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.
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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...