Decisions, Decisions

I just got done spending two weeks on the endocrinology service. I saw some interesting patients with strange things happening to their thyroids and pituitaries and adrenals, but mostly we just saw diabetic after diabetic after diabetic, most of whom did not understand their medications and took up oodles of time with us trying to explain how to get their insulin correct--most of it very futile seeming. During these two weeks, I saw one patient that got me truly excited: an 18 year old who was transitioning to the adult endocrinology clinic from pediatrics, whose parents were exasperated and shocked by the lack of support to be found both in the transition and on the adult side of things compared to peds. The kid had a fairly rare tumor as a child for which s/he received radiation which basically destroyed his/her ability to make hormones. SO. COOL. (Not for the kid, obviously, but for me to learn and think about.)

Also last week we had a career exploration meeting with one of our deans, at which we could meet with the program directors of various residency programs within our own institution and get information about different specialties. I attended the peds info session, met the program director, and found out tons of amazing information from people who were open and welcoming and helpful.

This week I am working as a "career exploration elective" in the neonatal intensive care unit. This morning I didn't do anything but round with the team and it was glorious. Adorable babies, interesting diseases, happy and friendly and welcoming folks who were interested in teaching and are letting me actually see a patient tomorrow. When I walked into the children's hospital this morning, I felt comfortable, prepared, and at home.

In all the craziness about med-peds, it has come down to this realization, more than anything. Whenever I am around pediatricians and talking about pediatric subjects or patients, I am happy. More than happy, really. I feel more and more that it's where I'm meant to be. Having doing endocrine, I just don't think I could deal with patient after patient coming through my doors each day with the same kinds of chronic diseases that aren't being cared for and sometimes aren't even worth advocating for. When discussing program requirements with various directors at the meeting the other day, I realized that if I were to go with med-peds, rotations in the ICU were something I was already dreading, something to be gotten through and survived--while at our meeting with the peds directors, I was trying to get information about how I could set up a rotation this summer in the peds ICU and was SO. EXCITED.

Ladies and gentleman, with the caveat that I must get to my peds rotation in January and make sure.....

I'm going to be a pediatrician. :-)

Time Flies when you're going insane

A Discovery: It is sometimes hard to write about my experiences in medicine.

I thought back when I started this that third year would be a time ripe for the picking of fabulous tales of patients--the hilarious, the heartwarming, the heartbreaking, the annoyingly clueless, etc. Instead, I've been on Internal medicine for almost 3 months and have almost nothing to show for it, in terms of stories that have actually been jotted down on (virtual) paper. It's hard, you see, when you've been at work since 6am and aren't home til 7-8pm, and still have reading to do about your individual patients and about general exam material before you collapse into bed at the woefully "respectable" hour of 9-10pm because it's all going to happen again the next day, to find energy (or just time, for that matter) to reflect upon the happenings of the day. Toss that in with a healthy(?) mix of stressing over the fact that we're halfway through the year and I'm only more confused than ever about what to do with the rest of my life and a desire to spend some kind of time with my husband and my family, and well, writing just goes by the wayside for a while.

Whatever, I hear you saying out there in Internetland, Quit making excuses and just write something already, I've already been here 10 minutes and haven't heard any good stories about insanity or blood and guts. And so, SCENE.

Seriously though, one of the hardest things for me so far about internal medicine is the push-pull over the decision of whether or not I like adults enough to pursue med-peds vs. categorical peds for residency and my eventual career. I enjoyed (for the most part) my time on wards, and was told by my residents that I was very good at it, which got me thinking about the possibilities. On the one hand, adult medicine tends to be more complicated and would require a lot more involved thinking and problem solving on a daily basis, which might be a nice change to just looking in ears and doing physicals all day. Plus, the idea of the kind of continuity an outpatient med-peds doctor could have with their patients--seeing a person from birth to late adult life, for example--is an extremely appealing idea. I got even more into the idea on some of the days I was on an Infectious Disease service recently, as I enjoyed the continuity and complexity involved in working with the many HIV patients we saw throughout those three weeks. On the other hand, this week I've been on an endocrinology service, and I just honestly don't know if I could handle dealing with multiple diabetics who don't take their meds, don't understand their meds and aren't willing to learn, won't quit smoking, etc. day in and day out for the next 30+ years of my life.

I've been going back and forth, sometimes daily, on this debate for the past 6-8 weeks. I have tried very hard (and, I think, at least somewhat succeeded) to be open-minded when it comes to the possibility of medicine, and some days I find myself coming home very excited by it and some days absolutely disgusted. At this point, nearing the end of the clerkship, I feel I'm really no closer to a decision than I was at the beginning. If anything, I'm more confused and, with holiday season burnout setting in in a big way, it's getting harder to tell if the dislike I feel for what I'm doing right now has as much to do with the specialty as it does with my general need for a break. Some days I feel like I just have no empathy at all for my patients, that I just want to escape and go home and have some time to play video games or take a nap or just do NOTHING for a while, and I'm not sure if this is a sign that medicine is not for me or just a sign that Christmas is coming and I'm tired and beaten down by a grueling schedule.

Luckily, I have one more week of endocrine, and then I'm done with adults for a while. After that, I'm doing a week long "career exploration" elective in the NICU, then a week off to study for the medicine shelf exam, followed by two weeks of Christmas break and then Peds in January (for which I'm so excited I could pee myself). Maybe that in and of itself is a sign, who knows? For now I just have to get through the next week.

Of note

Today, I would like to officially note that I have finished wards (and a week of palliative care medicine) and definitely have all kinds of interesting things to say about these subjects that requires much further thought process and time spent typing away, but in lieu of those deep and important matters I will say this

WE ARE GOING TO THE RALLY TO RESTORE SANITY OHMYGODI'MSOEXCITEDICANHARDLYSTANDITOMGOMGOMGJOHNSTEWART!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

That is all.

We'll see.

A classmate asked me the other day how I was liking my time on the wards. One of his other friends, apparently, is loving the experience and genuinely considering internal medicine as a specialty. So it got me thinking--do I like medicine?

I did, after all, come into this rotation excited about the possibility because I have thought about doing med/peds. You know, in case looking into ears all day would be too boring. Also, the idea of being able to follow a patient throughout their life, rather than booting them out the door at 18, is intriguing, especially if you consider the possibility of subspecializing within med peds (for example, a friend of mine wants to do a med/peds cardiology fellowship so that she can treat congenital heart diseases in babies, and then follow her patients through adulthood too). So what's it been like, hanging out on the wards, the front lines of adult medicine? The most I can say, really, is that it's a mixed bag. Perhaps it's too soon to tell.

The Good: As with most general specialties, I enjoy the thought process. Looking at the patient's history, vitals, labs, imaging, developing the differential, figuring out what might be wrong and how you could test for it and treat it. It's a fascinating mystery that unfolds before your eyes.

The Bad: In medicine, once you've figured out the diagnosis and treatment plan, you often end up sitting around babysitting the patient with nothing else to do, either waiting for nursing home placement or consults or confirmatory tests or imaging to come back. I have a patient right now who has been with me for weeks while we try to figure out why he has diarrhea. For the past several days, we have done nothing but order some tests and wait for the results. We're helping him, yes, but not actively so, and that's frustrating.

The Good: You see some really interesting cases. On our call day on Wednesday, we took on a new patient with an incredibly rare type of cancer, one with a rare form of nephrotic syndrome that we're still teasing out the cause of, one with new-onset congestive heart failure, and one with (possibly) a very strange and dangerous form of pancreatitis.

The Bad: You also see some really not interesting patients. Our service is typically filled with patients who are either being treated for a COPD (emphysema) exacerbation, or who have cancer and are just waiting to get their chemo. Not that these diseases are not important, but they don't require a lot of work or thought, much like the original "looking in ears" problem. Also, even some of the interesting patients are, to put it frankly, gross. I have a patient with a chronic bone infection that smells AWFUL. Like, you know what room this person is in because you can smell it from down the hall. In kids, you can look past these things because they're kids and it's cute and you feel sad that they have this gross thing, but with adults, it's just kind of...gross.

The Good: Sometimes, your patients are very kind and thankful and wonderful. I had a patient last week with cellulitis who was effusively gracious about my help in getting him out of the hospital so quickly, and it was moving to have him feel so grateful. It felt good to feel needed and useful.

The Bad: Sometimes, the patients suck. My diarrhea patient (see above) is a cranky, nasty person who frequently tells me what an idiot I am because I ask questions that he has already answered--to someone else. We had another patient on the team whose family screamed at us en masse because we suggested that his confusion might be a result of alcohol withdrawal. I'm sure this is true of many medical specialties, but it's frustrating when you get yelled at for trying to help people.

So yeah. Medicine is interesting, and it's kind of hard to narrow down exactly how I feel about it. I'll have to see how my subspecialty parts of the rotation go. After next week, I spend a week on palliative care service, three weeks on infectious disease (which I'm really excited about), and two weeks on another subspecialty (likely endocrine). If I'm still on the fence, I'm considering doing a week long career exploration elective in the spring in one of the med-peds outpatient clinics to get a clearer picture of what "real life" practice is like. So we'll see.

