Closing down this chapter...

I've decided that blogging about life in medicine isn't something I want to continue doing.  Not because it's not a huge part of my life with interesting and vexing elements to it, but because it is more stressful to think about those things a second time for the sake of sharing.  While some may find it therapeutic to share anecdotes from daily life that were anxiety inducing, scary, stressful, difficult, or harrowing learning experiences, much of medicine for me is now either "the usual," or stuff that just gets me frustrated.

I have participated in National Novel Writing Month during 2012, 2014, and 2015 - this year I finally beat the challenge and wrote 50,000 words in 30 days, despite my many obligations.  The setting was a Martian terraforming colony in a dystopic near-future, in case anyone was wondering.  I bring this up because in 2014, I thought I would try "writing what I know," which meant a comedic satire on life as a doctor, ending up someplace that you didn't think you would end up a la Northern Exposure, gaining insight into a world not many people have.  I found that trying to describe my life and the lives of my fellow residents in prose simply made me feel depressed.  It was much like reliving those experiences and was hardly cathartic or helpful.  It just enhanced my jaded attitude, which is already premature considering my length of practice.  I find it better not to think about it and just do my job the best that I can.

In that regard, I have succeeded.  I am pretty darn good at what I do for my level of experience and training compared to my peers, and will only improve from here.  I will still devote myself to providing the most evidence-based, clinically and personally appropriate care for my patients.  Whenever there is an unanswered question, I will leave no stone unturned and never stop working for them.  My passion for medicine and knowledge has not ceased, but I no longer have any desire to write about it at length for the sake of psychosocial commentary or sharing it with others.  One time is more than enough.

I am now halfway through my third year of residency.  I am poised to easily pass my boards come April, according to our yearly assessment test.  I still have a few residency hoops to jump through, but then I will be leaving and moving on to bigger and better things.  I find I prefer in my spare time after long days in the hospital or at the clinic, provided I don't have extra stuff to read up on at home, to ruminate on fantastical things and fictional worlds, or enhance other skills such as languages, musical instruments, art, knowledge of the natural world, etc.  I have enough medicine in my life, so blogging about it feels superfluous.  Time to tie up this final loose end here.  If there are any who follow this who are curious about the non-medical side of my life, though medical stuff does pop up from time to time there as well, you can switch over to my other rarely updated blog Embracing Obsession.  With that, adieu.

A couple weeks from being a senior resident!

It has been a long time since I posted, things have been busy.  I guess the big updates include... being advanced to second year, getting through nearly all of first year with essentially flying colors and strong recommendations within my program, passing COMLEX Step 3 with a better score than Steps 1 and 2, and making a few new friendships.  Made it also through my first year of marriage, and couldn't be happier.  I guess I don't know what else to say - I've heard from some people that some of my patients have been recommending me, or at least saying good things about me to other people in the community, which is about as unbiased an opinion as you can get.  

What's on the horizon...I get to be a senior resident, and I'm on the internal medicine service first, so I'm trying to mentally prepare for the task of being the first to manage the completely green interns.  The two I am with I feel optimistic about, but we will see what skills, expectations, and experiences they come in with and go from there.  I've got a bunch of handouts and things to talk about planned, without overloading them I'm hoping, so should be interesting.  I am looking forward to my vacation in September, which will be a more official 1 year wedding anniversary celebration, since there aren't any good times in the next couple weeks to celebrate...  

Anyhow, I am still alive, I'm feeling more confident in my skills and knowledge, and looking forward to as well as feeling anxious about the coming year.  Soon I'll have my DEA number assigned and have more autonomy, too!  Speaking of which...I need to start the paperwork for that...

Night Float...

Well, this is my second week on Night Float - 5:30pm to 7:30am.  The roughest thing isn't so much medicine itself, but rather only having 2 hours of time where you are awake at home.  I get home around 8am, sleep until 3pm if I want to get 7 hours, shower, put some kind of food together for "lunch," prepare a sandwich and grab some fruit for the night shift, and...well, there's not really much time for anything else.  Do some chores, maybe watch one episode of something.  

The nights themselves, for me anyhow, have been pretty relaxed.  It is rather nice to not have a senior staring over your shoulder, checking to make sure you've done your work the way you are supposed to, etc.  The extra responsibility isn't too much to shoulder, as I've been pretty self-sufficient for a while.  Since it's pretty much living at the hospital for 14 hours, it's a mix of work and play.  I've been going through American Board of Family Medicine modules (well, admittedly just one because it requires a lot of focus, but hey, that one I did is complete!), reading guidelines (management of supratherapeutic INR, hospital-acquired and community acquired pneumonia, definitions of leukocytosis, to name a few), and updating the patient list and of course admitting patients as I get pages, which hasn't been particularly frequent.  I also have practice board questions to go through.  

