The Final Countdown

The minutes are ticking away... the 11th hour approaches, a time for fear (shelf test!) and celebration (vacation!!).

Today I had my oral/written exam portion of the peds rotation, and tomorrow morning is the shelf test. Therefore, this entry will be short so I can get back to alternately freaking out and succumbing to complete apathy.

First, my take. Peds: I liked it. I actually liked it a whole lot. I can't see myself as a general outpatient pediatrician, but that doesn't surprise me, because I think that general outpatient anything would bore me beyond tears and into the realm of automatic weaponry. However, I could see loving inpatient peds or specialty peds (depending on the specialty). I'm not sure that I'll end up doing it, but it gets a big thumbs up in by book. The oral and written exam were not too bad, although I am somewhat (between a little and gosh-darn) irked that I missed a question about immunizations and I'm still not sure why; they even provided the immunization chart, I'm sure with the thought "Now even severely handicapped students can get this question right!". So really it's a mix of feeling like an idiot and feeling like a major idiot since I still don't understand why I got it wrong. But whatever.

As for the shelf, I am in the same place I always seem to be the night before these things. I want to care; I try to care; there are fleeting moments where I actually do mange to care; but mostly, no. I am tired, and tired, and oh yeah, tired, and I don't want to study this stuff any more. I want to take the test now and be done. (Or--better idea--not take the test at all.)

Sadly, as is so often the case with the MD/PhD program, there is no rest for the weary. I must trudge ahead and try to study... at least pretend to study... maybe pretend to try to study. I'm still trying to work that out. Okay... here I go... books out... where's my pen... okay...

Oh, hey! A Christmas Story is on!!



Happy Holidays everyone, and try to enjoy your vacation as much as I plan to, which is a lot.

Sludging

Sludging is something I was just reading about, and it struck me that this is the perfect term to describe what is going on with the information I am currently attempting to cram into my brain.

In medicine, sludging refers to what happens when you have hyperviscosity syndrome--that is, your blood gets thick (usually from too many red blood cells) and forms "sludge" in vessels which supply your most vital organs: for some of us, the brain; for others, not so much. But it is essentially like what happens in sewer pipes when goo causes a back-up of unfathomable grossness right into your bathroom, only this happens inside your body.

Ew, indeed.

But, I was trying to find the words to describe my current knowledge of pediatrics, and sludging is the absolute perfect term. I read, and read, and read, and if I still have the ability to retain saliva in my mouth, I read some more. I listen to residents and attending as they hurl information at me like jai alai players on speed, and I try to pack it all into my poor brain, but what I have now is simply sludge.

Brain sludge is very dangerous, because not only is it useless, but it precludes adding new, non-sludge knowledge. It gums up the works. It's driving me mad.

And just to accentuate the horror, I must update my previous post and say that I was wrong about the FIVE cases. The actual required number--REQUIRED--is t-e-n. TEN. 10. X.

I have manged to finish ten, and I can promise you one thing: I am much dumber for it. On the bright side, I have even less pride. But not to worry: the sludge is slowly spreading through my brain and I have it on good authority that it will soon reach the part which retains the memories of the cases that I... hmm. I'm sorry. What was I saying?

ChumpWork

Dude. Make it stop.

Just when I thought I was out of the woods, homework-wise, they drop the frickin' A-bomb of busywork on me.

I can sum up my misery in four words: Stupid, online, required cases.

Ugh. Apparently, many med schools around the country use them. You log on to a web site and are led through a web of lameness like a small blind child, and are occasionally forced to answer a multiple choice answer or (shudder) type a response in a box. The web site says that the cases should take about 40 min to complete; I've been taking 20-30min each, which is still 20-30min each of my life I will never get back. We are required to complete at least 5.

FIVE.

But that's not the worst of it. They set it up so that you are required to complete at least 5, but that just gets you a pass. To get a high pass or honors you have to complete more LOTS, LOTS more. And although it only accounts for 5% of your total grade (WHY do they insist on acting like your 3rd year grades are objective by assigning things percentages and numbers? It is a total lie. I may talk about this in a future post...) you just know that if you decide to slack and only do the minimum that you would miss a good grade by 2.5% and the you'd just die.

Anyway, the cases go something like this. You open the page and it has a picture of a scary person who as far as you know just broke out of prison. They say,

"Hello. My name is Dr. Doverschlogenmarchowitz. Today we'll be seeing little Timmy, a 4 year old who insists on traveling everywhere by hopping on one leg and has a history of explosive diarrhea. Why don't you go in and introduce yourself?"

Then you click on the next page button and it has a picture of Timmy, and it asks you some kind of question mildly related to the situation, like:

"Explosive diarrhea can stem from many causes, such as watching reality television. Which ONE of the following is the least medically accurate television program?
A. Grey's Anatomy
B. ER
C. House
D. Diagnosis: Sexy!: The Search for the Hottest Doc in America"

Then you are forced to click on questions for the patient and read their answers and it goes on and on and oh my God it is horrible.

Anyway, I could mock them all night, but really I'd like to finish another one of these stinkbombs so I can go to sleep. By the way, in the interest of full disclosure, I would like to state that I know that at least one of my classmates, an otherwise totally sane human, has stated that he believes these cases are helpful. For this person I would like to suggest haldol. For Timmy, I suggest laying off America's Most Smartest Model.

Student, evaluate thyself

First of all, WHEW.

I'm done with inpatient pediatrics. One more month left in this rotation, which is a week of newborn nursery and three weeks of outpatient clinics. But the tough stuff is the inpatient, with longer hours, call and weekends.

So, how was it? Well, I am totally beat, but I really like peds for a bunch of reasons I won't go into here. In fact my liking of it is such a majority that it is easier to say what I don't like about it, which is:
1. Crazy adolescent patients
2. Crazy parents
3. 1 and 2 (they often go together)
4. Extremely depressing patients, such as victims of child abuse (shaken baby syndrome being possibly the most depressing) and those with profound CP and mental retardation

Still, even with the above, I could see myself really enjoying pediatrics. Because the vast majority of time, even in bad situations 1-4, you still leave feeling like you managed to help, even in the smallest way.

But that is not what I would like to talk about today. Today I would like to discuss (with my keyboard and my three readers) the idea of self-evaluation.

Most rotations do this in some respect, but peds does it more formally than others I've had so far. At the half-way point they give you a long questionnaire which you fill out in what is supposed to be an intensely self-searching and honest manner, and then you go over it with one of the attendings.

Now, as an oftentimes exorbitantly introspective (and, okay, insecure) person, I found this process both redundant and depressing. Basically, it allowed me to write down all the shortcomings I have been acutely aware of since day one on the wards, while at the same time introducing new and disturbing facets of inadequacy which I may now ruminate over at my leisure. When I finished the forms, and was feeling even more disappointing than usual, I started questioning the utility of this form of review. The way I see it, there are Three Main Classes of Student, and self-evaluation fails each of them, albeit for different reasons:

-The Egotistical Jackass: This is the person who sees most everything as beneath them and their superior level of function. The self-evaluation fails here because the egotistical jackass will never consciously acknowledge that they have room for improvement; if they do it tends to be something inane like "I will try not to make the other students as jealous of my awesomeness." (You think I am lying, but there are definitely students like this out there. Sometimes they actually are pretty good, and sometimes not. Sometimes their ego is kind of endearing, and sometimes it makes you want to tie their vulnerable appendages to your car bumper and drive off.)
-The Oblivious and Often Inappropriate Nutbar: Again, it is surprising how many there are. Most of these people, in my opinion, simply lack introspective prowesses. They say and do ridiculous things and don't seem to understand why they are wildly inappropriate. Example: one of my fellow students, who is so strange and inappropriate that it would not surprise me in the least to learn that he is actually a humanoid robot shell operated by alien beings, actually started pimping us, our interns and our senior resident in the middle of rounds. By name. As in, "(Senior Resident's name), why don't you tell us some metabolic derangements you might see with this disease." It would have been even funnier if it wasn't so sad. Asking them to figure out how they can improve is like asking an cow to derive the equations of motion.
-The Paranoid, Insecure Self-Torturer: I think I fall into this category, and I think the result of self-evaluation for most of us is as I described above. The last thing we need is more stuff to beat ourselves up about.

I think the main goal of this self-evaluation stuff is to come up with an "action plan"; that is, a way to address the areas you think need to be improved. Again, in light of the Three Major Types of Student, I think this step is not useful. The egotistical jackass has not come up with anything reasonable to improve, so it's kind of a moot point there. The Oblivious and Often Inappropriate Nutbar... well, it's best not to delve deeper into their psyche. And the Paranoid, Insecure Self-Torturer formulates about 20 action plans for their perceived areas of weakness every single day on their way home, so to ask them to do it formally is to risk pushing them into Generalized Insecurity Paralysis (GIP) which I think we can all agree is counter-productive.

All that being said, my session was somewhat helpful for me. For instance, my attending moved several areas of self-perceived weakness into the "strengths" category, which was honestly a load off of my mind. Example: my knowledge base. I always feel behind my peers, so having an attending tell me that wasn't true was frankly a load off of my mind. She also did point out that some things I perceived as deficits in my presentations were actually not an issue, but that my lack of confidence was; and as I had not realized my insecurity was so apparent, that was a helpful observation.

