Thursday, December 13, 2012

Interviews: Done

Well, all is complete.  Finished all my interviews, am one week into vacation, and it has been a busy vacation indeed!  After getting my thank you notes all figured out, had a weekend in Monterey to take care of wedding vendor business (Florist, Cake, and Hair/Makeup).  We also have a guest for the month, and another guest coming next week.  It's nice to be busy with only fun things.  Ordered the Save-the-Dates, got the guest list finalized... just riding out the end of the month.  Things are pretty much going awesome, and I feel very confident that I will match at my top choice, and if not then my second choice, both in Sacramento.  I doubt Davis will rank me particularly high, and after that one then Redding and Modesto are perfectly feasible options.  

Not too sure what else to update - I feel very fortunate compared to some of my classmates.  I know what I want, I'm competitive in the field that I want, I'm compatible with the field I want...  Compared to others who don't know what they want or aren't competitive for what they think they want.  I'll probably hold off on any more updates to this blog until I start my Neurology rotation in January, and then the Emergency Department rotation mid-January.

Thursday, November 29, 2012

Change in Reception...

Well, this was certainly a little different than the previous places I went to. Today's interview day went okay. It was mostly negative, though. First off, none of the residents who were showing us around seemed to know what they were doing. The day started off with a tour, instead of an orientation like all my previous days had started, so we didn't even have an agenda. The person giving the tour was an intern resident, who has only been with the program since July and hasn't even worked in all the hospital departments yet. Usually it's a 2nd or 3rd year resident who does the tours. They also were frank about telling us some of the negatives about the program. When we got back, first I was with a faculty member and she seemed to start off a little colder but she warmed up gradually. Went over my application, I got a bit of a skeptical vibe from her, but I kinda shrugged it off, it didn't seem to be a big deal. After that interview, I was with a current resident who was pretty nice and seemed to like me fine. He even told me a little about the criteria for ranking people, which he probably shouldn't have, and said that being a Spanish speaker, interested in OB/GYN, underserved and rural medicine, etc. are all part of their checklist for whether to rank someone or not. 

After that came the program director (PD). I was willing to give him the benefit of the doubt at first, but he didn't seem particularly warm or excited about me. Certainly not like the Sutter had. Sutter probably knew I had genuine interest in them based on me doing the sub-internship, and I had spent a month with them being nothing but nice and pleasant and enthusiastic. I basically felt like the PD here started the interview with the assumption that I was a lying game-player trying to dupe them into thinking I wanted to be in their program so they would rank me highly. For one, he didn't seem enthusiastic or happy at all when I said (TRUE) stuff that matched their mission goals. I DO want to work with Spanish speaking patients, I DO want to have full-spectrum experience and know what resources are available to uninsured patients in California. I don't want to do nothing but OB/GYN but I'd like to be able to handle my primary patients when they get pregnant instead of sending them off to a "specialist".  He basically told me not to rank them unless I really wanted the program, and whenever I said what I liked about the program he seemed entirely nonplussed and just reiterated his previous statements. He even went so far as to say that it's "better to scramble for a residency than match at a place that is just a backup." 

Also, mid-interview, he asked about my Spanish experience and then proceeded to say (in MEXICAN Spanish) "How about we chat in Spanish for a bit?" At first I was thrown off because he used the Mexican-Spanish word for chat instead of the more common verbs like hablar or charlar. I never use the word he used, but based on the context of the rest of the sentence I figured it out after a second of confusion. I asked what he would like to discuss and he said tell me about a patient I saw in the past year. So I start telling him about a patient, and I wanted go on, since I was starting to get going better, and he basically cut me off and played it off like he just likes hearing peoples' accents. First off, part of me feels like he intentionally used the Mexican parlance to make it more challenging. Second, he didn't even let me talk long enough to hear much of an accent, OR let me get in the rhythm of it. He knows it's not my native language, and interviews are somewhat stressful even when you're a competitive semi-confident applicant. Obviously he was checking to make sure I didn't just lie all over my application.  I was expecting to run into someone who would want to speak Spanish with me as a subtle 'test', after all, they always say never to overestimate your language skills unless you can conduct the interview in Spanish.  It wasn't the fact that he tested me, but his skeptical expression and tone. I kind of wonder if it was because my personal statement seemed overly-tailored for their program - I only tailored the very last short paragraph, but the rest of the personal statement (the generic family medicine part) just so happens to perfectly suit their mission statement over the other programs a bit. My scores are also pretty competitive.  Maybe on paper it looks a little too good to be true for their program.

Either way, I had been starting to consider that the place might be nice to be at, if it came to it - it would definitely give me my Spanish experience, the residents all seemed pretty chill and nice, and the earlier faculty member I was interviewed by seemed nice and interesting.  Plus its location is pretty nice is near some nice places.  Ultimately, this program director's attitude was a complete turnoff, and the PD plays a pretty significant role in your residency training over the next three years.  I don't want to have to be around someone like him who treats me in such a judgmental manner and isn't even open to hear what I have to say. One of the other faculty members also attacked a 3rd year student from UCSF who was giving a talk about a global non-profit organization she started before medical school that was reducing maternal morbidity and mortality worldwide.  After we finished clapping and it was opened up for comments and questions, the first guy who raised his hand was this faculty member who essentially told her that some of their efforts were a waste of resources and time, and that they were going about it wrong.  Not a single word of encouragement.  A couple other people commended her after that initial commenter, and of course she took the initial criticisms in stride, but...I was upset because her accomplishments were honestly quite impressive.  

Tuesday, November 27, 2012

Two Interviews Left...

Well, two more days of GI left, and two interviews left.  I decided to cancel my Reno interview.  I've gotten good enough vibes from three of my top four programs, and two of my backup programs, that I don't really want to risk driving my two-wheel drive car into Reno in January when it would be at the bottom of my rank list anyway.  I am almost tempted to cancel the next two interviews, because I'm getting tired of interviews, the novelty has worn off, and these last two places are also at the bottom of my list.  However, one of the interviews is Thursday, and the next one is a week from Thursday.  They are coming up so soon that I might as well just do them.  

Currently on my GI rotation - mostly just trying to get through it.  I'm already tired of seeing colonoscopies.  They're interesting enough, but ... pretty brutal to watch and most of them are very routine.  Nice preceptor, very glad I'm only spending two weeks doing this.  Really more like one week considering the Thanksgiving vacation and my two interview days.  After this, it's a month off!

On another note, got my wedding dress ordered, got my car repaired (one more expensive repair coming up but I'll do that after I get my next loan disbursement), and have all of December off during which I get to visit my maid of honor in Seattle, have two friends stay over, and celebrate two Christmases.  Oh yeah, and my Birthday.  The guy at the Pinkberry Frozen Yogurt place today guessed that I was turning twenty - off by about 6 years.  Glad I still pass for a college kid in a college town.  I would think it would be even more obvious when you're surrounded by people who actually are younger than you.  Also going down to Monterey soon for a few days to check out wedding venues, and next year Mom's taking us to Hawaii for a few days.  All-in-all, 4th year is winding down to be pretty good, and I feel like when you really set your mind to something, anything can happen...

Probably because today's interview felt like it went really well.  Maybe I was just overconfident or over-comfortable  but I feel like I got really good vibes from them.  Like Kit always says, "Be nice to the administrative people, because they make a big difference and are usually unappreciated."  Very true.  When I did my sub-internship at this place (my number one choice for residency), I tended to go through the back entrance since the front included the waiting room.  The back entrance I had to ring the bell every day and they were always smiling and very happy to get up and open the door for me - I even apologized most of the time, saying I wish there were some easier ways to get through, and started using the other door after a while.  I always chatted with them, smiled a lot, showed my appreciation.  Today I feel like they not only remembered and liked me from before, but I felt like they tried to put the spotlight more on me a few times, and I feel like they even might have talked a little to the program director.  They definitely made an effort to remind her that I had done a sub-internship at the site, and when she came back while I was the only one sitting in the room (others had gone to their scheduled interviews, I was on a scheduled "break") she said she had looked over my application just then and talked to me in a kind of informal interview.  Just the level of comfort from knowing the facility and all the residents was really encouraging and confidence boosting.  

Also, when they're saying to the interview group "We allowed to tell you that you're a shoo-in for the program," I couldn't help but feel like they were half-directing it at me.  I don't know.  They aren't allowed to tell us this stuff because if they do, then students get the wrong idea, and cancel their other interviews and put all their eggs in one basket when there are no guarantees that the program plans to follow through.  It's all part of the game I suppose.  

