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!  

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.

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.

ICU

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.  

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.......

Last Day of Actual Surgery and Didactics Presentation

So today was my last day doing actual surgeries - tomorrow I have my last day of clinic with the orthopedic surgeon.  We did two arthroscopic surgery repairs, one of them was a rotator cuff repair which I hadn't seen before.  Another was an arthroscopic knee meniscal repair, and the other two were hand surgeries: carpal tunnel release surgery and a ganglion cyst removal.  I still get along great with the surgeon and his PA, so I'm not worried about my grade for this rotation.  He isn't very book-focused and they always joke when they see me studying so much so I assume they think I am intelligent enough.  

Throughout most of today I was reading and rereading my presentation for today.  As part of our third year clinical rotations, we have to attend didactic lectures on Tuesday, only an hour usually.  Every other Tuesday, one or two of us present, and we each have to do a total of two presentations by ourselves - one on a topic that we can elaborate on, and another on a selected clinical case.  My turn was today, and my topic was Psychiatry, so I chose Major Depressive Disorder because it is applicable to everyone.  I was worried about a lot of things - whether I would run overtime, whether I would bore everyone by talking about antidepressant medications, whether I was saying too much or too little, whether people would be unresponsive or not know how to answer my quiz questions, and whether people are bored to death with depression, because I remember we had a lot of lectures about that at Touro.

Anyhow, I gave my presentation - I got a slight boost of confidence because I went over it orally beforehand and managed to get it down to 19 minutes and 30 seconds, so I wasn't as worried about going overtime.  So I gave my presentation, people seemed to pay attention and like it.  Basically everyone was answering my pharmacology quiz questions, so it was definitely sticking.  When I got feedback, it was essentially a unanimous response that it was the best presentation all year, was really informative, I sounded confident and knowledgeable, had all the information that everyone had been craving, was varied, kept attention, etc.  The physician who attends all the didactic sessions and grades our presentations agreed that it was the best all year and was even at the next caliber level for what he expects from us - that it is the kind of presentation one could expect at the professional level at a real conference.  

Needless to say, this was awesome.  Honestly, I feel like I'm a decent presenter.  I try to convey my enthusiasm for a topic and hopefully drag a few unwilling audience members with me, but it worked out great. I used PowerPoint animations, humor, color coding, quotes... this was exactly the boost I needed to help me keep going on through studying boards and rotations.  I think I'm going to be happy and charged up the rest of the night!  Man.  

Infectious Disease, Last Week

Things are going well with Infectious Disease still.  We've had a few interesting developments.  One of our patients, the homeless young female patient who has had altered mental status and been in full restraints for the past week and has systemic Methicillin-Resistant Staphylococcus Aureus infection has actually started to come out of it.  From the start she had altered mental status and we haven't been able to get an MRI to see how her brain is functioning, so we have had no way to know how her brain was doing.  Through this we were speculating that she had bacterial vegetations forming throughout her body that could be throwing clots to her brain, and she even grew MRSA in her spinal fluid, so it could have been forming microabscesses in her brain as well.  Not to mention the huge abscesses in her iliacus and piriformis muscles (anterior to the spine in the lower back, behind the abdominal viscera) that started the whole deal.  I think none of us were really expecting her to ever come back to mental awareness, and we had not seen her in anything resembling a lucid state since we started treating her.  

Today she woke up.  

For her it almost seemed like nothing ever happened - just saying "I'm hungry," and "I feel tired," like she'd had a really long nap.  Calm and tired, not thrashing about or pulling at her tubes or anything like that.  No alarm yet, maybe has a little bit of a drugged look (understandably), and we still don't know the extent of the damage of this week of MRSA sepsis, but she's lucky she had my preceptor on the case for her infection and such a good team of ICU specialists.  It's amazing - there are some patients who you really don't know if they will recover who somehow bounce back, and then there are others who look fine and are ready for discharge and they die that evening.  Definitely drives home how unpredictable medicine can be.  