So, med school bigwigs, on behalf of my other equally though differently dysfunctional classmates, just tell us what we are good at, and what we suck at, so we can go back to being in denial, or insane, or self-deprecating. Thank you, and I hope I've given you a plan for improvement.

Like Being in the Ring with Mike Tyson

That is what it's like on the wards for a 3rd year medical student.

You step into the ring and KAPOW!!! You're reeling, you try to shake it off, but before you can JABJABJAB! BODY BLOW! You hit the canvas, they're counting, you stagger to your feet and KABLAM!! Lights out.

What I mean here is, it's tough on the wards for people like me, still trying to figure out what the hell is going on. As soon as you recover from one mistake, you make a complete ass of yourself in front of your team and possibly trip over an IV on your way out. One time I dropped something on a patient's leg, right where she had just had a skin graft. She cried. It was horrible.

Dumbass Moment 1: Presentations during rounds
I swear to God, it doesn't seem to matter what time I get to the hospital to prepare, how much reading I do about my patient, how carefully I write out what I need to say. I cannot seem to get through a single presentation without making some mistake. I wish I could say that I make a new and different mistake every time, but sadly, that is not the case. There is a set of mistakes that I make over and over and over again, forcing the attending to ask things like "So why is this patient here?" and "Are you sure their heart exam was normal? Because that child has a murmur you can hear from Mars." In addition, I'm generally spastic and strange throughout most of my presentations (see "Medical Tourette's" below). You are supposed to go in a very specific order, and sometimes I'll make it the whole way through the presentation, but then people are still looking at me, so I'll just kind of yell "LASIX 30mg PO BID" for no reason.
Yesterday I presented a new patient. I had a particularly bad day the day before, so I worked very hard to shake it off and make it my best presentation, and when I finished, I felt great... for about two seconds. Then a fellow pointed out that I had said "lungs clear to auscultation, except for some scattered wheezes". That's like saying "patient is doing well, except that he is dead". Last week I was actually given a very complex patient to follow, but after one horrible crash-and-burn presentation they switched me to a patient just saying overnight after a percutaneous cath. It was like "There, there. Give mommy the power tool. Here is a nice soft plastic block with rounded edges."

Dumbass Moment 2: Totally off-base answer to pimping question
This happens to me a lot. They'll ask something like, "What is something in your differential diagnosis for lower abdominal pain?" And I'll just blurt out "CHEST TOAD!" It's like I have Medical Tourette's. I say completely idiotic things, and I say them loudly. It's horrible.

Dumbass Moment 3: Flubbing the Interview/Exam in Front of a Patient
I have done this plenty, but my favorite example is actually something a fellow medical student said. He was interviewing a patient's mom about her daughter's vomiting, and he actually said, "Any pets? How about a beaver?"

These are just a few examples of classic Ward Dumbass Moments. There are many more. What makes is hard is that these are inevitably scattered throughout every single day, and you have to find a way to immediately recover from the humiliation and shame so that you can go back to making the next mistake. It's very exhausting. So far Mike hasn't gone for my ear, but I'm sure it's just a matter of time.

FanTASTIC

Now playing on Lifetime Movie Network:
(I swear this is true):

"Baby Monitor: Sound of Fear"

I sure wish I had more time to kill... this post would be followed by a review.

Back to clinic... now how do I use this stethamathingy again?

I start Pediatrics tomorrow morning after having a super fantastic three week vacation, and I have to say, I'm pretty nervous. I feel like I have actually forgotten stuff, as weird as that sounds. It's amazing how quickly that pile of information starts to drift away.

I have high hopes for this rotation... I think I will really enjoy it, if I can somehow get back into the constantly working mode I was in before. For the rest of the year, my longest vacation will be one week, and I hate to say it but I think that is for the best. My poor brain needs as much help as it can get.

In other news it looks like I am going to have to have an upper endoscopy, and this brings up something I've been thinking about: how much harder it is to be sick or to be a patient when you've seen the behind-the-scenes action. I know for a fact I would not be one tenth as freaked out at the prospect of an upper endoscopy if I hadn't seen one done. But I have. And I am totally dreading it.

The other part of this is that I know all of the Really Bad Things they have to rule out. You start to be able to look at yourself from the outside, as if you were just one of your patients. It is not a good place to be, believe me. Anyway, I am hoping to get this over with as soon as possible and I will write all about it. After all, it's important to remember that the people we treat are no different than us. They need compassion, understanding, and most of all, Versed.

Lots of Versed.

Hopefully, all I'll write about is how I can't remember a thing about the upper endoscopy. In the meantime, I have to go get started on some reading. You see, unlike most of my classmates, I don't remember jack about EKGs or electrolytes or acid-base balance, so I have to relearn these things in addition to learning all of the other mounds of stuff for this rotation. So off I go, to read about bundle branch block and dream of being the person with the huge camera being stuffed down my throat... and an IV full of Versed.

MD/PhDs are people, too

A theme has emerged lately, and I've been thinking about it a lot.

The first incident was a comment made by a higher-up my husband was meeting with to discuss his then upcoming residency applications. Now, I know I'm biased, but my husband kicks just about all the academic ass there is (it ain't braggin' if it's true). The guy is just amazing. Reduce him to numbers, and he's amazing; look at his personal recommendations from all kinds of people, and he's amazing. He basically lacks chinks in his application armor. Yes, his armor is chinkless. It's actually quite exasperating, following a guy like that through the program. But that's a discussion for another day.

Anyway, the doc he met with was very nice and supportive and was going through my hubby's app with him, making various suggestions about how to present things, etc. The really interesting thing came when they started talking about letters of recommendation. You are only allowed so many, so they usually advise you to chose the authors carefully. My husband had a long list of impressive people who said they would be happy to write him a great letter (did I mention exasperating?) and was asking the doc's advice on which would be best to include. Here is what they guy said.

"It's important, since you are an MD/PhD, to have a letter which says you can interact well with patients and staff. People tend to think of MD/PhDs as lab geeks who lack social skills."

We both thought that was interesting, but mostly just funny. I mean, at least in our program, there are tons of really cool people who have sufficient to superfluous social skills. Yes, there are definitely individuals whose social abilities are roughly equivalent to, say, Michael Myers, but I know quite a few straight MD students who are the same. I don't think the percentages are any different; if anything, I'd argue that there are more functional MD/PhDs. So, I had decided that that particular doc had maybe had some unfortunate run-ins with socially handicapped mudphuds, and was therefore unfairly biased.

Then, just a few weeks after that, I was hanging out with my family medicine preceptor and another doc in his practice, and one asked the other about something, I can't even remember what, but something about the disease I studied for my PhD. The other doc didn't know, but I did, so I started explaining how we thought things worked and a little about my research. This started some teasing on their part which continued throughout the remainder of my rotation, and the gist of the teasing was: Boy, you sure are a science nerd! I thought it was odd, since the "science" they teased me about knowing was the basis of medicine, but whatever.
Additional thoughts on this were:
1. I know I probably do qualify as a science nerd, and
2. I did actually like both of the docs quite a bit, but...
3. HEY!
Perhaps I wouldn't have even remembered all of this, except for the real corker, which was that at the end of the rotation when my preceptor was evaluating me, he told me how amazed he was that I was maybe the best med student he had ever had when it came to interacting with patients and staff, "even though you're an MD/PhD."

Okay... WHAT?

And possibly, HEY!

I don't get it. What do people see us as? Giant albino cave-dwelling mutants with a crippling stutter? Or maybe we can only carry on conversations if the topic is meiosis in fruit flies? Allow me to re-emphasise that some of the weirdest, least socially functional people I have ever met are either 1. doctors or 2. training to be doctors. Are there total freakish, socially inept dorks in research? Does the pope wear a funny hat? Of course there are. But let he who is without dorkiness cast the first stone, docs.

It also kind of scares me that there are doctors out there that think of science as "nerdy". HELLO! You're a flippin' doctor, man! Have you really divorced medicine from science to the point where you can feel like a varsity jock compared to the nerdling members of the Chemistry Club? Give me a break.

I will not even go into how they actually said that it was a good thing I was already married, because being a female "super smart science nerd" is not appealing to men.

Excuse me for a moment of stunned silence.

Okay, I'm back. Anyway, in my thinking about this, I've been wondering: Is our program an exception? Are most MD/PhD's social bulls in the china shop of medicine? Are we really that much geekier than regular doctors? I mean, we can't be more socially inept than most surgeons, right? If I had a nickel for every time I saw a surgeon make a patient cry, I'd have--let's see--at least 25 cents... which, okay, is not a lot, but let's not forget I haven't been in the clinic very much. What if I told you that once, after the very empathetic move of breaking the news that a patient had cancer by reading it directly from the chart to her, a surgeon I worked with was distracted by the crying of the patient, paused the reading aloud mid-sentence, looked up from the chart and said (clearly irritated), "Can I go on?"

I mean, we can't be worse than that, can we?

In closing, I would like to say that I know lots of super great mudphuds, and we are not mutants, thank you very much, and we may be smart and enjoy learning but there is no need to assume that we are all weirdo loser geeks who never talk to normal people. Now if you'll excuse me, I need to go catalog my Star Wars figurines.

Sprechen Sie AWESOME?

So the hubby and I decided that we've earned it, and goshdarnit, we're going to Europe.