On another note, we toured the Davis maternity facilities and when I graduate, it would be pretty sweet to deliver my first baby there.  They have one of the lowest C-section rates in the country, have facilities to allow you to be in a pool for labor or for water birth deliveries... it looks pretty dang awesome.  You can also connect your music player up to the sound system in the rooms.  I have 4 years or so to figure it out, so we shall see.  But I've got my eyes set on that location - not to mention it's only 10 minutes from where I live now.  That would be pretty awesome.

Friday, November 16, 2012

Update from the Interview Trail...

Well, it has been a long two weeks.  I have been to Redding, Merced, Fresno, UC Davis, and Methodist (Sacramento) for interviews.  Redding I had to do two sets of interviews because they have two tracts.  Each time, I have had to meet the current residents at a dinner the night before, sometimes stay in a hotel, be enthusiastic and pleasant and sociable for an evening and then even more so the next day in a suit walking around a hospital and discussing "Why X program is the one I want and why I think it would suit me super well."  

It gets tiring... lots of free meals, but it does come with a price.  

On the plus side, I now know a lot more about those programs.  Problem is, everywhere I go, no matter where it is, I feel like "Yea, this would be fun!"  It's all part of them selling themselves, but each time I think to myself "I should go to this one."  Then I think at the next site, "Yknow, this one might be THE one I like most!"  And it keeps going on.  My requirements are not very exclusive as far as these programs go, and the fact that they are all Family Medicine programs in California = lots of nice people who I could get along with whom I probably have much in common.  

In case you are curious (this entry shouldn't be visible to any would-be googlers) my current preference list in descending order...

Sutter Sacramento (Sacramento Tract)
Sutter Sacramento (Davis Tract)
Methodist Sacramento
UC Davis
Redding (Shasta Tract)
Redding (Traditional Tract)
UCSF Fresno

Salinas / Modesto

I haven't yet interviewed at the last three, and I am still waiting to hear from Contra Costa in Martinez.  I am not really holding out hope for them, and I don't know how high I would rank them anyway.  I've heard some negative things about them, like I have about Salinas.  Modesto... it's more because it's just another central California program.  Reno because it's far away and out of state, so it means it'd be a headache to get licensed to practice in California after I complete my training.

It might seem odd that I rank UC Davis lower than two community programs, and I must say the facilities were huge and super impressive - it reminded me of UCSD a lot - but something didn't seem right.  I want to have a close knit group of faculty members and residents.  The way they did it was a little too manufactured at UC Davis for my tastes.  I would put UCSF Fresno above Redding because they have a patient population more to my liking and better didactics... but I would probably enjoy living in Redding far more than Fresno.  

Anyhoo, I now have a short break from interviews - Sutter Sacramento on the 27th and Salinas on the 29th. I should reserve a hotel for Salinas...

Friday, November 2, 2012

Halfway Through Pediatric Psychiatry

I've been on pediatric psychiatry for a couple weeks now - it's been fun so far.  I only actually have two more days left because I have so many interviews coming up.  I got a call from our school's dean of clinical education, who writes most of the students' dean's letters and guides us through our third and fourth years, because he was worried that one of my letters of recommendation was not a good one.  He had actually misunderstood, as it was just a very thorough evaluation written in prose and directed at my school, not a letter of recommendation aimed at residency committees.  While on the phone, he asked about my interview status, since I had applied to only 11 places (now 12, since I added the new Redding track).  He was also the professor who had advised me to take the USMLE when I knew I wasn't ready for it and had I listened to him, would have probably cost me all these interviews that I have secured.  I told him I had 8 interviews scheduled (actually I have 9 now, since I called one of the programs to make sure they had my information and they had actually lost the paper version, but had put me on the interview list earlier).  He was pleasantly surprised and pleased.

Pediatric psychiatry has been a lot of shadowing, ADHD students, attending group therapy sessions for depression and anxiety, a lot of free lunches, and chatting with my preceptor about this and that.  Next week I get to drive to Merced and Redding for my first interviews.  Should be exciting.  The week after is Fresno, Davis, and Methodist.  Intense days ahead.  I get a break during Thanksgiving, but then it's Salinas and Sutter, and after that Modesto.  Reno is in January, and I'm still waiting on Santa Clara and Contra Costa.  Honestly I wouldn't care too much if either of those reject me, since Contra Costa has a bit of a bad reputation for being a "full of themselves, anti-DO" program.  

Anyhow, this weekend I will be going over the book "The Successful Match," particularly the interview question list, and formulating answers to the most common or challenging ones I will have.  I'll have plenty of time on my drive down on Monday to practice the questions aloud.  The interview trail begins!

Thursday, October 18, 2012

Subinternship Day Before the Last Day...

Wow, had a crazy day today.  The morning was okay, but this afternoon had a really crazy patient...

So...patient is on 120 mg of adderall - an amphetamine derivative.  He's a graduate from a medical school, had to leave his advanced fellowship because of "personality clashes" with a faculty member, has a history of ADHD supposedly.  This kid... (I say kid despite the fact this person is older than me) ... is talking a mile a minute.  He's got a pale color.  He looks like he's got some amount of sweating.  He's talking rapidly, looking  around the room, shaking his legs back and forth, fidgeting with his hands.  His eyes look mildly bloodshot and the lids look a little red, as if he hasn't slept very much.  He's repeating that he needs his medications particularly because he has a term paper due in two weeks or so.  He describes an erratic sleep schedule.  He is extremely intelligent and knowledgeable, citing research articles from pubmed and arguing "Why shouldn't ADHD people take amphetamine derivatives if it means they will be functional members of society instead of bums?" or "Studies have shown people taking lower doses have had heart complications but people taking higher doses haven't, so the cardiovascular risk is overestimated."  Then he goes into his own research about this or that, in logical medical jargon that is beyond my level of education.  Then at the end he adds that he wants to be castrated because he identifies as asexual.

If this person wasn't on medication before, and wasn't as knowledgeable as he was, I would want him in a psychiatric facility and watched for 72 hours without medication, and then probably put on an anti-psychotic.   Don't get me wrong, I think that bipolar disorder, major depression, and ADHD are grossly overdiagnosed, misdiagnosed, and overtreated.  I would rather send a person with major depression to counseling than give them an SSRI.  If he wasn't on insane amounts of supposedly "therapeutic" adderall, then I would think he had schizoaffective disorder with manic qualities - meaning a combination of schizophrenic symptoms and a mood disorder like depression or mania, in this case mania.  

Adding in the asexual identification just further complicates thing.  I am all for people modifying their bodies to suit their unique psychological needs.  We all do it to some extent, modifying how we look: Adding tattoos or makeup to affect our appearance.  Some people don't feel particular genitalia are suited to them, in this case just the testicles.  That is fine, if that is the decision of a rational, unmedicated person, or a person with a psychiatric disorder who has found a stable medication dosing that allows him to have coherent thoughts.  Honestly, I hadn't seen someone with these characteristics since seeing bipolar and schizophrenia in Stockton, and these people were nonfunctional.  We are talking covering themselves with mud and telling cops that they know jiujitsu and are ninjas and you can't see them kind of nonfunctional.  

Something else you notice about people with psychotic disorders is the way they respond to questions.  When you ask a normal person, "So, how much sleep do you think you're getting per night?  Just average it over a week, about how much?"  The typical person with sleep trouble might say, "Well, sometimes I have trouble getting to sleep, I'll go to bed and lie in bed for an hour two, then fall asleep and wake up early and not be able to get back to sleep, I probably get about 4 or 5 hours a night."  On the other hand, someone who is psychotic, paranoid, or delusional might respond initially in an evasive manner, i.e. "You know, that's a very good question, a very good question.  How much do I sleep.  I think I sleep pretty well." "Well, how much, if you could put a number on it.  Just an average, over the course of a month."  "Hehe, that's a good question.  I suppose... I mean, I take naps, I sleep, I might sleep at times other people don't or take a nap under a desk but people do that sometimes, there's nothing wrong with that, ..."  

You still haven't given me a range of hours.

It's a very different train of thought.  It's very distinct.  You pick up on it immediately if you have been around psychotic individuals more than once.  In thinking about it right now, I almost wonder if deep down this patient knows he is abusing his drug, and that his behavior, to any rational medical professional, looks like someone who is addicted to chronic low levels of amphetamines, and he is trying to circumvent it despite his own knowledge.  Why conceal something if there isn't a problem?  He isn't lying, yet he isn't answering the question clearly, and either he lacks insight as to the purpose of the question (assess how much sleep he is getting) or is afraid the answer would affect him negatively or impact his ability to get medication.  