A tale of three patients

As I'm making my way through my month on the wards at the local VA hospital, I find myself slowly moving out of the realm of "OMG I'M SUCH AN IDIOT HOW DID I EVER PASS THE FIRST TWO YEARS OF MEDICAL SCHOOL" and more into the "ok, I may not know everything we need to do for this patient but I am at least competent enough to reason through what is for sure not happening and discuss with the resident the rest of what might be happening." In other words, yesterday for the first time I admitted a patient and was probably more than 75% correct about what was likely to be wrong with him and how to go about figuring out the exact diagnosis and treatment. I am also starting to feel slightly more comfortable about how to get around the hospital, call consults, talk to families, what my responsibilities are in terms of patient care, etc. It helps, of course, that I have a wonderful new team (for the most part)--one of the new interns is incredibly smart and with-it and also a really fun guy, and our upper level resident is much more approachable and less PIMP-tastic* than the previous one. My comfort level may change with the arrival of our new attending on Friday morning, but I'll hold out for my hopes that the progression of learning and competency will continue.

Today, I was carrying (aka in charge of seeing and taking care of) three patients. These three patients are interesting and challenging in different ways, and I think their stories are a really good representation of what medicine is as a career, a specific specialty, and a learning experience. So of course, for myself and posterity and all three people who might read this blog (Hi, mom!), I thought I'd share.

Patient A was the first patient that I "picked up" last week, who came to us with some pretty nasty diarrhea. A has multiple medical issues, mostly the result of years of rampant and untreated diabetes. A's medical problems are many, but we aren't really doing anything for most of them other than maintaining his current medications while we try to get his intestines under control. When I first met A, he was unhappy with me because I had to repeat a great deal of questions that he had already answered, and his attitude has not improved much since. Each morning that I speak with him, A typically tells me at least once or twice how little I know, how I am not paying attention to him, etc. This despite the fact that yesterday I stayed in his room an extra 20 minutes in order to cut his breakfast food up and assist him in getting ready to eat it. It can be amazingly frustrating to work with a patient who cannot understand that you are trying to help them, and A has been a learning experience if for no other reason than to learn how to do with people who will not be satisfied no matter what, and to treat them with just as much compassion as the kinder, easier patients.

Patient B was my next patient--a kinder, older lady who was recently admitted for a lung problem and was found to have a mass elsewhere in her body that we discovered essentially by accident. She is doing quite well, recovering nicely, but really needs to have the mass removed before it becomes a problem. Our surgeons want to remove the mass in the next few days while her lung function is still doing well, but she refuses to make a decision until she talks to all of her (many) children. We have stressed to both her and her spouse that sooner is better than later in terms of safety of surgery, and while the spouse seems to understand, she adamantly refuses to make a decision. I understand completely that this is a frightening choice that could have dire consequences, and therefore I have worked diligently to not rush B, but simply to present her with the situation as we understand it. Unfortunately, this too can be frustrating as you watch time tick away, betting against the clock that in the two weeks it might take to reach a decision that B's lung function will not deteriorate to the point that there are no more choices available.

Patient C is my most recent acquisition, a lovely gentleman with some intestinal issues. He and his family are sweet and wonderful and easy to get along with, and we will hopefully have a diagnosis for him soon so that he can go home and return to his normal and happy life. I look forward to seeing him every day, and the only challenge he presents is that of remembering how I treat him when I go see my other patients.

Medicine is interesting. I'm not sure if I love it or if this experience will tip me into the idea of Med-Peds over Peds, but if nothing else I feel like I'm learning a lot.

* To "PIMP", sometimes said to stand for "Put In My Place," is the process of attendings or upper level residents quizzing medical students on the intricacies of their patient's disease, some other random disease, or sometimes just ridiculously useless information that the attending or upper level feels the student should, by now, know. Usually comes with a negative connotation, as in those attendings who will continue pimping until the student doesn't know an answer, at which point the attending will ridicule said student for being an idiot who doesn't think his/her job is important enough to study for (even if that student had answered the first 99 questions correctly).

Wards

On Monday, I officially moved on from psych (well, technically I took the exam last Friday, but whatever) and began the three month adventure that is Internal Medicine. Medicine is our longest rotation of the year, and rightfully so, as no matter what type of doctor you end up being, the basics of how to care for sick adults is going to come up on a daily basis. Luckily, they break up the 12 weeks for us a good deal--we spend a month on the wards (the hospital floors where the sick people get admitted), a week on palliative care, three weeks on one subspecialty (something like cardiology, GI, endocrinology, infectious disease, nephrology, or ICU medicine), two weeks on another specialty, and two weeks on vacation. During my vacation weeks, I'll be spending a week in the NICU playing with tiny babies. The fact that I'll end my semester doing so is probably the happiest news I've received in months. I mean, have you seen how cute and tiny they are?!?! (Ahem. I digress.)

I was actually really excited to start medicine because, unlike psych and ob-gyn which are so focused in scope, here I would finally get around to something that felt like doctoring. Learning how to manage patients with everything from pneumonia to heart failure to cancer to HIV. Stretching my skills at diagnosis and discovering the best treatment modalities for things that I've heard about on paper but never seen in real life. The fact that I've still not ruled out med-peds as a dual specialization for residency was in the front of my mind when I started on the wards at our local VA medical center Monday morning.

Sadly, so far the experience has not exactly been what I was hoping. The first day or two were quite frustrating--full of lots of sitting around with nothing to do, working with residents who will leave me tomorrow and move to a new rotation and therefore have essentially stopped caring about anything but their most essential duties (not to say they're not caring for patients, mind you--they just don't really care about things like teaching me to use the computer system or going through a differential for my patient with a probable stroke). I get to start working with a new team tomorrow and Saturday, and I'm hoping they might be a little less jaded from their month at the VA and a little more enthusiastic about teaching. It's hard to figure out if you really might like to work in a specialty for your entire damn existence when the people you're working with don't give you a good picture of what it's like.

There are definitely things I can tell I like so far--I enjoy my patients and seeing them in the morning, cracking jokes while I listen to their lungs at o'dark thirty. I enjoy thinking through the process of exactly what is happening to them and why, and learning what there is to be done about it. These are the things I like about every specialty, and they are obviously quite available in medicine as a specialty option. The only problem for now is that I still feel so lost, so incapable of remembering enough to formulate a good differential (read: list of everything that could be causing the patient's symptoms, narrowed down to what's likely based on their history) and I just end up feeling kind of stuck wishing someone could sit down and talk me through what I'm thinking. It's getting better, and I'm getting more confident, but with only 4 weeks to get a feel for this business I'm hoping to pull a lot more out of the next several days.

In which it becomes hard to tell who, exactly, is the crazy one

So. Psych. It's been an interesting month, but I'm kind of ready for it to be over with at this point. I am finding myself incredibly lucky to have been assigned to child psych, because the attendings and residents are lovely and fun and laid-back and somewhat less weird than most of the psychiatrists I've come into contact with (not to mention the awesome hours--left at noon today). The patients, however, can range anywhere from incredibly sad (the four year old who wanted to die rather than see his biological father) to the incredibly weird (a teenager who believes her parents have been replaced by body doubles), to the incredibly frustrating (my patient, who has been depressed for an inordinate amount of time and literally refuses to accept the fact that he's getting better...in fact, continues to claim that he's worse despite the fact that he smiles all the time now).

There are things that I like about psych, but they are, in general, the things I like about most general practice specialties--talking to patients, hearing their stories, and figuring out what is wrong with them by putting the puzzle pieces together (and then of course coming up with the treatment plan). The things I definitely don't like, however, are far stronger. I do not think I could do a specialty day in and day out for the rest of my life wherein people don't, as a rule, get better. Yes, there are many patients for whom we make a big difference, and those are wonderful moments. But for many, we simply listen to their sadness, give them some medication to help balance out their brain chemistry, and send them home to a terrible family and terrible situation that will probably only perpetuate the problem as long as they continue to be sent there. We can't keep the patients forever, and only rarely is there enough of a problem to involve CPS and find a better living arrangement. Instead, we diagnose a lot of patients (especially the younger kids, so often admitted to our service for aggression or other behavioral problems) with "Parental Disorder NOS"* and do what we can for as long as we get to keep them in our care.

Perhaps this is why many people express frustration with internal medicine and family practice--dealing with patients who refuse to get better, refuse to take their meds, wind up back in your office months later for exacerbations of the same problem over and over. Except in this case, it's even more depressing because at least as a family doctor you can place some of the blame on the patient for bailing on their end of the bargain. On the child psych floor, it's almost never the kids' fault that they have a crappy home that has taught them crappy coping skills.

I am incredibly glad that there are people who feel called to be child psychiatrists (or any kind of psychiatrists, for that matter), but I think you might have to be a little bit crazy to be one of them.

Fall

Today, the temperature hit the low 80s, and I sat on my back deck and studied in the sun and the breeze without melting. When I took the dog out tonight, there was just the slightest hint of chill in the air--enough for a jacket, but only just. It's the kind of weather that speaks of apple cider and harvest fairs and backyard bonfires and football games and bold beautiful colors on trees and I love it so, so much. It puts me at peace with the world after the heat and bustle of summer.