We have been talking about it for a while, but were too busy to really plan it. So when we started looking at tickets and there were some good deals to Germany, we decided, what the hell. Let's do it.

I am SO EXCITED, and am in the throes of planning right now. My husband is currently studying for Step 2 of the boards, which he takes soon, and then we're outta here. The great news for him is that after this exam the pressure is basically off for a good long while; he has interviews, which should be fun, and lots of months without any required stuff to do. So, for the first time in literally years, I get to spend some time with my husband where neither of us have anything--no publications or dissertations to work on, no applications to finish or big exams to study for--that we have to do. We can read fun books, travel, and talk. It's pretty stunning.

In other news, I am two months away from being half way through 3rd year. Unreal. The main survival technique I've learned for not just getting through, but doing well in 3rd year is: Study every day, for at least 1 hour. More is good, but less gets dicey. It is definitely hard to do after a loooooooong day in the hospital or clinic, but it is what has to happen. It is also rewarding to start occasionally knowing things when attendings pimp you.

Okay, I have to get back to tracking down a room in Munich, and trying to relearn cardiology before I start my next rotation. Such is the life of a medical student...

I can't complain.

Vacation, all I ever wanted!

What could be truer than the truths sung by the immortal GoGos?

I am done, done, DONE for THREE WHOLE WEEKS!!! At the risk of sounding Texan, YEEEEEEHAAAAAAAAAA!

I'm sitting here, on a Monday, in my pj's, with not a study book in sight. It's amazing.

The weird thing is that after a weekend full of playing catch-up for chores and errands, I'm not sure what to do with myself. I still have lots I need to do--for example, I can't see my desk due to the enormous pile of papers and mail and books covering it. Also, there are no fewer than two closets in our house which, if they are opened, would bury the poor hapless individual under a pile of random junk. Also, I need to get my hair cut (you know you're in bad shape when your hair looks bad even in a ponytail). But where's the studying? Where's the stress, and the fear? The frustration?

Hmmm. Strangely absent.

Anyway, due to our not so regularly scheduled vacation, I don't have a lot to ramble or rant about today. However we have something brewing on the back burner which may result in some awesomeness shortly. I'll keep you posted. And in the meantime, Dr. VonB abides.

Deep breath, deep breath, deep breath, deep breath, ok, breathe normally.

If you read the title, you've just experienced what it's like to have me perform a physical exam on you. Just envision me listening to each side of your back on the bottom, then each side on the top, then to your chest. I've done it so much that I catch myself doing it like a zombie sometimes.

Which is good, because it's important to get a rhythm going with the physical exam. This is for several reasons:
Reason 1: You don't want the patient to suspect you don't really know what you're doing.
Reason 2: You usually feel like a giant wonk, so it's easy to get flustered, which also tends to result in some patient uncertainty. If you have a system you tend not to get flustered, unless they have a really obscene tattoo or something (not that uncommon).
Reason 3: It's amazing how easy it is to forget to check things that you should be checking. For example, if someone has a URI (upper respiratory infection), you should listen to the lungs, and then often we throw in a heart listen for free, 'cause we're in the neighborhood, then you are supposed to look in their ears, their throat, and their nose (Believe me, it's as gross as it sounds. I used to always worry when the doctor looked in my nose that it was gross and embarrassing, and as it turns out, I was right. It is gross and embarrassing.). But for at least the first two weeks I would be looking in the ears, trying so hard to see something, anything, and I would get focused on that and inevitably forget to look in either the throat or the nose. If I had my rhythm down then, I wouldn't have had that problem.

The neuro exam is even worse, 'cause there's a bazillion things you are technically supposed to check, but most doctors only check about a million of them, but you don't always know which ones the doctor you're working with thinks are important enough to do. Then there's the abdominal exam, which sucks on 1) fat people, 2) people who currently have abdominal pain, or 3) both (this accounts for most of the patients I saw). It sucks because you feel really strange pushing around on this GIANT stomach and moving it around (I am not exaggerating), and you feel really bad pushing on it and making them cry out in pain (also not exaggerating).

Anyway I was thinking about the physical exam because I took that stupid Family Medicine test on Friday, the videotape one (see last post), and it sucked gluteus. It was actually four patients, and I think I did so badly that I am expecting a call any day now from the medical school advising me to go into a field more suited to my particular style of physical exam, such as herding cattle or mud wrestling. I guess I can at least be glad it's over, and I get about two months to sweat about my grade since it takes forever to get it back. This coming week I have a nice, short, relaxed rotation, followed by three weeks of vacation bliss. There will be painting of my grandmother's house, yes, but there will also be sleeping. And beer.

I'll be back when I have something interesting to say about resuscitating people. In the meantime, if you see me coming with a stethoscope, run the other way.

I have a fever... and sadly the cure is not more cowbell

This will totally shock those of you that know me personally, but I have a wicked head cold.

It was just a matter of time. I've been seeing about five to ten sick kids a day for three weeks. About 75% of them have some type of nasty virus which affects the respiratory tract, while the other 25% have some type of nasty virus which affects the intestinal tract; so, I guess if I was going to catch a virus, I'd rather have this one.

Anyway the main thing that is bad about it is that I have two choices: 1) feel totally spaced out due to the virus or 2) feel totally spaced out due to the only medicines which give me even minor relief from the virus. I've been alternating between the two and I can't decide which leads to more productive studying. Every time I pick up the pills it's like, "Well, would I rather have my main insight into diabetes be "uhhhhhhhhhhhhwha?" or would I rather have it be 'uggggggSNORTuuurhhhhhhh'?"

This whole event has made me much more nervous about having my pediatric rotation in Nov/Dec. From what I've heard, peds during this particular period becomes like a frickin' flea market of RSV (respiratory syncytial virus, a super nasty respiratory tract infection), rotavirus (Severe diarrhea and vomiting! Yay!), and various other unappealing and highly contagious infections. Hopefully my pathetic excuse for an immune system (that's right, immune system--you heard me. I called you pathetic. If you want some respect, take a moment and contemplate why you go into full red alert over dust mite poop but roll out the frickin' red carpet for Mr. Nasty Flu) will manage to scrape together enough sense among its billion cells or so to remember whatever I have now and keep me from getting it again. But I'm not holding my breath. Which is good, because it's not easy to breathe when your nose is completely blocked off and draining into your throat, choking you. Stupid virus.

Anyway, otherwise, things are going well. I feel pretty good about studying for Family Medicine because it's kind of like a sneak preview for the rest of the year: peds, medicine, OB/Gyn, psych--it's all here. Just laying good ground work for everything that's ahead. It's great! (Psst: does that stuff sound convincing to you? 'Cause it's not really making studying sound any better to me. Stupid hypertension drugs!!) My husband just got his residency applications submitted, which is a load off his mind and mine, plus I don't have to listen to him whine about them anymore. He finishes his current rotation Friday, after which he will be free to be my personal servant until Christmas. Just kidding. Kind of. Actually, he will have to study for Step 2 of the boards, and then he will have residency interviews and stuff, but I trust that there will be lots of servitude blended in. Right, honey?

As for me, I have one more week of Family Medicine--my exam is on Friday. The exam, as I mentioned, consists of a multiple-choice test, a videotaped interview and exam on an actor playing a patient, and a brief written/oral exam. Allow me to express my feelings about this exam: YIPE. I mean, videotape? Ugh. My theory is that all the doctors get together and have a big party, and show bloopers from people's exams where they inadvertently poke the actor in the eye or knock him unconscious with a reflex hammer and then sit down on the floor and cry. In any case, I will try to update the blog with details of that super fun experience once I am done.

The following week I have a one week course where you learn about acute care--mostly resuscitation stuff. Then I get a glorious vacation before starting peds. I can't wait... I can almost smell the vomit now.

How about filling this prescription for STOP EATING

A few confessions right up front: I am not a skinny person. I never have been. And, I love food. A bunch. Finally, I am not athletic. I've always been one of those stereotypical nerdy kids who likes school and has asthma and tries for the cool hairdo but falls sadly short.

However, I have a rule. If my pants start to get tight, I institute THE diet, the most fantastic diet in the world. There are two parts to this diet.
Part 1: Eat less.
Part 2: Exercise more.

Amazingly, it works every time. I think about that two part diet a lot. I first heard this precise diet from a doctor I worked with my first year of medical school. He is an amazing doctor. He trained in India and could diagnose twenty diseases just by looking at a patient's hands. We would see tons (no pun intended) of patients come through his practice who were not only overweight but have diabetes and countless other health problems. Some of them would enthusiastically tell the doc about whatever new crazy diet they were trying; all liquid, no carbs, only carbs, only foods that start with the letter z, whatever. And he would always close his eyes and shake his head and say, "It is good you are trying to losing weight. But there is only one way to lose weight, and that is to eat less and exercise more."

The best part is that 99% of the time the patient would look at him like he was nuts.

It's a simple concept, people. I didn't say easy; it is, however, undeniably simple. Every single day in Family medicine we would see patients who were easily 100lbs over their ideal weight, and, shockingly, they would have all kinds of problems. Doc, my knee hurts. Doc, my lower back hurts. Doc, my heart's bad. And oh, by the way, I smoke 2 packs a day.