It's an odd internal conflict between having a psychotic disorder that prevents you from having insight into your condition, yet at the same time being so knowledgeable and rational that you DO have extensive knowledge about the condition.  It's a very unique situation, since he IS a medical professional.  The last time there was a patient similar, it was a schizophrenic woman who spoke of having been in the military and the CIA being at her house checking up on her because it was a service that all ex-members of her group got, and she explained it in a very rational descriptive manner.  Very logical.  Reasoning.  And yet, it was all a fabrication.  This person almost certainly is who he says he is.  It is likely all effects of the medication.  I've seen the effects of amphetamines, I know what they look like at a lower level of use, and this is amphetamine abuse x 1000.  

This patient reflects a harrowing vision of the dangers of treating ADHD with stimulants - at what point do you decide the medications aren't appropriate?  What was his psychiatrist thinking giving him slowly increasing levels of amphetamines?  With what reasoning would he prescribe this?  In some cases, physicians are so convinced that medication is the only answer, they will exhaust all non-amphetamine medications and finally, have to resort to amphetamines and gradually increasing the dosages.  This patient was on dosages far exceeding the regular amount.  By comparison, a 10 year old with supposed ADHD would probably be getting 10 mg in the morning, and a half tablet at lunch.  Compare that to this individual, with 120 mg evened out throughout the day.  It is scary to think what unbridled medical treatment of possibly behavioral disorders can lead to.  I have no idea what this patient is like at baseline, without medications.  I wonder if he would be functional.  I wonder if he would suddenly have more insight to his condition, or have an epiphany that he can live without the constant push from amphetamines to be electrified into focusing on something.  I wonder how much difference we can make at this point, and how much of him is him, or the drugs.  

As a doctor, you want to believe patients, be their advocates, and fight for them when no one else will.  However, when you can't trust that a patient is even himself, where does that leave you?  Ultimately you are left with your interpretation of the scientific and clinical data, the knowledge and experience you and you peers have, and that intangible feeling of "your gut instinct."  I don't know when I will see a patient like this again, but it is one of those dilemmas where you are truly torn.  

Friday, October 12, 2012

Sub Internship - Week 3

Well, I know I haven't been updating much - it's been busy.  A lot of fun stuff going on - seeing all kinds of patients, getting to know the residents and faculty... it's really enjoyable.  I had almost forgotten how much I enjoyed family medicine - there are so many things you get to do in family medicine that you can't do in other fields of medicine.  A day could involve diagnosing a patient with anorexia, managing a patient with depression, removing a sebaceous cyst, performing maneuvers to treat a patient's vertigo, putting a cast on a 10 year old boy, identifying a rash and prescribing antibiotics to prevent future heart complications, managing a patient with hypertension + diabetes + chronic kidney disease + depression + foot ulcers + macular degeneration, managing a patient with sinusitis, counseling a patient on weight loss, removing an ingrown toenail, identifying a urinary tract infection... and so on.

Essentially any medical problem a patient has, they go to you first.  So much fun.  I'm at the point where I know enough that sometimes it feels like I really have the answers.  There have been many encounters that would be blog-worthy in these past weeks, I just don't know where to start.  A woman at 37 weeks gestation who has gestational diabetes, who also just developed symptomatic gallstones, who has an OB/GYN physician who seems indifferent to the fact her pregnancy is one problem away from becoming an emergency surgery?  Breaking the news to a young skinny girl that she has dieted to the point that she isn't having periods and needs to gain more weight when that's the last thing she wants?  A man with crippling chronic pain from an accident years ago who is allergic to morphine?  

The residents have been great, the attendings have all been great, I feel like I fit in really well.  I love the area, the city, our new place.  I really hope I get into this program.  

Currently my tally is 8 interviews scheduled out of 11 programs I applied to.  I think I'll get an interview with Davis, and I am still hoping for at least one more interview offer.  I'm not holding my breath for one of the programs.  I'm kind of looking forward to interviews as well - two places are covering my lodging.  One of them is letting me stay with a resident, and another is paying for my hotel room.  Tomorrow hopefully I can relax a bit.  I need to get back on my exercise regimen but I strained my calf muscle two weeks ago and it still hurts really bad and I don't want to be impatient and hurt it even more.  After next week I start Pediatric Psychiatry - should be nice.

Monday, September 24, 2012

Sub-Internship Day 1

Things are going well so far - they have EPIC electronic medical records and I have full access, so I have started making my own note forms and am getting on great with everyone I've met.  To make things better, before the end of the day I had an interview request from Merced, called Salinas and confirmed my interview for end of November, and the coordinator I met this morning (at place I am currently doing my sub-internship) sent me an e-mail requesting/confirming an interview date!  So now I have two interviews scheduled, and two I'm waiting for official date scheduling, but 4/11 within 1 week of applying ain't bad!  

I also like my preceptor and hope to get along with everyone super well.  I'm just trying to remember to smile as much as humanly possible, without it looking inhuman.  They seem to think my patient presentations are pretty decent too, even though right now I feel like I'm so scatterbrained.  It's been a LONG time since I did any rotations in a clinic, so my outpatient presentation skills are really rusty.  Shouldn't be long before I'm back in the swing of things, but until then, it's a slightly rocky start.  I'm definitely glad I'd touched base with a couple current residents - it's nice to see familiar faces, who all seem encouraging. 

At any rate, I think I'm going to go and read up on some stuff I saw today and then do some pleasure-reading.  

Friday, September 21, 2012

Applying for Residency

Well, some of you may see this around the time it is posted, others may not see it until far later - why?  Residency applications.  It is a well-known fact in this world of technology and the internet that potential employers and programs "google" their applicants to see if they have any unsavory activities.  Not that this blog or any of my other interests are unsavory, because honestly they are not, but I don't know that I want any program directors perusing my blog entries and overanalyzing any hints of cynicism or detachment I may portray in them.  As always, this blog is an outlet for my medical experiences, and lets me take a step back from the nitty gritty of everything.  

I shall now continue.

A few days ago, I finished tailoring all my personal statements for the family medicine programs I have decided to apply for.  In total, I have selected 11.  I was originally only choosing 10, but my adviser encouraged me to go higher, so I added on a program in Reno, NV.  We are encouraged to send tailored applications, according to a book I have about "Acing the Match."  Supposedly, programs do not expect it, but when they see a tailored personal statement, they pay much closer attention to you.  Combine that with the fact that my personal statement pretty much screams "Amazing Family Medicine resident," and I have a decent application.  Board scores are about average for those applying, but for super clinical medicine, numbers aren't really the most important thing, and the interview is their number one criteria for ranking applicants.

That said, I sent out all my applications, each with their tailored application, on Monday.  Our Dean's letter is another major criteria they use to determine who they invite for interviews, as most programs only interview 100-250 students for about 8-16 spots, so I wasn't expecting to get much as far as responses for another couple weeks.  Much to my surprise, today I got not one, but TWO interview invites.  Super exciting!  Kind of a "This is happening too fast!" feeling.  Two other programs notified me that the received my application and will be reviewing it over the next couple weeks - one had me list my interview date preferences in case they choose to invite me for an interview after reviewing my completed application, including the Dean's letter.  Dean's letter should go out around the beginning of October, so I should start hearing from a lot more programs then.  Having two interviews already in the works is really exciting, especially when one is a program I thought would be more difficult to get an interview at, and one of the programs is in my top 4 choices.  Things are looking good.

On the other hand, next week I start my sub-internship at Sutter Sacramento, which is my tentative first choice residency program.  I am not sure whether it will still be my first choice after interviewing at a bunch of places, but we shall see.  It is the most compatible and geographically convenient of the programs I have looked at.  If I get interviews at the 10 California programs, I may just withdraw my application to the Nevada program, since they mostly accept MD students from the Caribbean, Nevada students, and DO students, suggesting their program is not of very high caliber.  I also didn't get a very strong impression from their website, short of them offering wilderness medicine.  

The next couple weeks will be exciting to see who is interested in me, and how many choices I will have.  The thing I don't know is whether they have actually read my personal statement or if these interview invitations are based on my COMLEX/USMLE scores.  I have a feeling they must have read my personal statements, because my scores, as I said, were around the average for successful family medicine applicants. I really hope I get an interview at every place I listed, because that would make me feel a lot more comfortable about the match, come March.  Time to drink in celebration!

