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.
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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...