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.