Saturday, August 18, 2012


Well I just finished a week on ICU.  Definitely more intense than previous rotations, but getting a lot of experience and trying as hard as possible to be a fast learner.  So many sick patients.  Many vegetable or "anoxic encephalopathic" patients, from quadriplegics with huge ulcers who need to get a trachostomy because of recurrent pneumonia, to people with interstitial lung disease who have been in and out of the hospital for many years and just start taking a turn for the worse.  I've assisted in several intubations and central line placements.  Central line placements feel the most natural - intubations are unpleasant.  My second one was aspirating "coffee ground emesis" the entire time and we are still not sure where her upper GI bleed is.  

This weekend I have one day free, so I'll be hopefully using it to work on my personal statement for residency and setting up my applications online.  Also hopefully spend some time with the fiance.  We get a few hours every evening but now we are both working until essentially 8pm each day.  At least we are both busy.  

I don't know that I could work in a field where most of the people do not get better, or they get slightly better and then you see them a month or two later nearly brain-dead with family refusing to accept that this might be the time they don't come back.  It's hard hearing the explanations for patients who are vegetables, where patients' families will swear that they were looking at them, or had tears coming down their face, or squeezed their hand.  Bad news every day is very depressing.  We actually had a family that was rather quick about it today - Three hours after we intubated an old woman who had severe pneumonia and many other comorbidities, her family arrived to remove it and let her die in peace.  This compared to three others on the ward which will probably not get better.  

Anyway, another three weeks of this.  I have heard that the preceptor next week (they alternate weeks) is easier than my current one, which is fine since it might be nice to have a reprieve.  It's funny, my current preceptor talks about how he doesn't want to be anyone's boss, so he joined a physician group, would never join Kaiser because they own your life, and yet he is constantly taking calls about patients, staying beyond 12 hour days, etc.  I find it hard to believe he has more of a life than a lot of the doctors I talked to at Kaiser, where they can actually leave a lot of their work at work.  We'll see - he's given me more to think about as far as potential work environments.  I will definitely have to thoroughly investigate the different options for practice.  Short of solo practice.  

Tuesday, August 7, 2012

USMLE Step 2

It has been a while since my last post.  I've been busy studying.  Questions every day and whatnot.  Instead of Neurology, there was a scheduling conflict and I got switched to another Radiologist.  Luckily, this guy has a lot more to see during the day than the first guy, so I got a lot of experience seeing different plain films, CTs, MRIs, ultrasounds, etc.  Some of it will hopefully help on the exam tomorrow.  After this week I head on to ICU, which will likely be intense, have long hours, and be rather stressful.  Probably will have some weekend call days.  

After tomorrow's exam, there won't be any more standardized future-of-medical-career exams until Step 3, which will probably be after I get into a residency program.  In the meantime, I have to work on my application to residency - write some personal statements, research programs, etc.  It will be stress of a different nature.  We move to Davis in September, and then near the end of September I start the Sub-Internship at my number one potential spot for residency, so hopefully that will go well...   Yet more stressful stuff to worry about.

Tonight hopefully I can put most of that out of my head and try to relax a little bit.  After tomorrow, no more endless practice questions for a while.  Oh yeah, my 6-year anniversary of having been dating my fiance is tomorrow as well, and I should also be getting my COMLEX Step 2 written exam score back as well.  We aren't celebrating our anniversary until Friday, but either way, lots of stuff going on.  

Thursday, June 28, 2012

COMLEX Step 2 Written Exam - Attempt 1

So, yesterday I went to take my COMLEX Step 2 exam.  I felt pretty prepared, got through the first four sections without any real hangups.  Then came the after lunch portion.  When I returned, suddenly I only had 25 minutes left!  I was confused because the first section showed the cumulative time for all four sections at once, so at the beginning I had 3 hours 59 minutes, but then when I started section four of eight, I only had 25 minutes.  I thought maybe they just changed the format for some reason, rushed through as best I could, and the time ran out of course.  At that point, the entire test crashed.  When the Prometric called to see what was going on, the line was busy due to 'extremely high queue for service regarding the COMLEX' so... turns out the test crashed nationwide.  

The most annoying part was having to drive out there to take the test through rush hour traffic - took me almost an hour and a half.  On the plus side, I basically got a trial run of the actual COMLEX Step 2, so that was kinda nice.  I also get more study time.  No clue when I'll schedule the actual test, though.  I'd prefer to do it on a weekend, so maybe I can get next Sunday or something... if not, then who knows.  I also need to reschedule my USMLE - I wanted a full month to study for that between the two tests. 

That's the latest.  Next week I'm starting radiology for two weeks, it's supposed to be pretty relaxing.  After that is neurology.  Then ICU, which should be rigorous.  Then eventually moving to Davis, CA.

Wednesday, June 13, 2012


Well, today I had the COMLEX PE exam - it's a pass/fail exam where you have to have 12 standardized patient visits and then do a write-up.  You have 14 minutes to see the patient, and 9 minutes to do the write-up.  For DOs it is only offered on the east coast in Pennsylvania, so of course, off to Pennsylvania I had to go.  So jetlagged...  Anyhow, things were starting out fine, ironed my white coat, did some spot cleaning, looked great.  Then when I put it on after carrying it over one arm to the test center, I realize I got blood on it somehow - I nicked my knuckle somehow.  So I had to cover it up with something, first I just had clear tape, next I had an actual white paper cover, which was better.  Hopefully it won't count against me too much in the exam - I think it'll all average out okay, but it was really disappointing.  

As far as the patient encounters, they all went about as expected - and I was surprised that I never really found myself running out of time for either the visit or the write-up.  I feel like I always got through it, was able to ask them if they had any questions or concerns or if I can help them with anything else, etc.  Super exhausted though.  Treated myself to a nice dinner, and now just debating how much sleep I want to try to get before my 6am flight.  This time we get to change flights in Chicago, but at least the second leg will have Wi-Fi, so I won't be as bored out of my mind as I was for the first flight.  My stomach has felt funky the whole time I've been here, so I'm looking forward to getting back to my normal food.

Another bummer today was I got an email saying I didn't get a rotation spot at one of the programs I wanted to do a sub-Internship at.  It sucks that they took so long to figure that out because now I can't really make any other arrangements - I have to just scrounge for some other rotation.  Hopefully our department at school will be working through rotation requests a lot faster now that they got some extra people to take care of student health.  

As far as Psychiatry, it went well overall.  The preceptor was great, the patients were interesting, and the hours were very reasonable.  I was not too happy that I had to cut a lot of the days out because of mandatory lectures at school and this trip to take the exam, but at least I made the most of my time there.  The end-of-rotation exam is Friday and then I'm on vacation for two weeks.  Got some nice activities queued up, and I need to start seriously planning my wedding.  

Wednesday, May 23, 2012

Psychiatry Week 1

This rotation is a breath of fresh air compared to the previous one.  First off, our preceptor is a nice middle-aged white chap who I have no trouble understanding and who likes to sit and chat about psychiatry.  Second, it is not a high-stress environment, despite being surrounded by many psychotic patients (in the medical sense). Third, I have a fellow classmate with me on the rotation, so we have each other to hang out with during lunch and on breaks.  The patients are all quite interesting, and we get off relatively early most of the days.  Also I get to wake up at 6:00-ish instead of 5:00-ish, like I did last time.  I still have a 1.5 hour drive each way, but again, plenty of lectures to watch on the way.  

Another nice thing about psychiatry, is I know a fair amount about the topic so it's less stressful, less pressure.  I have another week here, then the week after we have a week of mandatory lectures and sessions at the main campus that everyone in our class has to attend, so I will be making a much shorter commute each day.  The final week I have to fly out to Pennsylvania on Tuesday, take the physical examination portion of the boards on Wednesday, then I fly back on Thursday.  I am most looking forward to finding a really nice restaurant in the area and having a solo celebratory meal after the exam.  It will be an awesome feeling.  

Then the next big events will be the board exams.  

I also cancelled my family medicine rotation up at the hospital I was at previously for internal medicine - it was scheduled for mid-December to mid-January and I do NOT want to be doing a sub-internship with long hours at a program that I really do not want to get into (not the best environment, and word has it that it is a very weak program) and which would require long hours and that 1.5 hour drive.  During the holiday season.  It's not worth it.  I'll fill that time with another elective of some sort.  I should send some requests for those sorts of things now.

Off off and away!