That's not to say that I think we should do everything in our power to keep a human body running when it is beyond what a clinician would estimate is "the point of no return".  Some absolutely septic patients, with multi-organ failure, and other comorbidities like diabetes and obesity are still getting specialty bone scans and send out labs even when their lactic acid level is at 14, they are on 5 different pressor medications and their blood pressure is still not in control, their stats are steadily dropping, and they're on a ventilator.  There is a time and place for hospice and palliative care.  Some points that indicated that perhaps our homeless young woman might recover were the following: she was never on a ventilator, her laboratory values were never all that particularly horrible, she was young, AND she wasn't obese, diabetic, or suffering any other comorbidities that we knew of (aside from drug abuse).  It's amazing what diabetes and obesity will do to your survival rates in a hospital.

FM2 Week 3

I'm in my second to last week of  Family Medicine - things have gotten even more routine feeling, especially since my current preceptor is a little more relaxed even than the first one.  He's great, just very chill, so he doesn't really pressure me to make SOAP notes and such.  I'm glad all the doctors have such good bedside manner, except that one that I mentioned before who had the difficulty communicating.  There was also this other doctor I was with one day who sounded tired/bored the whole time, no real emotional changes in his voice, but that's beside the point.  

This week there have been a few interesting cases - we saw a woman who had a gastric bypass who "felt like she had something stuck in her throat" and was feeling nauseous and unable to drink liquids.  She ended up having to be sent to the ER to get her esophagus checked and sure enough she had a bolus of food stuck in her lower esophagus.  I feel like most of the presentations I am seeing in the office are familiar to me now and I have a pretty good idea of what medications and treatment plans to use.  

Today I was with the sports medicine doctor again and confirmed that he will write me a letter of recommendation - I just need to email him my stuff.  It had been a while since I saw him (2 weeks), so I was glad our previous dynamic was still intact.  This afternoon my current preceptor and I went to do a home visit for a patient we saw previously in the office who is now on hospice care for his metastatic melanoma.  As far as terminal patients go, this one is rather fortunate - he is 86 years old, has two great-grandchildren, his wife of 66 years is still mobile and caring for him, and his daughter is helping as well, and he doesn't live in a nursing facility, he is at the home of he and his wife.  My preceptor essentially went over the basics for hospice - making sure he's eating and drinking, that he doesn't have any pain, and managing side effects of pain medications (constipation, which can cause secondary pain).  The wife talked to me a fair amount, and we did a check up with the patient, who has had a lot of family visits and support.  It would be horrible to know you only have a month or two left at best, but if that were the case, his situation is probably one of the more fortunate.  At the end they gave my preceptor two bottles of wine (it's Napa) and he ended up giving me one of them - a 2009 Rose Syrah.  I imagine as a doctor in Napa he gets a lot of gifts of wine from patients - and for good reason, he's a very nice and thorough physician.  

I have finished all the "modules" for my Family Medicine rotation, so now I need to finish the last two quizzes and start reading/preparing for my end of rotation exam.  Sometime next week I will ask Dr. Cotter if he is willing to write me a letter of recommendation - I feel like it will be odd having all my recommendations from Kaiser Family Medicine doctors, but since I am considering family medicine and have gotten along great at Kaiser, this will be very helpful.  The sports medicine doctor (the associate dean of our clinical education) may also be the one who writes my Dean's letter, which would be good since I actually know him - versus the main dean of clinical education is not very well known to me, aside from his bad advice regarding USMLE vs COMLEX for those on the border.   Time to get some light exercise in and eat and study...

