PICU

HOLYMOTHEROFGOD...

PICU is like all the hard rotations I've had so far, but put together all at once, at 10x the speed, in a foreign language. And with more sad stories.

Remember waaaaaaaaaaay back when I posted this about not understanding medical abbreviations and jargon? Well, I look back on that post and laugh, it's so second-nature to me now. But PICU is like starting right back there. Most of the time I just either stare vapidly or, when that gets old, I nod. But I have no idea what people are talking about at least 30%, and probably more like 50% of the time.

I picked up a highly recommended book about the rotation which I will be reading in between bites of turkey. At least I get Thanksgiving off, which is good, because I need to sleep for at least 24 hours straight. I will let you know if said reading helps me understand what the #$(*& is going on in that place.

Until then, happy Thanksgiving!

'Round and 'Round

A random brief post about rounds... some new 3rd years have asked, so here is what to expect:

SURGERY ROUNDS
Start time: 6am
End time: 6:15am
What to know about your patients: If they have eaten, pooed, or started bleeding from any orifice
What to present about your patients: If they are still alive
How many seconds attendings usually listen to your presentation: 0 (To be fair, they are not usually present.)

PEDIATRICS ROUNDS
Start time: 8 or 9am
End time: 11am
What to know about your patients: Medical stuff plus their birth history, growth and development history, grade in school, favorite subject, teacher's name, pets, names of pets, stuffed animal's name, symptoms expressed by stuffed animal (if present)
What to present about your patients: Significant overnight events, abnormal vitals, lab results
How many seconds attendings usually listen to your presentation: Usually to the whole thing (!), unless the attending is a cardiologist, in which case, 5

PSYCHIATRY ROUNDS
Start time: Between 10am and whenever everyone feels emotionally ready to round
End time: Depends directly on the quantity of both the patients themselves and the amount of crazy present in each individual patient
What to know about your patients: If they still think that you are an alien and they are communicating with the reincarnation of Elvis through a transmitter in their teeth
What to present about your patients: If they fought off the 8pm dose of Haldol
How many seconds attendings usually listen to your presentation: Often the whole thing, while nodding thoughtfully

MEDICINE ROUNDS:
Start time: 8am
End time: 5pm (on a short day)
What to know about your patients: Every health issue or experience that has happened to the patient and the patient's relatives or close acquaintances from when they were in the womb until now.
What to present about your patients: Any overnight event, including what time patient turned over, all vitals including trends in vitals since admission or possibly before, lab results for patient and patient's first degree relatives, or as much of this as you can get in before someone on the team interrupts you
How many seconds attendings usually listen to your presentation: They may pretend to listen for up to 60, but often not well enough to avoid asking you a series of questions which were answered in the first 60 seconds of your already given presentation

Like a 12 step program

One day at a time. And so time has moved along, and for the most part, been good to us.

My husband had his PET scan, and it was good news. He still has enlarged nodes, though they are smaller, and none of them took up the label, so they consider the therapy a success. 6 months of chemo instead of 8, and most likely no radiation needed (thank God). I finally feel like I can breathe again.

On the bad side, chemo sucks so much. I guess I have realized how caviler we are with prescribing things for our patients, how quickly we are to dismiss them as "not too bad", when really they are pretty horrible and life-changing. To be fair, we were basically warned pretty accurately about the chemo, but there are parts of it that were downplayed to a ridiculous degree. For example, Mr. Dr. Dr. VonB had to get a central port, which they really blew off as not a big deal. In fact, the VIR (vascular interventional radiology) guys who did it didn't even prescribe pain medicines, they told him that Tylanol would be more than sufficient. What a joke! He was absolutely miserable for at least three days after that procedure, unable to sleep, unable to be comfortable, and in lots of pain. It was so much worse than his lymph node biopsy that he was using the pain medicine they'd given him for that (which he used once right after his surgery, and then had gotten by fine with Tylanol).

It's still a struggle to try to find something that doesn't make chemo so horrible. He just feels awful for 4-5 days after each treatment (and each one is getting a little worse). We keep switching around his medicines to help treat the nausea but most of them make him feel bad too. It is indecribably sucky to watch your partner suffer like this and be completely powerless to do anything.

In other news... OldMDGirl was actually right, though not about what my worst nightmare is. I found out the day after my husband's official diagnosis that I'm pregnant. It isn't that I'm not happy, it's just... nice timing, right? The first trimester was just... well, it was pretty miserable. I was worried about the baby, worried about my husband, worried about how much I was worrying (anyone else catch the study published right around that time linking maternal stress in the first trimester with schizophrenia in the child?), and oh yeah, yacking every single day while trying to continue rotations. Good. Times.

But things are better now. We got the Happy PET Scan News, the scary 1st trimester is behind me, along with the yacking, and I'm 5 short weeks from being essentially done with medical school. I took and passed Step 2, and surprisingly managed to to better than OK, which really blew my mind. I am done with my AI in three days (well, almost four, since one of those days is a call day) and it was pretty good even though I reaaaaaaaaaaalllllllllly didn't want to be working. Then I have four weeks of PICU and I'm outta there. Well, there's this crazy two week long course we all have to take in March. Oh, and I have to drive to FREAKING ATLANTA to take the Biggest Rip-Off in Existence (aka Step 2 CS) in February. But other than that... done.

And did I mention the baby is due the day after graduation? I don't care if I have to wheel myself, in labor, across the stage... I WILL ATTEND GRADUATION AND BE HANDED MY FREAKING DEGREE AND BE HOODED AND ALL THAT. This little munchkin is either going to have to be a little early, or a little late. Hear that, munchkin?

Anyway, that is a quick update of stuff here. I had actually meant to write more about the AI and what that's like, but I will have to do that another time. Here's a preview: overall, it's pretty awesome.

Until then... thanks so much for all of your thoughts, prayers and well-wishes. For those of you in graduate or medical school, keep the faith, because I am proof that even with random hideous life curve-balls, you do eventually get through it and move on.

Not supposed to happen

Here it is.

My husband has cancer.

Though we've known now for almost 2 months it is still blowing my mind. The worst part was the two weeks of waiting for a diagnosis. See, he woke up one morning and his armpit was sore. He was worried it might be something bad (always the optimist, that hubby of mine), and I made fun of him and told him he'd over-used his arm. A week later he called me from the kitchen.

"Hey, honey... wanna check this out?"

I sighed and put down my book.

"Look at this," he said, holding down the collar of his shirt.

On left side of his neck, right above the collarbone, was visibly swollen compared to the right. My stomach dropped.

"Feel this," he said, pushing around with is fingers.

I was almost shaking as I did to my husband what I've done to probably hundreds of patients--palpated for lymph nodes.

I've never felt a left supraclavicular node on a person before, but I've answered lots of test questions about what a firm, non-tender node in this area usually means: cancer. And there it was. A firm, non-tender left supraclavicular node.

On my husband.

My heart started pounding.

Strangely, at this point, he got more optimistic, while I began sinking into despair. "Maybe I have a weird infection," he said. "I've been taking care of a lot of dudes with TB, maybe I have that."

"Maybe," I said. I didn't mean it.

"Or Cat Scratch Fever."

"Yeah, maybe."

I wanted to go to the doctor right away, but this was a Friday afternoon, so we had to wait until Monday. We were there when the office opened Monday, but as he was a new patient, they wouldn't see him until Tuesday. Those days were awful, but they weren't anything compared to what was coming. Tuesday morning the resident examined him and said he probably had an infection. A trial of antibiotics, he said.

"I'm worried about cancer," I said, trying to sound like I was wondering if it would rain or not. "Specifically, lymphoma or testicular cancer."

The resident shrugged. "Well, we could do a chest x-ray just to be sure."

"Great," I said. "Thanks."

The report came back showing a mediastinal mass, a large one. Just like how, though most people might have blown it off, I knew that his node was bad news, I knew what this meant. I had been sort of rooting for testicular cancer, something that had a pretty darn good prognosis. But a mediastinal mass meant lymphoma, and that was the kind of diagnosis that could carry less than a 50% 5-year survival rate.