Fall has always been my favorite time of year

Good thing, bad thing

My new patient is practically a baby--not even old enough for kindergarten. He is adorable and sweet and playful and happy and says "otay" when you ask him how he's doing. He loves his toy truck and playing with bouncy balls. If you spent an hour with him you would probably think he was a completely normal child with a loving family. Until you ask him why he's in the hospital, at which point he'll tell you about how he told his mom that he wanted to kill himself (in a very brutal, detailed fashion) because a close family member has been touching him inappropriately.

Sometimes, child psych sucks.

On the other hand, I got to spend the vast majority of my morning playing with a toy truck, and a bouncy ball, and showing a happy child just what can happen when adults care for you and want what's best for you. We played "What Time Is It Mr. Fox?" in the hallway and colored and watched PBS videos with other little kids and had an all-around wonderful time, when we weren't talking about deep dark horrible secrets.

Sometimes, child psych is awesome.

Night Call at EPS

Last night, I had one of our three mandatory call nights at the local emergency psych service. We were pretty much slammed the whole night, and it was certainly an interesting experience, if nothing else. Some of the patients were funny, some were touching and kind and knew they needed some help, some were sad, some were strange and a little frightening. Here's a glimpse of what we dealt with.

First up was a teenager* with depression. We think he was just lonely, because when he was brought in, he kept telling us that he wanted to commit a crime so he could go to jail and join a gang, but no one would let him. We called his mom to let her know where he was, and sent him home.

Next on the roster was a man who told us about the 6 spirits that live in his house, one of whom inhabits his body, and makes him do things like stick his tongue out at people without meaning too. He wanted to get admitted to a local hospital, but his insurance was too good so we tried to find alternatives.

I also spoke with a lady who spent almost half an hour just explaining her medical and surgical history to me, who was hearing voices and very tearful about the idea that people would think she was crazy. According to the doctors I work with, she was extremely delusional, seen there many times, and most of her health problems probably weren't real either.

Among other highlights were a teenager who got in a fight with his parents over moving out and going to college, a patient whose mother brought her in because she found her walking down the street in the middle of the night backwards because she needed to find god and ward off the devil, and a lady who, when I asked why she was there, spent 15 minutes telling me about her dental work she wanted done (apparently, she was threatening people in her apartment building, and someone called the police).

All in all, psych can be fascinating, but I think what I could never do is deal with patients who you just can't help. I mean, as a general practitioner you see lots of patients with chronic problems who come in for the same thing over and over, but usually you can offer them symptomatic relief if nothing else. In psych, no matter what drug you use, there's a decent chance it won't work and the voices will still be there, preventing the patient from having any semblance of a normal life. And that, I think, is just too sad and frustrating for me to do day after day.

*All names, identifying details, etc. have been removed and/or changed from this post.

Case of the Crazies

I've started Psychiatry. I was lucky enough to get my first choice placement for the rotation, which was child psych, and the two classmates I'm working with are great. This first week kind of sucks, because we had lecture all day Monday and all afternoon every other day, but from here out I guess we only have lectures on Thursday afternoons for a couple of hours (although this still seems like an inordinate amount of lecture for a rotation that, while important, is just NOT that big of a deal compared to, say, internal medicine or surgery).

The difficulty of starting every new clerkship (it seems, since this is only my second one) is figuring out the routine and getting into a pattern. On OB/Gyn, we switched around a lot between labor and delivery, gyn/onc, private practice, etc., but usually there was a pretty clear routine to start the day--see a patient or two, write a note, wait to present or go to a meeting. Here on child psych, the people have been great--our attending is funny and personable and actually talks to us, the two residents are friendly and helpful--but it's so much more laid-back than OB that we still haven't quite figured out what we're supposed to be doing. Our day starts with rounds at 8, where we sit around a table with the whole team and discuss each kid, what happened overnight, their plan of action. Usually, after such an event I would expect everyone to get up, go see patients, write notes, and generally get to work. Instead, this morning we were basically told we could "go wander around" or follow one of the residents to see patients. I was assigned a patient yesterday, so I was going to go visit her again this morning. But right as we got done with rounds, her mom came in for a visit, so I first sat in on the meeting with the social worker. Then I chatted with everyone while she and her mom had some alone time. Then I went in and asked if I could talk to her for a minute and began asking what I thought were some basic questions about how she was doing, at which point one of the psychology interns interrupted to come play cards and ask her the same questions over again. Then I went back out and chatted with the other students and residents for a bit, and then it was time for lunch--none of us ever wrote a note or anything, and no one really seemed to give us any reason to. I mean, don't get me wrong, I don't mind having very little work to do, but I also hate not knowing if what we're doing is ok, or if everyone will think we're slackers simply because we were never told specifically to do something. Ah well. My kid is cute, and has a lot fewer issues than most of the other patients on the floor, so at least she's fun to see. Maybe tomorrow I'll actually do something productive with my morning.

Distant Imaginings

So, if you know me (and I'm assuming everyone who reads this, does), you know that I'm a planner. A big time planner. I pretty much enjoy knowing what's going to happen in my life months if not years in advance. It's one of my qualities that my husband loves most about me (::insert sarcasm::).

One of the most daunting problems of medical school for a planner like myself is...(dun dun duuunnnnnn) The Match. The Match, for those lucky enough to be uninitiated in this sadistic ritual, is the way that we med students apply for, interview for, and discover where we will spend our residency years. Basically, you apply for whatever programs you think you might be interested in, interview at the places that like you enough to extend the offer, and then create a list of your favorites, in order. The tricky part is, the residency programs also create a list of their favorite interviewees, in order. So, let's say that my number one choice for residency is Program X, number two choice is Program Y, and number three choice is Program Z (and so on ad infinitum). Let's suppose that Program X has 25 slots available, and they rank me in their 5th slot (which means there were 4 people they liked more than me--impossible to imagine, I know). A fancy computer somewhere in the ether says to itself, "B likes Program X and they ranked her as well, so she gets a tentative spot at Program X. Now, Susie Q over here also ranked X as her number one choice, but they ranked her higher than B so she gets a slot above B." This continues so on and so forth. If a program has 25 spots and ranked me 26th, and the 25 people they ranked ahead of me all rank that program number one, then I get bumped to my 2nd choice, etc. This continues until all spots are filled. The big Catch is the fact that wherever you get "matched," no matter how far down your list you went, is where you are contractually bound to spend your residency.

The biggest issue with this system is the fact that, until Match Day (the day that every single 4th year medical student in the country opens a little white envelope telling them their fate for the next several years), you have NO IDEA where you will go. Programs may hint at "we like you," but there are no guarantees that your number one will rank you high enough for you to match with them. Which means that until 2 months before your graduation, you can't make plans for the future.

This is an even bigger issue for people like me with spouses or significant others who are committed to going along for the ride and uprooting (or staying put) to who-knows-where for 3+ years with no real choice in the matter at the end of med school. This generally means that us attached folks try to apply to, interview at, and rank programs that are in areas where our loved ones could tolerate living, find jobs, etc. The application process for me is still about a year away, but D and I have already begun to discuss these kinds of topics so that, when the time comes, I will have a decent idea of what programs to check out and where I might want to apply. Originally, we both thought that we'd like to stay at my home program (i.e., do residency in the same town where I've been in med school), because this is essentially our home town, our families are nearby, and it's a nice area in general. This is still quite the possibility, but more recently we've begun exploring other options, mainly because D's job prospects in this area are not the best. Not that he doesn't have a job, or couldn't find a better job, but his dream job exists most decidedly Elsewhere. It seems to exist, in fact, in the vicinity of Washington, DC. And, knowing how much D has sacrificed for me to become a doctor, wouldn't it make sense for our next big step to take him into more consideration?

There is a residency program in DC (for the field that I think I might like to pursue) that seems wonderful. They have a lot of really interesting options not seen other places, international electives that I would seriously enjoy (and can't find at other programs), pays more than any residency I've ever heard of, and it's highly praised in a lot of areas. Obviously, I am intrigued. But with intrigue comes also worry, for a planner like me. As much as I ponder how interesting it could be to learn medicine at this program, how exciting to spend weekends at the Smithsonian or Lincoln Memorial, how convenient to live within drivable distances of beaches, mountains, and big cities all at once, I also start thinking about logistics and worrying over the small possibilities. How would we afford to live there? Our home now is somewhat small but lovely, with a big yard and nice neighbors and a school down the street. Were we to move to the DC area, we might be able to afford a condo but certainly not a house--where will the dog play? What if the bills are too much? Traffic is supposed to be horrendous, how will I manage coming home from a 24 hour call shift if the commute takes an hour at rush hour? Most importantly, how will we get along without our support system? Our families are here, our best friends are here--when you're tired and bored and unsure of yourself, there's just nothing that beats being able to drive a few minutes to have dinner with your best friend or hang out with your mom. It's a scary thought, being 10+ hours away from our cozy midwestern roots.

Obviously, this is all distant, and simply theoretical. But my brain likes to play with the possibilities, because that's the only way I can plan. And planning, well, that's just what I do.