End of the First Week

Family Medicine is off to a good start - I've seen a few patients multiple times.  One example - I saw an elderly man with the sports medicine doctor, then I saw his wife with another doctor, and then I saw both of them with the man's primary care doctor.  I have also been practicing writing SOAP notes and trying to refine that practice.  I still have good rapport with all the doctors, and am getting a better sense of how to conduct patient history and physical exams.  One gray area that I was a little nervous about was doing a basic physical exam on someone - I didn't know how thorough I should be when my preceptor is not there (mostly as far as having the patient disrobe, doing genital exams, etc).  The first time I came across this, I decided to do a thorough history, do some health education, and then wait and see how she conducted the 'complete physical'.  I went through everything, and included information about doing monthly self-checks for testicular cancer (highest rates in men in their 20s, 30s, and 40s, unlike prostate cancer which is highest in men over 50).  After the doctor did the exam (which didn't include a genital exam), she mentioned that normally she does that if the patient has complaints and I told her I did some patient education on that topic and she was very pleased.  She also seemed satisfied with my SOAP note that I did that day.

One small snag I have noticed is that my preceptor leans toward holistic/natural medicine.  That is perfectly fine with me, since I like the idea of combining lesser-known but similarly efficacious remedies for various diseases.  Also, according to our review forms, we are graded on whether we make references to medical studies and readings.  I thought a good way to combine the two would be to pick one or two things that she talks about that I am interested in and then look up articles that go into more detail.  On my first day with her, she cautioned a patient to get refrigerated probiotics because it was her understanding that ambient temperature probiotics are not effective.  Since I myself have some ambient temperature probiotics, I wanted to see exactly how poorly they fared against refrigerated ones - and despite going in with the expectation that she would be right, the study I found (from 2010, a pediatric medicine publication) found that they were equally efficacious in reducing the length of bacterial diarrhea compared to placebo.  I mentioned this to her as nicely as possible and she didn't seem to have a problem with it, which was good.  However, the next thing I thought I chose to look up had to do with how glucose levels exacerbate atopic dermatitis (AD), because she cautioned a patient to avoid food with high carbohydrate content in order decrease her overactive immune response.  I started looking up information on PubMed today about that and the first article on the topic that I found stated there was no change in symptoms in patients with AD when they were placed on sugar-free diets.  I only have partial access to PubMed at the moment, but I emailed our library director about how to gain access remotely (I know I can access it from school computers).  She expects me to have looked into this topic and I really really don't want to have to contradict her again - I want her to be right about these things, and I really like her too, so I want to keep her looking favorably on me.  If I really can't find any studies in favor of her sugar free diet, I will at least try to find a few on other factors that may increase AD (she also mentioned caffeine, antibiotics).  She is an MD for what it is worth, as are all the other Family Medicine doctors I am rotating with at Kaiser.

A final note on OMT - I have decided that I want to find ways to practice a little more OMM in the clinic, since it was part of my training, it can provide relief for some patients, and it will be included in my Step 2 board exam practical.  Considering this, I have made a goal to treat at least one patient each day with some form of OMM - most patients are very open to trying it.  The first patient I tried it on was suffering from low back pain and was a Spanish speaker, so it was a little challenging to communicate what I wanted him to do, and he was also in pain, so that was a little intimidating.  The next patient I tried it on was a middle-aged woman who had some neck/shoulder pain, which seemed muscular in origin, so I decided to do some occipital release, muscle inhibition, and long cervical muscle stretches - I was still doing some treatments when my preceptor came in and she was very approving.  The patient did report some decrease in pain, but again, I need more practice with patients.  Since I'm a little nervous about treating patients with real complaints (I don't want to make things WORSE) I am considering doing an OMM elective rotation.  I am still trying to schedule an ID rotation, but the guy hasn't emailed me back and it is really difficult to get anyone on the phone - I'm always transferred to voice mail or some department that doesn't know how to handle my request.  I'll try again next week, but the time I have left to schedule it before getting randomly assigned is ticking down...

I have also started listening to German audio lessons and audio books on my way to and from the clinic - it takes me 45-60 minutes each way.  I was looking for some audio books for Harrison's Principles of Internal Medicine (a huuuuge reference book) but none that were free.  I already have a hard copy of the book and online access, so I'll have to do that during my non-driving time.