It was another week and a half of CTs and lymph node biopsies before we had a diagnosis. Each test looked more like the diagnosis was lymphoma, and it was more wide-spread than we had realized. The problem is that there are lots of types, and some are pretty OK, prognosis-wise, and some are horrific. So I tried to hope, but it was hard, knowing that it was more likely he had a horrific kind (they are more common) than a pretty OK kind.

And that's what life was: hoping for the least horrible kind of cancer.

Finally, we got a diagnosis. Hodgkin's Disease. It was the best diagnosis I could have hoped for given what we knew. His labs came back--again, the best labs we could have hoped for, given his stage. They started Chemo the following week.

I never even really had much time to think. How did this happen? He's 31 years old! Healthy! Never smoked, excersises, eats well, hardly ever drinks, and then only one or two beers. This isn't right. It isn't fair. I take care of people all stinking day who have abused their bodies maliciously for 50, 60, 70 years, and they are still hanging around, complaining that they cough (You're kidding, Mr. 100-pack-years? You COUGH??).

I'd find myself thinking a lot when I had to tell people, "My husband has lymphoma." Husband doesn't really say it. It's not right. It doesn't mean to everyone what it means to me. I wanted to say, "The love of my life, my best friend, my soul mate I never thought I would find, has cancer. He could die. And I'm supposed to keep showing up to clinic, keep doing laundry, keep eating and sleeping like any of it matters."

I would overhear people talking about their problems and want to cry. "My wife got in a fender-bender, my computer died, and I lost my wallet," I heard one person lament. "Could my life get any worse?"

For your sake, buddy, I thought--I hope not.

That's all I can write for now. Things are going as well as can be expected. He's tolerating the chemo okay. Having to watch him go through so many horrible procedures, tests and therapies is torture. Waiting for his PET scan, where we find out if his cancer is responding to the chemo, is hell.

But I am still doing my rotations (on his insistence... he always makes me do the right thing). I am studying for Step 2, which I take in two weeks--just days before his PET scan. I'm still going to clinic, and doing laundry, and eating and sleeping, because I guess that stuff does matter, somehow.

Just not as much as it used to.

Life throws Dr. VonB a big ol' curve ball to the face

You know, I casually throw around words like "survive" around a lot on this blog. It seems kind of silly now.

Unfortunately I can't tell you a lot about this curve ball except that it is basically one of my worst nightmares come true, and I probably won't be writing much for a while.

In the future I may, however, be in a position to talk more about real survival, and being on the other side of medical care.

Until then... keep believing in wondrous advancements in medicine. For those of you in med school/grad school/mudphud adventures, keep believing in what you do. It matters, and it changes people's lives.

Thanks for reading, everyone, and please send Mrs. Dr. and Mr. Dr. VonB all the positive vibes you can spare. I'm off to face my nightmare.

It's graduate school that sucks; not research

Yes, I honestly believe that. Research does not suck like graduate school does. Here's why:

1. Hordes of minions. This is something I've been looking forward to since before I came back to school. I worked for a biotech company for a while, and I went from being a minion to having my own minions. I can't begin to tell you how awesome it is to do research when you have your own minions. All that drudgery, all those banal things you hate can be tasked to other, often more capable, people. You can focus on the best things about research: thinking about data. Coming up with theories. Designing experiments to test those theories. Communicating your ideas to others. Personally, I also really enjoy writing grants and papers, as that really boils down to doing all of the above. In any case, this one is easy: in grad school you are a minion; in research, you get to command minions.

2. Having some small measure of power over your own destiny. I've always felt that, in graduate school, you have all of the responsibility, but none of the power. You are expected to produce, but all you can bring to bear is your own blood, sweat and tears. Others control everything: lab space. Equipment. Supplies. Manpower other than your own. You have to wait for your boss to edit stuff, which can take years. Wait for him or her to submit papers. Ask permission from your committee. Obviously, some of these requirements make lots of sense; after all, you're only learning. However, as a very take-charge person it was a relentlessly frustrating situation for me to be expected to produce, on a schedule, but have so little ability to ensure that could happen. Now, I am not so naive to think that at some point you are magically no longer beholden to anyone; no matter how high you climb you can't just do whatever you want (ahem, recent NIEHS Director badness). But, no one, and I mean no one has a more deranged power-to-responsibility ration than a graduate student. As a full fledged MD/PhD, at least you get a little leverage and a little say in your own little lab-verse.

3. Did I mention minions?

4. You can have a life outside of the lab. In my ideal career, at least, I will also have clinic, and patients. I won't live and die chained to my bench. I will be able to be out, teaching, seeing patients, speaking, hearing talks, going to conferences. Yes, I got to do some of this in graduate school, but I think that when you are a PI this whole new world of freedom opens up for you--I can't wait.

5. Minions.

Okay, I'm sure there are more, but for now I must return to the luxurious weekend. I have but a few precious hours to do whatever I want (I've been reading fun books like a madwoman--it feels like forever since I've read fiction) and I'm going to dive right in, baby. Also, I am already working hard to secure my horde, and I have a pile of applications to go through.

Whatcha, whatcha, whatcha want?

You've survived almost EIGHT YEARS of intensive schooling and, dare I add, intermittent torture. You are possibly mildly in debt, or at least way behind saving for retirement. Most of your friends make more money than you, and ALL of them have more spare time. BUT, up ahead, you see a light... blazing more brightly with each passing day: graduation.

What's next? Disneyland? Rampage of revenge? Huddling in a ball and crying for days as though you just survived a plane crash? Perhaps. But the biggest question for most mudphuds is:

What the heck am I gonna do with the five years of employment I have before I retire?

It's very fun to see where your friends end up. Some you expect, some come out of left field. It's even more interesting to hear why they choose what they choose.

For me, it's peds because they are a lot of acutely ill patients that you can actually make almost or completely better. And it's derm because, well, dermatology is the awesomest thing ever.

A lot of people think of derm as lots of acne. I think that in some private practice settings that's true. But what I want to do--academic derm--is very different. There is a huge variety in patients and conditions, lots of research, surgery... it's heaven. I love that people come from hours and hours away to see you, and that often you are able to help them when numerous previous doctors have not been able to. I love seeing them come back better, and happy. Also, don't discount how horrible some of these conditions can be. I have seen many patients that are physically debilitated, and that isn't including the ones who don't date because of embarrassment.

Anyway, enough about my choice. The thing is to figure out yours. From what I've seen you need to answer an important question:

Do you want to do research? It seems a lot of mudphuds end up burned out on research. It's very sad. I can't blame them, but I wish we could figure out why this happens. I mean, yes, graduate school is often hellacious. But a lot of what makes it so is intrinsic to graduate school and not research in general. In any case, be honest with yourself, and decide if it's for you. I think it's important to choose this before you settle on a specialty, because some are much more amenable to research than others. It's good to find an example--someone who is in your field of interest who is doing what you would like to do, and--this is important--doing it well.

For me, I was trying to decide between peds rheum and derm, and what it came down to was research. Peds rheum is a very under served specialty, and the clinical aspects would always be so demanding that doing research would be very difficult. And here's the thing: research is hard enough without adding extra crap.

Anyway, those are my nonsensical ramblings. Now that I've chosen my field my full-time job is arranging meetings to try to be admitted to said field, and it's time to get back to that. Please share your thoughts on field selection below, and with luck your 4th year schedule will allow you, as mine has, to mull these things over at some length. And also to have days where you don't have to change out of your pj's.

Entry for Most Disturbing, Strange, Offensive, and Yet Amusing Patient Quote Ever Contest

(it's a very specific contest)

From a pretty old, gnarled southern dude, said to me for reasons that, even on very careful and repeated reflection, are still not clear:

"There's two things a man lies about. The gas mileage of his truck, and how many women he's bent over."

Huh.

Any other entires out there?