I am not minimizing the problems of all those people in the US who are overweight. As I said, I struggle with it myself. It is very difficult living in the US today, with mounds of delicious, tasty, and horribly bad-for-you-food not only available but in your face constantly, day in and day out. Lots of them have all kinds of other difficult psychological and social issues which I am very fortunate not to have to shoulder. But, OH MY GOD, people, STOP. EATING. And, occasionally, consider moving your ass.

It gets very frustrating. Even besides the fact that I want to do clinical research, I know now that I could not go into primary care. I don't think I could spend every day overlooking the major problems in people's lives and trying, usually in vain, to treat the results of those problems. Yes, this is an overly simplified view of primary care, and yes, there are truckloads of amazing doctors who do manage to change people's life every day. But, in my experience, even those doctors will admit that they are happy if they reach even 10% of their patients.

I think the truth is that Americans take things for granted. Their wealth, their lifestyle, and as I have learned, their health. Most patients want to abuse their bodies for 40 or 50 years and then get a pill to make it all better.

I salute all those doctors who are happy with 10%. I am in awe of them. I can't do it.

I need to go work out.

Cough, cough, fever

Kind of like duck, duck, goose, only with more mucous. That pretty much sums up Family Medicine.

Actually, I like it. I don't know that it is for me, for a lifetime, but for now it's good. There's a lot of variety, and good practice for general and focused H&Ps (history and physical). My preceptor is very very nice. I do have to admit that, unfortunately, I feel that the slope of my learning curve has really leveled out. That could be because I'm studying way less than I was on Surgery. Why? Well, first, the textbook we are supposed to use pretty much blows. Also, in contrast to Surgery, with Family, you don't have The Fear.

The Fear is very important, and it isn't just about the Socratic method, pimping, or angry, angry surgeons yelling at you. It's also about having a lot of patients who might just die on you if you don't figure out what is going on and how to fix it. It gives the whole thing a sense of urgency that frankly is lacking in Family Medicine, an urgency you can use very well to fuel your studying.

Don't get me wrong, there is a ton to learn--for example, I'm trying to remember at least three major medications and what they're used for (I try not to set my standards too high). There is a ton of breadth, but not a lot of depth, and I think that works against my disposition a little bit. Anyway, writing about this has made me feel that I should really go and get some studying done. So I will. That's a very, very important thing to remember in 3rd year: when you get the urge to study, for whatever reason, run with it. Just remember to put down the scissors.

And we're back

Family medicine is a lot busier than I expected it to be.

First of all, I have to commute a little more than an hour each way (that's more than two hours of driving per day, for those of you who are math-challenged). Then, there's the homework.

Yes, that's right. All of a sudden you're like a frickin' 5th grader, with homework.

They try to dress it up; they're "presentations" and "research summaries", but honestly, that just makes it more insulting. In my opinion, it's time to stop this ridiculous crap. There's already a big exam at the end of the rotation (written and verbal). Plus--and I hope I'm not understating this here--I feel that if the motivation to NOT KILL PEOPLE isn't enough to make someone learn of their own volition, then I don't see how homework is going to do it.

Let me learn on my own. I am NOT a 5th grader. I don't need your damn homework. I can learn all by myself, just like I brush my teeth without being told and wear matching socks without you picking them out (well, most of the time).

My other gripe (Yes!! There's more!!) is that a big part of being a doctor (okay, a GOOD doctor) is to be what they like to call a "self-directed learner". This means--stick with me here, because this is a startling and complex idea--that if you don't know something, you look it up. Radical concept, huh? Well, they tell you that it's time that you become a "self-directed learner", and in some rotations (coughSURGERYcough) if you don't do that you are a dead doornail, while in others, I'm talking to you, FAMILY, they make you do stupid. Frickin. Homework.

The cherry on top: I won't be able to say for sure until after the exam, but my hunch is that these homework assignments are not going to be super helpful on the exam. I mean, I think that they are overall theoretically important things, but the kind of things that I could have learned on my own in about one third or less of the time it took me to put it together into homework.

There is another part to this that I have to confess. One of my biggest pet peeves--other than having homework at the age of 32 and the song "American Pie"--is a little something I like to call "forced audience participation". I bet you know exactly what I'm taking about. It can happen anywhere, from a "Hey, let's put those hands together!! I can't hear you!" to "Where is everyone from?" to what I am experiencing now: "What kinds of psychosocial issues do you think we should consider in this patient?". Ironically, I don't really mind the more Socratic surgery method, where they direct a question to one particular audience member (usually warmly and personally, as in "that guy back there in the blue shirt who isn't paying attention"). But when they ask this very subjective, open-ended question, and just sit there, silently, waiting for someone to speak up, which finally someone does, but inevitably doesn't give exactly the answer the person wants, so they say something inane like "Um, yes, okay, but what else?", I just want to punch their face in.

Wow, okay, I've really woven all over the blog road here. Let me wrap up and we'll come back to some of these hard-hitting issues--plus the things I LIKE about Family Medicine--after a brief commercial break. Seriously, I will try to post again this weekend. In the meantime, keep on keepin' on, people, and let me hear you put those hands together!!

To sleep, perchance to, well, sleep

Today was my last clinical day of surgery; tomorrow is the surgery shelf exam. My feelings can be summarized by combining the traditional "zzzzzzzzzzz", indicating sleep or sleepiness, and the "ARRRGGGGGGGGGGGHHHHHHHHH" of fear/frustration, thusly forming the new compound expression:
zzzzzzzARRRGGGGGHHHHHHzzzzzzzzzz,
which is the rallying cry of 3rd year surgery clerkship students everywhere.

I was on call last night, and after two solid weeks of madness it really took a toll. I was able to leave the hospital early today but have found that I'm not doing very well with the last-minute studying. But I'm looking on the bright side: I'm too exhausted to panic.

I'm pretty sure I will be able to pass the shelf and therefore the rotation (knock on a forest full of wood). Unfortunately, though it is uncool to acknowledge that you are "gunning" for honors, these things do matter, especially if you are strongly considering a very competitive subspeciality, which I am. So, passing is not really enough. I'm trying to give myself a break since this is my first rotation back and I have, by careful calculation, ZERO knowledge of minor things such as, I dunno, ANY DRUGS AT ALL, but I can't allow myself to be complacent about being behind my classmates. I'm trying hard, but right now I'm not sure it is enough.

Also, much to my chagrin, I've found that osmosis learning does NOT occur after falling asleep on your book, which I have done more in the past few weeks than in the entirety of my life up until now. In addition, I have found that I've become stupider as the rotation wears on. I'm not sure if this is due to the previous "topping off" phenomenon I wrote about before, or the exhaustion, or hearing slightly different versions of "the next appropriate step of management" from three different books and ten different people, but it is definitely true.

In any case this will be over, for better or for worse, tomorrow before noon. I move on to family medicine next which will be AWESOME in terms of hours (closer to 9 to 5 than the 5 to 9 of surgery) but is a continuation of the brain-stuffing I've been attempting with mixed results. I am going to try to get caught up on my drugs (learning, not taking) and general medical knowledge, but also on remembing what my husband looks like. I miss him, a lot. Also I miss fun, and sleeping. And my dogs. And sleeping.

I am going to sign out before this becomes any more rambling... not surprising given that I wrote it more to have something to do other than study and not so much because I have something specific or interesting to say. My positive thought for the post is easy: tomorrow I'm done with surgery, considered by most to be the most difficult rotation of 3rd year. What have I learned?
1. Waking up any time after 5am is "sleeping in".
2. Caffeine can be your best friend, but use her wisely; she is a bitch-goddess who does not take either abandonment or abuse lightly.
3. Surgeons are crazy.
4. Papillary is the most common type of thyroid cancer.
5. I can't remember the fifth thing, 'cause my brain is full.

Okay, that's all for now. In closing, always rememzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz

On second thought, no post today.

I was about to write a quick but scathing post about my horrific day and my generally abysmal outlook on the entirety of my medical education when I noticed my previous post. Let's just say that given my current state of mind I don't think anything I could write today would be in keeping with my new resolution, so I am going to take tonight to cool off and hopefully have a more reasonable outlook tomorrow.

Positive thought for the day: Today, despite persistent thoughts to the contrary, I did not harm myself or others. At least not physically.

To the best of my knowledge.

So far.

Super happy shiny fun time!

In flipping back through my previous posts, a subtle, yet persistent, theme emerged: bitching.

Yes, if I had to rename this blog, it would have to be called: "The Incessant and Unrelenting Bitchfest: A Tale of Two Degrees."

I'm sorry about that, for two main reasons. First--and you are never going to believe me about this one--I am basically a positive person. (I know! After reading my previous posts, it surprised me too!!) I'm not depressive, am only mildly moody (I like to think I experience the least possible amount of moodiness possible for a girl). I tend to be an optimistic, glass-half-full kind of person. And second, overall, I didn't hate graduate school, and third year medical school is basically awesome. Painful and terrifying and sad and really, really hard, but awesome.

So why so much bitching?