Thursday, May 17, 2012

Last Day of Internal Medicine

It's a shame that I have to leave Internal Medicine right when it started getting enjoyable - mostly because of the preceptor.  I walked the team through a New England Journal of Medicine case and my preceptor and one of the interns commended me on my presentation of it.  My preceptor also seemed pretty impressed with my patient presentations, so that was reassuring.  I also started getting into the habit of picking up patients who had Hispanic-sounding names, since most of the people on the team speak little-no Spanish and it's a good opportunity to make a difference and look impressive.  Today we were shorter on prep time and I actually was the only person who had seen this one patient (Spanish-speaking) at the time we presented, so that was pretty cool.  My preceptor then gave me the rest of the day off to study - I ended up mostly sleeping because the last two days I've gotten about 3-4 hours of sleep each night.  

Tomorrow I have my Internal Medicine exam - going to go through practice questions.  As long as I pass it that's all I need.  I also got a "Medical Spanish made Ridiculously Simple" because while I speak Spanish decently, if I want to use it as a bullet point on my CV I'd rather have it be a little more honed.  Especially since my rotation in September at my #1 spot for possible residency will have me working with a preceptor who likes to emphasize Spanish-speaking patients and I suspect he is not a native speaker either.  

Anyhow, this weekend will be a bit relaxing - Friday and Saturday just for me and the boyfriend, then going out on Sunday to a dim sum brunch in SF with my best friend who will be leaving for Seattle in a couple short weeks for a new job... then possibly watching the eclipse with my family.  Next week I start Psychiatry - last one for a week and then, as luck would have it, I will have a 2 week vacation.  I had intended to fill this spot with Radiology, but the doctor could only take me for the first two weeks of July, not from mid June-mid July as I had wanted.  More time to study at least!  

Thursday, May 3, 2012

Internal Medicine...Week 2

Well, I'm still trucking along.  I've started watching Kaplan videos for Step 2 USMLE on my phone in the car - yes, yes, bad I know, but I'm not really "watching" so much as listening and glancing over/laughing when he does some of his very odd antics.  I really like the lecturer - he always brings up references to literature (like fiction and non-fiction non-medical texts) or brings up the greek and latin origins for many of the words.  He also repeats everything about 3 ways, sometimes with funny voices.  Once I stopped looking at it as silly it's really quite useful.  Also, at the end of the day, if I'm too tired to study, at least I know I got 3 hours of decent quality Step 2 studying done, in addition to seeing medicine practiced in real life.

Example of the Kaplan videos coming through for me: Today we had a patient (who I am following) who presented with a million problems, but most concerning today were sharp chest pain.  We are thinking it is unstable angina, however he also has end-stage renal disease and is getting dialysis on a regular basis.  We THINK he may have been getting too much potassium in the dialysis wash, and the level we measured was 6.4 (normal range is 3.5-5).  Just the other day I had finished watching all the nephrology (kidney) lectures, including acid base.  So when we were discussing treatments for hyperkalemia, I was super on top of things.  We also have started seeing some acute coronary syndromes, and I am about halfway through the cardiology lectures, so I'll be prepared for that too.  I'm definitely absorbing the material, that's the most important part.

Lately we've been having a lot of patients who delayed getting medical care for way too long and are suffering pretty bad consequences.

Case 1: Middle aged white man comes in for chest pain - 5 months ago he developed a large mass (about golf-ball sized) in his lower cheek, which he was told was likely cancer and he should have resected at a nearby academic facility.  For some reason or another, he never followed up with that, despite the mass becoming about the size of a tennis ball (NOT exaggerating), ulcerating, and bleeding from time to time.  If I had a tennis-ball sized crater on my face, I would probably be worried.  Anyhow, he comes in for chest pain/shortness of breath, and turns out he has tons and tons of metastases in his lungs and bone (he had an occult rib fracture as well).  Verdict: even without a biopsy, we can tell him it's stage 4, 99.9% incurable, and he probably has a year or less.  

Lesson: If you have a big mass, even without the breaking down and bleeding and oozing, get it removed.  You may have far less time to get around to it than you think.

Case 2: Middle aged black man comes in because he can't see - two weeks ago he lost vision in one of his eyes, and a couple days ago his other eye also lost vision, except just barely at the edge.  You would think losing vision would make someone come into the hospital.  Anyhow, the workup shows he has bilateral acute angle glaucoma - which is very unlikely to happen in both eyes simultaneously, but it DOES happen.  He left it for so long that the build up of fluid within his eyes likely has given him permanent damage to his optic nerve and local structures.

Lesson: If you go blind, don't shrug it off.  Time is of the essence.

Case 3: White female in her 20s (Untreated diabetic type 2, history of drug use, fighting with passerby, and living with boyfriend after another) presents with about two or three months of severe headaches, swollen face on one side, and one eyelid shut.  A month ago she was seen for headaches and her eyelid, and they diagnosed severe sinusitis and gave her antibiotics.  For some reason, she only took 2 or 3 days of the antibiotics (Sinusitis requires at least 2 weeks).  Of course, that didn't do anything.  Now she's back, and the nerves that control her eyelid pass through one of her deeper sinuses in her skull and the fluid/infection has increased the pressure to the point that the nerves are compressed.  Surgical drainage is performed, and we try to beat it into her skull that she has to finish her antibiotics and take her blood sugar medications.  She should regain the ability to open her eyelid on the affected side, but progress will be slow if it ever does come back.

Lesson: Take your medicine

There are a few other interesting cases, but after a while it all feels like work.  I can see why patients complain that doctors don't care about them, but honestly, when you see a person with COPD, you expect them to be on a respirator.  When you see someone with cirrhosis, you expect them to vomit up blood or die from jaundice or develop huge fluid collections and die of heart failure.  You just expect it, and you see it so often, you know what the treatments are, and you know what the percentages are for the different outcomes.  It's hard to be surprised by what happens.  It's even worse when it's a completely preventable cause, such as something caused by drinking, drugs, failure to take medications, obesity, smoking, etc.

Anyhow, time to get back to studying, eating, all the usual stuff.  As far as the group, I am now a 4th or 5th wheel among Indian female interns who have no interest in making friends with me or including me in discussions.  You'd think there'd be small talk even.  Sigh.

Wednesday, April 25, 2012

Inpatient Medicine - Finally

Well, I have finally started my inpatient medicine internal medicine rotation at a teaching hospital.  The first day was pretty exciting - we rounded on patients, I got to know my team, we hung out in the emergency department and admitted people, ran to catch a code blue, etc.  It had a very "Scrubs in India" feeling to it because the residents and the attending are all from India (except one woman from Bosnia?).  They are nice, but one challenge is they have very thick accents and are kind of clique-y.  One of them in particular has a very thick accent that I have a lot of trouble understanding, and I know he has trouble enunciating so I feel a little bad asking him to repeat himself all the time.  They all talk softly too, mumbling, so it is hard to tell what they are discussing unless I am super close.  

It's gotten a bit more negative as time goes on - first day I thought things were going to be good: I would follow a patient, the attending told me to pick a patient and a topic to research, and then I'd discuss it with them and present the patient.  My first day I wanted to follow a patient with COPD, but then she was going to be transferred to ICU where we don't really round or follow patients.  This was after I had already done a writeup and was preparing on that topic.  It was then suggested that I follow another patient - so I picked a man with liver cirrhosis and varices.  So that's two writeups and two topics I needed to look over that night, on the off-chance we went to the ICU.  When I finally try to present the next day, the attending corrects me on the order in which I was giving information, the standard form that were taught and how I've been doing it over the last year with no complaints from any of my preceptors.  After I do half a presentation,  then the resident I was working with filled in the physical exam portion (which was essentially what I would have said, minus two small findings), and another resident presented the next patient.  That person did the EXACT format of presentation that I did, but of course without being called on it.

To make things a bit worse, today the resident who has a thick accent wanted me to look up some information - how a medicine is connected to a condition.  I figured it was a "this is a good topic to know, look it up and we'll discuss it" type task, similar to what attendings have done in the past, and he didn't give me any indication it was otherwise.  After a 30 minute search on my usual online textbooks, all reputable sources like Harrison's and Current Medical Dx and Tx, I couldn't find anything linking the two.  I come back, told them what I found out about the topic and medication, and they tell me to just google it or search on pubmed.  I got pretty annoyed because I didn't know he was just scouting possibilities for research projects and there WASN'T an established link between the two things.  I go back to pubmed, which they spelled out to me as if I had no clue what it was even though I've used it a million times, and I still couldn't find a single article linking the two conditions.  Everything was consistent with what I had previously reported.  

Ultimately I found an article about use for the medication in the condition in general (which I had already described) and there was another medication he was curious about so I found a couple token articles about that, but I left in a rather sour mood after having to do almost 2 hours of busywork for no real payoff and reviewing an esoteric topic that I already knew.  