Dumbass Medical Student Move

Okay, so I'm in this low-end procedures room, helping to do an excisional biopsy. I'm the non-scrubbed in person, grabbing non-sterile things, moving the table up and down, etc. etc. Then I offer to adjust the procedure light, the one on the arm. Now, the OR lights I am used to having a handle in the middle--which hardly ever actually positions the light the way you want--and very nice handles on the sides. So, first I try the handle in the middle. Then, making the ridiculous assumption without actually looking that this piece of crap light has the same side handles, I grab the side where the other handles usually are, firmly, to swing it around.
All I can say is I am damn lucky that I was wearing gloves, because even then I manged to burn the living @(*$%& out of my thumb, which I planted directly on one of the exposed bulbs. Then, being that there was a (conscious) patient and three residents trying to close up a giant wound about six inches from me , I had to pretend I hadn't just done that and it didn't hurt like a sonofabitch and I wasn't really, really embarrassed. I don't know how I managed to casually finish adjusting the light, pull off my gloves, and examine the giant blister on my thumb.
I quietly excused myself, taking my glove with me, to curse under my breath and find an ice machine and create a makeshift ice pack.

Which brings me to my next point: latex-free gloves are not very waterproof, and the only thing more embarrassing than burning your thumb on the overhead light during a procedure is dripping water from your makeshift ice pack onto the patient and the electrocautery plate during the procedure.

And I thought being a 4th year meant most of my bonehead moments were behind me...

Final side note: my favorite personal 3rd year bonehead moment was when, on my first day in the OR (actually, my first day of 3rd year!), the scrub nurse asked what size glove I wear (you have to know what size surgery glove you wear so they can pull the sterile gloves out for you). I said, I don't know, it's my first day. She said, hey, why don't you go next door to the other OR and ask Cindy to give you the glove sizer? I--and the other medical student--said, oh, okay! Sure! And like the pair of gullible brand new 3rd years that we were, went next door and asked for the glove sizer.

Well. The entire OR just looked at us like we rode in on goats. Then the circulating nurse kind of smiled and said, oh, yeah, the glove sizer. No, I think that's back in the other OR.

I'd like to say that we knew before the moment that we walked back into our OR and the ENTIRE OR--scrub nurse, circulating nurse, intern, resident, attending... hell, I think the anesthesiologists--were laughing heartily, that we had been had. But we didn't.

And they say doctors don't have a sense of humor. No one, of course, says that medical students aren't boneheads most of the time.

'Cause we are.

Okay, I am, anyway.

Whole New Scene

Well, today was my first day of 4th year medical school. It was great, and also scary. It was great to say out loud, "I'm a 4th year." It was scary to have people assume that somehow that means I know what I'm doing.

It's also great and scary because I'm no longer at my home base. I am doing a rotation at a somewhat nearby (also, major rival) school. In a field, which I love and want to enter, which I have not done, ever. With my limited, one-day experience, I have to say it has been pretty great. It's always scary for me to try completely new things, but I'm trying to focus on the positive, exciting parts of trying completely new things. Like, for example, it's nice to have new things to suck at, when all the other things I suck at start to get old.

No, but really, everyone was very nice today, and I think I am going to have a good month, which is followed by a super awesome two more weeks off. So, overall, I'm very pleased. Except...

Well, here's the thing I can't stop thinking about.

Vacation was awesome. You know what I really liked about it? The part where I don't have to do anything. It is actually making me feel kind of conflicted. Like, shouldn't I have been more excited to get back to things? Shouldn't I have at least been less depressed to be done with my vacation?

Here's the thing. I think that whole "Do for a living what you would do for free" thing is real nice in theory, but it hardly ever works out like that. I think that finding that job is like winning the lottery. I think that you are pretty damn lucky if you don't hate your job, and even luckier if you sort of like it.

I don't know... how many people do you know who would keep their job if they won the lottery? I'd like to say that I would, but I don't know that I would. I am trying to chalk some of this up to the fact that we are still not really moved in yet. The place is a mess, which I hate, but I hit a wall, and with the hubby on night float I'm not sure how much more I can do. I'm telling myself that if we can just make it through this damn night float that things will be better. And that's a whole separate post... how many times I've said that over the past 7 years of training. "If I can just make it through (insert whatever phase I'm in at the point), things will be better". But there's always something new.

But those are thoughts for another day. Today it is time to start some reading, and here's another reason to cheer: I'm reading to try and look like less of an idiot, but NOT FOR A SHELF EXAM. If that's not a reason to embrace novelty, I don't know what is.

My ERAS, my tormentor

Dude. Just when you think that the Parade of Menial, Banal Tasks that No One Should Ever Have to Do that is medical school is tapering off, they drop the bomb.

ERAS, which stands for... um, hang on, I have to look this one up... Electronic Residency Application Service... wow. That basically explains it. Nice job with the naming, residency people! Anyway, it's nice that it's electronic and all, except that the interface is slowly driving me insane.

They have boxes for everything--and I mean EVERYTHING. Now, normally I am a big fan of having boxes to fill in. That's just the kind of person I am. I color inside the lines, and I like to fill in forms. (Caveat: they have to be well-designed forms. I hate when I have to write outside of existing boxes on a form.) I know--I sound like a load of fun at parties, huh?

Anyway, I have spent hours thus far copying my CV into this ridiculous form. It's totally out of control. It is rigid, very detailed, and wants to know everything about everything I've done since I graduated from high school, which for me is 15 years ago*. Actually, I'm not totally sure they don't want to know about stuff I did in high school.

Look, ERAS, I don't remember what month that abstract I was on in 1997 came out, and PubMed doesn't either. But ERAS doesn't care, and won't save it unless I lie. I am being forced to lie by a stupid web-based application.

In any case I am TOTALLY sick of myself right now. I'm sick of my publications, my research experience, my teaching experience, and basically every other experience I've had. I'm sick of estimating how many hours a week I spend doing ANYTHING.

I will end this with a piece of advice. This is for everyone, but especially for mudphuds:
ALWAYS KEEP A CONTINUALLY UPDATED CV.

My husband did not do this, and his ERAS experience was exponentially more painful than mine, meaning that it almost killed him.

So, go forth and update your CV. Put EVERYTHING on there. You'll thank me later.

*I know. I'm old. Tell me something I don't know.

Hey, wait, didn't I use to have a husband around here somewhere?

So. We moved. Right now it feels like we relocated to the inner circle of hell, but I'm pretty sure that's just because I hate moving and unpacking and repacking and recycling zillions of those tiny little foam peanuts which get everywhere and under furniture and stuck in your dogs' fur and fly around when you try to sweep them up and eventually require you to set fire to your new home just to get rid of them.

There are a lot of things I still can't find, including my husband. I'm pretty sure I wrapped him very carefully in bubble wrap and put him in Styrofoam molds and labeled the box "HUSBAND--LIVING ROOM", but I thought that about the accent lamp that goes in the guest room, and that's nowhere to be found, either.

Okay, I didn't lose him in the move. He started internship this week, and his first month is night float. That means that he gets home around 9am, at which time he eats and stumbles to bed to pass out, sometimes still wearing his scrubs, then a few hours later he's up and out the door. It's so weird. Most of my time with him these days is on the phone during his commute. Turns out that Bluetooth headset was the perfect graduation gift for him.

In any case, I'm thankful to have so much stuff to keep me occupied while he's always away. I have about 2K years of unpacking and settling in to do. I have a few more rooms to paint. And, just so I don't forget that I'm still in medical school, I have a bunch of residency application stuff to do, a personal statement to write, my packet of random stupid crap to turn in for my last rotation, and some studying to prepare for my next rotation. How am I supposed to fit all of that around my Arrested Development marathon?

Well, it's time for me to turn in--I have a big day tomorrow, getting my VERY PROFESSIONAL (=black suit, white shirt, understated makeup) picture taken for my residency applications, and before I go to bed I have to practice my "I'm a serious, professional doctor but still fun to work with" expressions in the mirror. But first, time to page my hubby a kiss goodnight.

Medicine vs Peds

The main reason people will give you for choosing medicine over peds is, "I can't stand dealing with the obnoxious parents."

Here's the thing I don't get: when you go into medicine, the parents are your obnoxious patients.

Medicine was, in fact, more fun than I thought it would be. However, I discovered a not-so-pleasing fact about myself, which is that I don't enjoy taking care of people as much when what I am doing is trying to re-arrange the deck chairs on the Titanic. AND, the reason the Titanic is sinking is that the captain repeatedly and intentionally rammed it into every iceberg in sight, despite being told each time that if he did that again he was gonna sink the sucker.

