Message in a Bottle

Well, HELLO there blogosphere! Or is it blogesphere? Whatever, it's a sphere of bloggers.

Word reached my ears fairly recently that there are readers--actual, human readers with functional brains--who read my blog. Even more surprisingly, it sounds like some of these functional brained, human readers actually liked it!

It's been a long absence, it is true. Things in my sphere (VonB-ospehere, I guess) are great, and I am happy to announce that I, and those I love, all survived the past--okay, hang on, let me fire up my calculator watch--HOLY COW IT'S BEEN FIVE YEARS.

Well I feel each and every one of those five years, from my soggy brain to my possibly soggier ass. But I am an honest-to-God, board-certified, fully employed MD/PhD. I know, right?!?

Anyway I have no idea if anyone, anywhere still looks at this thing, and if so, if any of them would be interested in hearing more inane musings about the training process and what lies beyond from the mind that brought you such Nobel prize-winning material as "ChumpWork". But, I thought I'd throw a baited hook in the waters, and see what bites.

I'll keep a closer eye on things for a while. I might even think of some things to write about (off the top of my head: "Residency is an often soul-sucking roller coaster ride through the outskirts of hell").

If there is anyone who is still paying attention, and/or who still cares, I'll have an eye out--if you have questions, ask away!

And I hope that you have all had a mostly-good, sometimes-amazing, rarely-horrible last five years. I've missed this!

Woah

I start residency orientation a week from Monday.

What else can I say? It just feels so huge. It is still not real that I graduated and am an actual medical doctor. Perhaps this is because I certainly do not have the knowledge or experience required to be a medical doctor. Which makes it all the more terrifying that in one week I will be expected to do the job of a medical doctor.

It's funny, looking back, at how stressed out I was about rotations and exams and stuff. I mean, those were grades--that's all. And starting in a few weeks, I will have ACTUAL LIVE PATIENTS for whom I am ordering tests and treatments and medications. Before, I could fail an exam. Now, I could FREAKING KILL SOMEONE.

Now, all of you in medicine know that this isn't exactly 100% true. There are layers and layers of supervision and oversight designed expressly to prevent me, as an intern, from killing someone. But just because I can look down from the high wire and see the net doesn't make me feel all that much better about being up there. I mean, I could fall onto the net, then bounce off of it and land directly in the mouth of a hungry lion. I could fall right into the sole location of a gap in the net. The whole damn net could break, my skull along with it. I will be way the hell up there, and having a net below you is not equal to being on nice, solid ground.

What brought this panic on is the info I just got about taking my PALS (Pediatric Advanced Life Support) class, a two day long affair you have to spend some time studying for ahead of time. And, suddenly, it occurred to me that, holy cow, I might very well end up in a position where instead of hovering against the wall or, at most, being the bag mask girl during a code, I might be expected to actually run the code on a kid. And then I broke out in a cold sweat.

I know that this will pass, and that after a few months of trial by fire I will feel more sure of myself, and less scared. But I kind of hope that the fear never completely goes away; that I never feel totally confident in my abilities. It's a price I have to pay to be the best physician I can. It's the way to keep me on my toes, keep me reading, keep me trying to be better every day. Fear, my constant companion.

(Quick side note: Since I started medical school, every day I find it harder to understand doctors who have a huge ego. Nothing, nothing has made me feel more humble, more naive, less knowledgeable, less confident than studying medicine. And because of its nature, I can't imagine ever feeling differently. Just because you are an excellent swimmer doesn't mean you can just dive in swim across the ocean, no matter how long you train.)

In any case, I leave you with the advice that all those in the medical profession already know: for God's sake, don't get sick in July.

M.D. -> Patient -> Mommy -> Resident

Weird transitions to be happening so very closely together.
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A little over a week ago I graduated. The big one. THE graduation. The Grandaddy I've been working towards for eight long years.

Less than two days later, I was admitted into the hospital where I had been a student, into one of the rooms where I had delivered a baby as a medical student, to have a baby of my own.

About 13 hours after that, I became a mother.

My head is spinning. Doing this baby thing is completely overwhelming. Obviously I have tremendous support (which is the main reason I'm still alive) but still--insane.