As for the play, well, I have my computer and my external hard drive, so possibilities abound.  Lately the other night resident (who is on a different service) and I have started watching Breaking Bad.  I think we can justify it because it gives us an inside perspective on all the meth abusers we see here, plus on giving patients bad news about cancer or medical conditions, and just seeing more and more of the drug abuser and patient perspective.  Plus it's good drama.  I can't quite justify playing Doom 3 the same way...

Only three more night shifts and then I get to go on vacation!  It is sorely needed.  Sometimes I feel less motivated, I need more time to do my own thing.  I am studying but it's hard to do that when you're trapped in one place.  Cabin fever a bit, I guess.  Lots of fun planned, mostly with friends and family.  Simply being in Davis will be a relief, where there are many other young educated people, enthusiastic about education and life, and where you feel comfortable walking around town to get dinner at 8:30pm and don't feel like you need to speed walk to your car.  Plus boba and fresh sushi!

Half way through Intern Year

Well, I'm still here, still doing the doctor thing.  It's been exhausting of course, but still trying to find time to do fun stuff.  I'm about ready to make my New Year's resolution list, usually I choose 10 things, but that will go on the other blog.  Recently I've done more Obstetrics, Medicine, and Pediatrics.  A recent development in the last couple weeks - I had heard whispers that some of the second and third year residents were concerned about one of the first years' readiness for night float, where we are the only one on the service without a second or third year helping us.  As it turns out, they all met and discussed the readiness of the interns, and they decided to swap me into this intern's slot and rearrange things so that that intern would be going last, to allow more time to be ready.  It actually works out well for me because now I get to have my two weeks on Medicine at night right before my two week vacation, instead of right after.  Also is nice to know that the residents think I'm doing well. 

Coming up for me is a week on psych, so I should be able to get a little bit of a break before I start on night float.  There have been difficult patients, challenging patients, all that, but it's hard to know when something is interesting enough to report.  Seen a lot of drama in the hospitals, luckily I'm staying out of all that.  Anyhow, I'll try to think of something good to write about... just working and working and working for now!

Night on Call

Well, here I am, another night in the hospital. I decided to plan ahead and took about an hour nap, maybe slightly longer, before coming to work at 7pm, and took a 100mg caffeine tablet. Just took my second 100mg tablet now, at 12:45am. I was anticipating it being a nonstop night, however everything is all organized now, did a vaginal delivery, my notes, etc. and now... just waiting for admits or for all hell to break loose. This is just a weekend call though, 7pm to 11am the next day (at most). OB and Pediatrics. This past week and this coming week I am on surgery. It's been a nice change of pace, and getting home at a more reasonable hour as well. My attending looks and sounds exactly like Hugh Laurie on House. It's rather uncanny. One of his patients even pulled me aside and asked, "Does Dr. so-and-so look like Dr. House to you?" I don't know if it's surgeons in general, but he also has a lot of interesting stories. My previous surgery rotations were also filled with story telling. I wonder if it's because sewing, cutting, spreading, etc. isn't super cerebral and you can just chat while doing it. I had my in-training exam last week - I kinda just rushed through it... I know I probably should have taken it more seriously but...meh. Just wasn't in the mood, and at this point I feel like either I know it or I don't. Well, next weekend I get both days off, yay! I'll be driving over to my parents for my dad and sister's birthday - should be fun! Anyhow... guess I'll go back to studying random stuff... what to study, what to study...

Starting on Obstetrics

Well, after having four nightmares in a row about starting Obstetrics and hearing horror stories about staying horribly late and being super busy and stressed all day charting, I wasn't expecting this OB rotation to be as enjoyable as it is.  It's fairly relaxed, the Attendings are nice, and the first day I got to deliver two babies in a row, delivery times were 11:44am and 12:07pm, and they were in rooms across the hall from each other!  Felt pretty exciting.  I also have all the notes I need to write prepared in templates, so I can get things written a lot faster.  Today I delivered another baby and the family wanted me to take a picture with them - it's definitely a different environment than Medicine or ICU.  

Vacation was great, though I was sick for the first few days - back to the grind.  The weather is getting cool and routine is returning after a lack of much of a schedule for two weeks.  A few things I still have to get around to are my loans, which will be due December 7th, and I need to schedule my Step 3 exam.  For now though, things are quite peachy.  After this, is Pediatrics.

