

According to QBank, 5 days of moderately intense studying has apparently made me less knowledgable. The first 3 days of studying, I was where I thought I should be in relation to my previous assessments. I even started to show an upward trend (as much of a trend as you can see with 3 points). I was able make a good number of the diagnoses from the description and when I could't I was using the questions to answer the questions, which is usually sound test taking strategy.

However, days 4 and 5 have kicked my ass and squashed my budding self confidence. If I had to pull something positive out of this mess, I'm consistently getting the vast majority of the initial diagnoses correct, which means that I have some vague idea of what's going on. The bad news is that the vaguely worded questions combined with the 2-5 step jumps in logic that Kaplan likes to toss into the mix are tripping me up. I'm kicking myself for not learning things in an integrated fashion during my courses...looks like it's time to do so now!!! That and I've forgotten most of anatomy as it relates to pathological conditions.

Innervation? Forget about it!

The inguinal canal? Yeah some stuff goes through it and there's a couple of rings...not good enough!

Brachial plexus? Roots, Trunks, Divisions, Cords, Branches (randy travis drinks cold beer)...you want me to know what they do and where they go AND DERMATOMES??? Crap!

Well I'm going back to snuggle in the cold, pages of my First Aid and Step 1 Secrets. To all of ya'll out there studying...good luck.

Learning something new...

I'm sitting here reading one of my "less-reputable" Step 1 review books and I get to the following case presentation:

34 yo obese woman complains of muscle aches "all over" and increasing fatigue over the past 6 months. Despite sleeping 8-10 hours per night, she feels more tired in the morning than when she went to bed. She admits to a long history of anxiety and depression but is adamant that the aches are real. PE is remarkable for tenderness at 14 0f 18 trigger points, lab, biopsy and EMG studies are all negative.

I was completely stumped at what this phantom illness was...until I read the answer: Fibromyalgia