Again I am faced with the same issues I was when Mr. Dr. Dr. VonB got sick. I know too much, and too little. Though I'm going into a peds prelim year in four weeks, there is so very much I don't know about healthy infants. Sadly, I know way more about sick infants, the result being that I have been one of "those" mothers, the ones who drive pediatricians crazy; wondering about every single little thing incessantly. Is she breathing too hard during this feeding (subtext: could she have a congenital heart defect)? What's up with her peeling skin and nails (subtext: could she have some kind of weird genetic connective tissue disorder)? Why is she so pale (subtext: could she have a red blood cell disorder? (real answer: because you and your hubby are dairy white, crazypants...))? You know. Crazy.

Being in the hospital was strange, too. All of a sudden, instead of the medical student dealing with a frustrated patient waiting hours to be discharged, I was the frustrated patient. Instead of fielding 1000 paranoid questions about a new baby, I was the one hurling them out there.

Having not been in the hospital in forever, I had forgotten how horrible it is being woken up every 10 minutes. At one point, when my husband was taking care of the baby so I could have the first nap I'd had in almost two days, I started counting: in 1 hour we had EIGHT people knock on our door to come in and examine me, examine the baby, tell us about the new study they'd like to enroll us in, offer to clean the room, examine me again... I was ready to die. The hospital is such a HORRIBLE place to try and get any rest or recuperation. And the worst part is that when you do want to see someone, they don't show up. Ever. The lactation nurse came by once, and I was anxious to meet one more time before we left, but of course she was two hours late and I was therefore discharged before I could see her. The attending came right in the middle of my nap, but when we were ready to be discharged (and I mean, REALLY ready), it took her three hours to get the orders in. Ugh. Things to remember when I'm back on the other side.

Speaking of which, that's right around the corner. I feel I have forgotten everything I've ever learned, and it's freaking me out. I have two weeks of orientation and then I'm fresh meat on the wards (though starting with a very easy rotation).

My other problem is that I never imagined I would be one of those women who finds herself crushed thinking about leaving her child to go back to work. I'm not heartless; I assumed it would be difficult. But I can't put into words how hard it is to think about now. I am 150% sure at least part of it is the hormones and the sleep deprivation, but still. This is going to be a doozy. Strangely, at the same time, I'm excited to be a real doc. It's remarkably difficult.

Well, baby is stirring and calling for the cow (me). At her next nap I am going to try to get some reviewing in, but I'm not holding out much hope. Lately whenever I'm not actually standing or walking I tend to fall asleep, and this time I don't think that even the fear of being an intern will be enough to keep me awake while reading about strep throat.

Graduation cometh

Well, this is it. Time's up. Graduation is tomorrow.

Last night we had our mudphud program graduation party. Today we had graduation rehearsal, so I got to hear them call my name, then say, "VonB, Doctor of Medicine and Doctor of Philosophy", then I walked across the stage so they could put the crazy hood on me. Then I sat back down.

I have to tell you--so far, this whole thing has been strangely and unsettlingly anticlimactic. Maybe it will be different when everyone has on their robes and hats, and the bleachers are full of friends and family cheering. Maybe it will be different when I have a program that has my name in it. I don't know. For now it's all just surreal and, well, tiring.

Little VonB has not made her appearance. I can't wear the dress I bought for graduation, both because I can't go without support hose now (by the way, 3+ edema is VERY uncomfortable; I have a whole new level of sympathy for patients who have it) and because I can't get my feet into any shoes besides sneakers. She's due on Sunday, and I am lucky enough to have an OB who understands that I am eminently beginning residency and was happy to schedule an induction on Monday should the tike continue to be stubborn.

So, it is looking like I will be able to waddle across the stage tomorrow after all. But like I said--it isn't as exciting as I thought it would be, somehow. I find myself not really hoping that Little VonB holds out until after graduation, but feeling more indifferent. It's like when I had my dissertation defense. Then, I blamed it on not having a graduation. But I see now it's not that at all. Maybe it's because I've been doing this thing so long, it feels much more like a job than anything else. Maybe it's because endings are often anticlimactic. Maybe it's my crazy hormones. I'm sure it will dawn on me soon and I will feel all kinds of emotions. But for now, I mostly feel: meh.

I admit, have been feeling sort of nostalgic and sad; a lot of it is for the friends who are moving away, but some of it is for my MSTP program itself. It's been like a family to me for so long. I've invested a lot in it, made a lot of changes I'm proud of. I hope I've left it a little better than it was before. And it isn't like I won't be around and able to check in from time to time. It's just... well, I won't be part of that group anymore. I'll be in a new group.