Honestly, I'm not 100% sure. I think a lot of it is that there are a whole lot of things about this career path that are extremely stressful, frustrating, challenging, etc. etc., and at some point my husband, family and friends get really sick of hearing about it, and tell me to knock it off, already! and I still have some venting to do, and, hey!, blog. Another part of it is that--and this is especially true of the grad school stuff--once you crawl out of a pit of despair, you want to put orange cones and CAUTION! tape and stuff around it, so other people don't fall into it, too. (Unless you are a certain person I am having to interact with a lot lately, in which case if you happen to fall into a pit with tigers and spikes and poisonous snakes I would laugh and laugh, and maybe throw rocks).

In any case I have resolved to try and always include something positive in every single one of my posts. Even if all I can manage is "Today I continue to successfully turn oxygen into carbon dioxide", my God, it'll be in there.

Currently, I am working on a list of "Everything you ever wanted to know about the surgical rotation, asked about, and were yelled at by a nurse." Expect it after I shake off my 30 hour shift. Until then, remember: fluffy bunnies are happy and cute!! Yay!

Ow... my brain

You know how there are signs at the gas station that tell you not to "top off" your tank? Well, I think I've topped off my brain.

It seems that no matter how much reading or studying I do there is actually MORE that I don't know. It's like when you are packing up your house and you spend two days putting stuff in boxes but somehow now there is still the same amount of stuff unpacked, so you pack more frantically, and now there is EVEN MORE STUFF UNPACKED THAN WHEN YOU STARTED PACKING AHHHHHHHHHHH.

Lately I don't know if I have any more boxes upstairs, if you know what I mean.

I have to admit, it's all pretty interesting. With as much studying as I've been doing, none of it has been nearly as painful as other stages of this process. Basically everything I'm trying to learn now is clinical, it's about taking care of people, and I really like that. Also, it's amazing actually seeing diseases and syndromes that somewhere along the line you convinced yourself existed only in books. It's amazing seeing how the new innovations in care over the last few years are actually being used to save people's lives, and seeing what new things are on the horizon.

I could go on and on, but I can feel details about primary hyperparathyroidism leaking out of my ears as I type, and I need that for tomorrow, when I'm on overnight call. Overnight call is often a prime time for pimping, because it is even funnier when medical students not only don't know the answer, but we cry. If you come up with any new innovations in brain drain plugs, definitely let me know, if I can remember why I needed it.

I don't know where time is, but it ain't on my side

Okay, this is going to be short. Why? Check out the title.

How in God's name to surgeons do this?!? It is NUTS. I mean, I haven't even had hours that were that bad and I feel like I'm barely scraping by. To be fair, I do have to do a whole truckload of reading and studying and other random busywork stuff when I'm not in the hospital, but still. Interns have it a lot worse, hour-wise. To give you a more specific idea of the hours I'm talking about, I have been spending 12-16 hours a day, an average of 6 days a week in the hospital. Then I need another 1-3 hours of studying time each day. My schedule has me working the next 13 days straight; then I get one day off, then work six more days. Then the exam. Included within those spans are two nights of all-night call where I could get five hours of sleep or zero sleep.

Also, I have to take the shelf test in less than three weeks, and that is freaking me out. The shelf test is a big, really hard, national exam you take at the end of each clinical clerkship--so, two weeks from Friday, I'll be taking the surgery shelf. Lots of people say it's the hardest one, but I don't listen to them. I listen to my brain, which is shrieking: AHHHHHHHH, we will never pass this exam!!!!!!!!!!!!!!!!!!


Okay, in any case, I have to go get some work done so I can get more than six hours of sleep tonight. Your final random thought: don't you think that Daniel Radcliffe always wears WAY too much blush in interviews?

You say Mudphud, I say Sucker

I'm old.

Like, really old. Seriously. I'm a third year medical student who is usually the same age as the youngest attendings. ATTENDINGS.

Brief side note: if you don't know the whole medical hierarchy, here's how it goes, in ascending order:
3rd year medical students
4th year medical students/acting interns (AIs)
Cockroaches
Interns (although in some services the interns are treated worse than the medical students, and in all services they work a lot harder)
Food service employees
Residents (ranked from 1st year to whatever the last year of that particular residency is, usually called the "senior resident")
Chief Resident (usually in the final year of residency, but sometimes it adds an extra year of residency to be chief resident)
Fellows (depending on if whatever you are doing is a fellowship)
Anyone who brings people good coffee
Attendings (have finished all of their training)
Friends of the Chief who want to see what medicine is like
Chief (head of the department)

Anyway. My point here is that I am usually being taught and generally bossed around by people who are up to seven years younger than me. Which is usually okay, other than all those whippersnappers making a racket, and sometimes I develop the strong urge to knit and put my hair up in a bun. So far they at least have the courtesy to act surprised upon learning my age, which is inevitably followed by the question: so what have you been up to (insinuated addition: "for all those years")?

There are two parts to this answer. Part one: I spent four pretty awesome years working in biopharmaceutical research, traveling, and having a total blast with tons of fantastic people after college. I needed the time to decide what to do with my life and although I sometimes wish I was four years younger now (then again, who doesn't??), I needed that time and I don't regret it one iota.
Part two: I spent four years as everyone's bitch getting a PhD which I now pray will pay off in some small way in the future and will not mean I have missed my chance to have kids or have a career which lasts for more than five years before retirement.

I know that sounds kinda bitter, and I don't really mean it that way exactly. It's just that I think a lot of us Mudphuds start feeling this way when we go back to 3rd year. We are all at least four or five years older, four or five years more jaded and tired and frustrated, and more importantly we have forgotten most of what we tried so hard to learn in the first few years of medical school. We finish our dissertations and show up to 3rd year like middle aged, haggard marathon runners staggering over the finish line, only to find another starting line, populated with these fresh-faced young people who have just gotten a full night's sleep and tons of carb loading. They just took their boards and it is all still fresh in their minds; they are still at an age where they can stay up all night and still remember where they live the next morning.

I haven't quite made up my mind about the abuse issue; that is, does having just gone through four to five years of consistent abuse make it easier to be abused for another three to five years, or is it better to go into it fresh? Maybe it is both, but speaking for myself, it isn't always easy to be treated like scum having just finished the scumfest of all scumfests. I know that medicine is a whole different field and basically everyone in the hospital, including the janitors, know more about medicine than I do, but come on! Didn't I just do this? As they say, it's déjà vu all over again.

Back to my original point. When I tell these younger bosses of mine that I have a PhD, most of them act impressed. They say really aggravating things, like, "Wow!" and "That's great!".

Is it? Is it really?

I dunno. I have been told over and over that I will be glad I did this, and in fact I do think I want to do clinical research, but right now, feeling old and behind and lost, I have to wonder.

And that's not even getting in to the thoughts I sometimes have about what I'd be doing with my six figures a year if I had gone straight into programming after college...

Pretend I didn't say that.

Finding words to say the worst

Today I met a completely disarming 6 year old girl. She was sweet and giggly, and very cute even though she lost all of her hair during her chemo and radiation. You could see how big her smile was even before she took off the mask she has to wear whenever she is out in the world, to keep her from getting sick. She has no immune system, you see--she, and her family, are waiting to see if the one she had transplanted into her is going to take.

She was referred to our clinic by her pediatric oncologist because they noticed that one of her eyes was occasionally drifting to the side, almost imperceptibly. My resident was concerned that they hadn't corrected this yet at the age of 6, because if you don't correct those sorts of disorders by age 7 they become almost impossible to fix. Even as he was telling me this I could tell there was something else he was worried about.

One of the worst things about being a doctor is knowing the bad signs. I knew as soon as I watched her pupil react to the swinging flashlight test that things were not okay, that they were a lot worse than we had at first feared. As we completed the eye exam, it was pretty clear that this little girl was blind in her right eye.

How do you tell her and her mother this? They did not come in today because they noticed something was wrong with her eye. They came in for a check up, and after her initial diagnosis, initial chemo and remission, then her relapse, more aggressive treatment, and bone marrow transplant, they thought things were just going to get easier from here. In fact, it was probably the radiation and chemotherapy that did it; the same things that probably saved her life took her right eye as payment.

As the resident went to call the referring doctor, the little girl's mom asked me what we thought. What was wrong? Why was it wrong? What was she seeing in that eye--were things fuzzy? Blurry?

I didn't know what to say. I thought she had seen that when we covered up her daughter's left eye, she couldn't see anything. I didn't know how to tell her she was blind in that eye--that she didn't see fuzzy things; she might--might--see a little light when you shined it right in that eye.

Luckily for me my resident came back, and he carefully explained everything, ending it by saying that the little girl could do whatever she wanted, that this would not hold her back in life at all. I added that just last week we did a check up on a physician who had been blind in one eye since birth. The mom didn't cry; she didn't really even look sad. She looked... the closest I can say is that she looked like a solider. She just put her arm around her daughter and said, "Okay."

And I find myself thinking about them tonight. Did the little girl understand what we were saying? Does she know that she won't ever see out of that eye again? Is her mom crying in her bed tonight?

I doubt it. They are much braver than I, and more thankful for everything they have. She has 20/20 vision in her left eye, and for now, that's enough.

Sweet dreams are made of this

Okay. The stress dreams have got to stop.

Just a sampling of the nightmares I've had in the past few weeks:

Dream One: I was operating with two residents, and we didn't really know what we were doing, and one of them made a mistake and the patient died, right there in my arms while I was trying to save her, and then the resident who killed her starting threatening that if I told anyone there would be big trouble... possibly another murder...