Spring Semester and Boards

Well, just finished the 3rd week of Spring Semester - this unit is gastrointestinal, endocrine, reproductive, and dermatology - or GERD. Just signed up for our "Project Prepare" time slots, where we get to practice breast, prostate, and vaginal exams on hired "actors". We always kind of wonder what kind of people choose to do this sort of work, but hey, in this economy, why wouldn't they?

At any rate, the first week we covered mostly dermatology, and the second and third weeks have been focused on the endocrine system (so the pituitary, adrenal glands, pancreas, etc.). I am also getting geared up with my boards review program. I am taking Boards Bootcamp, where we get video lectures, as well as a study plan in the mean time. Near the end of the program we attend some live lectures locally. We got a super discount because at first we committed to the comprehensive program which was supposed to have weekly live lectures and cost 1700 or so, but we were going to get it for about 1300, then when we didn't get the minimum number of students to sign up, they upgraded those who did sign up to the elite program which normally costs 2200 (but we still only paid 1300). It's a lot to work on, but frankly I enjoy studying for boards more than Touro material - it just feels like it's better organized and more relevant. Anyway, I devote my Sundays to studying Boards material - works out well because my boyfriend works essentially all day on Sunday, and Monday-Thursday, so I don't feel like I'm neglecting him too much.

I have been managing to have a little fun on the side - spending time with my boyfriend, hosting a New Year's Party, heading out to a brewery here and there, a movie or two, played nearly all the way through Fallout: New Vegas. Even trying my hand at some new dinner recipes. Now I just have to re-incorporate an exercise regimen...

Oh, I also got all two of my wisdom teeth out a couple days ago - first time going under anesthesia. But there was barely any after-effect and I'm recovering quite quickly. It sucks not being able to eat much solid food, but because I only had wisdom teeth on my left side, I can still chew a little bit on my right without disturbing my stitches. The whole procedure was only about 25 minutes, I was surprised.

Almost time for school...

Well, my 2nd year is coming swiftly upon me - apologizes for the lack of updates, these last few weeks have been crazy. After Bolivia I went to the Galapagos Islands for a week with my family, then I came home and my boyfriend and I sorted stuff out and plan to move in together this fall. It'll be nice having him there, after a year of long distance. We had to look for apartments and budget my financial aid money, since I took out a bit less than I probably should have and so we don't have much breathing room.

Our first unit will be Neurology - so we get to learn brain functions, nerve stuff, etc. It is supposed to be really hard, so I'm glad I've had a sequence of Cognitive Science courses at UCSD. I have at least two textbooks I can refer to if things get too complicated. I am also reviewing old material from Semester 1 - I want to review old material and make flashcards for it at least once a week, since it'll be good practice for the USMLE/COMLEX when that comes around in the Summer (shudder).

I may continue my research on bacteriophages, I would like to, but we shall see. Also, since I took Medical Spanish last year and went to Bolivia, I now have a spot for an elective for fun, so I am curious what will be offered. Anyhow, tonight I drive back up to Northern California after spending the rest of the summer in San Diego - Kit will be following me up in a few days, but I have some meetings at school on Monday and that was our assigned moving day, so I have to get up there. I got a new phone too, a Droid Incredible, which is, indeed, quite incredible - I love some of the medical apps - particularly the drug interactions app. Really cool. It'll even tell you the details and why.

Another Hurdle

Well, just finished a pseudo-midterm - feels like I've been doing nothing but study lately - and in my spare time, computer games. I really need to get out more and exercise... Feels like I'm trying to do a million things at once, but I guess that's nothing all that new. I can't believe I'm almost done with my first year of medical school. It's rather intimidating because sometimes I feel like I've learned a lot, and other times I feel like I haven't learned anything. Now with the midterm done, I plan to just relax as much as humanly possible between now and Saturday night - Saturday we have a semi-dance thing on campus, it's a fundraiser for the group that is going abroad to Ethiopia and Tanzania. Unfortunately they're more established, better organized, and have the Global Health program director in charge of their group, so they have been putting on a lot more events than my group (Bolivia) and the Taiwan and Israel group.