One Down

Well, I have successfully completed my first rotation of third year by taking the OB/Gyn shelf (aka nationally standardized exam for the clerkship) this morning. Overall, I think it went well--there were a good number of pretty straightforward questions, but there were also a few really weird "what would you do next" kind of questions where all of the possible answers seemed like something you could do and maybe even would do but who the hell knows which one would actually come first? Ah well. I'm confidant I did well enough to pass, and hoping I did well enough for Honors.

Overall, OB was an interesting ride. I enjoyed some things more than I expected, and actually discovered more about what I want and don't want out of my medical career than I would have thought possible from a 6 week rotation through a specialty I wasn't that interested in to begin with.

For one, I learned that bringing babies into the world for a living is awesome. I really loved my time on labor and delivery, and got tears in my eyes at the last birth I attended because everyone in the room was so excited. The problem is, as soon as the baby is out, I pretty much lose interest. Sewing up huge tears in the perineum just seems anticlimactic and not so exciting. Another thing I liked was that patients are mostly healthy, responsive to your suggestions, and compliant with treatment. I find that this is something I really like, which lines up with a big part of why I like pediatrics so much--patients want to see you, are generally pretty healthy without a ton of chronic diseases, and are much more likely to quit smoking/drinking/etc. when they are a) pregnant or b) have small kids. I also learned that I'm pretty sure I don't want to do a specialty that involves a lot of surgery--or maybe any. The OR is interesting, but just not my cup of tea, I think.

Now I get a nice weekend off, and then we start psych on Monday. I'm really excited because I get to do my rotation on child psych, which is not only interesting to me from the pediatrics perspective but also supposedly has the best hours--so we shall see. Hopefully if nothing else it'll make for some really interesting stories.

Well, I survived my last week on gyn onc (barely) and have emerged into the shining rays of private practice. For the next two weeks, I basically get to spend my day in the normal office of a normal ob/gyn doctor, following her around. Unfortunately, the downside to being with Dr. B is that she has a very busy practice, which means she really doesn't have time for me to see a patient and present, and then her to see the patient. So my day (at least yesterday) basically consisted of a lot of shadowing--I go in, watch her see the patient, maybe help measure the belly or find fetal heart tones, but that's it. I appreciate the time she takes to talk me through the patient's history, but otherwise it's a little harder to enjoy when I'm not the one actually doing anything for myself. Ah well. On the upside, I don't have to arrive in the mornings until 9:30, and we are usually out by 5-6 (she says). Yesterday we were out late because there was a delivery in the middle of the afternoon that put her behind schedule.

We also didn't leave until 7 because the last couple of the day was so neurotic about their "birth plan" for their very-soon-to-be-born baby. Let this be a lesson to you, folks--when it's time to have your first kid, it's all well and good to have an idea of what you want for your experience and such, but it's also good to have at least a little flexibility. I mean, sheesh. Hoping today we have a more normal, not so behind day.

Cancer Sucks

This morning on rounds, my team and I visited a lovely older lady who has ovarian cancer. It has spread throughout her abdomen, and she isn't responding to chemo any more. We were trying to solve some of her main problems, which are (relatively) minor things like nausea and constipation, when she tearfully began to explain to us that all she really wanted was to go home. She had spoken to family, who all wanted her to keep up the good fight for as long as possible, but really she was just so tired of being uncomfortable. You could tell in her voice and her eyes that, deep down in her soul, she was ready to be done and move on and not suffer, but she also did not want to let her family down. Medically, there's really not much to be done for her except keep giving her chemo that's only holding the most severe symptoms at bay, all while creating new symptoms that aren't all that much better than the old ones. And down in my heart, as we patted her shoulder and told her we would call a chaplain and arrange a family meeting to decide where to go from here, I saw the face of my grandfather as he begged us, not long before he passed away, to just take him home from the hospital.

Moments like these are visceral, soulful, painful, terrifying, gut-wrenching and momentous. They are the reason I wanted to become a doctor, and they make otherwise boring rotations meaningful. I hope I am able to visit her again tomorrow on rounds, even though she is not technically my patient. And I hope that whatever choices she makes, they are the right ones for her and she is able to live out her remaining time in as little pain as possible.

Gyn/Onc

One week into Gyn/Onc and I have very mixed feelings. Well, maybe not so mixed. I mean, on the one hand, some of the surgeries are relatively interesting (at least, what I can see of them from my appointed student spot of "the end of the table" with my retractor firmly in hand). On the other hand, the surgeries are often long and tedious and repetitive--mostly just hysterectomy after hysterectomy--and I have to stand for really long periods, which is painful for me with my back issues, and did I mention that the days are reeeeeeeally long?

I think what I've learned from this week is that I like doing. Which is kind of odd, because most people who are "doers" by nature LOVE surgery--it's the ultimate hands-on fixing of people. But for me, I get impatient. For example: in a surgery I watched the other day, we removed a mass the size of a watermelon from a woman's abdomen. It was crazy (and crazy long, at almost 6 hours between getting into the room and getting out), and something a lot of students would kill to see. But for me, while the getting out of the tumor was interesting, after that all of the nit-picky detail of digging about looking for lymph nodes was just flat out boring. Maybe it's just because as a student, I'm not the one with the scalpel, but I'm not sure I would find it that much better even then. I really prefer things like the morning I spent in clinic, where I got to see several patients and actually talk to them. A lot of people I know hate clinic because they find it tedious (and it's true that you do see a lot of the same problems over and over), but I think the time flies by much faster there than surgery because I am actively involved with a person the entire time.

Maybe this is just how I confirm that general specialties are the way to go for me--but I have to admit, I'll be rather glad when gyn/onc is over at the end of next week and I can head into an outpatient setting for two whole weeks, to see what this specialty is really like in the real world.

Two Weeks

It's amazing what a difference just two short weeks can make. For the past two weeks, I have been working on the labor and delivery service, first on day shift, then on night shift. It's hard to believe it's only been that long, because I feel like I've learned so much that I've been doing this forever. I wish I could have updated more with some of the funnier and/or crazier stories, but when you work a 14-15 hour night, pretty much all that's left is to come home, sleep as long as you can, and head straight back. Luckily, I am off all weekend (!!) before starting on the Gyn/Onc (pelvic cancers) service on Monday. In lieu of an entire post of insane stories, here is a list of some of the lessons we learned as we began our first year of clinical education.

1. There is safety in numbers. It must be a relatively entertaining sight to be an upper level resident or attending wandering through a hospital in early July, watching the looks on the faces of the brand-new third years. I mean, this week we were given a ten minute "tour" of our university's hospital, and then on day 1 were basically dropped off at our location du jour and told to get things going. Lost doesn't even begin to describe. To cope, we tended to travel almost everywhere we went in a pack.

2. It is startling how fast you can adjust to getting up at 4am. I thought it would take years, but that first week I actually wasn't all that tired--I just went to bed at 9 every day. Of course, along with that comes the fact that when you get off work at 5 and go to bed at 9, there's not much time to do anything, but oh well.

3. Medicine is not for the weak-of-heart. On my very first day on the labor floor, I got to deliver a placenta, which is possibly one of the bloodiest and most disgusting things in all of medicine. Some of the surgeries I saw were less gross. But when you're in there, it's kind of just surreal because you don't think about the gross, just about trying to do the right thing at the right time and not piss off the resident. Oh, and not kill the patient. Of course.

4. The emotions can get you. On my last night on night shift on labor and delivery, the juxtaposition between the two main patients who arrived that night was so great that I almost couldn't wrap my head around. On the one hand, we got to share in the incredible joy of a new mom giving birth with her entire family present, screaming and jumping and applauding the arrival of a new life into the world. On the other, we stood by helplessly as the doctors informed another couple that their just-shy-of-viable fetus was probably not going to live, and their devastation was palpable. It was a strange gamut of emotion that rather eloquently wrapped up the experiences on the floor.

5. You learn SO much more doing things in real life. Two years of medical education behind me, and I'm pretty sure I've retained more information in the past two weeks. While I don't know that I'm necessarily interested in OB as a specialty, it is certainly way more entertaining and satisfying to work and learn in the hospital, where information has meaning because there's someone down the hall with the problem you just talked about. Honestly, I thought I would die working 12-15 hour shifts, but they go by fast when you're busy and you get to see a lot and learn a lot. In fact, just this week I saw: at least 4-5 deliveries, 3-4 C-sections, an open surgery to evacuate a blood clot in someone's abdomen, a laparoscopic surgery to diagnose abdominal pain, and countless patients coming in and out of our triage area with complaints ranging from labor to back pain to swollen feet to urinary tract infections. And from all of them, amazingly, I learned something. Who knew?

The Calm Before the Storm

So last Wednesday and Thursday we had our third year clinical orientation, wherein we were given a bunch of relatively useless and time-consuming lectures about things we learned last year (lab values, note writing, etc.), remembered how to perform CPR (and got the cards to prove it), and got a tour of the hospital where we begin our first rotation. I start on OB/GYN, and I'll be doing 2 weeks of labor and delivery (first day shift, then night shift), 2 weeks of gynecologic oncology, and 2 weeks of working in a private practice somewhere in town. I start Tuesday morning at 7, have a few hours of orientation to the service, and then get to change into scrubs and get going. Wednesday through Saturday I'll be working 5am-5pm, then next week 5pm-7:30am. I'm not quite sure what to do, but I've been told we're not expected to know much, which is slightly comforting. I am both indescribably excited and completely terrified--after all, this is what I've been waiting for.