The topic I'm reading up on for the attending currently, bacterial meningitis, was something I read through yesterday - I must have read through 3 different full-length UpToDate articles, and where I thought there were holes in my knowledge I continued to investigate.  Wrote everything out, went and checked out the pertinent sections in my review books, and today he still wanted to give me more time because he said UpToDate isn't the best source and kept asking about random textbooks that they used back in India.  At least he approves of Harrison's and CMDT, but I read over the meningitis information in those texts, and it was verbatim what I found in the UTD articles, and actually was less detailed.  I understand that UTD is a quick reference and half the articles are short and to the point, but I went for the full-length meaty articles.  

Long story short: Feels like they underestimate how much I know without even testing me, or letting me go on when I try to engage in a discussion.  

Plus sides: There is night call twice a week, 8pm to 8am, and then morning rounds, usually get off around 11am the next day - meaning I get to sleep in the day before, study, eat at home, and then spend the night in the hospital, knowing I have the entire next day off.  Essentially reduces my number of shifts by two.  I am not sure if I have weekend duty, but if I can get by with just 3 shifts per week, I'll be pretty stoked.  

As far as rotations go, I got sub-internship at the program I plan to rank #1 - the guy who called was I think a rank higher than the lady who actually does the coordinating and he went over my application.  He commended my USMLE Step 1 score and grades, and liked my personal statement - tried to connect a bit with some things he's done as well.  It almost felt like an interview - which, in a sense, it was, but it felt almost like a residency-screening interview.  I'll assume that his positive feedback about my application indicates I have a good chance of getting an interview for the residency program (provided I don't screw up my boards and rotations between now and then).  

Called a few more places today, starting to get a few more things on board - I'm going to see about doing some easy rotations while studying for my Step 2's so that I can have more vacation left over for a potential trip to Europe.  I think I have ER and Surgery in the bag, and ICU and a Medicine Subspecialties should be easy enough to arrange since Touro has a few exclusive arrangements.  Still waiting on Davis to get back to me, but I'm not really holding my breath too much for them.  Also waiting on another program out there, but they just updated me that they're looking over the application and I should hear from them any day now.

Perhaps time to take a nap and then read up on more meningitis and do some practice questions.......

Monday, April 9, 2012

Internal Medicine - first 2 weeks

Internal medicine for the first four weeks is to be outpatient, so I am essentially back in Family Medicine.  The only difference is we see a lot more older patients, and instead of being with one doctor for four weeks and another for four weeks, I am with a total of 4 or 5 different doctors, and usually two different ones in a single day - one for the morning and one for the afternoon.  It's a challenge getting used to what they expect in terms of presentations and their personalities - harder to get a good rhythm going, so it feels more chaotic and stressful.  Also with all the older patients that I see, I can't help but feel a little depressed thinking of myself one day being where they are with lost loved ones, being unable to get up and around, unable to hear, or demented.  Two days a week I work with a doctor or a nurse who each goes to skilled nursing facilities.  I see a lot of demented people there, who are so far gone they can only half-feed themselves, smack their lips, and don't recognize their family members - who wish they would hurry up and die because they are quickly destroying their life savings.  I asked and you are able to stipulate in your advanced directive that if you are unable to recognize family members or have an acceptable quality of life for someone of your age and physical condition (not mental) that you give permission to discontinue all medications, including ones that were being given prior to mental deterioration.  The catch with dementia is you can't stop any treatments once you've started, but you can abstain from starting treatments.  So a patient with palliative care lung cancer patient starts bleeding per rectum, you don't have to go looking for colon cancer, you can just keep doing what you're doing and give narcotics.  It's a tragedy so many families are trapped watching the husk of someone they once loved deteriorate further and drain their finances that could put their grandkids through college, or help pay off debts.

In other news, I've been adhering to a stricter study schedule and trying to make sure to get my quota done each day - if I don't, it means no fun time.  Last week it definitely cut into my fun time, so I have to become a faster reader...  I also have to give a presentation next week, so this coming weekend will probably be spent working on that.  Also been busy trying to get rotations set up for fourth year.  Soon I'll need to call another place in Sacramento, but hopefully after I hear about two other sites because I don't want to be stuck without a rotation...  So much stress.  Wish I could just be done with medschool and onto residency.

Thursday, March 22, 2012

Last Day in Peds

Last day - it's been a fair 6 weeks.  Aside from being sick for one of the weeks, it's gone really well.  My preceptor thinks very highly of me and I've gotten my timing, writing, and presentation skills down as far as history and physicals go.  I'm looking forward to seeing adults again - kids are fun, but honestly, only if they can talk.  Babies are kinda boring.  Either way, seen a few good cases, gotten a couple challenging things to diagnose, but for the most part I refined my examination and presenting skills.  I have the test tomorrow and then it's off to Internal Medicine. 

In other news, I finally went to the other hospital and downloaded the case information for the patient who I want to present to my classmates.  I have a presentation in mid-April that I need to prepare.  Trying to get my rotations for fourth year all set up.  Our school's 4th year coordinator is apparently really bogged down with doing these, so I don't know how soon they will be out - I'm a bit anxious about getting the information out in time.  Hopefully it'll all work out and my rotations will fall into place without a problem.  Thank goodness UC Davis does an online application.  I should schedule my flight and hotel for my Step 2 exam - the part where we have to do 10 full patient visits in a row somewhere on the east coast.  Studying for the Step 2 written exam hasn't quite revved up, I'll need to get my butt on that.  This weekend I get a bit of a vacation, then it's back to work.

Wednesday, March 14, 2012

Pediatrics, Week 5

Okay, it's been a while since I updated - various things have happened - boyfriend had surgery, we had a friend visit and stay with us for a week, oh yeah, and I got a really bad cold after not being sick with anything of any kind for over a year.  Anyhow, pediatrics is going well, even if it is still pretty boring by my standards.  I like patients that can actually talk to you, and the majority of our visits seem to either be under 24 month well checks or kids with runny noses and ear infections.  Occasionally we get older kids, ADHD kids, and the like.  I got to hang out with a pediatric cardiologist, a pediatric behavioralist, and a pediatric endocrinologist.  I'll stick to the highlights...

As far as my preceptor goes, he seems to think I'm pretty smart and capable - he constantly comments that I am really good at writing up history and physical notes and write really quickly and well.  Basically I have them done at Step 2 Board Physical speed - get in the room, start writing, and by the time I'm out I have the history written and am halfway through the physical, already having discussed the assessment and plan with the patient to some degree.  I also have Step 1 USMLE studying to thank for having a reputation now as a medical dictionary.  It's funny, but I'm glad he thinks highly of me.  Even though I'm not particularly interested in pediatrics, I'm considering asking him for a letter of recommendation - simply because he would probably write a very complimentary one and has said on many occasions that I will be a great primary care doctor.

The only real complaint I have about him is that he won't let me interview Spanish-speaking patients, he insists on us just getting an interpreter and not letting me have a try at it.  I'm not sure why, I suspect it's for medical-legal reasons, perhaps he doesn't want to end up relying on what I say and then if something goes wrong then he can't refer back to interpreter #### who misinterpreted for him.

Still going to my didactic sessions, been mostly working on getting my applications together for my year 4 rotations.  I found several places I want to go for - my list of possible good places has increased from 2-3 to 3-4, and my list of total feasible options from 4 to a bit over 10.  It helps that I am going for family medicine, which is more receptive to DO students.

Next month around this time I will have to do case presentation - I'm planning on doing it on that young homeless woman who came in with abscesses in her muscles that we thought at first was meningitis or endocarditis.  It was a really interesting case and is a good way to talk about diagnosing meningitis, which is an important thing to understand.

Good news: I also got back my board exam score and not only did I pass, but I scored the average for all 4th years who go into family medicine residencies.  While it is just barely over the cutoff for one of the programs in Sacramento that I wanted, I can do better on my Step 2 and hopefully that cutoff was more for COMLEX scores and not USMLE.  Either way, I passed that and am essentially caught up to where I should be.  Now to study for Step 2 and get my fourth year figured out.

Thursday, February 16, 2012

Pediatrics, Week 1

Well, I have started pediatrics.  It is generally not the most interesting rotation, but there is a lot of stuff to memorize and it requires more participation.  Also, since it is a regular schedule, where I have to leave at 8:15 and end up back here around 6pm, I am finding my energy levels waning quite noticeably.  I've decided I'm just going to have to bring an energy drink every day to drink between 8 and 12, and that'll keep me going decently well for the whole day.  Luckily they don't cost much more than a cup of coffee, so it won't break my bank.  