It felt like 90% of our patients were in the hospital secondary to one of three reasons (and often a combination of all three):
1. Years of drug abuse (tobacco, alcohol, heroin, crack--I also include the HIV or hepatitis they contracted because they were using dirty needles).
2. Years of eating everything within reach (and never getting off the couch).
3. Years of either not going to the doctor or flatly ignoring everything doctors have told them.

Actually, now that I think about it, I think that you could combine 1 and 2 given that for many people food seems to be an addiction akin to any other drug.

In any case, I find it hard to enjoy taking care of these patients. It isn't that I don't feel empathy and pity for them. I do. I took care of a lot of people right at the moment that it occurs to them that they have thrown away their entire lives. That is not a happy moment. I suppose it's good that I can be there for them, but what am I supposed to say? You're right, you have thrown away your life, and now you're dying, and there's nothing we can really do about it. But buck up! It's sunny outside!

The thing is, I'm sure that they have horrible, sad life stories. I've heard a lot of them. My problem isn't that I can't find any compassion in myself. My problem is that I have what my dad calls "a strong bias towards action". I don't like to deal with problems that have no solution. I'm not proud of that, but I can't pretend that it isn't true. When I find a problem, my natural instinct--no, my need--is to solve it.

And, for most of these people, that can't be done. The best you can hope for is maybe postponing their eminent death for a short while, or making it more comfortable. Which, actually, I feel is a very honorable mission. It's just not my mission.

To survive in medicine, you have to have a mission. You have to have something that makes you excited and fulfilled. Because Lord knows you don't get money, or leisure time. You don't often get kudos either. When you do, it definitely feels great--but if you rely on those, that's a one-way ticket to Burnout Town.

Anyway, I like Peds because the proportions are reversed. 90% of the patients did nothing do themselves to get sick or hurt. 90% of them will get better and lead normal lives. They have problems which you can diagnose, treat, and solve. Yes, parents can be annoying. But as I said, I'd rather have them as parents than as my patients.

And the Angels Sang...

As I FINISHED 3RD YEAR OF MEDICAL SCHOOL.

I cannot wrap my mind properly around that concept. I am just starting a nice, long vacation, but I had to go out of town immediately after taking my shelf test, so it isn't really real that I don't have to go back to work as soon as I get home. And beyond that, it isn't real that I don't have any more shelf exams, and that the pressure is generally much lower in almost every way.

But not to fear. I will still have plenty of things to complain about, because what I DO have starting me in the face is:
1. My university's clinical skills exam (standardized patients)
2. Step 2 CK (step 2 of the boards, the written part)
3. Step 2 CS (step 2 of the boards, the standardized patient part)
4. And most terrifyingly... RESIDENCY APPLICATIONS, INTERVIEWS and MATCHING!!

In any case, I will try to gather my thoughts about 3rd year as I max it and relax it. Too bad I have about three months worth of real life work which has accumulated over my past few rotations. Until then, may you know the joy of a well-earned vacation and the satisfaction of using it to catch up on Little House on the Prairie episodes. Oh, Pa...

Longest rotation ever.

I have one more week--actually, less than a week--of 3rd year. And it couldn't come too soon.

I am SO TIRED. The hours on this rotation have been nuttypants. Let's put aside that I am taking q2 call.

No, let's NOT put that aside. q2 call is cruel and unusual punishment for a 3rd year student just trying to pass the medicine shelf test.

In any case, I am working ALL the hours, and trying to study on top of it.

But that's okay... I'm counting down... one... more... week...

BOOM.

(If you don't get the title, hop on the bus to Philly and rent the awesomest show in quite some time).

Anyway, we got our 4th year schedules. And although I could choose to gripe about how I asked for a month off to study for Step 2 CK (Clinical Knowledge) and they totally ignored me, I will instead choose to focus on how I got all my other requests and importantly WILL BE COMPLETELY DONE WITH 4TH YEAR BY DEC 21.

Flipping. Awesome.

The Ecstasy and The Agony

THE ECSTASY
Today I finished my general medicine rotation and took our school's mid-medicine written exam, my second-to-last exam of 3rd year. It wasn't too bad--statistics, concepts, EKGs and CXRs. I'm pretty sure I got everything right but I'm usually surprised by just how dumb I can be on exams. The most important thing about this is that I now have only have ONE test left in all of 3rd year, and it's a biggie... the Medicine Shelf Test. Which transitions us nicely to:

THE AGONY
Of course, there's the looming Medicine Shelf. There is also another month of medicine (I do have high hopes that it will be good). However, NOTHING compares to this horrible, crippling pain in my lower back. I am seriously walking like a 100-year-old. It is SO pathetic. Plus I'm in pain basically 100% of the time. This has been going on for three or four days now and it is flipping killing me. Yesterday I tried to stand up from a chair, had a giant spasm and almost FELL DOWN in front of my whole team. I was going to try to get a lot done this weekend since I have it off, but now I'm considering drugging the bajesus out of myself and finally getting some relief/sleep (which I have not had since this started). Also--walk rounds=usually painful; walk rounds when your back is one giant spasm=unbearable. It's like every second takes an hour, and you WANT to be concentrating on learning whatever the attending is talking about, but instead all you can focus on is trying not to throw up or a fantasy about finding a dark room to lay down in and cry or how much you wish someone would take pity on you and just kill you already.
Is it just me? OldMDGirl, you too claim to be old--do you ever have this problem?

In any case I am taking my broken self and money I don't have down to get a professional to address this problem right now. Those of you reading in other states--let me know when my screams of pain reach your time zone.

Until then, cherish your youth. For you too will someday become whiny, old and pathetic.

Hell hath no torture

like 8 full patient write-ups which have to include ridiculous level of detail including a full neuro and rectal exam in every patient and a minimum 1 pg long discussion with references.

In fact, I'm pretty sure there's a special level of hell reserved for people who smack their food and drive in the far left lane going the same speed as the car next to them where all you do, day in and day out, is patient write-ups.

I've done six, but it feels like a bazillion.




Side note: Maybe it's just me, but doing a rectal exam in every patient kind of feels like assault.

so... close...

Well, I only have 4.5 weeks left of 3rd year medical school. And it's totally blowing my mind.

Medicine is the rollercoaster of 3rd year squared. You have days where you panic because you are convinced that when you become an intern--something that is terrifyingly close to happening--you are certain to kill patient after patient. Then you have days where you just seem to know what is going on, where the attending likes every patient plan you have, where they basically just sign your orders as they are and you think hey, you might be able to do this after all.

So, on the one hand I am SO excited to be almost done with 3rd year. I have a written exam on Friday about EKGs, x-rays and--*shudder*--statistics. Then, in a little less than 5 weeks, the medicine shelf test. My very... last... shelf test. Holy moley.

Medicine is a lot more fun than I thought... and it is also a lot harder. Which is saying something, because I expected it to be hard. I guess I expected it to be hard like an 80's move montage where the main character does lots of hard work set to peppy music over the course of about 30 seconds. Whereas instead it mostly involves rounding for 5 hours a day, doing a bunch of scut for another 5 hours, rounding some more, and coming home to read and study for another 2 hours or so. Maybe if we had a guy follow us around with a boombox on rounds, playing some peppy 80's music, that would be better.

Hm... maybe I'll bring that up at the next team meeting. I'm thinking "Working for the Weekend", or maybe "Danger Zone". Ohh...what's that song from the Karate Kid? You know, "You're the BEST! Around! Nothin's ever gonna keep you down!"

Yes. That should make rounds go faster.

Things don't just appear in your colon.

They can only get there two ways: from the top, or from the bottom.

You can tell me you have no idea how they got there.

But I'll know you're lying.

Okay, Jerkheads

Listen very carefully.

Are you listening?

Good.

STOP. F'ING. SMOKING. YOU. IDIOTS.

I am tired of helping doctors try to save your stupid ass from 80 pack years of retardation. I am tired of pretending that I'm not silently passing judgment on your decision to use your money to buy cigarettes instead of your medications. I get that you can't undo the past, but when you TURN OFF YOUR FRICKING OXYGEN TO SMOKE YOUR TWO PACKS A DAY I WANT TO STRANGLE YOU.