But before all that gets started, a brief word to celebrate the idea that became the goal of a baby nation with almost no chance of survival, from a group of rebels who (had things gone differently) could have been hanged for treason.

We hold these truths to be self-evident, that all men are created equal. That they are endowed by their Creator with certain inalienable rights; that among these rights are life, liberty, and the pursuit of happiness.

ALL. All men are created equal. No matter what we think or believe or how we vote or what struggles we face today, that's really the crux of what became the United States. Not some men, or white men, or rich or straight or English-speaking men. ALL men (and women!) are equal. We don't always get it right, but it's there and it's beautiful if you really sit down and think about it.

Shiny!

So obviously, I've updated the format of the blog, now that blogger gave us all these fancy new "design templates" rather than the uber-generic previous five options. I think it's fitting!

Not much to report recently, except that this morning I actually discovered my real life schedule (mostly) for the next six weeks--I'll be starting m Ob/Gyn rotation on Labor and Delivery, doing a week of day shift and then a week of night shift. Then I'll be doing two weeks on gynecologic oncology, and two weeks in a private practice doctor's office. It's exciting to know what's coming, even as it's terrifying to have no idea what to expect on the floors. One thing I am sure of, however, is it will probably provide for multiple hilarious stories, which I promise will make me update this thing much more often.

Recap

Yesterday D and I returned from an absolutely fabulous week's vacation with my family in Florida. We had a wonderful time lazing around by the pool and on the beach, ate some good food and enjoyed some good books and good company. Now that my head has been clear of Step 1 for over a week, I also feel compelled (and capable) to write a little about that lovely experience.

So. Step 1. It's kind of a beast, but honestly I didn't feel like it was too awful. The questions that I got (they basically comprise the test out of a huge bank of different questions, so everyone's test is different) were all in all very similar to what I saw on my USMLE World question bank in terms of content and how much of a subject you saw (i.e. there was a lot of path, decent phys, little bits here and there of other things). My anatomy questions, thankfully, were pretty easy and understandable, as opposed to some nightmares I heard about from friends. There was not nearly as much micro or biochem as I expected or prepared for. I got a couple of really out there questions that I was lucky enough to know (thanks to random UWorld questions), and a few questions that were simply classified under the WTF category (but that's to be expected). I should get my score in 3-6 weeks, hoping for closer to 3 but not going to hold my breath.

I expected to be absolutely overjoyed at the end, but really it didn't sink in for about two days. If anything, the night of the exam I just felt...tired. It didn't hit me that I was done until I'd gotten to sleep in for a few days, but now I'm thoroughly enjoying my vacation. Other than our trip, I've basically just been chilling out, but now that I have a week or so before orientation for third year, I'm hoping to get some work done around the house and yard. There are a couple of closets here that are dying to be organized, and the mulch looks atrocious. Tomorrow, though, is reserved for D and I to celebrate our second anniversary! Not sure exactly what we'll be doing, but I know it will involve at least dinner and a movie, so I'll update on the exciting events later.

Sweet Nothings

So I've been enjoying my much needed vacation for a week now, and tomorrow D and I head off to join my family on a much-anticipated trip to the beach. Crossing fingers that BP hasn't completely F-ed the coastline where we're going, but looking forward to lounging by the pool and sticking my toes in the sand nonetheless.

Today was just about the most perfect day of all time--we slept in, had lunch, went shopping and found D a new swimsuit, located possibly the last remaining US team world cup soccer jersey in the entire galaxy, and I bought a cute World Cup Germany hat to keep my outrageously pale face from frying in the tropical sun. We found a birthday gift for a friend, took the dog out for ice cream, and are currently working on getting packed. All in all, it's been a glorious and relaxing day.

In other news, we are both (D especially) looking forward to the US v. England match tomorrow, but also preparing to cheer for England once the US is inevitably knocked out (though hopefully not until the quarterfinals).

What I have NOT been doing is anything whatsoever related to medicine, studying, or work. And it's been everything I knew it could be.

I'm....

FREEEEEEEEEEEEEEE!!!!!!!!!!!!!!!!!!!!!!!!!!

Here we go Here we go Here we go

Tomorrow's the big day. After a month and two days of essentially non-stop work, I take the boards tomorrow morning. This past week has very much felt like spinning my wheels--I took a practice test last Friday and was satisfied with my score, and ever since I've felt like I'm just sort of killing time and trying to keep information from seeping out my ears faster than what I'm reviewing. As of tomorrow afternoon I'll be free for the next month and couldn't be more excited.

On the list for the next month:

--A party Saturday night to celebrate the whole "done-ness" thing

--Vacationing in Florida for a week with family

--Road trip up to Former College Town with my friend F (who's never been, and went to college in a town where they apparently have no awesome ethnic food streets)

--Celebrating D's birthday and our 2nd wedding anniversary

17 hours (or so) and counting.

The Home Stretch

I now have less than two weeks until the big day, and I'm feeling decidedly more relaxed now. I think the two weeks of path and micro were just more difficult because they were tougher subjects, with more information, to cram into a very small amount of time. Since finishing micro, I have busted out neuroanatomy in 2 days and finished this afternoon, which was a big ego boost--I hadn't planned on finishing until Tuesday, so now I can have a nice relaxed week of studying biochem (probably my weakest subject) rather than trying to cram all that into 3 days as well. Then, once biochem's done, it's just one big review of First Aid (the sort of "everything you need to know in one book" book) and then BAM, done. In fact, I'm almost looking forward to it at this point, not least because I have taken several people's advice to not study on the day before the exam. Instead, I have booked myself an appointment for a professional massage followed by a haircut the afternoon before, which is totally exciting. I've never had a massage, but have always said that I'd treat myself for various things--"once I'm finished with the semester," "once I achieve X goal," etc.--but never actually gotten done for one reason or another. Now there's no turning back because the appointment is booked, which means I'll be spending the day before boards getting pampered and relaxed and hopefully this will put me in an excellent state of mind. I'm already looking forward to it immensely.

Board Prep Day...I don't even know

Well I'm about halfway done with this beast and I'm really starting to feel it. The first week was pretty easy. Last week, pathology about did me in. Not because it's difficult--it's just a LOT of information to cover in a week. I mean, we spent over 6 months studying all this stuff in lecture. Luckily, even though it sucked my practice test scores have been going up so I guess that means it's paying off. This week I'm working my way through microbiology, which has thus far been one of my weaker subjects on all the practice exams. I finished bacteria this morning--it's one of those weird things that has a lot of factoid memorization involved, which means that while the information is all in my brain somewhere, the little rote tidbits were not within reach. They seem to be coming back into consciousness relatively easily, though, so I'm hoping they'll stay there for the next 2 1/2 weeks until test day. All I know is that at this point, I'm about ready to just take the darn thing and have it done. I don't know how people say they study for this for months...5 weeks is too many for me.

Board Prep Day 4--Or, My Kingdom for a Library

You know, you wouldn't think it would be that hard to find a quiet place to study in a town this big. Part of the problem is that I usually study at home. For the past two years, I've really not spent much of any time anywhere but my own couch or desk working on flashcards or reading notes. But when it came time for boards study, that just didn't seem like such a grand idea. For one, D is off work on Mondays and Tuesdays, and a blaring TV is just not conducive to efficient work. For another, if I studied at home there would just be no boundary between "studying" and "not studying" and I would probably end up just studying (or feeling like I should be studying) every waking hour of the day. I also (as stated in the previous post) knew that I did not want to be studying at school so as to avoid my dearly beloved fellow classmates as well as the time and money spent on gas to get there.

So initially, my plan was to head down to my local county library to study. It's right across from my dad's office building, which meant that I could make copies and such easily, and could have a space to store cold food for lunch right nearby. So Monday morning, I got up bright and early and headed down to the library right at 8 to get started...only to realize that the library doesn't open til 9. Oops. I started to drive over to school instead, but basically realized that by the time I drove all the way there, found a place to park, and walked into campus, it would be close to 9 anyway. Instead, I sat and read a little in my car til the place opened. Yesterday, I had to study at school because of a meeting. Today, I decided to try something different and go down to the library at the local community college, which is only about a five minute drive away and opens at 8. When I got there, it was perfect. This place is quiet (practically abandoned, actually), full of natural light, and has tons of desks and carrels with plugs for my laptop. Unfortunately, it also has locked wi-fi, and it took me twenty minutes to get help to figure out how to log onto it. Luckily, a helpful IT person was able to assign me a guest account (which only lasts for 3 days, but I can renew. A lot.). So now it's settled. I have officially found my study space, and will be going back there pretty much every morning from now on. Hooray!