Medicine and ICU

Phew, it's been exhausting!  I had a month on internal medicine service where basically every day for 12-15 hours I'd be at the hospital managing a panel of patients and admitting new ones from the emergency department.  It was rough, and there was plenty of weekend hours put in as well.  I had an easier time of it compared to some of my colleagues because, again, I'm pretty comfortable with electronic medical records and working with computers in general.  I didn't have any real time to do readings, however, so now that I'm on ICU which is more about learning than having any intense responsibility for patients, I'm finally able to catch up on all the stuff I wanted to review.

For example, while on medicine service I saw at least 3 cases of "acute pancreatitis," with two legit cases and one (maybe more) case of not-so-legit pancreatitis.  I finally had time to go to the American Gastroenterological Association website and find their guidelines for acute pancreatitis and read up on the latest "word" from the experts.  We definitely weren't managing the patients ideally, we were managing them fine but not particularly ideally.  That's one of the challenges in medicine is that it's a constantly evolving field and you have to stay super up to date on the latest treatment protocols and what the studies are saying.  We even have a website that is essentially a wikipedia for physicians, called "UpToDate" - the name says it all, it's where doctors go to stay up to date on information.  However, UpToDate isn't always the best organized website and I don't particularly like how it's structured, plus the articles aren't necessarily peer reviewed by experts in the field based on only the best, most solid, studies.  That's where specialty society guidelines come into the picture.

In ICU, we actually had a pretty 'exciting' semi-TV moment of emergency patient care - an older woman currently on a ventilator suddenly started having blood come up her nasogastric tube, so essentially she suddenly developed bleeding and her vital signs showed she was in distress.  The rooms in ICU should be bigger than they are, and this one felt particularly cramped.  The crash-cart was between the end of the bed and the opposite wall, and I was on the inside half of the room and my attending (a very intelligent younger doctor who looks more like a college student than a seasoned ICU doctor) literally ran over the bed to get to my side so we could insert a chest tube - he didn't have a gown on (just a white coat with the sleeves rolled up to his elbows) and ended up getting sprayed with some of the fluid when the tube was in - he had eye guards in place at least (aka glasses).  Then we immediately pulled from the other cart a fiber optic cable to see where the bleeding was coming from and it was essentially seeping from every surface in her lungs - diffuse alveolar hemorrhage as they call it.  No source to suture, cauterize, or slap a bandage on - just have to keep giving her suction, oxygen, and start steroids.  She had developed a chronic lung condition over the past year and it was not going well.

Heroics aside, ICU can be a very difficult place.  We had a young girl come in and die within hours, and it shook the ICU physicians and staff for the next several days, and it made news in the community.  It's not part of the plan for young, otherwise healthy people to suddenly die of overwhelming bacterial sepsis, but it happens and there's very little you can do to stop it.  Also, one of my patients who I had been managing a week prior on the normal hospital floors for a pneumonia and fluid in her lungs, a very sweet older woman with mild Alzheimer's dementia, ended up choking on her morning breakfast and ended up in the ICU on a ventilator, likely with brain damage from lack of oxygen.  She had been on a dysphagia diet, but hadn't been officially evaluated for her swallow by a speech therapist - her eating challenge wasn't obviously apparent, it was more that she would eat too fast and choke slightly on her food rather than any physical deficit.  I hadn't seen her since, and she was probably going to be discharged from the hospital that day or the next to a rehab facility and then an assisted living home.  I don't know if it would have made a difference to have that swallow evaluation or not, part of me thinks it would have gotten her out of the hospital, home, and then maybe a little longer in this world, but on the other hand, it may have only been a matter of time before something like that happened.  If she'd been switched to a liquid only diet, would it have changed anything, or would she have developed an aspiration pneumonia later and ended up in ICU in a month anyway?  She died that night - no code was called, so it's likely the neurologic findings were dismal and the family agreed to withdraw life support.

On the more positive side of things, I've been appreciating more how much patients like seeing their doctor in the hospital, even if it's a resident physician.  It's still hard for me to see myself as a REAL doctor, but we are making decisions for the patients and know them better than the attendings.  We check on them two or more times a day, not including all the calls to the nurses, reading up on previous visit notes, calling their physicians and specialists, and checking and ordering labs and radiographs, which patients don't get to see.  After I moved to ICU service, I went back and checked on one of my other patients from medicine a few times, as she was an especially complicated case, and helped the new team manage her discharge a bit.  She was really appreciative that I was still coming and managing her - she had had a somewhat 'flat' affect and wasn't all that talkative or cheerful so I wasn't sure initially if she even liked seeing me, but she made it clear later that she was glad I was still involved in her care.  Another patient I had discharged a couple weeks ago, a young person who had gotten frustrated several times while in the hospital about being kept there for treatment and had landed himself there by some fault of his own, came back today to get some paperwork filled out and actually said of the doctors who were coming to see him he liked me the most and was glad to see me.  I was his regular doctor, and when people are in pain and are grumpy it's hard to tell if they're mad at you or if they think you should be doing something that you're not doing.  I'm glad to know that even the patients that I think are not satisfied with their care do actually appreciate the work we do.

In another example of networking and working as a team, I talked to a nurse who had semi-challenged me on a medication decision.  Long story short, I thanked her for voicing her concerns, because after the fact I went and re-examined the data behind the study that a senior resident had very emphatically told me was going to be the new standard of care, and decided that the risks do not outweigh the benefits.  Initially she may have thought I was blowing her off because I told her my justifications for wanting to prescribe the medicine which, don't worry folks, never ended up getting taken by the patient because he felt like refusing meds and even if he had gotten that one dose before I discontinued it, it's the kind of medication that takes time to build up to a therapeutic level.  I didn't HAVE to talk to her about it, as it wasn't really an issue, but I elected to for a number of reasons.

First, it's important for nurses to feel respected and not marginalized in a very hierarchical system where doctors are traditionally seen as their opponents, not partners.  We rely on them for patient care and we want them on our side and voicing concerns, when legitimate.

Second, nurses talk - if she thought I had blown off her concerns, she probably would have gone complaining to all the other nurses that I'm a bad doctor and endangering a patient, or that I'm one of "those doctors who think they are better than nurses," and I have to work here for the next three years.

Third, if nurses think their patients are in danger and that physicians aren't listening to their concerns, they will start doing things on their own - which in rare cases does help patients, and in many other cases doesn't, like times when nurses think a doctor has prescribed too high an insulin dose, pretend or abstain from giving it to the patient, and in the morning the patient has blood glucose > 300.

Fourth, good karma.

Well, at the end of this week, I'm free for two weeks to do whatever - my first vacation of intern year.  When I get back I get to jump into OB/GYN... Not looking forward to it very much.  On the plus side, I got my call schedule for next month and I won't have to do a weekend shift for the first two weekends, which is great since on the first weekend there is a Cardiovascular Symposium I'd really like to attend!  I've got a bunch of nice stuff planned for my vacation, and can't wait to get started, but I'm also really liking the pace and learning opportunities in ICU.  Having an attending who likes discussing the latest care guidelines and is passionate about evidence-based medicine is always very invigorating - it's the most academic we get, as clinicians.  Time to go read more stuff!

A Couple Weeks In...

Well, still at it - doing the whole doctor thing.  It's fun, though I still gotta say I like clinic the most.  Clinic is where I see myself practicing most of the time.  Right now, though, I've got another week of Emergency left.  It's fun, it's interesting - a fair few procedures and such.  Only thing about it though is it's all very short term - essentially putting a bandage on someone's problem.  I would find that very demoralizing after a while.  I guess it has the same appeal as surgery - there's a problem, and you fix what you see in front of you.  Maybe it was my education at an osteopathic school, but I just don't see the appeal.  Or at least it doesn't really feel like being a 'doctor.'  You don't even get to do elaborate labs when you have an interesting case - it's just 'not our problem, they'll work that up later.'  The lifestyle is somewhat appealing, a few long shifts then a few days off, but still - doesn't have the same appeal in terms of feeling fulfilled.  

Right now trying to figure out what I should focus on learning on my own - there's so much stuff to learn more about, and it's hard to know what to focus on.  

Also enjoying being employed - getting paychecks is great.  Once I get used to the schedule of how things work I'll feel better about everything and a little less stressed - scheduling in enough sleep is the biggest challenge.  I want to get more out of my day when I've been gone a long time, and end up cutting into sleep.  Almost August...my how time flies.  Well, I think I'll try to read up on one medical topic and one medication each day.  Or every other day.  Whichever I can accomplish.  I'd really like to at least know what receptors everything acts upon - some of them I know but some I just memorized what you use them for.  The nuances count the most...

As far as my crusade against poor management of mental health in outpatient medicine, I'm still not backing down.  Still using my PHQ-9s, documenting them, discussing it with patients... it would be really hard to manage some patients if I were limited by time the way the real doctors are.  I'm given a lot of time to see patients and hear their stories, and I'm really thankful for that.  It'll be a challenge in the future when I have to boil down a 45 minute psychiatric visit into a 15-20 minute visit that includes their other problems.  Gotta pick the battles where you can...

First Week of Residency Year 1

Well, I've had about a week of being a resident - I have to say, parking in "Doctor's Only" spots, getting all the free cafeteria food I want, introducing myself as a Doctor so-and-so, it's been pretty great!  It's taking a little getting used to, but it's fun!  I'm finally having a part in patient care and I think the confidence that comes from having decent decision making skills is making me better with my patient interactions.  Also, I have electronic medical records down almost like a second language after only a day or two.  I haven't used this system before, but I've always been good with computers so...after two years of gritting my teeth while watching my attendings attempt to chart patient visits, finally I am the one doing that!  

I've started out with clinic and homeless medicine - which is very interesting and it's a pretty easy way to start out.  The hours aren't that long and I get to do a lot of reading and videos.  I like that I get noon conferences - kind of a daily lecture on random stuff.  Also the commute from my place is less than 15 minutes no matter where I have to go so far!  For emergency, which I start next week, it gets a little more tricky - I might end up driving 30 minutes each way.  My first call is this weekend, luckily it's 7pm to 7am, starting on Saturday, so I get to sleep in and get both days to hang out and do stuff.  

Pretty much all moved in up here - our place is all settled, wedding and honeymoon are all done for now, time to get back to work...  I'm trying to start out with good habits - always taking care of things on time, staying organized, you know.  The things everyone says they'll do but usually don't do.  Well, I'm hoping to do them!  Anyhow, time to enjoy my evening... after a long day running around trying to keep a bunch of things straight in my head...

As a PS:  I keep seeing emails from recent medical graduates, international, caribbean and domestic, all sending us their applications hoping we've had a vacancy or to get started for the next round of residency applications.  All I can say is I am sooooo thankful to be done with that and finally I can stay put for three years and get paid money!  MONEY!  It's not much but it's something!  

Next Steps...

The last day of fourth year/rotations was last Friday - my last two rotations were allergy/immunology and forensic pathology.  It was quite neat seeing how they track bullets through people and the various gross findings in freshly deceased persons.  At any rate, I'm finally done and I am looking forward to putting Touro behind me and moving onto better things, with my excessively high 300k debt following behind me.  We have our apartments in Davis and Redding secured, and soon I'll have to do some PALS training, computer training, ACLS, BLS, etc.  That won't be until June 19 though, so until then I get to relax and do some prep work for those things, and the wedding.  The wedding is the last hurdle - I'm half excited and half wishing it would just be over already, since we've been planning it for months and the Bora Bora honeymoon awaits us...  

Wish I had more to say.  I'm sure some of my experiences on the rotations are worth reporting but all I can think about is wanting to get away from Touro and start earning money.  I'm tired of just racking up debt in an overpriced institution (when you look at the national averages...) and standing in rooms while doctors and patients interact.  I'm tired of waiting and watching and want to start DOING.  Yes, it comes with responsibility, stress, and long hours, but I want to start moving forward in my life.  This is a big year in terms of moving forward, and I want to get on with it!  Graduation is June 2, tomorrow I'm picking up my regalia.  Soon...  soon...

Match Day: Redding

Well, the results are in and my match is Redding - specifically the new Shasta Community Health Center program for Family Medicine up in Redding, which shares its first year training curriculum with the Redding Family Medicine program.  Basically I am looking at 3 years of training and I should get a well-rounded family medicine education, considering the community-based nature of the program and the resources available.  

What this means is that now my fiance and I must change our current living arrangement - while we had really hoped to stay in the Sacramento area, in many ways Redding may be a better fit for me.  It emphasizes clinical medicine more than one of the Sacramento programs, UC Davis definitely wasn't a real "fit" for me, and the other Sacramento program would have been a close tie with Redding.  However, the fact that the Shasta program wants me makes them all the more desirable.  Currently we are looking for two bedroom/two bath cat-friendly places in Redding, and tomorrow will investigate a one bedroom/one bath place in Davis.  Hopefully schedules will work out so we can spend maximum amount of time with each other.  The other two residents in my program so far (they are still interviewing for a second PGY-2 spot) are both married with children, as are most of the previous years' Redding residents, which hopefully will foster a supportive environment for married individuals.  

I am starting to get excited about checking out the Redding area - see what the local area has in store for us. Our current landlord let us out of our lease agreement, since we signed without knowing we would be moving.  Didn't even charge us for backing out of the lease, which I definitely appreciated.  Hopefully we can sign a lease tomorrow and get that element squared away.  Heading to Monterey for a bit then going to start an Allergy/Immunology rotation.  

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.

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.  

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.

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
Merced

Salinas / Modesto
Reno

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...

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!

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.  

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.

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.  

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!