Dream Two: They tell me to do a procedure I have never done or even SEEN, one I don't really know how to do even in theory. But I have to do it, so I start by cutting into this fully conscious dude's scalp with a scalpel, and then I realize, horribly, that I didn't sterilize the area, and I'm not scrubbed in or even wearing gloves, so I try to play it cool but it's too late to use the betadine now, and one of the surgeons calls me over to tell me that I'm not cut out for medicine, that I'm a truly horrible student, not just because I just started cutting without any anesthetic or betadine or scrubbing but also because I keep scratching my leg, and even as she is telling me this I realize I'm scratching my damn leg, and they're telling me I'm no good, and the guy is bleeding, etc etc etc...

This is just a small sampling; there have been many, many other dreams (there are lots, since I've been having at least one, and usually several, per night). So what does it all mean?

It means that 3rd year is scary as hell. It's amazing, and great, and exhilarating, and definitely totally, completely terrifying. If you have never experienced it, the closest I can come to explaining it is to envision that you are on a jetliner, and all of the crew has passed out, and they grab you and plop you in front of the controls and say, "It's up to you to land this plane! The lives of you and everyone on it depend on you!" Then they slam the cockpit door and it's just you and the controls, the millions and millions of controls and blinking lights and switches with no labels. This analogy only works if you have never even set a toe inside a cockpit before.

Alright, enough of my melodrama. The irony in all of this is that they basically never ask you to do anything that matters (which, perhaps, makes it all the worse when you do it ineptly). I have to get some decent studying in since I spent most of yesterday reading the new Harry Potter book (it was AWESOME), and then get some sleep to prepare for my last week of reprieve before my general surgery month. Until then, may you dream of sunsets and waterfalls and butterfiles, none of which need a central line.

Two weeks down, six to go

So. Surgery.
What can you say?

I've had a fairly easy time so far, as surgery goes. The hours have been very reasonable (for surgery) and the people have been very nice (not just for surgery, but nice by any standard... with maybe one or two exceptions). I'm switching services now though, so things may get considerably more crazy.

So far I've seen some remarkable things. Today I saw a brain. It was just out there, with the skull about 60% removed. It pulsated with every heartbeat. I've seen surgeons drill holes through skulls and noses, bedsores that go to the bone, and tubes threaded through the tear ducts. I've smelled some smells I thought never could exist. I've put staples and stitches into people and taken them out, helped take and place skin grafts, and retracted for 34098213487.3 hours. So, now, at this one quarter-way point, what do I think of surgery?

In short, I have a great deal of respect for surgeons, and for the field of surgery. These people are cool cucumbers, and I salute them. They totally could have made it on the prairie.

From a medical student perspective, however, surgery is very challenging. They don't have much time to tell you what is going on, what you should be doing, etc. It's very scary, actually.

First of all, they engage in something called "pimping". Pimping is when they put you on the spot and ask you questions in front of a big group of people. Pimping is a very frightening experience, even when they are nice and don't really give you a hard time when you get the answers wrong. So far I have been really bad at this process. Even answers that I know fall right out of my head when they ask me in front of lots of other people, and most of the answers I didn't know in the first place.

Also, the OR is a very stressful place to be. It functions in a very regimented way, but that way varies depending on the people running the OR. Some are nice when you don't do things their way; others yell at you. It's hard to remember all the musts and mustn'ts.

Plus, sometimes you almost pass out. This happened to me. It was actually the first time I ever scrubbed in, on a breast reconstruction. I'm not 100% sure what happened, but I think it was a combo of sweating under hot lights and about 50 pounds of occlusive, non-breathing clothing, awkward posture, and the Bovie. The Bovie is an electrocautery device that they use to essentially burn through tissue and it emits all of this horrible smoke. It smells frickin' awful, especially when they are cutting through fat. Anyway I was about to pass out face down on the patient (not recommended) when I fessed up. They were nice as they told me to get out and get a drink of water. It was still embarrassing.

Anyway, there is more to my rambling, but for now I need to get some sleep. I will try to write some more random thoughts tomorrow. Until then, remember this: when they get out the Bovie, always ask for suction. You can suck up the smoke; it really cuts down on the passing out.

Ho. Lee. Lord.

Okay, people. I'm not sure what to write, because I can only think of maybe three people who would want to hear about the stuff I've seen in the past few days. I'm on surgery--plastics, to be exact--and let's just say we aren't just doing breast reductions and tummy tucks (abdominoplasty). I have seen one of each, however, and let me tell you what:
1. Do not ever have a breast reduction, even if your wabambas are the size of two dwarfs clinging to your chest.
2. If Weight Watchers wanted to become really effective, it would make all of its new clients watch a tummy tuck. Ask yourself: do I want that cupcake bad enough to have a whole Office Depot worth of staples in my body?

Anyway, plastics does lots of other things; hand surgeries, facial reconstructions after car accidents, skin grafts for burn patients, debridement of wounds, etc. My thoughts are as follows. First, do not ever get into a car accident. Second, never set yourself on fire. Third, don't get a giant wound.

I don't mean to be flippant; these surgeons are AMAZING, and the work they do is quite often miraculous. But seeing these patients and what they have to go through makes me thankful every second that I am not sick or injured.

Anyway, the hours haven't been awful. Sure, I'm getting up at the crack of dawn, but the patient load has been pretty light so we've been finishing pretty early. Of course, I pass out pretty early, and have been having to do a lot of reading; in fact, all I've done this week is work, drive, shower, study, and sleep. Occasionally, just to mix things up, I eat.

So far, I really like patient care, if I can get past my fear and confusion and frustration and ignorance and constantly being in the way and not knowing what I'm supposed to be doing or when or to whom. It is slowly getting better, though, and I'm definitely pretty excited to go in every morning, despite the fact that even God isn't up yet.

I need to go study, but I will leave you with this thought: did you know cheese slicers aren't just for cheese?

The early bird gets the nausea when she brushes her teeth

I've been pushing back my "wake up" time for the past few days so that today, the day before I start surgery, I got up at 5:30am. I'm guessing that, normally, I will have to get up no later than 5am, and probably earlier, depending on how short I can make my morning routine. I think that 4:45am will be a normal time, with the occasional 4am.

UGH.

That's one thing you can say for graduate school: there is hardly ever a reason why you would have to be in lab at a specific time, much less an early one. I mean, some people have lab meeting once a week in the morning, or journal club, but the earliest time for either of these things that I've ever heard is 8:30am. In fact, I had a journal club that was at 9am on Fridays, and I can't tell you how often I was late to that thing (or slept through it entirely).

I did go through a phase where I got in to lab at 7am or 7:30am because my husband was on pediatrics and would drop me off on his way to the hospital. Once I got used to that, it wasn't really that bad; in fact, I got to the point where I would basically wake up spontaneously most mornings. But, somehow, I don't see how that will happen for 4:45am.

What I can see happening is the following:
1. Nausea.
2. Self pity.
3. Occasionally dragging myself out of bed, slowly and painfully getting ready, and being about to leave the house, when my alarm goes off and I realize I am still in bed and it was all a dream and now I have to do it again.

But that's okay. I only have to do it for a couple of weeks, and then I get a two week break from ridiculous mornings when I switch to a service with less crappy hours. But after that, I have four weeks on another service which will start just as early, if not earlier.

So, six weeks. I can do this. Six weeks of getting up in the dark (but I can see the sun come up on my way to work!) and dry heaving when I brush my teeth (maybe I can lose a few pounds!) and being dressed and in the hospital a full three hours before I would normally even consider opening my eyes (but I get to wear scrubs sometimes, which is just like pajamas!!). As you can see, I'm trying to listen to that little, positive voice in my head, but at this hour, it doesn't always make a lot of sense (breakdancing chicken!).

I will try to post a short update after my first few days, but you might not hear from me for a little while. My schedule is packed with pushing my snooze button.

The Drama of Grad School (Rodent Reinactment)

Click below to see how to respond to the question, "How's the dissertation going?" Be sure to always have a tape recorder handy for the music, a very important thematic element.

Diagnose me, student doctor!

One really tough thing about being a medical student is that everyone thinks you know lots of stuff and can help them out with any number of medical and diagnostic conundrums. It isn't that I mind answering questions; at least I wouldn't, if I actually knew the answers. That's the problem. At my stage, you don't know much of anything practical. The first two years are basic science, physiology, and the like. There isn't all that much medicine (Surprise! You came to medical school to learn medicine, but first, here are two hideous and painful years of genetics and biochemistry!).

You do learn some medicine; but as I said, what is really lacking is "practical" part. You see, the medicine you learn is the kind of stuff that would scare the living bejeezus out of people if you told them about it. What they mostly teach you are worst case scenarios, I suppose to prevent you from missing those and causing someone to die later on when you are actually doing medicine stuff. For example, the fact that a headache is just a headache in 99% of cases isn't really emphasized very much in the first two years. Rather, you learn about meningitis, epidural hemorrhage, West Nile virus, tumors, and a slew of other horrible things that it could be. We are taught that even something as innocuous as a runny nose could be—and again, it isn't as though this is likely, even if you have recently sustained a major head injury—cerebrospinal fluid leaking out of your brain. Do you see how this type of knowledge might be a problem when trying to council people about the possible cause of their typically completely benign symptoms? “Well, Aunt Molly, your abdominal pain could be that ten day old tuna you ate, or you could have a bowel torsion leading to ischemia which requires surgical removal of your colon so that for the rest of your life you will be pooping into a bag.” I therefore try to refrain from doing this, unless my last birthday gift from the person was less than satisfactory.