Board Prep: Day 1/2

That's "one slash two," not "one-half," fyi. Today was supposed to be my first official day of board review, but instead I was really super bored yesterday and went ahead and got started then. I'm glad I did. Having started (even just a little), I now have a much clearer plan about how this is going to work. Some things, of course, just cause issues no matter when you get started--like the fact that I dutifully got up and ready this morning to drive down to the local library (studying at home just doesn't work when D is off...for this type of work, even the tv is distracting) only to arrive at 8:15 when they apparently don't open til 9. So I started to drive to school, realized that by the time I arrived, parked, and walked to the campus library it would be 9 anyway, and just sat in my car reading for half an hour. Otherwise it was pretty uneventful--I got done what I planned to get done by about 4:00, which left me with a lovely afternoon/evening break and now I'm going to do just a bit of review of what I looked at today (because otherwise I feel like I'm not doing enough. This is what med school does to you, my friends.).

Unfortunately, tomorrow I have a lunch meeting at school and so will have to trek into campus to avoid having to get up and move in the middle of the day. I so hate studying at campus. It's actually not the library that bothers me--it's extremely quiet and nice and warm usually--but you just run way too big of a risk of running into other people, and a lot of folks in my class are the kind of people who can stress you out just by saying hello. I think I'll arrive early to snag a table as far away from everything as possible.

Step 1 Study: Prologue

So, on Monday (or maybe tomorrow, if I really feel motivated) I start my official studying for Step 1 of the USMLE (aka the Board exams). To kick things of, tonight I took a practice exam--basically an accumulation of former test questions put out by the boards people which gives you a guesstimated score that you'd get if you took the test today, and then tells you which sections/subjects you did well (and not so well) on. We actually took one of these earlier in the year as a requirement for school, and at that time I got a predicted score that I would quite honestly be perfectly happy with as an actual score come test day. Knowing that I took that one without having taken psych or 1/3 of pharm yet, I figured I could only go up. Today I took another one (having just finished pharm and psych last week) and it predicted a pretty high score. Part of me is psyched about that--knowing that I'm doing well going in is obviously an ego boost--but part of me feels like it's really just a reflection of guessing well, since some of the areas where I supposedly did really well were ones where I felt like I was guessing a LOT. So, take it with a grain of salt, I suppose.

The good things that I did take away from this one were the areas that I really need to hit hard throughout my next month of preparation--namely, kidney (I apparently forgot everything to do with the stupid thing), biostats (surprise, surprise--this was probably the least-taught subject in my curriculum), micro (not a shock, I knew I had forgotten a lot of this since we learned it), and biochem (same basic idea). This basically confirms my idea from earlier in the week that I should save biochem and micro stuff for closer to the end of studying, since those tend to be short-term memory subjects that I'll just need to cram in before the exam (as opposed to pathology, which is much longer-term and easier to remember with tons of questions throughout studying).

So for those who are interested (who am I kidding--for those who are still reading, despite lack of interest), here's how I plan on tackling the next month or so. Wish me luck!

May 3-6: Physiology

May 7-8: Anatomy/Embryology

May 9: Catch up day, questions

May 10-14: Path (maybe only til the 13th, then treat the 14th as a review day and some pharm and/or biostats)

May 15: Behavioral science and Biostats

May 16: Catch up day, mock exam, then the rest of the day off

May 17-20: Micro

May 20-21: Immuno, go back over some more biostats if needed

May 22: Neuro

May 23: Day off/questions

May 24-25: Neuro

May 26-28: Biochem

May 29: Mock exam, rest of the day off

May 30: Catch up day, start massive review of First Aid (the Bible of Board Review)

May 31-June 2: First Aid, do tons of practice questions

June 3: Day off/last minute cramming of high-yield topics

June 4: Test.

Good day

Today is a good day.

I took my final block of exams as a second year student (and passed with flying colors), which makes me officially half a doctor and done with full-time classroom education forever. It's a beautiful day, we're grilling out tonight and I drove home with the windows open and Neil Diamond blaring.

Good times never seemed so good. :-)

Oooooooklahoma

For those who know me personally, I'm pretty obviously ensconced in the more liberal end of the political spectrum. (For those who don't know me personally, you probably figured that out if you read the whole health care debacle post a while back.) And from that stance and from my position as a woman and a future physician, I was incredibly sad today to learn of the legislation passed by the Oklahoma state senate which blatantly infringes upon individual freedoms represented by a woman's right to choose.

I'll preface this by saying that while I am definitively pro-choice, I am not in any way pro-abortion. I understand the point of view of my colleagues who believe that there should be laws protecting those who cannot protect themselves--and I don't believe that anyone, really, would willingly end an unborn life without first going through an incredibly difficult and painful decision. But while I don't necessarily believe that I personally would choose abortion, I have always believed that it is vital that in a free country women have a right to choose what to do with their bodies. If we tell a woman that she is not allowed to seek an abortion (or even to consider the option), we are in essence removing a piece of her personhood. We are telling that woman that the government knows better than she does about what is good for her, her family, and any theoretical future child she may bear. We are taking away her freedoms.

What the Oklahoma law says is that now in order to have an abortion in the state, a woman must have an ultrasound of her fetus. Not only that, but the doctor or technician performing the ultrasound must turn the screen so that the woman can see it, and must describe for the woman (presumably whether or not she wishes to know) the fetus's body parts and organs in detail. The object of this procedure, obviously, is the idea that if a woman learns this information she will be less likely to choose abortion. What it amounts to, essentially, is the government stepping in to coerce upon a vulnerable person at a difficult time a decision that conservative leadership finds appealing, rather than truly allowing a person to make a decision based on what is best for them (or, perhaps, even their baby). I doubt Republican senators in Oklahoma consider the fact that when a 16 year old mother of three who lives in an abusive household chooses to have an abortion, she might actually be considering that it would be better for a child to simply not be born into that world where it could not be cared for and protected. But I digress.

The part of this bill that I personally find the most appalling is a clause wherein doctors are protected from malpractice suits if they choose not to disclose birth defects to a mother with the intent of dissuading her from having an abortion. In essence, here's what that means. Let's say I'm pregnant (I'm not, by the way. Didn't want to freak anyway out or anything.). Let's say that my husband and I have decided that if the baby has a debilitating genetic defect (for example, trisomy 18--a terrible disorder that usually kills in utero, but for those babies who make it to term generally kills within a few hours or days) we will choose to abort. Let's say that I inform my obstetrician that I'd like to have prenatal testing done with the intent of discovering if the child has trisomy 18. We have the test, which comes back positive for trisomy 18. Now let's say that my obstetrician is vehemently pro-life, and chooses not to disclose to us the results of the test because she believes that we should not have an abortion. In almost every state, this kind of non-disclosure is considered a violation of patients' rights, and my husband and I would be able to sue for malpractice. In Oklahoma, we would now have no recourse to sue the physician for failing to disclose the information as a result of her pro-life stance. This, to me, is unconscionable. I may not agree with every decision my future patients make--in fact, I will probably disagree with many of them, including the decision of patients to smoke, drink, do drugs, have unprotected sex, eat Burger King for every meal and gain 500 pounds just to name a few. But I am in no way allowed to restrict those patients' access to information about their health simply because I do not agree with their decisions about what to do with their bodies.

I truly hope that the law gets overturned, and that those who are pro-life realize that they cannot dictate morality to the masses. In fact, when they do so, they destroy a little bit of the fabric that makes us truly American--our freedom to make our own choices, even if others (especially governments) disagree. Unfortunately, I don't see that happening any time soon.

In closing, I'll leave you with one of my most favorite quotes of all time:

American isn't easy. American is advanced citizenship--you gotta want it bad. It's gonna say, "You want free speech? Let's see you acknowledge a man whose words make your blood boil, who's standing center stage and advocating at the top of his lungs that which you would spend a lifetime opposing at the top of yours. You want to claim this land as the land of the free? Then the symbol of your country can't just be a flag; the symbol also has to be one of its citizens exercising his right to burn that flag in protest. Show me that, defend that, celebrate that in your classrooms. Then, you can stand up and sing about the "land of the free".

--Andrew Shepherd in The American President

I feel like I haven't written much for the past couple/few months, but in all honesty, it's because there just hasn't been that much to say. Basically life has consisted of class as usual, some relaxing with family and friends and D when I can manage it, and just general about-the-house kind of things. We did have a great time last weekend at the annual med school "Cadaver Ball"--D and I went with my friend F and her boyfriend and had a raucous good time with all our classmates (as well as the other 3 classes). It's nice to just let loose every once in a while (and in fact, I plan on doing so again the day after I take the boards).

The only other really exciting thing is that Thursday was my last official day of classroom learning. Ever. From here out, we have a week of studying, a pharmacology and psychiatry final, and then I'll be studying for Step 1 for about 4 1/2 weeks. Then 3 1/2 weeks vacation, and then boom--ob/gyn. While the idea of being in the hospital looking much like a deer in the headlights is admittedly a bit terrifying, I'm also really, really excited. I loved being in clinic last summer for the month opportunity that I had, and really, it's just so much more fun to learn in a "doing" environment, rather than sitting on your butt on a couch or desk chair day in and day out.