I think that's part of it, too. I'm excited to meet the new interns and get to know all of the residents I hadn't met before--but I'm nervous, too. And kind of tired just thinking about it. Although basically everyone would describe me as an extrovert, I'm shy in my own way. I'm also not good with change (I guess most people aren't, but still). Also, like when I started medical school, I'm hesitant to get too attached to a new set of people I will be leaving so soon. However, I always regretted not making more friends in my original medical school class, so maybe this is my chance for a do-over.

On the other hand, as we recently discussed over on OldMDGirl's blog, it can be hard making friends with people who are so much younger than you, with such different life experiences. Maybe residency will level some of that out. Hmm. Not holding my breath, but still hopeful.

Now I'm just rambling, which is my cue to sign off. When next I post, I will be VonB, M.D., Ph.D. For reals.

Weird.

Residency, husband, baby, nervous breakdown

Old MD Girl recently posted her thoughts on "The Good Life", specifically the musings about it she had heard from a male lecturer. It got me thinking a lot about my experiences so far and what I am facing down when it comes to being a mudphud, married to another mudphud, looking down the barrel of us both being interns and then residents, with a baby on the way and hopes for at least one more in the future.

Like Old MD Girl, I have also been privy to the musings of many a physician or practicing mudphud when it comes to "lifestyle", "goals", "balancing career and family", etc. The striking thing is how differently this is talked about by males vs females.

I do hate to generalize and certainly hate to generalize based on gender--Lord knows I resent it when anyone else does--but I would be lying if I said there wasn't a persistent difference in my experience. So far, without fail, when a man is talking all about how "you CAN have it all", how he has a thriving practice, two grants, and three great kids, he says it all has to do with balance and good decisions and careful planning. I always ask these men: "What does your wife do?" And so far, without fail, they look slightly abashed as they answer, "she stays at home with the kids." Aha. So she's the one running the parts of your life that aren't lab or patients; she's the one that makes sure that when you are at home you get Quality Time with the Family, because she's already done the laundry and the cooking and the shopping and the cleaning and the paying the bills and... well, you get my point.

When women mudphuds or physician-scientists talk about Life Balance, they almost always say you can't really have it all, that something has to give. They talk about hiring help; nannies, cooks, maids, whatever you need to get through. They talk about having to cut back hours sometimes, and finding lots of good after-school programs; about working part time if you have to, and having a very supportive spouse (interestingly, they always bring this up without me having to ask. So far, none of the men have).

There was one exception to this. We heard from a couple who were both physician scientists and had a young child. I'm sure they are perfectly lovely and accomplished people but please believe me of understatement when I say that after hearing their presentation on "balancing" professional and private life, my husband and I wanted to shoot ourselves. Their system went something like this: one would go in to to work around 4am while the other kept the baby until the nanny arrived; then they would both work all day; then the one who went in at 4am would come home around 6 or 7pm and relieve the nanny, while the other would stay at work until around midnight. The one who stayed at home would work from there, writing grants. Sometimes, they said maybe once a week, they would both be home and have dinner together--although this meant one would have to go back to work until 1 or 2am.

Horrible, horrible, horrible, we thought. There must be another way. I don't know about you, readers, but I can't live like that. As I said when I was interviewing for residency and was repeatedly asked why I couldn't expand my geographical area and just live away from my husband for three years: I married him for a reason. I like having him around, and honestly being apart for three years is not an option I am willing to consider. Sorry; life is too short not to be with the ones you love.

Likewise, I can't imagine never seeing my children. I have no delusions that I will not see my daughter as much as I'd like this coming year; however, I can manage because it is a temporary situation. The couple described above intended to keep up such a schedule for at least three years until their fellowships were completed (and hinted it would be many more before their labs were established enough they could give up such a schedule).

I'm sorry, but since when did becoming a doc mirror entering the priesthood? Is it reasonable to expect us to give up any chance at having a life outside of work? Although we both love our chosen fields, my husband and I picked ophthalmology and dermatology partially because we knew those areas gave us the best shot at being able to be fully functional mudphuds--patients and research--without guaranteeing that we would suck at one or the other (or both), and without having years of never seeing each other or our children. Had one or both of us chosen medicine, followed by a fellowship, it's hard to image a way to escape the misery of the docs described above.