The latest stuff we have been studying is all the respiratory illnesses - mostly those that cause pneumonia, bronchitis, that sort of thing. There was a section on pediatric illnesses and upper respiratory problems, which was okay. I'm not a fan of babies in general, and learning about the millions of ways that babies can turn out wrong frustrates me, since there are no laws permitting parents to relinquish their responsibilities for an incredibly unfit offspring. Definitely a controversial view, which as far as I'm concerned will only apply to myself and my future offspring, not the patients for whom I care (so don't worry), but human societies have practiced infanticide since before they were even humans - all animals practice infanticide if they do not have the resources or the animal is too unfit to survive and care for itself. It seems a crime to force parents to spend say, 5 years of their lives caring for a child that is 99.99% doomed to die - that's 5 years in which the child will be suffering, becoming progressively more mentally retarded, and slowly wasting away until its inevitable demise. It's an emotional drain for sure, not to mention a financial drain on the parents.

Like I said, I know it is my duty as a physician do everything in my power to keep a patient alive, and I will do that wholeheartedly - I just don't want to end up a slave to any offspring I produce with conditions that are incompatible with life for which medicine can offer no acceptable end.

In other news, still doing bacteriophage research. My medical Spanish classes have picked up again, so we're practicing those and we have our practicals next week. The trip to Bolivia is essentially ready, though I still need to get all my vaccinations...mental note: call the travel center. OMM is going well, I suppose - we're learning the high velocity, low amplitude techniques (the cracking techniques). I've had mixed success with them, so I definitely need more practice. Thank goodness we don't need to make an audible crack for it to be 'treated' - otherwise I don't know how we could get anything to treat during a practical after we've been practicing on each other for days.

Still working on balancing personal life with school, but everything's a work in progress these days... Now for the joy of computer games!

Fun and the Future

Even with so much to do, medical students can still have a little fun. The last weekend I went to a house party, with drinking and silly stuff, then to a shooting range, then a BBQ and a turkey dinner, and then played computer games all night. It's nice to know that we can kick back occasionally, but we better enjoy it now, because it's going to get a lot worse. The number of drugs we need to memorize is steadily adding up - I wish I knew them all as well as I know drugs like tylenol or omeprazole, typical OTC drugs that I've known about most of my life.

We're getting into hypertension lectures, angina, coronary artery disease (CAD), congestive heart failure (CHF) and similar problems. It's funny, with all the talk about eating healthy, and how CAD can be seen as early as in teenagers or people in their twenties - the food I'm craving the most right now is fast food. I haven't craved it in ages, but here we are.

Every so often, the curriculum at our school throws in a "Managing Stress" class, where we are told ways to deal with stress, as well as the kinds of stress we are going to encounter (which of course gives us a lot of stress right then and there). Today, the doctor teaching the class was talking about how the first two years of medical school are a breeze compared to third and fourth years when you begin your clinical rotations and have to use whole different sets of skills (communcation versus booksmarts). Then she went on to say you think rotations are bad, wait til residency - where there will be hallways or stairwells essentially devoted to hiding and crying when your attending shouts the crap out of you. I imagine something like Dr. Cox from Scrubs, except no one is laughing. She then added how even then, you start your internship somewhere and it's just as bad - with more power comes more responsibility, which comes with more and more work. It's like being spider man except that everyone knows where you live and you're expected to work 16 hours straight.

As she talked about us being on rotations or in residencies, I couldn't help picturing how some of my classmates would be during rotations - getting picked on by the attending, or stepping into a patient room with an air of authority and asking them what the problem is and trying to help. Now that I know more about a doctor's thought processes, and my classmates' strengths and weaknesses, it is hard to picture myself as a patient of theirs - putting my problem in their hands and trusting their judgment. Though, in my mind at least, I always picture my classmates looking very proper, professional, and knowledgeable in these situations. I suppose that means I have a good amount of respect for my peers as future physicians and human beings (well, most of them - there's always a couple you wouldn't want as your doctor). Hopefully I'll pull everything together and become as awesome a physician as I picture most of my peers becoming.