Speaking of sitting (or not), I've also been working on a program called Couch to 5K ever since D and I got back from Europe. You can check it out at www.c25k.com. Basically it's a program that's designed to help people who have never run seriously to get into a regular exercise routine. It starts out with almost no running at all and gradually increases the amount that you run and decreases the amount that you walk, until 9 weeks later you are running about 3 miles (or 5K). I'm currently getting ready to start week 7, although I'll admit that I cheated a bit and started on week 3 because I had been working out at least a bit going in. Thus far it's been a really good program, although the only problem I have (that I've always had with running) is the fact that I just plain get bored. After a few minutes, my brain needs something to occupy me. Even Goljan's Pathology lectures aren't enough. I'm thinking once the boards are over and I've had my fill of path and all else medical, I might load a Harry Potter book onto my iPod and see if that makes life a little easier.

Shocking Revelation

I just realized that I have 2 weeks of classroom study left, a week of exam study, and then a month of boards study and then HOLY SHIT I HAVE TO TAKE THE BOARDS AND WORK IN A HOSPITAL AND PRETEND TO BE A REAL DOCTOR WHO KNOWS SOMETHING. (Well...I don't really have to pretend to be a real doctor...the short white coat makes it painfully obvious that we are all peons with no real power or responsibility other than waking up at O-dark thirty and poking annoyed patients' bellies. But still. WHOA.)

Three months from right now I will be on my Ob/Gyn rotation. How in the world did that happen?

Heartbroken

Oh, Butler.

Gordon Hayward--the hero that almost was.

Why must you break my heart?

Stupid Duke. Now there's nothing to be excited about except a Tuesday full of school.

Spring Break and Other Happenings

So. Healthcare Reform. Fun Stuff. I wanted to leave that last post at the top of the page for a bit just to see if anyone else out there had thoughts or comments, but I think a couple of weeks is enough time to admit that we've all kind of moved on a bit, and things seem to be settling down politically anyway so I guess that's my cue to give it up already. :-)

Let's see...not a ton of stuff going on lately so just some general updating...D and I spent spring break a couple of weeks ago in Austria, which was awesome. I had studied there for a summer in college, and he had never been, so we had a thoroughly enjoyable (if a little chilly) vacation. Since then, life has been pretty much back to normal, if not a little better than usual since we came back not only refreshed but to the arrival of spring. I don't think it's been below 55 degrees since we got back, and that's enough to raise anyone's spirits, really.

I took my first NBME assessment test today, which basically is a shortened practice version of the Board exam coming up in June, designed for us to gauge what we know already vs. what we need to study prior to actually hunkering down in our bunkers for the month of May. I actually did pretty well--above a passing level on my predicted score, so that's nice. I definitely need to study the daylights out of neurology and physiology--but to be fair, those subjects were covered last year and who really remembers anything from a year ago? Everything else seems to be pretty good to go, at least for a starting point. Now I just have to actually break down and read First Aid (the Bible of Board Review).

Also working on getting back into the gym and in shape this week because I didn't go at all over spring break, and then the week after we got back D gave me The Plague and I couldn't breathe for a week until I was rescued by the mighty Z-Pack. Good news: Now that I'm feeling all better I'm also feeling all motivated to get my butt moving again, especially given the nice weather.

Healthcare Reform

So, with the passage of the Healthcare Reform Bill last night, and with the knowledge of my somewhat unique position as a medical student, I felt compelled to write this. I also sent it as a message to a conservative friend of mine who was asking for thoughts on the bill, and I think it turned out far more eloquently than I might have expected. Hope you enjoy.

I've been behind this whole idea from the beginning for several reasons. I will first, however, point out that I do not think it's perfect--there are several things I wonder/worry about, including any measures to address cost-containment in medicine without first addressing the huge problem of defensive medicine in this country (that is, the fact that far too many doctors waste money on tests and things that are unnecessary for patients, but only done because they fear being sued for missing something that has a 1 in a million chance of happening) and the prospect of undervaluing the exceptionally hard work of doctors and healthcare professionals in the name of "keeping costs down." In that respect, I'll probably be lucky as a doctor because I'm interested in primary care, which will most likely be paid *more* in the future because primary care doctors will come to be valued more than they are now because of their focus on preventive medicine. But it is obviously still an issue, and the fact that I will still make excellent money as a doctor will put me in a higher tax bracket than most, which means the new tax increases will affect me more than a lot of people.

BUT. Oh, but. As my not-so-beloved George W. once said (in another context, obviously), "The essence of civilization is that the strong have a duty to protect the weak." And that is a dear, dear idea in this country, and has been from day one. It's also a dear idea to me as a Christian. Jesus healed the sick, no questions asked. Those who have the ability to take action, not only can but must do so. And in this country, we do that in many ways--we provide for disasters with FEMA, we help people who lose their jobs when the economy goes to crap with unemployment, we help the elderly with Social Security and Medicare. The whole idea here is that we are a rich, prosperous, and well-meaning nation, and as such we take care of those who temporarily cannot take care of themselves. Interestingly enough, as much as most Americans cherish those values more than almost any country, we are the only advanced nation of the world that does *not* offer our citizens healthcare as a right. We do not heal the sick without first asking how they're going to pay. Now, I'm not saying that a single-payer system like they have in most European nations is ideal either, but it is reprehensible to me that 47 million people in this country have no way to pay for vital healthcare expenses.

I have close friends whose families have gone bankrupt because of an automobile accident that left their father injured and unable to work, but with hundreds of thousands in medical bills. I see patients every week who refuse to take medications that will save their life because they must choose between the pills and their children's home/food/clothing. Until last night with the passage of this bill, my own sister would have been unable to obtain health insurance other than Medicaid (which isn't necessarily a horrible thing, mind you, but would have meant she had to change doctors--which isn't great when you have a very long and sordid health history) because Down Syndrome is the ultimate pre-existing condition. With the passage of this bill, my mom will now be able to get her coverage like she has had her whole life, keep her doctors, etc. That alone is enough to make me cry tears of joy over this reform.

Another reason I support this bill is because it will, hopefully, in the long run actually reduce the current inordinate expenditures on healthcare in the country overall. Right now, the vast majority of people seen in emergency rooms across the country are there because they are uninsured and have no doctor they can go to. I don't know if you've heard of EMTALA, but it was a mandate put in place many years ago requiring all ERs to treat patients regardless of ability to pay. This is, at heart, a Good Thing--the Hippocratic Oath requires it, after all. But the problem with it is that anyone who needs any care at all can wander into an ER and must get treated. And what this translates into at this point is that hundreds of thousands of people in ERs are there for simple ailments like colds, coughs, and sore throats. They can't pay to see anyone else, so they go where they can to get medicine for their kids/parents/spouses/etc. It's understandable, but the problem here is that it costs TOO much. Because over 50% (and that's a rough guess...honestly it's probably much more) of the people who show up in the ER on any given day are uninsured, the hospital has to get those costs back somehow. And so they charge everyone else more. People who *can* pay get charged 5x as much as whatever they're receiving costs, simply because the last 4 people behind them couldn't pay for it, and the hospital has doctors to pay and medicines to buy. That translates to higher costs for you out of pocket, but even more it translates to higher costs for the insurance company that's paying on your behalf. And that translates to much higher premiums. Now to make things really confusing, it also makes things much worse because the insurance company paying for you won't actually pay the full amount the hospital charges. So when the hospital charges you 5x the price of your tylenol, the insurance company will only pay them maybe 2x the price. But the hospital still needs the 5x price to pay for the drug and doctors etc. So instead, the hospital charges 10x the price, because then they know the insurance company will pay 5x. And costs go up--and will continue to go up, if we do nothing. It's one of the reasons that our country is slated to spend up to 25% of the GDP on healthcare within 10 years. This is in comparison to countries like Canada, Germany, England, and France, who all have government-run systems but spend approximately 10% of their expenses on healthcare--with NO better results than the US. In recent studies, the US ranks #1 in only one aspect of healthcare--Cost. In outcomes, we are number 37. Much of this is because of the vast number of uninsured patients who could be much more easily and efficiently (and, most of all, more cheaply) at a family practitioner's office--if only they were insured. This bill will provide insurance to 37 Million Americans who have previously been without it, which will hopefully eventually translate into lots more people getting access to primary care docs, and lots less people showing up in the ER with an earache. This passes the savings onto the insurance companies, and you. (And people get medicine they need without shelling out their savings--it's a win/win!)

The bill also creates capitalistic events in healthcare. By setting up these new insurance exchanges, insurance companies will actually have to compete for consumer interest--they'll have to offer better coverage at a lower price in order to get people to buy their plans, which not only drives down costs for us but is the essence of Capitalism (which is one reason why I've been so bugged by all the Republican opposition to this as a "Communist" idea). Insurance companies right now have all but a monopoly on us, with the ability to raise rates or deny coverage indiscriminately, especially to the people who need it most. I've seen it in my family and I've seen it in the hospitals where I'm starting to work--it's way too common for an insurance company to simply say "No" to paying for an expensive medication or procedure without any reason, even though it is necessary or life-saving. Insurance companies look out for one thing--the bottom line. I'm not saying it's not within their right to make money, but I don't believe it is within their rights as companies to exploit the American public in the name of profit, especially those who are at their weakest and most vulnerable in a time of great need.