That is all.

O Medicine, why dost thou bludgeon me?

Okay. I have done a lot of flipping out on this blog. But nothing--nothing--has prepared me for the amount of flipping out that is about to commence.

I was so damn cocky. I have studied and worked very, very hard over the course of this year, partially because I want to get into a very competitive speciality, partially because of THE FEAR (that old friend to all mudphuds returning to the clinic after a prolonged absence), partially because, and call me crazy, but I want to be a good doctor. In any case, I felt that I was really doing well and getting more than the gist of 3rd year. I mean, I'm practically DONE, right? I've done all my rotations except medicine. I felt like I at least mostly knew the basics of what was going on.

Until now.

Right now the main thing I'm feeling is YIKES. Because I. Don't. Know. Crap.

The things I don't know fall into many categories:

1. Things I Thought I Knew But Clearly Don't Know: Antibiotic coverage, diabetes.
2. Things I Thought I At Least Sort of Knew But Know Nothing About: EKGs, VERY basic labs and their meaning.
3. Things I Knew I Didn't Know And Thought I Had More Time to Learn Before Looking Like an Idiot: Basically everything else.

Add to this that the entire week has been crammed full of graduation events for my husband. I'm very proud of him, but couldn't he have picked a more convenient time to graduate?!?! In any case, that's all for now. I'm sure you recognize the pattern by now, of me starting something new->freaking out->posting about said freakout->going into crazy study mode->chilling out slightly->getting close to the shelf test->freaking out again and more robustly->taking shelf->posting about how tolerable or terrifying the shelf test was->moving on to the next freakout. So, I will go now to partake in crazy study mode. I'll see you when I'm approaching chilling out slightly!!!

Five down, one to go

So awesome holy wow! I just finished my psych shelf. HUZZAH! It was not that bad. I mean, I don't know that I tore it up or anything, but I am 99% sure I passed (knock on wood).

The craziest thing ever is that I only have one shelf test left. I can't really wrap my mind around it. I mean, two months left of 3rd year!! Wow. I only have seven months total of coursework left in medical school. That means that I will be unleashed on an unwitting patient population in a frighteningly short period of time. Hmmm... that feeling of anxiety which went away when I finished the test is beginning to come back...

In any case, psych was a great rotation. The hours are great. The people were nice. The subject was interesting. But I think that the best thing about the rotation was how included they made us feel. I had a role, which was actually meaningful and useful. After lots of rotations where you are basically a shadow of a shadow, it is such a nice change of pace to feel like people want you to be there, and that you help them out.

Anyway, I have a bazillion things to do... more on that a little later... but for now, just a deep breath, and reminding myself... five down, one to go.

WOOHOO!!!

I did not fail the neurology shelf exam!! HURRAH!!

It was my lowest raw shelf score ever, but I still beat the mean by a decent margin. I'm not sure how I pulled that one off, but DAMN.

Psych ward continues to be amusing/scary/sad. At least the hours on psych are nice and cushy, although I do have call this week. In any case, the shelf is on Friday and other than continuing to get all of the stupid drugs mixed up in my head (the names, actions, and side effects of the drugs, not the actual drugs, unfortunately) I am feeling pretty okay about it. Also, this is my second to last shelf test EVER!! Wow.

WOW!

Okay, back to studying. There's nothing like studying crazy people on a Sunday night...

The interesting thing about delusions...

No matter how crazy they are, most patients just sort of assume that you believe them.

I was worried about how I would respond if someone busted out with something really nuts and one of those "You gotta believe me, doc!" sort of rants you see in the movies. But really, it's been more like "It's that cat. The one that can smell you and hunt you down and suck out your soul. It's comin' for me."

It is WEIRD.

It is also kind of disturbing how profoundly your mind can betray you. One dude can't even draw a clock anymore; he was totally fine three days ago. It's amazing what a little acute renal failure and oxycodone can do to your brain.

Okay, I have to get back to memorizing the psych dictionary. That's mostly what you are tested on for the psych shelf; it's the DSM criteria, which are basically just long, complicated definitions. You know, stuff like the patient has X if they have 2 from column A and 3 from column B. Which makes for a lot of memorization, since column A and column B are usually not too short and fairly complex. There are also a lot of sister diagnoses, meaning that A is just like B except with (or without) symptom whatever. It is interesting, at least.

So far I only have one diagnosis: generalized anxiety disorder. I keep reminding myself that I am just a little too high functioning to truly have a disorder, but I definitely have most of the symptoms:
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). CHECK!
B. The person finds it difficult to control the worry. CHECK!
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months).
-restlessness or feeling keyed up or on edge CHECK!
-being easily fatigued CHECK!
-difficulty concentrating or mind going blank MEGACHECK!!
-irritability Ask my husband!
-muscle tension OH LORD YES!
-sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) Okay, not this one... KIDDING! ABSOLUTELY!
D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in a Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder. Okay, I may be a little afraid of being embarrassed on rounds, does that count?
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder. Not as far as I know...
F. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. THIS is the one that saves me. I don't think I can say that this one is true.

So there you are. I'm one step away from a psychiatric diagnosis. How come I can't get my hands on any of the good meds?!?

Bi-Polar Bear

("This looks like a job for Bi-Polar Bear!!! But I just can't get out of bed this month..." For those of you who are not familiar with The Tick, I suggest you clickity click and find out what you are missing).

Anyway, friends and neighbors, I have come to realize that some of you are angels straight from heaven, and some of you hate me and wish I would just go ahead and knock myself off so you wouldn't have to deal with me anymore. Of course I haven't had thoughts of killing myself, but if someone doesn't stop this pain, what choice do I have? Would you want to live with pain like this? No, that would be it. You can't put me on the Crisis unit for saying that, can you? I'm not saying I am going to kill myself. It's just that if I wanted to, you couldn't stop me. Why should I stick around here? Even my father wouldn't care; he 's always said I'm a loser. Now how am I supposed to feel about that? You know, if I could just get a little something to take the edge off... no, not that, only lorazepam really works... no, 2mg isn't enough, I'll need more like 10 or 15mg to really help... seriously, they haven't been giving me my home medicines and now I haven't slept for four days! Just don't give up on me. You understand me. That other doc who was in here, I don't know what his problem was, but it was like he wouldn't listen. Or he thought I was crazy, or something--just made me feel terrible. But not you, I'm so blessed to have you, you are the one who is really going to be able to help me. You are so wonderful, God sent you, and... what? What do you mean you won't give me 15mg of lorazepam? You're just like all of those other doctors, aren't you? Where is that other doctor, the nice one, the one who actually listened? Send him back in here, and don't bother coming back, okay?

OK! Now, those of you who have not had psych or the delightful experience of interacting with numerous patients probably feel confused and blindsided. Everyone else got to the second or third line and a neon sign in their head lit up, and that sign flashed BORDERLINE! BORDERLINE! BORDERLINE!

Believe me, it is just as fun as it sounds to interact with Borderline patients. By which I mean, it is no fun at all. It is one of the most frustrating things that exists in medicine, although what makes it so hard sometimes varies from person to person. For me, it's hard because most of these patients have had lots of bad things happen to them--some just because, some self-inflicted in some respect--and they are in a lot of pain but have no idea how to get themselves out of it. Also, Borderline patients tend to be master manipulators, they push your buttons, good or bad, they make it REALLY hard to take care of them, either because they are not telling the truth, alienating the team, disobeying orders, etc etc.

Also, a tip for those of you just starting into the clinical world: At least half of the patients who tell you they are "bipolar" actually have Borderline Personality Disorder. Probably more like 80%. Unless you are on psych, and then you probably will be lucky enough to see truly bipolar patients in a manic phase ("No weapon forged will prevail against me!!"--not a Tick quote, an actual patient quote). You'll secretly wish you could feel like them for just a little while.

Quick side note: I've learned that just because someone thinks that a white van full of Navy SEALS is following them around and then jumping out of the van to chase them with bicycles doesn't mean they have paranoid schizophrenia. Apparently it can also mean that they have been taking 16-30 pills of dextromethorphan at a time for the past five years or so (along with several other street drugs, of course).