I feel there has to be a better way to do things. I worry that by asking so much sacrifice, the most talented people are being driven away from medicine and research, and particularly those fields where they are most needed (primary care, etc.). And the sacrifices seem to only get bigger as time goes on--more debt upon graduation, more hours spent on billing and insurance, more days on the phone with some random dude who has a bachelor's in rhetoric and communications and is trying to tell you how to treat your patient, more years working such long hours that you don't have anything to give at the end of the day to research, much less your family.

We are going to have to face the fact that we would have more, happier, better doctors if we didn't abuse them so. I read that Obama is struggling to find the best way to address the current and growingly alarming doctor shortage. How about allowing them to have a decent quality of life? More debt forgiveness for those who go into primary care; more flexible schedules and hours (which would often mean hiring more docs); more autonomy from the HMOs in how they treat their patients.

Well, I've gotten off topic, but I'm sure you get the gist. I wonder--I hope--my hubby and I are doing the right thing. Most days, I feel pretty confident that our kids will be fine in daycare. We'll have time for them and for each other, and hopefully won't suck at patient care or research. I'm hoping that we CAN "have it all". I'm pretty sure I will need a maid, though, since I'm unlucky enough not to have a stay-at-home spouse running the rest of my life. To those of you who do, I salute you. Just be sure to thank him or her the next time you're bragging about successful you are.

T minus 18 days until MD

Crazy, no?

It's extra strange to me because I have been so completely focused on other things--lab, getting my medical license (pain in the ASS), doing the mounds of paperwork required to be a resident, getting ready for the baby (YIKES), the foils of pregnancy (being essentially handicapped with various ailments, frequent doctor visits, etc etc), and importantly the hubby's PET scan which is at the end of the week--that I haven't thought much at all about the fact that I am about to graduate and be a student no more. It's a mind scrambler.

In other news, I passed Step 2 CS, which is good, because it means that no one at the NMBE has to get a whupping from me. What a lame experience that was.

My internship starts June 15th, which is more than a week sooner than I had hoped. Mainly I am sad to have less "maternity leave"/time to recover from childbirth and attempt to build up a supply of pumped milk. By the way, though I have seen lactation nurses teach new moms how to pump I am not relishing the thought of having to pump myself.

Which actually kind of explains my whole take on this pregnancy/childbirth thing. I've seen a third degree tear up close and personal, as well as lots of C sections, births gone awry, or even those that go okay but still leave mental scars for those who had to witness them. Having seen so much from the medical end of things must alter how you view the experience, but I can't say, having only had the experience from this point of view. It's also weird because I am reading books about Lamaze, approaches to laboring, etc., most of which are pretty darn anti-medicine; however, clearly I am NOT so much with the anti-medicine. But apparently I am pretty susceptible to suggestion because I keep finding myself thinking, "Yeah! Why DO they make laboring women do that?!" It's very strange.

And even though all the books try to make you feel guilty about having any drugs, I am totally getting an epidural. Why? Because I've seen what happens to first time moms who don't, and... well, no thanks.

In any case, that's all for now. The countdown to labor and--gasp!--graduation is ON. Hopefully I will labor early enough to be able to go to graduation. It's going to be a close shave, as I am due the day after graduation. I think I would be pretty bummed to miss graduation; after all, this is a big end to a looooooooong road, and I feel I've earned hearing my name and walking across the stage. I guess there are more important things, but damn. Come a little early, girl, and let your momma have her day in the sun!

Now I'm back to all those chores and errands which somehow seem to take up WAY less time when you are working than when you are on vacation. How does that always happen?

What Capstone Taught Me

-First, I am even more scared to get sued than I was before. I don't think that is what they were going for with their "Don't worry, you can avoid getting sued" talk.

-By the way, malpractice insurance is frickin' expensive.

-Also, it now seems inevitable that I, or someone I know, will develop a drug or alcohol problem. If it is someone I know, I will be forced to report that person to the Medical Licensing Board and potentially ruin their lives.

-Say what you will about the MD/PhD pathway (Lord knows I have), but at least I am not well into six figures in debt like my classmates, who will have to work just as hard as me (who am I kidding, I'm going in to Derm... they will have to work harder) and be much poorer for a looooooooong time.

-Docs sure do seem to get the s*** end of the stick.

-I figured it would be awful to have to tell the family of a patient that their loved one might die because I screwed up; standardized patient family members have helped me realize that "awful" is the understatement of the year.