Of course, as I said, the alternative to knowing the most horrible possibility is simply not knowing any possibility. This is also very common. But your loved ones seem so confident in your abilities, so certain you will know the answer, so trusting, that it is hard not to just make something up on the spot. It’s important to make up a name that is complex enough that the loved one will not remember it, and then follow that up by telling them that they should talk to their doctor about it. You know: “Hmmm. That sounds like it could be superiomedial recurrent extraclavicular uvulitis. You should probably talk to your doctor about that.”

In any case, remember that most of what medical students know is worse than knowing nothing. Don’t ask for their opinion of anything, except maybe pizza toppings. In the meantime, I’d be happy to give you my opinions on what that strange rash might be. I’d have to go with leprosy.

Hello! You look familiar… are we married?

Being in a program like this one can be a strain on all kinds of relationships. Your parents don’t really understand what you’re doing, or why you don’t know yet if you will have to work over Christmas. Things between the mudphud and his or her spouse/partner is even worse: The mudphud partner is exhausted, stressed, emotional, and has almost no spare time and no control over his or her life. The partner is lonely, bored, frustrated, and tired of hearing the mudphud constantly bitch about stuff. I know all about this from both sides, since my husband is also an MD/PhD student. I haven’t decided if being married to another crazy person like me makes things easier or harder. I’m pretty sure it’s both.

On one hand, we have all of the negatives associated with this mess times two. Both of us have very demanding schedules with long hours that we can’t control. Both of us have to study even when we get to be at home. We have both been through a major episode of clinical depression, aka “graduate school”.

On the other hand, we at least understand why the other has to do these things. I think all mudphud or medical spouses kind of understand. But the more I do this the more I believe it’s kind of like being at war with someone. It’s impossible to really, truly understand what it’s like unless you’ve been through it yourself.

There is another interesting wrinkle to this for me, which is having a front row seat to the madness to come. My husband is a year ahead of me in the program, so I get to watch the events—and the effects of those events—before they happen to me. I knew that finishing grad school, writing my dissertation, etc, would be hard. After watching my hubby go through it, I redefined my expectations of “hard”. Knowing exactly what I’m in for this coming year is good and bad. There is less mystery and I have the advantage of his survival tips and gems. On the other hand, I know things that other students at my level seem to not understand yet. For example, at our last class meeting, one of my classmates asked how many weekends we were going to have to work on surgery; another asked who they had to speak to to make sure they could leave by a certain time every day. I was almost the only one to laugh.

Anyway, the absolute hardest part of all of this is not getting to see very much of your spouse. My husband is my best friend and I love spending time with him—that is, after all, why I married the guy. It’s been hard all year, but now that I have lots of time and he has basically none, it is much worse. In a few weeks I won’t have much of a chance to think about it, but sadly he will have quite a bit of free time next year, and it will be my turn to be totally slammed. We will basically alternate this way—one of us AWOL, the other with a reasonable amount of time—for the next three or four years. Then, God willing, we’ll have more time and say-so about our schedules. At least we will have time off together, for the first time in a few years, for the holidays this year. And in a week we get a whole week off together! It’s the small victories you savor in this business.

I’ve been writing this while waiting for him to finish a question set. He’s studying hard for his last shelf exam (very difficult exams at the end of each rotation), but I have gotten to see a little of him this weekend, which has been great. He’s ready to take a break now, so off I go. I’ve learned that these past few years; be flexible, and you might just remember what your spouse looks like.

Studyin' again... naturally

When you're in medical school, you--by necessity--get used to studying a lot. I did my fair share in first and second year, but I was probably in the bottom third of the class in terms of hours logged. I'm not proud of it, and in fact, if I could, I would go back and kick up the hours I spent (not enough to push me into the top third, but a healthy middle of the middle third). In any case, what is done is done, and all I can do now is learn from my regrets.

By, for example, starting some proactive studying now, while I have lots and lots of spare time, before I start surgery and become overwhelmed with the hours. I have done a little bit, but nothing close to the one hour a day deal I had with myself before I started vacation. What the hell is my problem? It's not like I have anything pressing other than moving the laundry into the dryer before it mildews. It could be any number of things:
1. I'm scared to start studying again in earnest, because it will make me realize how much I've forgotten and made me even more nervous about starting back.
2. My brain reasons that starting too early will just be a waste of time since I will forget the stuff before I start.
3. I'm still recovering from graduate school trauma.
4. I'm a pathetic loser.

I think number four there has the edge. I mean, they all have merit, but it's number four that cuts to the heart of things. Some people think that insane individuals like me, who have chosen years and years (and years and years) of schooling like to study, or have a crazy robust work ethic, or whatever, but I am living proof that that is not always the case. However, once again, my recent fascination with LHotP has shown me the light. Yesterday's episode featured Pa working four jobs, seven days a week (including the Lord's day, as Ma repeatedly reminds him), from before dawn until after sunset, and then continuing to stack giant bags of grain despite four broken ribs, all so he wouldn't lose the farm. As I watched him sweat and wince and stagger and fall (all in a very manly fashion, of course), it occurred to me that picking up a book and doing something with my brain for one stupid hour out of the day is not such a big deal. So now, I go to read. For real. Seriously. Right after I take a little nap.

The four most important decisions of graduate school

Yes, there are lots of chump-traps you need to dodge to survive. But in essence, there are four decisions which will determine the bulk of your misery or happiness (okay, I'm not positive that one can truly be happy in graduate school, so let's say.... not-misery) in graduate school. Here they are, in order.

1. Make sure you really want to go to graduate school. This sounds silly, but I can't tell you how many students I ran in to who had not actually thought about this decision very much. Some did it because they were done with college and didn't really want to get a "real" job. Some did it because they did an undergraduate research project and kind of liked it. Some didn't know what else to do, and some like the idea of research and science but don't yet realize they hate the day-to-day. By my estimate, about half of these people drop out of graduate school, and the other half don't quit, usually for the same bad reasons they decided to come. Then they end up doing something totally different, usually after languishing for years. These days graduate schools are trying to limit entry of these people by requiring at least a year of post-undergraduate research, but sometimes that isn't enough. It's up to the individual to really understand what research is like; how political and grueling and repetitive and sometimes empty it can be, how much reading and writing and 'rithmetic is involved, etc etc. Make sure you understand these things, plus what kind of careers and pay is available to you if and when you get that degree. Make sure you are really happy with at least two of the options.

2. Choose the right department. Don't make this decision based purely on the subject matter. Know important things such as the nature of the preliminary (or qualifying) examination, class and teaching requirements, graduation requirements, reputation, pay, etc., all of which can sometimes vary widely from department to department. If you are an MD/PhD it is very important to learn how each department you're considering has treated mudphuds in the past, because believe me, this can vary wildly too. Often, if you like a particular primary investigator (PI, the person who would be your mentor/boss), and the project you are interested in is related to another field with a department which is a better fit for you, the PI will consider getting a joint appointment so you can have your cake and eat it, too.

3. Choose the right PI/lab. I've mentioned this in the past, but it is very, very, very important to find a PI whose style and personality is a good fit for you. For example, if you are a normal, balanced person, you would not want to work for a Yankees fan, since they all have strong tendencies towards evil. Don't work for a control freak if you are a control freak. Don't work for a slacker if you are a slacker. It's kind of like finding someone to marry, someone who will balance out all of your crazy parts, and whose crazy parts you can in turn balance out. Also it is better if you don't want to stab them with any handy object, blunt or sharp, after speaking with them for short periods of time. As I said, the other people in lab can be a good measure of this. Ask yourself: Do these people look despondent? Depressed? Are all the windows nailed down to prevent further suicide attempts? Are they angry? Drooling? Does their skin show signs of having seen even a few seconds of sunlight in the past year? These are important things to know. Also, ask about people who have recently left the lab. Did they do so in a tight, wrap-around coat and a white van, escorted by men with tranquilizer guns? Or did they move on in a normal span of time to a respectable position at a respectable institution (not the kind of institution the white van was going to)? Also: do you hate them?

4. Choose the right project. I learned this one the hard way. It might seem all shiny and flashy and awesome to start a new project, but this is the kiss of graduate school death in 95% of cases. Read that sentence again, because you, like dumb ol' me, will almost definitely be lured into this crap. You have to remember: It almost never works out for you. Who it works out for is the graduate student who follows you. And what are you, Mother Theresa? No, you will never graduate with that kind of altruistic attitude. What you need to find is some other poor Mother Theresa sap senior student who was tricked into starting such a project and is leaving and is ready to hand it to you with the four or five years of crappy, monotonous leg work all done. You might have to be co-author on the first paper (maybe), but believe me, it is almost always worth it. Also, the PI should be able to outline for you what sort of stuff will be included in your first paper in a decent amount of detail, and it should make sense to you and stand up to some hearty questions.

So there you are. The four main decision tree branches leading to graduate school success. Just try not to fall out of the tree, and you'll be all set.

The MD/PhD Journey: Welcome to the bottom of a new ladder!