Anyway, I'm off to learn about more psych, so I can find a few more frightening diagnoses which almost apply to me. Also, I think I see a white van outside.

Holy Mother of God

Today, for the first time, I left a shelf exam thinking, "Wow, it is entirely possible that I failed that exam."

The neuro shelf exam was horrible. HORRIBLE. Maybe it is partially due to how little I enjoy the subject, but it was brutal.

It's going to be a tense few weeks waiting to hear about THAT sucker.

And now to totally cleanse the palate of the mind and prepare myself for a weekend of working to catch up on life requirements and starting a whole new rotation! Hurrah!

But first, excuse me while I curl up into a ball in the corner, rocking and mumbling to myself.... there's no place like home... there's no place like home...

Hoping for that magic spark of panic

Otherwise, how will I ever find the motivation to study more neurology today?

I already blew hours of time yesterday which I could have used to study, but no. What has happened to me? I used to whine and complain but I would eventually study, and study big time. Now it seems the thrill is gone.

Maybe it's burnout. Maybe it's just neurology. Or maybe its... shudder... neuroanatomy.

In any case it will be all over tomorrow, when I take my third-to-last shelf exam, leaving only psych and medicine to conquer before I reach the promised land of 4th year.

So, what did I think of neurology? Well, the people (residents/attendings) were almost unanimously extremely nice. Okay, but how did I like neurology?

They were very, very nice.

You know, like the classic example from When Harry Met Sally, when Harry points out that saying a woman has a good personality only means she's unattractive if "she has a good personality" is the answer to the question, "What does she look like?"

Neurology is interesting in theory, but it goes against one of my core traits, something my dad calls "a strong bias towards action". I want to DO stuff to patients that makes them better. In neurology, it just seems like you do stuff to patients just to better define all of the stuff you can't really fix. Plus, there is something deeply and spiritually disturbing about seeing patients who are now different people because of a 1cm-wide change in their brain.

Plus--and please believe me of understatement when I say this--neurology easily ties rheumatology for the coveted Specialty With the Most Crazy Patients award.

And no, I'm not forgetting psychiatry.

In any case, like it or no, it's time for me to do the age-old medical student ritual of cramming what feels like millions of anti-convulsant drugs and their various uses into my brain for the exam so that I can immediately forget them for the tenth time.

Next post: the never-ending cycle of Relearning and Reforgetting: the Cornerstone of Medical Education.

Graham Crackers of Despair

Those of you who have been on inpatient services know exactly what I'm talking about.

You see, on inpatient services, there are many, many times where for whatever reason you will go for hours on end with no access to food. Be it call, or rounds which last all day (I wish I were kidding), or some procedure which lasts an hour longer than it should forcing you to run down the hall to the next disaster, there always seems to be something. And in these times your only hope for avoiding a hypglycemic coma is ducking into the supply rooms and grabbing the snacks they have set aside for patients.

I'm not saying this is a proud moment, but desperate times call for... well, frankly, they call for stealing food from sick people.

Anyway, when pilfering from the supply closet, your choices are scant, by which I mean your choice is to eat one of the graham crackers in the packet or to eat both of the graham crackers in the packet.

Now, I have nothing against the graham cracker in principle. They are handy little snacks. They are sweet, yet you can convince yourself that they are marginally good for you because they seem to have pieces of grain or some kind of grass in them. They go great with peanut butter and chamomile tea.

However, there are only so many times you can stuff graham crackers into your mouth while running down the hall wondering if you managed to get all of the influenza off of your hands from the patient you just examined while trying to prevent the gag reflex which may be due to the smell memory of the wound you just debrided or may be because you haven't slept in 30 hours, lamenting the fact that some protein might make your hands stop shaking but for now all you can eat is another... damn... graham cracker... before you totally lose it.

But Despair, you ask? Isn't "despair" a little dramatic? I mean, you're getting to eat, aren't you?

Well, the next time you see someone in a white coat walking down the hospital hall eating a graham cracker, take a look at their face. You will see Despair. Because, for most of us in white coats, the graham cracker has come to symbolize all that is crappy and unrelenting about our chosen profession.

Plus, they aren't even the kind with cinnamon-sugar on top.

Random Observations from the Clinics

1. The cervix can be significantly more difficult to find than you might think. It can be very wily, that cervix.

2. Also, it usually smells weird.

3. Speaking of smelling weird, the hands-down worst smell there is in medicine is the smell of an anerobic infection. It isn't exactly bad in the classic sense, it's just that it awakens something very primal in your brain which tells you to run away, or maybe yak.

4. Crazy people can be very funny, but they can also be scary. However, most of the time, they're just confusing.

5. If you're reading a magazine, you are NOT in 10 out of 10 pain.

6. Okay, in fact, if you are doing anything other than writhing and crying, you are not in 10 out of 10 pain. So it doesn't impress me that you say you are. It makes me not believe you.

7. The more medications someone tells you they are allergic to, the more likely it is that they have a personality disorder. If one of the medications they are "allergic" to is a mood stabilizer or antipsychotic, the likelihood increases 100 fold.

8. Related Public Service Announcement: "Messes up my bowels" is NOT an allergy. Antibiotics do that to everyone. Likewise, just because a certain narcotic makes you "sick on my stomach" or "real weird" does not mean you are allergic to it. It means you are responding fairly normally to the medication. It does NOT mean you need darvocet.

9. Also, if someone says the following phrase: "(Fill in name of powerful narcotic) doesn't even touch my pain", then you can be 95% sure they are drug-seeking. It is phenomenal, and phenomenally depressing, how accurate this observation is.

10. "I got the sugar and my blood is high" is southern for "I have type 2 diabetes and high blood pressure".

Grad vs Med: The Smackdown--UPDATE

First, a confession: I totally love tracking my blog visit stats. It is geeky and sad (yet not nearly the geekiest or saddest thing I have done in the past week) but there it is. My favorite is seeing what kind of Google searches bring readers to my blog.

One that keeps popping up is a phrase along the lines of "Which is harder, graduate school or medical school?". I find this very interesting. I mean, first of all, who are the people searching for this phrase? Are they trying to decide between going to medical school or going to graduate school? (By the way, if you happen to be one of these individuals, my feeling is PLEASE FOR THE LOVE OF GOD SAVE YOURSELF and GO TO MEDICAL SCHOOL.) Or are they MD/PhD students trying to see what the future holds? Maybe they're in some kind of smackdown themselves, where they are either med or grad students and the other type of student is trying to tell them that they have it easy.

Anyway, I re-read my original post, and it got me to thinking. I had said that grad school was more difficult by a hair. But now, with many of my psychological scars from grad school healing, and fresh ones from 3rd year springing up on an almost daily basis, I dunno. I guess I see them as more evenly matched now.

This tells me one thing: whichever you're doing is going to get extra points in the "ouch" column, because you're doing it right then. I think that the original analogies I wrote about there still hold pretty well, except I see now that, at least in 3rd year, there is less of a roadmap to success than in 1st or 2nd year med school. They tell you the things you can do to do well, but sometimes there are extra secret things you can do that no one tells you about. And sometimes, the things you can do to be great for one attending or team will really annoy the crap out of the next attending or team that you work with. True anecdotal example: One day, I got chastised for just starting to scrub in to a surgery without asking first. Two days later I got yelled at for asking if I should scrub in. I mean, at least in grad school they just don't tell you anything, which I guess is somewhat more helpful than telling you the wrong thing. Although I will note that it's really sad that those seem to be the two choices.

Also, 3rd year has really worn me down. It took longer for graduate school to wear me down; I think in the hitting a wall department it took 3rd year 8 months to accomplish what it took grad school 2.5 years to do. Now, I'm not sure if that would be the case if I hadn't been in school for six years before starting this one (and eight years older than many classmates); maybe those fresh-faced classmates of mine don't feel the same, never having tasted the triumph of making a plump salary in the real world for a few years (before becoming really, really poor), or the defeat of, well, most of graduate school.