-Sometimes, there are patients who have had bad health care experiences who have a lot of valuable things to say. And sometimes, there are patients you want to smack because they clearly think they understand what happened to them, but in reality they got most of their information from qacks and you have to listen to their ridiculous nonsensical ramblings about how awful doctors are.

-Apparently--and this TOTALLY blew my mind--it's a bad idea to have sex with one of your patients, especially if that patient has borderline personality disorder. Holy Cow! I am so glad I sat through an hour long lecture to learn this gem, because otherwise I might have gotten into real trouble!

-Residency is hard. No, seriously.

-You won't have time to take care of yourself, but you owe it to yourself and your patients to take care of yourself. Whatever that means.

-Finally and most importantly: I am completely done with medical school. Holy 8 year training program completion, Batman!

Dr. VonB is a lucky, lucky girl

Well, I am still in shock, but I have managed to get everything I hoped for. Yesterday I found out that I matched into my top choices for preliminary year (pediatrics) and my advanced year (dermatology)!
Match day was kind of bitter sweet. Lots of friends leaving, lots staying; lots got what they wanted, some were disappointed. I was a lucky one, getting what I wanted, sticking around. I'm sure I will be even more excited as days go on, but for now I'm kind of still in stunned disbelief.
Here's the thing: I can't tell you how excited I am about dermatology!! I love, love, LOVE it. It is just about perfect for me. I've said it before, but I get to do everything I love. Great diagnostic work, surgery, and kickass immunology. Plus, my daughter will probably even know what I look like!
As for intern year, I am also very excited, but nervous. It's such a huge leap, going from not doing anything without four levels of permission to basically being able to make decisions on my own. Also: the hours. Scary. And even scarier... Capstone has given me a very clear understanding of just how much stuff I've already managed to forget in just a few months. But I'm not thinking about that now. Right now all I'm thinking about is packing for a short, weekend getaway with my hubby which we have been looking forward to for months. :)
For those of you out there who matched, I hope you are as happy as I am. For those with the match still ahead... sitting on this side of things, I can tell you that keeping up with that hard work and studying does pay off! Hang in there! And enjoy the first day of spring.

Changing gears, Step 2 CS, and OHMYGOD MATCH DAY

Well, clearly I have not been 100% on top of updating this thing, which is probably appropriate since things will be moving on soon. I have been trying to decide if I will blog about this next great phase in my training--moving from being a student to being a resident--and I'm undecided. With a baby on the way and a husband who will also be an intern, there may not be time. On the other hand, Lord knows I always have lots to say.

These days things have become considerably more peaceful. It's nice, but almost frightening--I feel as though I keep waiting for the other shoe to drop. My husband has completed chemotherapy. He gets his port out soon and in another couple of months will have his follow-up PET scan. Waiting for that is certainly a source of anxiety; I try not to think about it, and to just rejoice in seeing him slowly return to his old self. Another huge source of anxiety, which was finding appropriate child care for next year, is now gone. We found a wonderful situation which we both feel great about, with the tiny exception that it will take MY ENTIRE RESIDENT SALARY to pay for it. That's right, folks. My. Entire. Salary. Repeat after me: MD/PhD training is worth it... MD/PhD training is worth it... MD/PhD training is worth it...

The following year we will probably be able to use considerably cheaper child care, but for now this is really the only way that we can both do our jobs. I keep reminding myself that this is still an investment, and that one way or another we will be able to survive on one resident's salary. Hey, it isn't really that different than what we did before, so I guess we'll be okay.

The big YIKES on the horizon right now is: MATCH DAY. Yipe. I think that a week from Monday is when we learn if we matched or not; official Match Day, where we learn where we will be, is March 19th. Now, I know that a lot of MS4s out there are feeling anxiety about this, but allow me to put it in perspective for you: I applied to dermatology. And ranked two programs. TWO. It is the height of madness, but luckily, I have to say that the PET is scarier, so there you go. In any case, hopefully I will at least have a prelim spot for next year, and if I am a REALLY lucky girl, I will have a place to call derm home after that. One way or another it will be nice to know for sure.

I also took Step 2 CS. I don't want them coming after me so I won't say anything about it except that I expected it to be really stupid, and it exceeded those expectations like a champ. I have never been forced to do anything that was such a racket, so pointless and aggravating, in medical school or graduate school, and those of you have done either or both know that is saying something. I urge anyone with the power to do so eliminate this charade, this rip-off disguised as an exam. Everyone knows you make us do it for the money. Why give us that final slap in the face after we've crawled through the sewer tunnel to graduation? I'll say no more.

These days I am all done with rotations, and am back in my dissertation lab for a while to help out with progressing my old project. Going back to research, changing gears again, is a strange experience. It's both harder and easier than I thought it would be to come back to it. My main issue right now is fatigue. It's hard to focus, hard to care as much as I did when I was here almost two years ago. I'm trying, but it ain't easy. It's also interesting to see how my perspective has changed with just a few years of clinical work under my belt. It's a good thing, and it makes me more certain that in the end I've done the right thing with the MD/PhD. A nice place to be.

No other big insights here for now. I have a Capstone course coming up, and my forecast for that is Stupid with occasional chance of Helpfulness. It sounds like most medical schools have these, so I might post a little something there. Also expect a triumphant or tragic post regarding match results. And wherever you are, whatever stage you are in, I wish you godspeed in your endeavors. We all have it pretty tough no matter where you are in this drawn out hot mess of physician-scientist-dom. Hang in there. I can honestly say that things keep getting cooler with each passing year.

No, I do not have any more #@*$&! questions about the program, or anything else

Interview season has come to a close for me. My interview season was relatively very short and painless; with my husband having a spot at a nearby university for residency, I only applied locally. Let's not talk about what that means for my matching chances, especially given that I am attempting to match in dermatology. We will pretend that this is NOT the scariest thing ever, and move on. Very well.

In any case, I only had five total interviews, and had to travel for exactly zero of them. Given how ecstatic I am that I am all done, I have to wonder--how do people DO this? Most people have 10-25 interviews, all over the country. I was ready to stab myself in the eye after just five. Plus, I actually liked all of the places I interviewed, which makes it even less painful.

However, there is something weird about interviewing only where you have done rotations. It leaves a lot more blank space where there would have been questions, and as anyone who has gone through interviews can tell you, there is already a lot of blank space where they expect questions that don't exist. After you've gone through two or three lectures about the place and met with residents and faculty both formally and informally, there just aren't. Any. More. Questions. But yet they ask, at some point during every individual interview: "Any questions for me? Anything you'd like to know about the program?"

It is especially tough for derm interviews, where you have to meet with essentially ALL of the faculty individually, typically at least 10 or more people. It's nice in these situations to have a Blue Ribbon Pony of a question all picked out that you can parade in front of any faculty member, especially if you care about the answer. My personal Pony was: "What do you see as the most important goals for the future of (fill in name of residency program here)?" Interviewers love this question, and it gives a lot of helpful information to you, too.

That is my one useful tip for today. I have been heavily engaged in recruiting for our MD/PhD program, which is fun but busy and stressful. It is also very weird to have just finished being on the interviewee side of things, and then being on the interviewer(-ish) side of things. Now I have been chained in the garage by my husband to help him sort through the mind-boggling amount of ridiculous crap we have in there. It's nice, but now I need a nap.

I had something else to say, but it's gone now. Will post more when brain working again. Unless I inadvertently put said brain in one of the to-donate boxes in the garage... hmmmm....

It's not just good things that must come to and end

Bye, bye, 2008. Please be sure to let the door hit you in the ass on your way out.

This year has had a few nice points for us, but overall, it can go straight to hell. I have a very optimistic eye trained on 2009, and that eye is looking through the laser sight of a powerful rifle, so you'd better watch your step, 2009. It's time to pony up and be good to us.

In other news, I'm all done, and it couldn't have come a day too soon. PICU was definitely the most difficult rotation of medical school for me. I would like to say that unconditionally, without the qualifier of what was going on in my personal life during that time, but I can't. After all, to be fair, the second most difficult rotation was probably OB/Gyn, due not in small part I'm sure to the fact that I had a miscarriage right smack dab in the middle of it (stupid 2008). So, clearly, personal issues cannot be put aside here.

However, I must say that even without the whole husband with cancer thing and the being pregnant thing, PICU is amazingly difficult. I have a whole new level of respect and awe for critical care physicians, particularly those in PICU. There is a new dimension added to critical care when you have children involved.

It's very feast or famine; my first week, we mostly had kids that needed a lot of very careful care but would almost certainly be okay. Then we had weeks where we lost three patients and an additional 30% of our service was about to die.

It blindsides you. There's the kid who comes in with headaches and is found to have terminal brain cancer; the kid who was totally healthy until infection led to meningitis led to stroke; the kid who came in for a simple, common operation and died three days later from massive cardiovascular collapse. I couldn't put it aside like I could with older adults. Losing patients has always hit me hard, but this was something new. The grief of parents of young children is somehow much harder to bear than the grief of adult children of elderly patients.

Then, you add in my current personal situations. Having to go see a family awaiting biopsy results for their child's brain mass every day, for days and days, without having an answer for them--and then having to deliver bad news--was heart wrenching. I had just waited for those results for my husband, and it was the longest and most horrible two weeks of my life (and we got relatively good news at the end). We still have scary waits--PET scan results, blood culture results, etc. etc.--and every minute still kills me.

I was waiting to have our 20 week ultrasound during the majority of the rotation, and seeing a parade of tragic lethal congenial malformations being desperately, and unsuccessfully, treated kept in fresh in my mind just how many things can go wrong with a baby. I went from being excited about the scan to being terrified. Luckily, everything looked great. It didn't stop my obsessive worry, but it took it down a few decibels.

Intellectually, it was always challenging. These are the most complicated patients around, with multiple life-threatening medical issues balanced against each other like a house of cards; every day you were trying to shift one of the bottom cards without having the whole thing collapse. I never felt that I developed a good grasp of the sickest patients. Yet, looking back, I am somewhat disappointed that I couldn't find within myself the usual regret to be moving on from something before I felt I really understood it. When I finished the rotation, I felt nothing but relief.

I was exhausted, in every sense of the word. At one point my husband spiked his first fever--luckily, he was not neutropenic (Go Go Gadget Neupogen!) but it was still terrifying. Having to be away from him so much was really agony, worse than it had been since his diagnosis, if that's possible.

What got me through it was 1) my deep, deep desire to never, ever, ever ever ever have to go back and do it again; 2) my husband's constant encouragement; and 3) my fantastic residents. Thanks a bunch guys--literally couldn't have done it without you.

And now I'm done, done, done. Though I'm technically on vacation it doesn't feel like it; at least, not yet. Hubby got very very sick a few weeks ago and we had to postpone his chemo. It was the worst week since after we got rolling on the treatments. I was terrified. He had high fevers, night sweats--it was a perfect example of how horrible it is to be newly minted MD when something like this goes down. We knew every possible bad thing that could be going on, but we both lack the practical experience to offset those fears with less frightening possibilities. The one thing I hadn't thought of was relapse, and when the doc pointed out that possibility, I well nigh had a meltdown. There were several nights I just laid in bed next to his sleeping, sweat-drenched form and cried. But he got much better, and today the doc informed us he thinks it is much, much more likely to have been a virus than anything else; sometimes, a little reassurance is magical.

We also found out that one of our doggies has a cancerous mass--can you believe that @)%&@? She has to go back in for a wider excision, and get an ultrasound of her spleen to see if there are any mets. This is the kind of tumor that if her spleen is clear, she will almost certainly be fine; if she has mets to her spleen, she's a goner. So, that has certainly added to my current Climate of Frenzied Panic.

Once I finished, I had about eight metric tons of random life chores to get done, the holidays, the family in town, blah, blah, blah... and I have a solid week of interviews starting Monday.

So, vacation, but not really. Looking ahead I think things will become substantially more sane towards the end of the month, but I've been saying crap like that for a while. Hubby only has three more treatments, then a PET, and if that sucker's clean, it will be the best thing ever (of course we have to await the 3 month PET...). The doggie gets her scan next week and if that looks good it will be a big relief (and if not... LALALA, I CAN'T HEAR YOU!). End of Feb I have to take--and pass, unless I want to cough up an additional thousand clams--Step 2 CS. Then comes the rank list and match. Baby looks awesome, still kickin' me with a vengeance.

So that's it for now. The long update. I am thinking of some ideas for future posts, perhaps about interviewing and ranking, exciting stuff like that. Until then I hope everyone had a wonderful, safe, happy and healthy Holidays, and that you remembered all of the wonderful things you have in your life. They are too precious and delicate not to be treasured.

Except for 2008. That sucker can go into concrete shoes at the bottom of the Hudson.

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.