One of the most difficult things about the MD/PhD training program is that every time you start to get good at something, you have to switch to something totally different. It’s not that there is never any overlap, but you are usually a stone’s throw away from square one, if not smack in the middle of it. Also, if you were starting to gain any kind of clout, you slide immediately back to whipping boy/girl.

The first is when you start medical school. Almost all medical students are starting something totally new, in a new language. It isn’t until you take Step 1 of the Board Examination at the end of second year medical school that you begin to feel like you know something—however meager—about medicine. It took two years of hard work, but you know something. At this point most medical students proceed on to third year, which in a lot of ways is a step down again, since it is very clinical and different from the classroom learning of years one and two. Also, although it is building on the foundation laid during the first two years, there is an enormous amount of new material to learn. This is also prime whipping boy/girl time, as you are the lowest man on the totem pole in the hospital (although some would argue that interns have it worse, and in a lot of ways this is true). However, you proceed with your classmates, so you at least have peer support. And that foundation of knowledge is still fresh and strong to learn the new stuff.

At this stage, MD/PhD students go to graduate school instead of clinic. This means that you start completely over. New classes, a totally different set of things to know, new (and often strange) people, etc. It isn’t until you are finishing up that you feel you are just beginning to learn the field you have chosen for your PhD. You have become attached to a new set of people who you have to leave again, and you have had plenty of time to forget all of that nice foundation you spent two years building up. You’re starting 3^rd year with a group of people who are largely strangers, most of whom are 4-8 years younger than you (whippersnappers!!). If you are lucky, there might be a few other MD/PhDs returning with you to 3^rd year, and if you are really lucky, you might like some of them, but it is unlikely you will have any rotations with them. You start completely over—again.

I’ve been told that there is not quite as much attrition in the medical knowledge as you fear; that it comes back faster and better than you expect. I hope that is true, but it still feels like I’m starting over for the third time in six years. But at least I get to stick with the clinical stuff for a while—probably about six years—before starting back in lab. Also, even then, I will still be doing clinical stuff, so in a way, I’m finally starting the job I’ll have the rest of my life. The one I've been working towards most of my life. Finally. There will be other ways in the coming years in which I'll be starting at the bottom of new ladders, but at least they will be ladders above the ones I’ve been climbing so far, and not on totally different walls, if you get my meaning. It’s a good feeling.

TODAY ON LITTLE HOUSE: Carolyn goes through menopause, becomes despondent, and fears Charles will no longer love her. Instead, they get remarried. Is there any issue this show doesn’t tackle?!?

"I did absolutely nothing, and it was everything I dreamed it could be."

So, I’m on vacation (hence the lack of posts). It hasn’t hit me yet that I am totally done in lab, but it feels awful nice to not be there. Yesterday I was painting a (very pathetic) picture when my phone rang. It was a friend of mine who is still trying to finish up, with a technical question about an experiment. I put down my paintbrush and answered his question, and he asked how things were.

Awesome. Things are awesome.

The time is going by frighteningly fast, but it is great. A few days ago I didn’t even change out of my pajamas until 3pm. Pathetic, you say? Definitely. But I’ve really been able to catch up on my Little House.

Let me tell you what: the shit always goes down on the prairie. One of my best friends, Andrea, and I realized this some years ago. We didn’t notice it so much when we were kids watching the show, but as an adult it can really put things in perspective. Have a rough day at work? I’ll bet it wasn’t as bad as the time that Pa got run over by the giant, one-ton milling wheel. Got stuck in traffic? Not as bad as the time that Mary, newly blind, got into a really bad stagecoach accident, was stranded for days with her also blind husband trapped under the coach, and almost died in the open plains. Missed your favorite TV show? At least you didn’t lose your baby and your best friend, mother of two young children, in a boarding school fire.

I haven’t just been sitting around watching LHotP. I’ve engaged in other highly impressive activities, such as going to the grocery store and occasionally showering. I’ve had a really good friend visiting so we’ve been hanging out and that forces me to put on real clothes, but I’m going back to the PJ’s when he leaves on Wednesday.

I worry sometimes that this lifestyle is spoiling me, and it will make it all the more painful when, in a few weeks, I have to get up at 4am, work for 15 hours, come home and eat whatever is in the fridge while studying for several hours, and then pass out, hopefully in or near the bed. On the other hand, maybe it will get me nice and rested up.

I sure will miss Little House, though. I might have to check in now and again, when I really feel sorry for myself, and see what kind of horrible plague has descended on the people of Walnut Grove, or who died in a tragic barn raising accident. It will help me remember that they, too, have to get up at 4am, but I'd take walking around an air conditioned hospital over slaving in scorched fields any day.

Graduate skill set number 2,304: Evaluating yourself

Every now and then, a grad student is lucky enough to have a mentor that will praise him or her on a regular basis. This is so rare that I have never heard of it happening. Usually, as a grad student, you are only praised once in a blue moon. And I'm not talking about mediocre or plain bad grad students, and I'm not being picky about what I call "praise", or requiring that kudos be lavished for the tiniest or most simple tasks, such as mearly showing (although sometimes this would have been very helpful). No--for the sake of this argument, let's give praise this definition:
When you are doing an exceptional job, or accomplish something impressive, you are bestowed with the following words: "Good job."
Even with this measly definition of praise, it doesn't happen very often. In fact, it wasn't until after my defense that some members of my committee very slid some really quality praise into our conversations. They did it almost sneakily, as if afraid that I would notice that they praised me. And we certainly couldn't have that.
I vividly recall when a particularly no-nonsense, kind of gruff bigwig told me one day, almost off-handedly, that I was a very good grad student, and he thought I would be a great researcher. I was so surprised that I said something like, "Wow, it's nice to hear that. We don't really get positive reinforcement like that."
He looked at me strangely and said, "You shouldn't need it."
I thought about those words for a long time. On one hand, it's true. We should be able to get to a point in our training where we know if we are doing a good job; we shouldn't need to hear it from anyone else. On the other hand--and I think this gets to the core of why grad school is so hard--we are beginners. Students. Just starting out. But they never really treat you like that. No, the way they approach training is to throw you in with both hands, and turn and walk away. A lot of the time they don't even stick around to see if you sink or swim; they might come back a few years later and see if there's a body to fish out of the pool, but that's about it. It's not as though they lavish you with praise early on and wean you off of it over time. No, in most cases, if they run into you later, they'll say, "Hey--way to get out of that pool without drowning."
So, if you are a mentor with access to grad students (they're easy to spot; just look for the most haggard, depressed people in the halls), I implore you: throw a little kindness their way. If they are doing a great job, would it kill you to let them know about it? In my experience, one morsel of praise can sustain a downtrodden student for months.
In the meantime, we will have to develop the ability to evaluate and praise ourselves. This task is almost insurmountably difficult, at least for me. If you're an insecure person (me!), it's tough to be fair with yourself. If you're an overly confident person (I know lots!), it's tough to be fair with yourself. But, with practice, and importantly, some caring, honest friends, you might be able to get to the point where you look yourself in the mirror after a particularly trying day and say to yourself:
Boy, you sure did screw the pooch on that one.

ATM, PDQ, ASAP FBI

I start my surgical rotation July 2^nd. To prepare for this, I have begun the following regimen:

1. I have my husband wake me up at random intervals throughout the night, and if I do not immediately and accurately recite the Gettysburg Address, he beats me with a sock full of nickels.
2. Sometimes, when I get out of my car, I slam my fingers in the door on purpose.
3. I’m slowly weaning myself off of coffee so that when I start it will be potent enough to keep me conscious.
4. I’m reading some of the study books for the surgical rotation.

It’s that last one that is really the problem. You see, doctors record patient information in the form of “notes”, and since doctors are usually too busy to even sign their full name (ever noticed that if your doctor’s name is, say, William Slatherington, his signature looks like Wie Saaa?), they have invented a lot of shorthand to write these notes. As a medical student I need to be able to (1) read, (2) understand, and (3) write this medical shorthand. So far this is not going very well, in the same way that the maiden voyage of the Titanic did not go very well.

How bad can it be? Well, friend, allow me to slide a little taste of confusion your way, in the form of this ACTUAL EXCERPT which I totally swear I am not making up. Seriously, I am copying this verbatim.

55 yo WM admitted for perforated PU, HD#3, POD#2 s/p Graham patch, NPO, abx=Ancef D#1/5, Flagyl D#1/5, central line D#1

D5 ½ NS @ 80cc/hr, JP output->15cc-12 hr total

PE: Gen: WD/WN male in NAD, A&O x 3.

CV: RRR, nl S1/S2, no M/R/G

Chest: CTAB, no W/R/R

Fantastic!!! Now, if you are a layperson, I know what you’re thinking. You’re thinking that since I have had two years of medical education that I can understand at least part of that mess. Allow me to correct you. My general reaction to the above string of letters and numbers is an abbreviation that I do know, one that you may be familiar with: WTF?

It’s kind of like reading personal ads from hell. I am slightly heartened that I managed to correctly guess what about three of the above letter strings stood for. Three. After two flippin’ years of medical school. Other than that it looks like one of the subway signs in New York.

I just wanted to fill you in on how things are going (Great! Just great! Haha!), and now, if you don’t mind, I’ll return to my regularly scheduled panic attack which was already in progress.