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!