As far as pediatrics goes, the most common visits involve a kid with a bad cold - usually with "sinusitis" or a possible ear infection associated with it.  If it's more than 2 weeks or the kid has strong symptoms, we prescribe antibiotics.  Personally, I think we are prescribing antibiotics too much and if it were me then I would not prescribe them, but right now I'm the student and I don't want to rock the boat.  We also see a bunch of kids for their ADHD, or monitoring their doses.  I still don't quite know what to make of it yet, as I've never attended a group session where the kids are seen interacting with each other and I don't know from experience what "normal" child behavior is.  Then there are the endless well-child checks, at 2 months, 4 or 5 or 6 months, 9 months, 12 months, etc.  We check their developmental milestones, answer parental questions, prepare the parent for the next stage of development and what to expect.  We haven't had any crying kids yet, so I'm kind of surprised - they are all really compliant with the exam, especially with the ear exam.  They've also let me examine them without much problem, they're all pretty nice.  I'm sure we'll have some combative screamers eventually, but so far so good.  

In other news, I finally got my isotretinoin medications today - better known as Accutane, though I have the generic version.  The process is extremely involved, especially if you are a female.  First you consult with a qualified physician who is familiar with isotretinoin, the indications, etc. and you discuss whether it is the right option - you are supposed to have exhausted every other treatment first.  Next, you get this packet for "females who have the potential to become pregnant."  You are required to read through everything, sign and initial tons of papers, and register and answer questions online swearing that you will use two forms of birth control (primary method such as hormones, an implantable device, or injections, and a secondary barrier method like a condom).  You must then wait for 30 days, and get a blood test within 7 days of your next appointment.  At that appointment the doctor makes sure you've done everything you're supposed to and that your blood tests check out, and they give you the prescription.  Once you have that, you have to take your special ID card, after having filled out the questionnaire online and registered, and go to your pharmacy to fill the prescription - if they do not have the medication on hand, then you have to wait until the next day when they will have it. was that day, and I now have it.  Side effects (aside from pregnancy) include skin sensitivity, depression, stomach upset, liver problems, skin dryness.  

I have seen some uncommon things though, which is cool - like Henoch-Schonlein Purpura and Roseola.  Also saw a case of Fetal Alcohol Syndrome, which is horribly tragic.  

Wednesday, February 8, 2012

Last Week of OB/GYN

Here I am, in my final week of OB/GYN.  Surprisingly little has happened between my last post and now.  There have been very few deliveries that I have been around to see.  I didn't do any 24 hour shifts last week because I was studying for my USMLE Step 1 exam (Feb 4).  I am also not doing any 24 hour shifts this week because I have my COMAT exam this Friday, which I take at the end of a block of rotations (e.g. OB/GYN, pediatrics).  As far as the USMLE goes, I think it went well, I am pretty confident I passed, and fairly confident I got around an average score.  It's hard for me to gauge because I took only one practice assessment and a lot of the questions that were on that test weren't very representative of the most commonly tested items.  Also, unlike practice questions, this test did not have very many of my weak spots on there; so, there were very few questions about CV/Respiratory physiology, elaborate equations, or complicated mechanisms about adrenergic receptors and drug combinations.  There were some endocrine questions which I may or may not have gotten right, and a few complicated ethical questions, but aside from those, I think I did decently well.  Only one or two questions were asking me about things I had no idea about.

Now onto this week - the most interesting thing that has happened was a woman in her mid-30s came in (she is in her late 2nd or early 3rd trimester) and she has profuse sweating, 102 degree fever, mild chest congestion, tachycardia, very fatigued.  She was kicked out of her house by the baby's father (likely because of her drug problems) and she was brought to the hospital by the homeless shelter people.  One of the more perplexing things about this case was that her white blood cell count was within normal range, and the ratios of cells was all practically normal - only up or down in a couple areas by 1 percentage point.  Also, her chest x-ray did not look very concerning - only some mild opacities along the central portion of her thorax and slightly on the left (mediastinum).  Her lung sounded pretty clear.  We also got a report from her past medical history that she has no asthma history, but she was diagnosed with hyperthyroidism back in the year 2000 and she said she hasn't taken any medications.  So of course the first thing I'm thinking is exacerbation of her thyroid disorder, possibly thyroid storm, because hyperthyroidism can cause all of her symptoms.  So my preceptor thought I might be onto something and ordered a stat TSH - it came back < 0.01 - in other words, something is suppressing her thyroid stimulating hormone production, this is most commonly caused by an excess amount of thyroid hormone causing feedback inhibition.  We ordered free T4 and free T3, as well as a thyroid hormone receptor antibody test to see if she has an autoimmune cause of hyperthyroidism (common in women 20-40) called Grave's disease.  My preceptor was very excited about me making a call she probably wouldn't have thought of - so hopefully that will reflect in my evaluation a bit - I haven't had any reviews yet that were particularly complimentary about my medical knowledge.  

At the moment I am keeping an eye on that patient from yesterday - her fever has resolved somewhat since starting the antibiotics for possible pneumonia, so maybe we just caught a really early pneumonia and the hyperthyroidism is just a longstanding comorbid condition.  Either way, hyperthyroidism is something really important to deal with in general, and in pregnancy especially.  I also have a presentation tomorrow about intrapartum anesthesia - emphasis on some of the lesser used modalities, such as nitrous oxide (commonly used outside the US), acupressure, and osteopathic medicine (mostly because my preceptor expressed interest).  I'll work on that when I get home probably, it's a little hard to focus here - I kinda need a break but I'm gonna stay at least a couple more hours.  My preceptor isn't here and we only have the one patient who probably isn't due for several weeks - and who knows if any other pregnant women will be coming in within the next few hours.  Even if they do, the odds that they will be imminently entering active labor are slim.

After my COMAT exam on Friday, I get to enjoy Valentine's Day weekend and then Monday I start Pediatrics after my Accutane appointment.  Wooh, fun times.

Thursday, January 26, 2012

3rd and 4th Weeks of OBGYN

Phew, it has been an intense couple weeks.  Have barely had time to think.  I'll start with my 3rd week (last with Preceptor #1).  As far as the clinic days went, we had some interesting cases - an IUD expulsion, a retained tampon, trichomoniasis, and lots of pregnant women with whom I got to practice finding fetal heart sounds.  The most recent thing I can remember is my last day there - Thursday which lasted 24 hours.  We had clinic during the day, then that evening we had an overnight call shift from 6:30pm-6:30am.  I think it was that night that at the start I joined the doctor for a laparoscopic ectopic pregnancy removal.  She was somewhere between 12-20 weeks.  Apparently it is rather rare for an ectopic to get as far as surgery because they usually catch it early enough to use medical interventions.  Anyhow, that was interesting.  Then I slept for a while and got woken up for the delivery at the end of the shift.  My preceptor let me sit in the front seat for this one and I delivered the baby, handed it to the mother, clamped the cord for the dad to cut, and delivered the placenta.  My preceptor sutured up the tears, of which there weren't very many, and we took care of that.  There was some retained placenta (I think because he was trying to get it out before it was fully detached, I would have given it more time but that's my side of things), but he got it out with a loop scraper. 

A few other things of note - I was following a patient who I had assisted on a delivery for.  She was a caesarean section because of a placenta previa.  As a result of excessive bleeding that was suspicious for retained placenta or at least failure to clot, we took her back to the OR but in the room the uterus had essentially stopped bleeding so we inserted a 'balloon' to help plug the bleeding via compression.  We took that out the next day.  There was another patient for who had a urethral sling, vaginal/cervical suspension and anterior and posterior repairs done on the pelvic floor.  Her posterior repair (the easy part at the end) wouldn't stop bleeding and she developed a painful hematoma so an hour after taking her out we had to bring her back into the OR to redo the stitching.  That was a bit of a pain.