Studying, Advocating, Consoling...so much to do

Well, spring semester has been coming on fast and furious - been extremely busy. Have also had tests every other week, essentially, and our first Block exams of the semester are next week. We have had two standardized patient encounters with our small group - where we must take histories and perform a physical exam. It's amazing the things you notice yourself and your classmates doing when interacting with patients - strengths and weaknesses, the importance of listening... We have also practiced doing SOAP note write-ups (subjective, objective, assessment, plan) and worked on differential diagnoses. The ailments of the patients are in line with what we are learning, so we can apply what we learn clinically.

Tomorrow we get to explore a new aspect of the physician-patient relationship - breaking bad news. We will have 12 minutes to break bad news to a standardized patient who has been trained on how to react convincingly to the news, including shouting or crying. We will be faced with one of these: a son whose father unexpectedly died, a woman with a suspicious breast lump who needs a biopsy, a man with inoperable pancreatic cancer, a childless woman who just had a miscarriage, and a man with an STD from an affair. Should be interesting and nerve-wracking - but I imagine it will be more difficult for some of my colleagues than for me. Working in the lab, I definitely got to deal with very angry patients, and one woman I drew as a trainee had just learned her husband was going to die - that was a difficult one. You really don't know what to say to a stranger who suddenly starts crying, especially when they're still holding back so much pain and you know almost nothing about their situation. I almost cried myself that time - but sometimes all you can do is squeeze a person's hand to let them know you're there with them, even if it's for just a moment. I'm usually someone who insists on a 3 foot personal space bubble and never hugs people unless they're family (and even then not so much), but somehow I was able to recognize that at that moment, she really needed to feel physically that someone was there with her. If you're really with them, and not just going through the motion, time almost seems to stand still for you both in a good, or at least meaningful, way. They say, "You can touch patients during a bad news situation if you think they would be okay with it," and you kind of wonder, "How will I know if they would be okay with it?" Well, that was one of those moments, and I could definitely tell even with no experience - though my rule is that if in doubt, it's better NOT to touch.

On a more positive note, last Thursday we were bussed by the Osteopathic Physicians and Surgeons of California (OPSC) to the state capitol to speak with assembly members and fellows about the recent merger between the Doctor of Osteopathy and Doctor of Naturopathy boards. Essentially, bill AB X4 20 merged the boards because the governor wanted to make it look like he was cleaning up the government - busting excess bureaucracy and saving money. However, both our boards are funded by those in the profession, no tax money is involved, and they approve licenses as well as oversee malpractice issues. NDs do not prescribe medications without supervision (and even then, no category 2 drugs) nor do they perform surgeries - so having them oversee us, or even have us oversee them, is not fair to either profession. I was the designated group leader to the assembly member whose fellow we spoke to because apparently I live within the district (14). Definitely nerve wracking, but everyone seemed to think I made a very eloquent case. The fellow we spoke to seemed very supportive of our cause. One of the senators (Lee) has submitted two goldenrod bills to his boss for approval, which we need in order to get numbers on them, support, and signatures. It was really enlightening to see how the process works in state government, and that people in the offices actually will listen to you and you can make a difference. We also got to speak to one of the governor's aids right before he was going to a meeting with Mr. Schwarzenegger himself, with the promise of at least mentioning the issue with him, so that was exciting. There were a bunch of school children outside of the governor's offices as we walked in and they were all asking us to say "Hi" to the governor for them, ask for more money for schools, it was adorable. All in all, a very exciting day - here we all are in front of the capitol building!