So, I have to say that the Smackdown is now officially a tie in my book. In the interest of full disclosure I have to say that that opinion is in the minority among my MD/PhD friends, most of whom fully endorse the "Grad school is way worse" stance. I can see their viewpoint, and must also confess that there are some personal reasons why this year has been possibly more stressful for me (although everyone has their own cross to bear). I think that next year, when I have vast spans of time completely off, things may be different, but for now, I am still trying to wrap my head around the concept of a real vacation.

Holy cow. I'm on vacation. Wait a minute! I'm on vacation! I'm going to go do something vacation-y, relaxing, or fun, like...

Hm. I can't seem to remember what people do to relax or have fun. Maybe I can look it up on eMedicine. (Okay, I just looked "fun" up on eMedicine, and the first hit is "Substance Abuse". Who says doctors don't know how to party?!?)

Another One Bites the Dust

Well, I'm all done with my eighth month of 3rd year; my sixth rotation. Holy Awesome Awesomeness!
How was the exam? Flippin' hard. It was a written exam and they really pulled some tough ones on us. Ugh. But now I get a small vacation! Joy!
So. Medicine. It is tough. I am glad I had this outpatient medicine rotation before my inpatient medicine rotation; hopefully it will give me a boost and make me somewhat less spastic and retarded. I don't know. I'm not holding my breath. I did get to see some really interesting patients, and I love coming up with differentials. So in that sense, I actually kind of enjoyed it.
I have neurology next, and just spoke to a friend who told me that the national mean on the neuro shelf test has been around 35%. My feelings on this: !!!!!!!!!!!!!!!!!!!!!!
I may have to spend some of my rotation reviewing neuroanatomy, as I remember only two things about neuroanatomy: Jack and shit. And Jack left town.
NOT looking forward to it.
I guess it will be good to learn this stuff... maybe.
Anyway, I am going to go ahead and close off this basically pointless post. I may try to gather some of my thoughts and get some meaningful posts in over these couple of weeks. Later suckers! I hope you have something good going on, and hang in there!

It's About That Time

You have probably been asking yourself: "Self, I wonder how long it will be until Dr. VonB decides she has been in 3rd year long enough to begin giving out often obvious advice in her know-it-all way?" Well, the answer is: right about now.

So, first off, a brief run-down of outpatient medicine. As with any rotation, the quality and overall suckitude (or, if you're lucky, the lack thereof) depends entirely on your preceptor. I am at our University's outpatient clinic and it is definitely higher pressure than most of my classmates seem to be experiencing. On the other hand, I think I have learned a ton, which brings me to my first official piece of advice about 3rd year medical school (or maybe I'm deluding myself, and I've already given out a bunch of advice, but as with most things these days I don't remember it):

OFFICIAL PIECE OF 3RD YEAR ADVICE #1: You get out what you put in.

I mean this in a few ways.

SUBADVICE 1A. Read every day. This may sound 1) oblivious and/or 2) like a pain in the ass, but either way, it is key to success in 3rd year. Most rotations have a lot more reading than you expect, and if you put it off it creeps up on you and kicks your everloving butt. I was told to pick your review book, divide the number of pages by the number of days in the rotation minus about 5 days, and read that number of pages every single day. Your residents and, if you are lucky, your attending, will notice, and importantly you will get more out of what you see in the clinic. Also, do not underestimate the shelf exams. Those who underestimate the shelf exams end up curled up in a small ball, crying, in a corner. And no one wants that.

SUBADVICE 1B. Be enthusiastic. Sometimes you may have to pretend, but if you came to medical school for the right reasons, that won't be too often. Most days you get to see at least one really cool thing. And the best thing about being enthusiastic is that most supervisors will give you more cool stuff to do if you follow pieces of subadvice 1A and 1B, which makes both easier to follow.

SUBADVICE 1C. Do a good job. I know how dumb that sounds, and yet I am consistently amazed at how many of my fellow classmates fail to do this every single day. And here's the thing: doing a good job is something within the grasp of just about every even semi-normal person, because all I mean by doing a good job is stuff like: show up when they tell you; if they tell you to look something up, look it up; try not to make the same mistake a bunch of times in a row; etc. It is NOT THAT HARD. Just try. Even a little.

Basically what I am getting at here is the fabled Cycle of Awesomeness. How this works is that the more you read, and try, and are enthusiastic, the more people trust you and teach you and let you do stuff, which makes you read more and try harder and be even more enthusiastic, etc etc, until you feel like you are actually getting close to be a realio, trulio doctor. And it. Is. AWESOME.

Also, before I forget, one thing you MUST have in your white coat pocket: Sabatine's Pocket Medicine. I cannot begin to describe the awesomeness of this book. If you are a student buy it IMMEDIATELY. No real need for it on surgical rotations or possibly stuff like psych, but it is stunningly useful on any vaguely medicine related rotation.

Okay, I need to follow my own SUBADVICE 1A and get to reading. I am about halfway through this rotation, and ahead lies neurology, psychology, and inpatient medicine. Then I will be an honest-to-God 4TH YEAR MEDICAL STUDENT! HURRAH!

In the meantime, keep an eye out for the crazy patient who came back to clinic with a knife today because we wouldn't give him percocet. Good times!

There's a first time for everything

Old MD Girl tagged me with this meme, and given that I have a ton of homework to do it only seemed natural to fill it out.

In 2008:

1. Will you be looking for a new job?
Job? What's a job? You mean people do things other than study? And they make more than $5/hr? Holy Cow, I gotta look into that...

2. Will you be looking for a new relationship?
I have to admit that I'm getting sick of my relationship with Blueprints. I'm thinking of having a torrid affair with Case Files.

3. New house?
God, I hope so. 1275 square feet is no way to live, especially with a husband who is morally opposed to throwing anything away, ever.

4. What will you do differently in 08?
Well, right now, I can't do much differently, but in the not-to-distant future my life will cease to revolve around evaluations and shelf scores. So, in short, I will become an actual human again, with feelings and interests outside of medicine, assuming there are such things.

5. New Years resolution?
Old MD Girl said: "Talk about things other than work." YES! Me too!! Any ideas on what else there is to talk about? I got nothin'.

6. What will you NOT be doing in 08?
I will not be seeing "Remember the Spartans". I promise. (Side note: remember when parody movies used to be awesome? Like Airplane? I miss those days.)

7. Any trips planned?
I trip all the time, but I rarely plan it. I blame my shoes.

8. Wedding?
An awesome family wedding coming up soon. Another good friend getting married later this year; frighteningly, most everyone else I know is married. When did this happen?!?

9. Major things on your calendar?
Husband graduates (GRADUATES!! From EVERYTHING!!) in May. Starts residency in June.

10. What can't you wait for?
To match into the residency of my choice (knock on wood) and to GRADUATE! Also, it may be time to start having tiny humans of our own...

11. What would you like to see happen differently?
In keeping with number 5 above, I would like to have things to talk about other than work.

12. What about yourself will you be changing?
Again, Old MD Girl and I are on the same page... I have gained some confidence in the last 7 months of clinical rotations, but I'm not quite where I need to be yet. Also I have to start working out before people confuse me with Jabba the Hutt.

13. What happened in 07 that you didn't think would ever happen?
I aced the surgery shelf test (I know! I couldn't believe it either!) and published my second dissertation paper... JOY!

14. Will you be nicer to the people you care about?
Mainly I plan on being nicer to people I don't give a shit about. It throws them off.

15. Will you dress differently this year than you did in 07?
Not unless I don't keep my plan as detailed in number 12 and I have to start buying Jabba the Hutt Wear.

16. Will you start or quit drinking?
A wise man once said: "I don't need to drink to have a good time. I need to drink to stop the voices in my head."

17. Will you better your relationship with your family?
I am basically happy with how things are now. The only thing which could improve would be if I had more time, which I won't, so I guess not.

18. Will you be nice to people you don't know?
No, as per my new policy, I have to figure out if I care about them or not before I can be nice to anyone.

19. Do you expect '08 to be a good year for you?
I am pretty sure it will be awesome.

20. How much did you change from this time last year till now?
A lot. I think I am more confident in most of what I do, even if I still have plenty of insecurity. I also learned an extraordinary amount, AND I'm a "Dr." now.