Now onto my 4th week (1st week with Preceptor #2).  My new preceptor is very nice, a bit more 'preceptor-like' than my previous ones - a lot more teaching, more presenting, more following patients, more is expected of me but I am rising to the challenge without much problem.  It's more mentally stimulating and it's nice to have a little autonomy.  The first day I saw one delivery that went well, and then there was another one that ended up being a shoulder dystocia.  Shoulder dystocias are one of the most scary complications in obstetrics because a healthy baby manages to get it's head out of the vaginal canal, but one of the shoulders gets caught beneath the woman's pelvic bone.  This causes compression of the cord, and compression of the baby - so the baby is getting less oxygenation from the mother, and is doubly unable to expand its lungs to breathe air from the outside.  At this point the team starts a timer and begins various maneuvers to free up the shoulder - including hyperflexion of the mother's legs at the hip, suprapubic compression, reaching into the uterus and trying to free up the arm, and various clockwise/counterclockwise rotations.  Last resort includes breaking the collarbone and/or humerus.  Many complications can occur as a result, one of the most notable ones is a brachial plexus injury which results in nerve damage to the impinged shoulder.  The baby comes out with an arm that doesn't rise, it is pinned to the baby's side and it's hand is facing behind it - Erb-Duchenne Palsy (or "Waiter's Tip" palsy).  Anyhow...this baby they got out and it ended up having decreased arm movement, it looked like it had some nerve damage.  Luckily, even when these signs are present at birth, 85-90% of the time the baby recovers in the first 2 months.  By the second day after the delivery, the baby was starting to move its hand and shoulder. 

Now onto today - a nice long 24 hour shift from 7am to 7pm.  This L&D floor is a lot smaller than the previous department that I was in so there aren't too many active patients, and there's a bit more down time.  However, as luck would have it, we had ANOTHER baby with shoulder dystocia today. The first baby ended up being 9 pounds 11 oz, and this one was 10 pounds 1 oz.  Needless to say, it is well documented in the literature that large "macrosomic" babies have a higher incidence of shoulder dystocia.  This one didn't have any real nerve damage though.  The mom was pushing for a good 2.5 hours, it was a little challenging with language barriers but it worked out okay.  From what I can tell, shoulder dystocias are not very common occurrences - some previous students haven't even seen a delivery period, so for me to see two dystocias is pretty crazy.  I'm glad the outcomes have been relatively good.

We also had an interesting ED consult for gynecology - a woman with a 14cm possible tubo-ovarian abscess.  We have started her on empiric antibiotic therapy while we wait for GC/Chlamydia results.  There is some concern that it may be a tumor, or have some tumor involvement because she has had significant unintentional weight loss over the past 6 months.  No way to know at the moment - just gotta treat.  I'm gonna nap now, I'll be woken up if we have any new admits - on the plus side, I get the day off tomorrow.  More studying, wooh!

Wednesday, January 11, 2012

Call Night and Week 2

OB-GYN is coming along without much of a problem.  I had my on-call night, and I thought I had been warming up to the whole baby thing, but I think the first vaginal delivery was kind of the ideal situation, along with ideal family responses, and environment.  The call night started out with figuring out logistics essentially - talked to the doctor for the evening, and it was my preceptor and this other female doctor on call that evening.  They divide the night into shifts, and so my preceptor slept from 9pm-2am, and the other doctor got to sleep from 2am-7am.  Like all medical students, I wanted to show my enthusiasm, so I decided to spend as much time with the other doctor before caving into sleep.  We had a couple interesting cases.

First case - fetal demise in an orthodox Jewish woman, 3rd pregnancy (has two living children).  A couple things are wrong with this case.  First, she was inconsistent with her prenatal care and was taking a lay midwife's advice over going to prenatal checks with her physician.  The doctors that I work with at the hospital have made a distinction between the midwife nurses at their hospitals and the lay midwives who are not affiliated - that in the hospital, their threshold for thinking a baby is in trouble (and thus, needing to interfere with the 'natural' progression of a gestation and vaginal birth) is a lot lower.  As a result, the hospital midwives are more willing to consult a doctor about a baby's status, or suggest a C-section.  Anyway, the woman stopped feeling any fetal movement around 23 weeks and the lay midwife said that was "normal".  The woman finally comes into the hospital after a WEEK of her baby not moving and there are no fetal heart tones of course, so it's dead.  The second problem is that a lack of prenatal screens/ultrasounds didn't catch what is most likely an anencephaly (or lack of a head) on the baby.  It could have been caught a couple weeks earlier, but no.  People like to talk up natural traditional methods of health care, but there's a reason we have these tests.  The third problem with this case is the orthodox religion - mostly it just makes patient care more difficult, but they need to consult another rabbi (even though her husband is a rabbi) to determine if they can test the placenta (dead baby is definitely off-limits) for chromosomal abnormalities.  Often when a woman has a fetal death, it is reassuring and relieves guilt to know that the baby had a chromosomal abnormality or other problems inherent in the baby that would have made it nonviable no matter what.  

Next case of the night... this really pretty Asian girl, possibly Filipina, late twenties, on her third child.  Her husband was with her, kinda ugly, but I gave him the benefit that maybe he's just a really sweet supportive guy to win a gal like her.  She decided to go through the vaginal delivery without any epidural anesthesia, and she barely made a peep - she did a great job, trembled a lot, but delivered the baby pretty quickly.  Right after this, the husband essentially ditches his shaking wife and stands with his back to her filming the baby in the warmer with his phone.  Once or twice the wife seemed to try to get his attention but he either glanced briefly or didn't respond.  This went on for at least 10 minutes, the whole time I was in the room anyway.  There also wasn't anyone else in the room, no other family.  I never saw him go over and ask her how she was feeling, or tell her she did a great job - made my blood boil.  

Next case before I went to bed - 21year old girl, second pregnancy, husband was this short kinda meek white guy - she delivered like a pro too - she did have an epidural, but she basically had no problems.  The husband on the other hand just about passed out when he saw the baby crowning - he wasn't intending to look, he was walking around where we were to the other side of her and his face just went white and he just about fell to the ground right there.  It was kinda funny, but at least all the family were supportive, smiling, and the husband stayed next to his wife this time.  

After that I went to sleep and my preceptor called me when he had a new case - we did a few checks to see if any girls' water was breaking, interesting stuff.  Around 8am I was done and in the car.  

That was it for that week - yesterday we started in the clinic and I got to do some Pap smears and some prenatal checks where I measured the uterus size (to see if it was consistent with the gestational age) and checked fetal orientation and heart rate.  The first one or two were a little challenging to find the heart beat for me, but I think I've started figuring out where the baby's body is oriented, so I was spot on the last 3 heart rate checks.  We saw a woman with an expelled IUD - usually that doesn't happen to women who have had pregnancies, but apparently she was told she has a short cervix.  

Today had two surgeries - one was a mid-urethral sling insertion, which is to help with incontinence.  The woman was awesome - she was a feisty, energetic, humourous elderly woman.  It's always reassuring to see older people with such vitality!  So that surgery took 35 minutes, no problem.  The next one was significantly longer, a laparoscopic vaginal hysterectomy, on a woman with an enlarged uterus and multiple fibroids - had to cut it up a lot and bring it out piece by piece.  The doctor my preceptor was assisting actually thanked me at the end for my help because the extra pair of hands made it go a lot better than they were expecting.  Yay!  

Tomorrow is a morning/afternoon of surgeries, and then another evening of call duty - I think I will try to sleep when my preceptor does this time, since I will not have had all day to relax.

Sunday, January 8, 2012

1st Week in OB/GYN

Well, almost done with my first week in OB/GYN.  The first day we were on gynecological duty, so we were seeing patients in the hospital for ovarian cysts, pyelonephritis, etc.  However, we did assist on two C-sections and I got to observe a vaginal delivery.  It feels very odd to see a family react to a "birth" in scrubs while surgery is still technically taking place (suturing everything up, still have half the environment sterile).  The vaginal delivery setting makes a lot more sense - the delivery I saw only took about 40 minutes too so that was a pretty quick delivery.  Watching the men is the funniest part because they look terrified and helpless at the same time - after all, it's not like they can relate in any way and they can't really participate in the actual process - she's doing it all herself.  Of the two delivery methods, I'd definitely rather do the vaginal one personally (with epidural of course) - it just looks a lot more impressive.  

The next time I was in the hospital we were rounding on patients and doing a lot of gynecological surgeries so several hysterectomies and salpingo-oophorectomies (tube/ovary removal).  Not the prettiest of surgeries...especially when they do a hysterectomy through the vagina.  Before heading into this rotation, I had no idea that OB/GYN doctors do so much surgery.  Anyway, tonight we are on-call from 7:30pm to 7:30am, so I best be getting off to that - should be interesting.  I like night time, and I'm packing an energy drink - I hear there will be many deliveries.  I will post about it next time I have a spare moment!

In other news though, I got my loan disbursement, so money is not a problem for a little while.  I emailed my school contact about year 4 rotations and I am still studying for the boards - Feb 4.