Also, on one final note, the founder of Touro University, Bernard Lander, last night at the age of 94. All the Touro campuses were closed out of respect. I don't really know what to say about it, as I never met him or knew much about him before now, but I am kind of wondering how it will affect the universities. At the least, I was productive and used the day to get more caught up on classes.

Spring Semester...

Monday is the first day back at school, and I am not particularly looking forward to it. I just got rid of my year-long writing block so now I want to work on that! Alas, it will have to be put aside. It looks like we're starting in on the cardiovascular system, and will be dissecting the chest wall, the heart, etc. I don't really want to go back to the anatomy lab... One more weekend to enjoy freedom before entering the grind of school again. I won't have a break again until spring break, and then not until I get back from Bolivia. I think I'm going to pass on Convocation this year, simply because I already have one expensive trip planned. Maybe next year I'll go. Anyhow back to enjoying the last break I have for months...

Hooray for Eyes

Here's the latest from Dr. Auker. I can now stop putting the Vigamox (the antibiotic) into my eyes! I still have to do the Vexol for another two weeks, but only twice a day, down from four. He did seem concerned that my eyes were rather dry, but my eyes have been dry before I got the surgery, so I know it's not associated with LASIK. After years of contacts, I'm not a very good judge of when my eyes are dry, so I probably wasn't putting the moisture drops in regularly enough. He put tear duct plugs in each eye, so that it will slow the drainage of my eye/lacrimal fluid. He also gave me more moisture drops - I was running low. The girl who got the low down from me before Dr. Auker came in checked my eyes again and I'm still seeing better than 20/20 - I am able to see 20/15 in both eyes, but it's slightly more difficult in my left, so my right may be slightly better than 20/15.

In other news, after dressing up "professionally" and wearing a white coat with a patient again, my mind is drifting to my dearth of decent clothing. I have no nice suits beyond the suit I bought for interviewing, I have no professional tops except a single blue blouse, and the only dress shoes I have are heels and uncomfortable. I wore tennis shoes to the patient encounter because a lot of the doctors I've shadowed wear tennis/sports shoes and it is only logical - if you're on your feet all day, you need durable, comfortable shoes, not ones that are just for show. I should probably invest in two pairs of "professional tennis shoes" - a white and a black pair. Ones that look like professional shoes but are actually really comfortable. But then there's the issue of body fluids getting on my nice shoes during rotations and residency...oh the scutwork shall be wonderful. Either way, no one commented on my wearing tennis shoes, though I think I was the only one in my group who did. I am painfully wardrobe-challenged.

Faster and Faster

I used to be more on the side of patients when it came to doctor visits, but now I'm feeling a lot worse for the doctors... We have gone through the general screening exam, which includes neuromuscular, cardiac, respiratory, gastrointestinal, HEENT and taking vitals thus far. If we are allowed to do it at our own pace, no rushing, talking sweetly to the patient, etc. it takes us about 30-40 minutes to do it at this point. We are expected to speed it up to 15 minutes. I have been able to do it all in about 15:45 minutes, but it feels so rushed as far as barking orders and telling the patient to jump and sit that I can see even more clearly how a patient would feel like a physician doesn't care about them. Unfortunately, when we're expected to cram exams into a tiny amount of time...it's hard to do it in a way that makes a patient feel happy.

Of course, I'm betting that's where the magic of experience and bedside manner kick in. I'm going to try to practice the exam in 15 minutes but also practice my tone of voice and memorize concise, simple instructions so that I don't feel like I need to cram my words together. That, and I need to get a really good feel for the order and routine, as well as the phrases...ugh! So much to remember! We are required to say specific "lines" when we do examinations, such as "Patient is breathing easily, quietly, and regularly" or "Patient presents with no edema and is not diaphoretic or cyanotic." It really feels like being an actor/actress almost, since they really are lines.

In other news, I got a massage table, which I plan to use for massages, OMM, and exams - so that should help a lot. Also, we're focusing on hemostasis and hematological diseases at the moment - all very interesting and familiar since I worked in the laboratory for 3 years and I've seen all the lab tests before. Goal for this is to memorize the clotting cascade, the diseases, and the treatments, as well as go back over all the stuff I've already learned and try to commit it to memory.