21. Do you plan on having a child?
I plan on having a child mow my lawn.

22. What are your plans for new year's eve?
We watched Aliens for the 293,393,595,391th time, and it was awesome.

23. Will you have someone to kiss at midnight?
We didn't realize when midnight happened, because Ridley was fighting the Queen Alien in the big robo-loader.

24. One wish for 08?
A big, fat raise. I want to know what it's like to live the life of the fat cats making minimum wage.

I tag Heidolicious and nosugrefneb. Now send me something else before I have to resort to doing my assignments.

Words you don't want to hear while working at a free clinc

"They said I had the syphilis on my brain."

Big Deal, I'm Very Professional

As you probably know, a huge portion of your grades in 3rd year medical school are based on evaluations. Everyone evaluates you; the interns, the residents, the fellows, the attendings--I've even had a rotation where a nurse coordinator evaluated me. Sometimes, it's nice to get evaluated, because it gives you an ego boost, plus some constructive things to work on. Sometimes it's crappy to get evaluated, because they give you a mediocre review for no apparent reason with nothing constructive (or even non-constructive) to work on.

For example, a friend of mine, who is brilliant plus a super great and hard-working guy with good social skills, got a very average evaluation from one of his attendings; you know, a "meets expectations" kind of thing. The attending told him, "You've been great, but I expect you to be great." So, my friend asked the attending, "What else could I have done to get an excellent evaluation?" And he said, "Nothing, really. Like I said, I expect you to be great, so you met my expectations." Awesome motivator, no?

The other kind of evaluation you can get is super lame because you are forced to get it from someone who basically works with you for five minutes. This happens often, because as a 3rd year medical student, you typically work almost exclusively with interns and residents, but you are required to get a certain number of evaluations from attendings, so you are forced to feel like a total wonk asking a bigwig to evaluate you when they couldn't say for sure that you don't work for food services.

Alright, I've gotten off topic here. What I wanted to write about were another type of evaluation that we have to do at our school: "Professionalism Evaluations". Believe me, they are as stupid as they sound.

Essentially, they are to try and make sure that you aren't some kind of a deranged weirdo with bad personal hygiene who is liable to get everyone on the team sued. The biggest reason that I think these are stupid is that they clearly don't work, as evidenced by a student I worked with a few rotations ago who was so wildly inappropriate that his "unprofessional behavior" actually crossed the line into felony (sadly, I am not kidding) and yet he is, as far as I know, still a student here.

However, they are terribly amusing to read. Whereas most evaluations are set up so that the boxes for "Best Ever Student Whom I Would Be Proud To Call Son/Daughter" are on the far right, and the boxes for "Should Consider Alternative Life Choice, Like Prison" are on the far left. However, on the Professionalism Evaluations, the good boxes--the only ones you want checked--are in the middle, and to either side there is badness to opposite extremes.

For example, one middle box is something like "Personal Appearance is Professional", and to the far left is "Looks like Pigpen From The Peanuts, with the Dirt Swirls and Everything" and to the far right is "Looks Like a Ho". Another is something like "Displays Appropriate Empathy", with "Spit on No Fewer than Three Patients" to the left and "Often Attempts to Hump Patients" to the right.

This setup has led to some hilarious, although unfortunate, evals where the attending, not having the time to read the ten zillionth eval form thrust at them by a 3rd year, tries to do the nice thing and check all the way down the right hand side--normally the side of honors, now the side of Axis II Personality Disorders.

In any case, it is clear that at some point some big, important committee told my school that professionalism is a Big Deal and they needed a Formal System in Place to Evaluate the Living *#$& out of us. Well, hats off to you, there, University. I could only be happier if you started evaluating how well I endure being evaluated.

Oh, wait... you already do that.

We Only Come Out at Night

So, I finished my week of night shifts and in five hours I have my OB/Gyn shelf exam. My take on nights: I hate nights. I'm too old for that crap. I'm exhausted, and cranky, and I've had a headache for three days. I realize that some nights are inevitable pretty much no matter what you do these days, but ugh. Most other fields, at least around here, have a night float system where you only have to do a week or so of nights at a time, and for surprisingly few weeks per year. On OB you spend months on nights. Months. And speaking of OB, I have one word for you about "NSVDs" (normal spontaneous vaginal deliveries--OB/Gyns flippin' LOVE their acronyms). Here is that word.
UggggghhhhhhhhhewwwwwwwyyeeeeeeeOOOOOOUUUUUUUCCCCCCHHHHHHHH-
uuuuhhhhGROSS!

Ok, so, OB/Gyn. I have to say that it was my least favorite rotation so far. Now, I do also want to say that around here, OB/Gyns sort of had a reputation for being awful to work with as a medical student, but I have to say I found the opposite. Everyone (okay, with a few scary exceptions) was fantastic and really interested in teaching. It's just that I don't like the rotation. The hours are awful, and just through luck of the draw I was on during one of the more depressing months in history, patient-wise. You know, pregnant moms being diagnosed with metastatic cancer and being given 2-6 months to live, moms miscarrying a second trimester multiple gestation after trying for 10 years to conceive, stuff like that. Wrist-slitting.

Also, at least half of the patients speak Spanish, and I do not speak Spanish. Well, I sort of do, but kind of like Tonto if he were drunk. (Me student. Me no talk large in Spanish. Tall pain is having you where? You have water from your (indecipherable)? Big water or little water?)

Okay, it is time for me to go study for the shelf exam even though I am getting hives just thinking about it. But I will post again soon and I already know exactly what I would like to rant a little about: a little something our school likes to call "Professionalism Evaluations". In the immortal words of Ron Burgundy, "Big deal! I'm very professional!"

Operation: Vajayjay

Just a few quick things:

1. My head is spinning. I am reading at a pace which is exceeding my ability to retain information. Sadly I do not have the option of slowing down if I wish to get through the reading before the shelf test.

2. I do not like the OR. I especially do not like the OR when I don't scrub in but instead stand on two stacked stools for hours and hours so I can catch an occasional glimpse of sheets/piles of random tissue and 34,234 clamps over the shoulders of three doctors crammed in between some poor woman's legs. Plus it's freezing.

3. If I never see another hoohoo, it will be much too soon, and I haven't even done labor & delivery yet. That goes for cervixes (cervi?) too.

4. As it turns out I got really lucky in that not only was Doc Mamma right and they can't make me work Thurs night before the shelf, but we also have a required holiday (I'm not kidding, it's required--we aren't techically allowed to be in the hospital) that Monday, so I will only have to do three nights instead of five. This almost makes up for me having my night shift week last.

Okay, as per usual, time to get back to reading. The great thing about this rotation is that you never know what fantastic thing you get to learn about next. Incontinence? Prolapse? Disgusting STDs? All of the horrible things that can happen to you before, during, and after childbirth? I'm so happy to be a woman! With complex parts that apparently fail all the time! Haha!!! By the way, I just learned that leakage which occurs while laughing is a sign of stress incontinence. Not that I have that problem.

Yet.

OB/Gyn, Thy Name is Terror

AHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH

Okay, I feel much better now. Today I started my OB/Gyn rotation, and although everyone I've met has been very to excessively nice, I am petrified. You see, our rotation is already only four weeks long, but we started two days late due to the holiday so it is even shorter. And my God, have you looked at OB/Gyn Blueprints lately? It's a kagillion pages long!!!

(PS: You might wonder why I didn't go ahead and start studying over break. This is an excellent question, and I would love to answer it, but calls to the decision-making regions of my brain were not immediately returned.)

There's more: the way the rotation is set up here, we don't have call for three of the weeks, but one of the weeks is all OB night shift (5pm-7am). And my nights week, as luck would have it, is the week of the shelf test. What this means is that I have two and a half weeks to learn enough OB/Gyn to pass the shelf test. Then I have to find a way to keep it in my brain as it (my brain) is scrambled due to a completely jacked up sleep pattern in the days leading up to the exam. Mix this in with the long hours of this rotation, and you have one trembling, sweating Dr. VonB.

Anyway, I have to get back to reading, for super duper serious. I will write more if I can stop my screaming, which, honestly, is really making it hard to read.