Other good things of note: The bill allows parents to keep kids on their insurance plans until age 26, which is much later than lots of them do now--and helps out a LOT because the 18-30 age group has one of the highest rates of un-insured people, mainly because this group contains students and recent graduates who may not have jobs, or don't have jobs that offer insurance, or just feel that they are not likely to get sick and that insurance isn't worth the money. It also closes the Medicare "Doughnut Hole" for seniors where their prescription drug coverage doesn't kick in until they've paid X amount out of pocket. It allows for doctors to actually get paid for visits in which the sole purpose is to discuss end-of-life issues with elderly patients--to set out living wills, ascertain the patients' wishes, etc. (currently, these discussions are held all-too-infrequently, because Medicare doesn't cover them as doctors visits...which leaves far too many seniors without any recourse to make their wishes known. This is where the whole "death panel" rumors got started, but it's actually a very, very Good Thing so that older people can let their doctor know that "no, I don't want to be on a ventilator" or "yes, keep me going until there's nothing left in me," preventing doctors from doing something against their wishes or placing such difficult decisions onto distraught family members at the most inopportune times.).

But all in all, my most ardent support for the reforms are emotional. I know that I am one of the lucky ones right now. I have health insurance, and it's pretty good. I'll probably keep it just the same even once these new reforms come across. But in my heart I know that every time I see someone who has lost their job, or gotten cancer at a young age, or been in a car wreck and paralyzed, I know in my heart that It Could Be Me. There is no guarantee that D won't lose his job and with it our insurance. There is no guarantee that I won't go out tomorrow and get run over by a Mack truck and need thousands of dollars in drugs and surgeries. And if one of those situations should arise, I sure as hell hope that there would be some sort of safety net available to me--that society would not turn its back. Until now, there hasn't been. Starting in 4 years, there will be. And I don't mind paying higher taxes because by doing so I will secure for myself the peace of mind that comes with knowing that in the event of catastrophe, I will not have to worry about myself or my loved ones losing everything, or having to make terrible decisions, in the name of keeping me or themselves well. And I wouldn't wish that on anyone--so that means that I don't mind paying a little extra to provide for my neighbor, too. Besides, if I'm paying for his healthcare, he's also paying for mine.

So in summary--yes, I think this is a momentous step forward for the American people. I think a lot of the nay-sayers will realize once they get to keep their insurance just as it is, once they can provide better for their adult children, once they can see that there are no "death panels" and the bill is firmly set against public money being used for abortions, once they realize that they might just have the opportunity to get some cheaper deals on their insurance and not get dropped when they have a heart attack, that this really is an excellent plan. Is it perfect? Far from it. But it is necessary. Our health care system now is in shambles, and will only fall apart more as the years go on. I commend the President for actually sticking to his campaign promises and getting such massive reform passed within a year and a half of his election--and that determination and follow-through is one of the reasons I voted for him, and will most likely vote for him again.

*steps off soap box*

Scheduled out

And so it went--I did indeed get the rotation I wanted for third year, and I was happy because my friend F got almost the rotation she wanted despite being number 124 out of 141. What did suck was the fact that the last 20 people in line basically got stuck doing what was left rather than what they probably wanted, but hey, that's life. The better news for me was the fact that for the most part, the group of people I get to be with for my rotations are awesome with only a couple exceptions. So hopefully I'll just avoid the few bad eggs and get to work with a lot of cool, hard-working people.

The only problem with knowing all of this is that now I have absolutely no motivation to get through the rest of the school year. Do I really have to keep studying this madly when I know I'll be helping deliver babies come July?

Real Live Medicine

My but time flies. I survived the path shelf (with flying colors) and the micro shelf (hopefully with flying colors) and have since continued studying pharmacology and started a class they call clinical neurosciences--basically neuropathology and psychiatric pathology. I still really enjoy pharm, but I find it more difficult to ace the tests simply because it is a LOT of rote memorization--just straight out knowing what each drug does, how it interacts with other drugs, what side effects it causes, and any other miscellaneous info. It doesn't help much that a lot of the drugs sound the same--Imipramine vs. Ipratropium, Colzapine vs. Clonidine vs. Colchicine. It's more than a little bit mind-boggling, especially when we're cramming upwards of 100 drugs a week into our brains. It is really interesting, though, to finally understand what drugs you've always heard about or seen on tv are actually doing to a person's body.

The more exciting news this week, however, is that we are preparing to select our third year tracks--basically, the order in which we'll do our rotations next year. At my school, we have to complete the following "classes" in our third year of training: 6 weeks of OB-Gyn, 6 weeks of family practice medicine, 8 weeks of pediatrics, 10 weeks of Internal Medicine (basically a general practice for adults), 8 weeks of surgery, and 6 weeks of psychiatry. There seems to be much myth, pomp and circumstance surrounding the order of these rotations. For example, if you are interested in a particular specialty as a career option, you shouldn't do that rotation first, because you want to have enough experience under your belt to look like you know something so as to impress attendings and get good letters of recommendation. But you also don't want to do that rotation last, because you need to make your schedule for 4th year before that and you don't want to be burned out. More than this, however, there are tons of other little snippets of advice tossed around. Do psychiatry first because it's a nice easy rotation to start out on. Do surgery first so you can get it over with while the residents want procedures so you have an easier time. Don't do pediatrics in the winter unless you want to be a pediatrician.

At my school, we don't get complete control over the order of our rotations. What happens is we have a lottery--each student is randomly assigned a number in which they will choose from about 24 different "track" combinations. The earlier your number in the lottery, the better chance you get exactly the rotation you would like. The later your number in the lottery, the more you can base your choices on the other people who are already assigned to a given rotation (if you want to try to be with friends, or avoid certain classmates--which is totally legit, considering some people are just *not* team players, unfortunately). I was lucky enough to draw number 8 in the lottery, which means I get my pick of rotations. As a result, here's what I plan on doing:

OB-Gyn

Psych

Internal Medicine

(Christmas break)

Pediatrics

(spring break--1 wk)

Surgery

(2 week vacation that's just built into our schedule--we can technically do an elective at this time if we choose)

Family Medicine

And there you have it, friends. My life, from July 2010 to July 2011.

But first I have to pass the boards. (eep!)

The Final Countdown

Somehow, I am now 2 days away from my block exam and 3 from my path shelf/final, and I am miraculously still on study schedule and not behind at all. Also feeling relatively confident, considering that I have finally started getting increased scores on my qBank (a big online compilation of practice boards-style questions). I think this is the most relaxed exam week I've had all year, and I'm not really sure how it worked out that way, but I'm not about to question it. Of course, that doesn't keep me from being really, really excited that it'll all be over this Friday at noon.

Burnination

When I started second year, everyone said that the absolute worst point in medical school was the month of January. It's dark and cold, they said, and you're burned out, and you just want to be done but you can't quite see the light at the end of the tunnel yet. I didn't really believe them. "How bad could it be?" I thought--I mean, after all we'll at least only have 2 classes instead of 3 at that point, and coming off a two week winter break should make things easier. Not to mention that this particular block only contains 3 weeks of legitimate classes prior to test week.

But oh--how right they were. The last 3 weeks have been absolutely trudging, tedious, laborious, hellish work. Not because the material isn't interesting--if anything, I've enjoyed pathology more in the last 3 weeks than almost any so far, and pharmacology (our newly added course) is quite interesting and well-taught. The problem is that we're still taking pathology, whereas all our other first-semester classes ended in December. And not only are we in a seemingly endless sea of diseases, but the test we take a week from this Friday is a cumulative final over everything since August. And not only is it a cumulative final, but the final is composed of retired board questions similar to what we'll see this summer when we face the beast that is Step 1. And we have to get a certain percentage to pass the course. Oh, and then there's the "regular" path test over the last 3 weeks and pharm too. And the fact that in less than 6 months, we have to take the first step of the national board licensing exam--a massive, 8 hour test cumulative for our entire first two years' material, mandatory to pass if you want to be a doctor and progress to 3rd year.

And so there's just a lot on our plates. I have spent the last 3 weeks getting up early, studying from minute one (more than once I've balanced my computer on the toilet seat while putting on my makeup so I could flip through flashcards simultaneously) to minute--well, however many minutes get me to about 10-12:oo at night. I have to cover each day's new material, read chapters of board review books to remember everything from last semester, do practice questions to get used to the type of question on the shelf exam. And while all of that sounds decently do-able, when you add it all together it becomes a very daunting amount of work that precludes almost any outside activity. The year and a half leading up to this point has obviously involved a lot of work, but this seems to be a whole new level of time consumption. Last week I got incredibly excited to watch some TV with D, only to realize that we had a pharm quiz the next morning that I needed to prepare for (which took about 3 hours). It's at that point that you can't help but question whether the 3 hours away from loved ones, shut up in your room with your nose plastered to a screen or a book, is really worth all this insanity.

Honestly, I'm starting to believe they do things this way on purpose--so that when we're done with the first two years of medicine, the 80 hour work weeks in the hospital are a welcome change just for the chance to actually do something, talk to someone, see real people and realize that all these weird diseases with their crazy names actually exist out in the world.

Here's hoping the next two weeks pass quickly.