Classes and Weekly Routine

Comparing my two blogs, I'm relieved that despite the uneven posting habits, I've essentially posted the same number of posts - go me. We're starting to get into the virus lectures, which is of course one of my main interests. I never really described our general weekly curriculum, so I'll delve into that briefly - I'm not sure how they do it at other schools, but I have a feeling we're somewhere in the middle as far as weekly hours. We also get an hour for lunch from noon to 1am.

Monday - usually a long day of lectures that set the tone for the week, lasting from 8am until 3pm-5pm. Tuesday through Thursday we have small group sessions in the morning and afternoon, and 2 hours of lecture each day. There are 3 divisions for the small group sessions, groups A, B, and C - I am group A, so I'll describe that arrangement. Tuesday we have morning small-group OMM lab, where we practice techniques, diagnostics, etc. from 8-10. From 10-12, we have lecture as a whole class. From 1-3, we sometimes have no class/independent study, it depends on how many classes are slated for that slot for those three days (2 classes, we have one afternoon off, 3 classes we have something each day). Usually it is a class-related workshop, working with new equations, concepts, etc. On Wednesday, we have morning "independent study" so we don't come in until 10, for the 10-12 whole class lecture. Our afternoon class is usually doctoring, where we practice clinical diagnostic techniques, examinations, etc. On Thursday, we have histology or pathology in the morning, and in the afternoon we either have more histology/pathology or another class-related workshop. Fridays we have lectures that may end as early as noon or as late as 5pm.

A few more observations as of late - one might think that after four years of undergraduate, some masters/higher level education, and clinical work, we would be desensitized to "sensitive" medical material, like genital warts or hypospadias. Nonetheless, I still catch a few students giggling at the mention of herpes and genital conditions. I'm sure by our second year most of the gigglers will have gotten used to it - or pelvic examinations will be extremely awkward for them (moreso than us non-gigglers).

Setbacks and Progress

Alas, a few unexpected setbacks occurred recently - first, the LAN party was cancelled...blah. Next, my ophthalmologist had to reschedule my surgery since he got a short-notice need to go out of town, so I'm trying to schedule it for the Friday after I get back from San Diego. On the plus side, I just started my Medical Spanish elective, which of course reminds me of the fact I'm going to go to Bolivia hopefully, and I met with my faculty adviser just to make sure I'm on track. My performance on the last exams was above average - and that's saying something when the average is 89%. My goal is to be in the top 25%, so that will be difficult...but hopefully doable! If I knew the standard deviation that would be more helpful, but you do what you can.

We're also learning more about doing histories and general survey exams, so HEENT, vitals, etc. It's fun - feels like we're really becoming doctors. I am anxious to update my insect blog, I have at least two insects to take pictures of and write about, one of which isn't even pinned yet, so hopefully I'll do that tomorrow or during the weekend. Wicked is still happening, and I'm probably going to the Renaissance Faire with the family, so that's good! Anyway, I still have some reading to do tonight, then sleep!

Blocks coming up...

Here I go off studying again - after which I fly down to San Diego for the weekend and then come back for Pharmacology. On the plus side, we should all be getting our medical equipment soon, so we will start learning how to use all the common doctor tools! In the meantime though, it's study study study! I'll have to corner my parents at some point this weekend and do all the techniques on them. I'll have a checklist and practice them all!

A friend of mine also made a program that I can load with a word bank to self quiz - I'll probably make a few versions of it - one that quizzes on anatomical stuff, another for actual disease names, etc. I'll also probably distribute it to my classmates, see if any of them would like to try it out. So...self-quizzing and practice quizzes; drawing out the muscles, landmarks, and the nervous system; reviewing histology slides; and practicing OMM seem like a decent way to study for this thing. So, until further notice, I am locked in my room studying with my study buddy: