Training Grounds

Not On My Body! The Dirty Secret of Surgical Training

noreply@blogger.com (MedZag) — Tue, 18 Oct 2011 00:59:00 +0000

It's the resident's responsibility the morning of surgery to check on the patient in the pre-operative area, make sure there's a current history & physical, make sure surgical consent has been signed, ensure the surgical site is marked, etc. It's often one of my favorite parts of the day. It puts a face to the person in front of you in the OR, humanizes them after the yellow iodine has been slapped on and the surgical drapes have been placed. Most of the time, it's the first time I'm meeting the patient and it reminds me of how important it is to be meticulous and thoughtful in the operating room. There's often some good-natured banter to soften the patient's nerves. I have a fairly consistent spiel I give when I first walk up.

"Good morning, I'm Dr. MedZag, one of the surgery residents. I'll be helping out with your surgery today."

Some small talk typically follows. I may explain to them what's going to happen during their surgery, or what to expect following it, or let the family know how long the operation is going to last. Many patients are curious about residency and what that actually means I am. I explain that it means I have completed medical school but this is part of my post-graduate training. A mentorship or discipleship, of sorts. I have a medical license but am not board certified. Many people ask how long it lasts. I explain that for the surgical fields, it's between 5 and 7 years, and many of us go on to do fellowships afterwards. "Oh wow, that's a long time!" is the common response. "Well, they don't let us go out and start operating on people without earning it first!" is my usual one liner. But occasionally, I get a bit of a skeptical eye from the patient, and I know what is coming next:

"But Dr. Very-Important-Attending is doing my surgery right?"

I still don't have a good way of answering this question. But I have a few canned responses I cycle through:
1. "Don't worry, Dr. Very-Important-Attending is the boss in the operating room."
2. "I will be assisting Dr. Very-Important-Attending in any way he/she feels necessary."
3. "My role is to help Dr. Very-Important-Attending as appropriate."
4. "Dr. Very-Important-Attending runs the show, simple as that."
5. "Yes, Dr. Very-Important-Attending will be calling all the shots."
6. Variations of above.

I admit that some of my responses are farther from the truth than others and I also acknowledge that I'm always intentionally vague. The fact is that as an intern, yes, for many operations I'm simply there to "assist where appropriate." But for some operations, I'm performing parts if not all of the surgery. This is how we move from "intern" to "junior resident" to "senior resident". You can't become skilled at operating without, well, operating.

But I often wondered what the patient would think if we were brutally honest and told them who would exactly being doing what in the operating room. And the general surgery department at Madigan Medical Center in Washington looked at just that:

It's a very though-provoking study, but there are a few particularly salient and dramatic points they found, with the last two being most interesting:
1. 91% of patients believed their care would be equivalent or better at a teaching institution.
2. 68% of patients perceived a personal benefit from participating in resident training, and 87% believed that their participation would benefit other patients.
3. Patients "overwhelmingly" preferred to be informed if a resident would be performing parts of their operation.
4. 94% of patients stated that they would consent to the involvement of a resident in their operation.
5. However, after being given specifics of the role of resident involvement, patient consent dropped to 32% if the resident was performing the operation with the attending assisting, and 20% if the resident was performing the operation with the attending observing.

The overall message: Patients recognize the importance of training the next generation of surgeons. They just don't want to be the ones being learned on.

There was a great study published in the Journal of the American College of Surgeons earlier this year:

They looked at over 600,000 surgeries at private and training hospitals, and what they found was both expected and surprising. There was a slightly higher rate of complications, but a slightly lower rate of death, when residents were involved in an operation. I find that a very interesting and telling statement. It acknowledges that yes, we are learning, and as such, we make more mistakes. But it also acknowledges that we care about our patients and their care, and I think the mortality benefit reflects the reality that at a teaching institution there are more doctors who care about you keeping their eye on you.

I struggle with this underbelly of my training. The reality is I am learning. But at some point in technical fields such as surgery, you must learn by doing. Even in my short time in residency, I have had complications as a result of things I have done in the operating room. Nothing life-threatening or dangerous, but complications nonetheless. Mistakes that a more experienced surgeon likely would not have made. The reality is that these mistakes follow me. I think about them daily. And I regret that a patient has suffered harm, however great or little, as a result of my actions. But I also recognize that they have imparted to me great lessons, and have made me a better surgeon as a result.

Like I said, I find answering the "but Dr. So-and-So will be doing my surgery, right?" question difficult. Do we accept the half truths that permeate such a conversation as a necessary evil for the greater good so that myself and other surgical trainees will be ready to serve society for the next 30-40 years? Or do we instead veer towards blunt honesty, acknowledging that at an 80% consent attrition rate it would take me 20 years instead of 5 to gain that necessary operations and experience to be a competent surgeon? Do we be completely honest with patients but focus on educating them on what "resident participation" means from a value standpoint? That seems to be the ideal scenario, but my inner pessimist tells me that no amount of patient education would make most people willing to be learned on.

These issues are important ones to think about, but ones I can't afford to think about too much right now. Because I'm an intern, and I have too much to learn and too much to practice. So tomorrow, I will be in the operating room. I'll cut skin with the knife, buzz blood vessels with the cautery, tie sutures. And I'll keep learning.

Warrior

noreply@blogger.com (MedZag) — Wed, 12 Oct 2011 00:57:00 +0000

He was young for his type of cancer - squamous cell carcinoma of the larynx. I can't remember if he was a smoker or not, I don't think it matters, because those little details tend to deceive us into judging whether a patient "deserves" their cancer or not, and no one deserves a diagnosis of cancer. His tumor fell into the "organ preservation" limb of treatment, and he underwent weeks of grueling radiation and chemotherapy with his wife steadfastly by his side. The first few scans came back clean, then a year or so after treatment - recurrence. The cancer would prove to be a formidable enemy.

"Salvage laryngectomy" is the term we use when our first treatment has failed for voice box cancer and the ultimate decision is to be more aggressive and wield cold steel and hot cautery against our opponent. I think in some ways the term is quite poignant. It implies a battle of sorts raging within the body - treatments and human will versus the scourge of the malignancy infiltrating the tissues. Poetic interruptions aside, it meant the patient lost his ability to speak when we removed his larynx in an attempt to also in turn remove the cancer. Once again, a period of reprieve and healing. He became artful in speaking with the electrolarynx, attacking this new challenge the way he had all other challenges before then. But once again, the cancer returned with a ferocity, infiltrating the skin around where his airway now exited from his neck.

"Peristomal recurrence" is the term we use when the cancer returns in such a location. In general, it is considered a very poor prognostic sign. The type of sign where all you have to do is utter the term and those knowledgable to the lingo simply nod their head sadly, understanding that you're implying the chance cure is essentially zero.

And so it went on, another round of chemotherapy. More radiation. More chemotherapy. Experimental regimens that were so new or different they weren't even clinical trials yet. He lost a lot of weight. Nausea. A tube was placed through his skin into his stomach. His tumor grew larger. He was hospitalized. His tumor grew larger. He had bleeding. He spent time in the ICU. His tumor grew larger. He had abdominal pain. That earned him a surgery, and more pain, only to find that the cancer had further metastasized. His tumor grew larger. He would spend the last few months of his life in the hospital, until one night he quietly passed.

The unfortunate fact is that half of head & neck cancer patients in an academic institution will succumb to their cancer. His story, however, struck a chord with me.

Our team was frustrated with his care. We had tried many times to lay out prognosis to him, to arrange end of life care, to make him comfortable. But he would always talk about the next round of treatment. He would always talk about the day when his cancer would be gone for good. In fact, up until the end, he talked quite a bit. About his favorite football team and the upcoming season. About his rec sports league and the joy he got from the competition. He struck he as the scrappy small guy you hated to compete against but always wanted on your team. Ultimately, he always equated palliative care with quitting no matter how how we tried to frame the conversation. We, the team of residents caring for him, had trouble with transferring our own opinions onto his life. We saw the last few months spent in the hospital as time wasted, unnecessary pain and suffering. (And wasted healthcare dollars if you work in Washington). Some would paint his case as a failure of our medical system to navigate end of life care. Every day as we passed through his room we were left with a dampening of our spirits, a daily reminder of our own mortality, and the futility of our care at times. He was the other, more real, 50% of head & neck cancer patients.

I think when it comes down to it, he derived value and meaning from the fight. And I think he measured the worth of his life in the end by how hard he fought. He was a warrior. He outlived prediction after prediction. 6 months to live. 3 months to live. 1 month to live. He tolerated an inhumane amount of painful and debilitating treatments. He demonstrated the tenacity of human will.

And ultimately, I can't help but admire his story. In the end, I think, it was a good death. A death befitting a warrior.

Worrywort

noreply@blogger.com (MedZag) — Mon, 19 Sep 2011 03:17:00 +0000

There was this one moment I remember vividly from when I was a third year medical student. I had been working with one specific doctor all week in clinic, and we were talking about an interesting patient we had seen the day before.

"I worried about her all night," the attending said.

I remember reflecting on that line later that night. I remember it so vividly because I didn't worry about her at all. I went home that night, did some reading, mucked around on the internet, and had a blissful night's sleep. And I wondered why. Was it because I didn't understand the complexity of her case? Or was it, I really worried, because I didn't care about my patients enough?

That continued throughout the rest of medical school. I felt like I connected well with patients during the day. Empathized with them. Felt concern for them. But when I went home, I could unplug from that. And always in the background was this vague gnawing feeling tha maybe I didn't care enough.

From the other side, I can see it was because you are so well protected as a student. Sure, you dabble in independence. One night as a fourth year student we were being hammered on call. The resident was busy with our 8th trauma ICU admission of the night and a big case just got out of the operating room. The resident sent me to evaluate the patient and come back and tell me "stable or spiraling" (i.e. is this a patient I need to see now, or in an hour when the traumas are done). I remember the anxiety of that moment standing in the ICU room alone with the patient - looking at monitors, drains, and drips and trying to get the overall gestalt of the situation. But by the end of the night, the resident had come and seen the patient, and had agreed with my assessment. I went home and had a worry-free nights sleep.

In some ways, moving from student to resident is like being a sheltered teenager that suddenly graduates high school and moves away to college, thrown into a crazy world where dangerous things lurk around the corner.

I worry about my patients now.

The patient I just operated on with post-op tachycardia and EKG changes. I do an assessment, order labs, look at her old EKG, and make the determination that her heart rate is secondary to pain and she ends up going home. I worry that she is doing OK, and I didn't miss her heart attack.

The patient whose feeding tube comes out prior to discharge. I place a new one, order the xray, and see it isn't comfortably into the stomach. Go, advance the tube, and re-order the scan. Somehow the patient gets discharged before he follow-up x-ray is taken, and I worry all night that the tube is in the right place.

The patient with shortness of breath after an operation where you SHOULD feel some shortness of breath, and I worry that her symptoms are covering up something more insidious.

There's a few things that I mull over about this newfound worrywort quality of mine:
1. I wonder if it is because I don't want to "get caught" doing something "wrong." I think that may be part of it, because all of us in medicine tend to have a perfectionistic quality. And I recognize that, as a person who didn't really get "into trouble" as a child growing up, I retain some of that quality in adulthood even now as a resident where I don't want to be in "trouble."
2. That being said, most of my focus is on my patients. The worst thoughts I have are of my patient at home, suffering, because of something I did or something I missed. So I think my worry comes from a good place, because my focus is on keeping my patients well.
3. I'm learning that its good to have worry. It keeps you vigilant. But you have to be able to turn it off. You have to be able to trust your colleagues to handle issues for you. You have to be comfortable with uncertainty and trust that if things begin to go downhill, the patient will let you know.
4. I'm also learning that perfection is a noble and good goal but not an attainable reality. You will make mistakes. There are mechanisms in place to pick up on mistakes. And, to use a cheap sports analogy, you have to forget about the botched play and get ready for the next one.

I think back to those days of medical school when I worried that I didn't worry enough and I smile. It's always fun to reflect on your own naïveté.

Big Boy Pants

noreply@blogger.com (MedZag) — Mon, 19 Sep 2011 02:29:00 +0000

Intern year is a weird limbo of sorts. In some ways, you're still like a medical student(+). Your activities consist some days mostly of carrying out other peoples orders throughout the day. The things you do handle independently are mostly algorithmic. Manage this patient's pain regimen. Work up this patient's chest pain. Evaluate this patient's shortness of breath. Put in this patient's admission orders. Anything beyond that, you are generally encouraged to page up the food chain to residents above you (or discouraged from handling these things on your own, depending on how you look at it).

But the other day I had to put on my big boy pants.

Due to a combination of the chief resident being out of town, one of our residents being post call, and the last one being in the OR all day, I was gifted with the responsibility of handling the otolaryngology consult pager for the day. The ENT consult pager is an interesting beast. Most of the time, our consults are something very benign and not particularly time-sensitive. The little old lady with an incidental mass found on imaging when she presented with stroke symptoms. The level 3 trauma with the mandible fracture. The cheek laceration in the motor vehicle accident. But the consult pager is also a terrifying thing, because it is also the emergent airway pager. These are very rare, but present. So every time the pager goes off your heart rate jumps a couple clicks.

Luckily, I escaped without an airway emergencies. However, I did pick up an emergency department consult later in the afternoon. It was supposed to be a curbside consult. "We have a patient with sinusitis and I was wondering whats the best imaging test to order." I ask to hear more about the patient, and there was enough concerning bits about the story I say "you know, we should probably formally consult and lay eyes on this patient." Go to evaluate the patient. Run the story by the chief on call, who is already home for the day. Get the imaging ordered. Read through the images with the chief, and decide the patient has to go to the OR. Immediately. Staff with the attending on call. Get the case booked, talk to the ED resident, explain the findings to the patient, answer questions, get the consent.

As the patient is being wheeled into the OR, the chief and attending still have not shown up, and I realize... I'm the only person who has physically seen this patient.

The necessary powers show up. The attending sits at the computer checking email and the chief ends up taking me through the case in its entirety. Whether it was luck or whatever may be, I end up being right, the operation was appropriate, and everything goes smoothly. With the case complete, I put in the admission orders and go and talk to the family.

When I finally get home later that evening, I think back on the whole sequence of events. It was a fairly straightforward consult. But I was the one who decided we needed to formally consult. I was the one who saw the patient, took the history, performed the physical exam, performed the endoscopy, and ordered the imaging. I was the one who talked to the patient about the findings, talked about the implications, obtained consent, booked the operation, performed the surgery, and talked to the family afterwards. From the patient's perspective, and from the family's, I was the only person they had seen and talked to. I was their doctor.

That was a profound feeling.

I know that is the endpoint for residency, to be able to independently evaluate and treat patients who come under you care. And I know that my chief and attending had my back, and if it wasn't something straightforward, they would have been there to see things over in person. But for someone still so green at all of this, it was a refreshing (and, in some ways, terrifying) experience to be the point person for everything.

The patient did great and went home the next day. I saw him on morning rounds, staffed with the attending by phone, and put in his discharge orders. He is scheduled to follow-up with the attending surgeon in two weeks for post-operative care. And part of me wonders what he will think when he shows up for his appointment and my attending, a person he never met, opens the door to the exam room.

I think I'll try to be there.

ahem

noreply@blogger.com (MedZag) — Fri, 16 Sep 2011 03:15:00 +0000

I am alive. I am loving residency. I have lots to write about.

Soon.

So are you going to be doing my surgery?

noreply@blogger.com (MedZag) — Mon, 18 Jul 2011 02:26:00 +0000

Residency is very different from medical school.

(Thanks, Captain Obvious.)

I had a flashback this week to our "orientation to the clinical years" just before beginning my third year of medical school. I remember the out-going third year trying to coach us on various things - like writing a good note, making a good presentation, etc. I remember asking "So, what does do you do as a third year?" He gave some answer involving "helping with floor work, updating the list, faxing for records, following up on labs, ad infinum", and I remember thinking by the end of is "Yeah... but what do you DO?". I ahd not tangible mental image of what my days would be like. As I discovered over the next few weeks, you can't really understand it until you have to do it.

I think the same goes for residency. Sure, you have a lot of interaction with residents as a student and you get a sense of their responsibilities and how a resident's day is structured. But you don't really understand until you have to do it. A few of the key differences I've found include:
1) There's way more things competing for your time than you have as a student. At any given time, this includes: managing patients on the floor, discharges, seeing patients in clinic, logging procedures, prepping for conferences or tumor board, teaching time, self-guided reading time, prepping for OR cases, didactics, preparing a presentation, practicing basic surgical skills, graded laparoscopic assignments, and maybe a research project or two. As a student, you also had some of these requirements, but if you skimped a bit someone may or may not notice, and no harm no foul. As a resident, if you don't do them, they don't get done, and someone always notices.

2) As a student, you try to know everything about your patients. As a resident, you need to know everything about your patients. There's redundancy in teams to help mitigate this, but there's always the possibility that you may be the only person to follow-up on a lab or check a vital during the day. And that may end up being critical to the patient. It requires a great deal of focus throughout the day to remember to follow-up on things when there's a myriad of other issues continually competing for your focus and attempting to distract you.

3) As a student, you study a lot, but your primary motivation is often your grade. Sure, you convince yourself to read sometimes because "you need to know this for the future" but that often becomes much less of a motivator than impressing those that will evaluate you or an upcoming shelf exam. You also jump around every month, so you reading often will be a sample platter rather than a 4 course meal. As a resident, you read because you need to know the information. Not just because its expected of you, but for the good of your patients. Reading is more intensive on given topics and can feel more exhausting - I feel like I need to hang on to everything that passes in front of me because it is all important, and I feel like there's so much to learn and retain and I want to tackle it all at once.

4) Your skills explode by sheer repetition. As a student, you develop certain skillsets, but the next month you're on to a new discipline and most things you learned pertinent to a specific field fade away. As a resident, the skills you need to learn how to do are the things you are doing every day, and you do them over and over again.

5) The attendings really do rely on you. There was talk at my medical school that a good student is always "value added" on a service. As a resident, you are "value needed."

I think it all comes down to a switch in the manner of your responsibility. As a student, you try to take on as much responsibility as possible. But a lot of it is faux-responsibility (both for medicolegal and practical reasons). As a resident, you continually accrue more and more responsibility over the care of your patient.

I was in clinic the other day with a pleasant patient. I went through a lot of the things I had practiced in medical school - took a history, did a physical exam, developed a plan, went and presented the patient to the attending. The attending came and whirled through the room, checked a few things, talked to the patient about surgery, then left me with the patient to consent them for the procedure.

As I shook his hand as he walked out the door he asked, genuinely: "So are you going to be doing my surgery?"

I think that encapsulates the big switch that occurs in residency. You turn from purely a student into a provider of care. Over the coming years, I will read about the patient's condition, I will learn how to do his surgery, I will learn how to manage patients like him post-operatively. And I will do it not just to provide care, but the best care possible for that patient. Residency is about living that mantra.

Residency, huh?

noreply@blogger.com (MedZag) — Mon, 27 Jun 2011 00:23:00 +0000

First of all, apologies for leaving the blog hanging in the wind like a bad M. Night Shyamalan cliffhanger for the past 3 months. You may (or may not) have noticed I dusted off some of the things around here and updated the header to note than I am no longer a short-coat-wearing, deer-in-headlights, hopelessly-clueless medical student. Since our last interaction, dear reader, I have shed the shackles of medical school, packed up all of my "stuff", drove 2,353 miles across the country, and settled down in a small city with a very big medical center where I have spent the last week preparing to be a long-coat-wearing, deer-in-headlights, hopelessly-clueless... intern.

Progress.

I debated for a long time what the fate of this little corner of the interweb would be when I would be forced to stop writing about medical school. For a long time, I was content to let it ride on out into obscurity like many medical student blogs before me. Less time during residency (especially a surgical residency), the changing face of medical social media, and increasingly stringent institutional policies would all stack up and make it easier to just stop writing altogether.

But a few things changed my mind. First, I remembered a conversation I had with a good friend of mine who is in a *wink* elite *nudge* branch of the military. During our conversation, we talked about unique and stressful experiences and how it is important to take time to reflect on those experiences to learn and grow from them. I know myself well enough to know that unless I'm writing it on this blog, I won't take the time to write it at all (I don't know what that says about me as a person... but moving on). Secondly, as I nostalgically romped through the end of medical school, I decided to go back and read this whole damn blog in its entirety. Reading posts was like reliving experiences all over again, and I was surprised by how much of those memories had already began to seep away into the dark recesses of my brain. Finally, during a conversation with one of my new co-interns, I discovered that he both read my blog and liked it, despite the fact that we never interacted on the interview trail and hailed from states on different ends of the continental time zone. I was reminded about the common thread of the medical student experience and how many comments in the past have remarked "I'm glad you're writing about this." These things have led me to the conclusion that:

Remembering the process is important.

Over the 4 rapid years of medical school, this blog has evolved from something analogous to a teenage chick flick, to a place for me wax sophomoric about my "difficult" life, to a place to reflect on the incredibly powerful moments laced into and around my chosen profession. But what this blog is is far less important than the purpose is serves... to remember the process.

So I plan to keep on writing. I have no idea how this space will change, only that it will change along with me. Hard to believe over 60,000 of you have been here to this point, but hopefully a few of you stick around for the next chapter. Because tomorrow I'll put on a long white coat for the first time, walk into the hospital, and get to be Dr. MedZag. And I'm sure it'll be a process.

Survey says...

noreply@blogger.com (MedZag) — Tue, 22 Mar 2011 04:06:00 +0000

Oh, hello. Didn't notice you there. Been distracted with this thing called "life" the past 2 1/2 months. Amazing how as my clinical responsibilities tail off, other things find a way to take their place.

Anyways, time to share the verdict. As I had said before, I was a late switch onto the ENT track (during the first half of my third year) and I approached the match process with more than a bit of apprehension. I was a good student, sure. I had the necessary board scores. But I hadn't set up any free clinics in Africa or presidented any associations or covered my walls with awards from medical school. I think I can fairly call myself a fairly "average" ENT applicant. That being said, I believe myself to be a very likable person, a hard worker, have a good rapport with patients, and I tend to be efficient & pick up things fairly quickly. As a result, I feel like the feedback I received from residents was that I was someone they would absolutely love to work with, and that I would interview very well. I think my LORs represented that fairly well.

I think it was difficult for me coming from a medical school in which a lot of students go into primary care and very few (4 in the last 5 years) go into ENT. I felt like I didn't have a good roadmap paved by former grads like some of my classmates did. I applied to 45 programs, which felt like an extraordinary amount of programs compared to my peds/FM/IM classmates who were applying to 15-20. In hindsight, I probably would have applied to 15-20 more.

In the end, I was probably lucky, but I net a good number of interview offers, and attended 11 interviews. The ones I did not attend were primarily due to conflict with other interview dates and inability to get to the destination program on time. So I basically accepted all comers. I ranked all 11 programs I interviewed at, because, on a whole, I was blown away by the quality of ENT programs across the board - seems like there really are no bad programs out there.

Making the rank list was incredibly difficult. I felt like I was perseverating over minor shades of gray concerning issues that really aren't that important for the quality of your training. But you need to sort out programs in some way, so I had to choose some points which were more important to me than others. The most important thing driving my rank list was the surgical volume and quality of surgical training. Overall, when I asked myself "what is my real goal in residency?", being comfortable with performing the breadth of ENT procedures was my #1 priority. Along those lines, I also ranked programs higher if they had a well rounded faculty and a good track record of sending graduates into both fellowship and private practicen and departments that were stable and growing. Second most important was the intangible camaraderie I felt amongst the residents and with the residents and staff. I favored programs where I could see myself having fun at work over programs where the residents tended to work then go home to their lives. The size and atmosphere of the city of the program also played a factor. Less important to me was weather, distance from home, cost of living, call schedule, etc.

I consider myself a fairly even-keeled person, and I didn't work myself up too much over the whole match process. But the week before match week, my id kicked in. I had nightmares I didn't match because I didn't certify my rank order list. Dreams I matched at my #1. Nightmares I matched at my home program but was failing as a resident. The subconscious is a crazy thing. The Monday of match week was one of the most nauseating mornings of my life. I'm lucky I am on a clinical rotation and had rounds to distract me, but from 8:30-9am, I was dreading the buzz of my iPhone on my belt. Finally, the buzz came and it took me a good 30 seconds to work up the courage to open the email.

"Congratulations, you have successfully matched!"

I don't know if what I felt at that moment was elation, excitement, or relief - probably a combination of all three. But it felt like a huge weight had been lifted off my shoulders. I didn't care where I ended up - I had matched into ENT. The rest of the week was a blur. I actually slept like a baby Wednesday night, unlike some of my classmates. But when Thursday morning arrived, the nausea returned. Turns out, I DID care where I would be spending the next half a decade plus of my life. The 30 minutes between 9 and 9:30am, mingling with friends and classmates, felt like 3 hours.

The moment came, and they opened the door to our "match room" where all our envelopes were located. I got my envelope and shimmied out of the cattle drive. I held the envelope for what felt like several minutes, then opened it slowly.

I had matched at my #2 program.

My response went somewhat in the sequence of shock -> excitement -> shock -> doubt -> shock -> excitement & doubt. I hadn't really considered the possibility of matching to my #2 program a whole lot, because I saw it as somewhat of a reach for an applicant of my stature. Frankly, it seemed out of my league. So, internalizing the reality that - (1) I had matched there (2) I was actually going there (3) I was moving there in 3 months - took more than a while to process. Frankly, I think I am still processing it. But the more it sinks in, the more excited I become.

So, yeah. All those hours spent slaving away over syllabi the first two years. The grueling days spent studying for Step 1. The mindless times spent crunching charts of research in front of my laptop. The long days and late nights of third year. My sub-i and aways. The pre-rounds, rounds, and presentations. The writeups and scut. That f'ing personal statement. The countless hours spent on airplanes and countless nights spent in hotel rooms. All of it brought me to this point. The finality of it is daunting, in a way. But in 3 months, I will be moving thousands of miles away from my home, my friends and family, to start the process of becoming a physician and surgeon for the next half decade of my life. There is something incredibly intimidating and exhilarating about that reality.

Still alive, on Q3 call.

noreply@blogger.com (MedZag) — Thu, 10 Feb 2011 05:06:00 +0000

In the surgical and trauma ICU. So busy I haven't even submitted a preliminary rank list yet. Gulp.

Will recap interview season soon. Sounds like a good call night project, as long the patients stop trying to die.

2k11: Things I've Learned On The Interview Trail

noreply@blogger.com (MedZag) — Tue, 04 Jan 2011 05:43:00 +0000

Long hiatus from blogging. Hard to find time for much on the interview trail when you're constantly switching time zones, packing/repacking the suitcase, and hustling to catch the next flight. I took a true "vacation" over the holidays and checked out from anything academic... first time in over 2 years.

Anyways, with a month spent traveling, thought I'd past along some tips from my own experiences and experiences of classmates and fellow applicants:
1. If at all humanly possible, downsize to only a check on bag
Yes, checked luggage does get lost, and it does happen to medical students. The risk of your luggage going lost increases exponentially if your flight gets delayed, or you have 1+ connections, and the last thing you want is to arrive in a city without your suit. Trust me, it happens every year and it happened to a few people I know this year. So go to the store and get those little 3 oz toiletries, and make it work. If you're having trouble fitting everything, wear your suit on the plane. The peace of mind is worth it.

2. TripIt.com
Interviews can be a logistical nightmare with all the airline flights, hotel confirmations, car rentals, etc. I was lucky I stumbled across this little gem, tripit.com. It allows you to create individual "trips" for each of your interviews and keep track off all your flight information, confirmation codes, addresses of interview dinners, and even gives you maps. They have an iPhone and Droid and you can access it online from any Smartphone or laptop. Plus it syncs so you don't need web access to retrieve your info. It's been a lifesaver as far as keeping everything in one place and being able to pull it up at a moment's notice. Plus it's free.

3. Research your hotels
The "recommended" hotels provided by programs are not all nice places to stay (learned that the hard way), and often are not the cheapest or closest places. Before you book anywhere, google the hotel and read some of the reviews to weed out the stinkers. You also want to make sure you are at a place with an iron (so you aren't crumpled on interview day) and internet access (for checking into flights and for sanity). If you have a rental car or there are limited hotels in the area around your interview, you can often get away with using hotline.com to get a deal as well. At one interview, there was only one hotel by the medical campus, and even with the "medical discount" it was still $100+ a night. I did a hotline search for the area, found the hotel (even though it was hidden, I knew it was the one) and was able to book for $68 a night. These little savings add up in an expensive endeavor.

4. When possible, book extra time in a city when you visit
It's impossible to get a feel for a city when you're around only for your interview day. When possible, I'd try to get in earlier the day before or stay the night after and see the city a bit. Plus, this whole process is supposed to be kind of FUN. It's way more fun when you have time to explore a bit and try out some cool little restaurants or walk around a downtown of a city you've never been in before.

Along the same lines, if you have an opportunity to stay with friends, take it up in a heartbeat. On one trek, I had a 4 day layoff between two interviews and didn't want to fly the 2000 miles home in between, so I made a quick jump up to a city 500 miles north and stayed with a friend I hadn't seen in 7 years. Made the trip much more enjoyable and I saved some money on airfare in the process.

5. If you're going to drink, tread carefully.
Many of the social dinners are open bars, and occasionally the residents and/or faculty will take you out beyond that. Don't be afraid to have fun, but also tread carefully. The last thing you want to be known as is the applicant who was sloppy or did something inappropriate. I have seen this happen at several of the social events. Interviews are exhausting and stressful, so feel free to have a drink or two, but know your limits.

6. Take notes
After a couple of interviews, the places start to blend together. Use the flight out of the city as an excuse to take 30 minutes and go stream-of-consciousness on a tablet of paper. It helps when you're trying to remember your impressions from places weeks later. It gets old, but at the same time I have no idea who I'd make me rank list without it.

7. Exercise and hydrate
When changing time zones a lot, your body gets really confused. When sitting on planes a lot, your muscles atrophy. When eating airport food and drinking airport coffee, you gain weight and get dehydrated. Bring along some running shoes and workout clothes and hit the pavement or the hotel gym when possible. You'll feel better and sleep better. And trust me, you want to be rested for your interview day. I've had two interviews already where I was absolutely exhausted the day of and between the powerpoint presentations and repetitive questions, it was very, very difficult to stay locked in. Do everything you can to help your energy level.

8. Relax
90% of my interviews have been very casual and very conversational. Even the more difficult ones have been because of interesting personalities or "behavior-based" questions. Even the curveballs have been fairly soft, so try to relax when the interviews come up. After the first couple interviews, you'll be in a flow and already have a rote response for 90% of the questions that will come your way.

Four interviews left then it's time to create my rank list. CRAZY.

Friendly Reminders

noreply@blogger.com (MedZag) — Mon, 06 Dec 2010 06:11:00 +0000

One of the nice things about traveling so much is it has afforded me the opportunity to read-for-pleasure for the first time in several years. I just finished digesting this 500 page behemoth:

A fictional tale of twins born to a disgraced nun slash scrub nurse in Ethiopia, the tale follows the narrative of one of the boys as he grew up in Ethiopia to two physician parents working in a small mission hospital. The protagonist follows in his parents footsteps of medicine, ultimately coming to America to train as a general surgeon.

The novel is penned by Dr. Verghese, an infectious disease doctor at Stanford who, like his characters, was also born in Ethiopia. A powerful read, with an very engaging plot and many poignant moments intertwined into the story.

Perhaps the most interesting parts of the story for me where when the main character was himself on the path of medical training, both in his youth and then in medical school proper. There were some very profound statements Verghese used to describe the "transformation into a physician" and his own personal viewpoint on care of the patient. I found most of them surprisingly on-point despite the fact that the author is not a surgeon himself.

To be a good surgeon, you need to commit to being a good surgeon. It's as simple as that. You need to be meticulous in the small things, not just in the operating room, but outside. A good surgeon would want to redo this knot. You're going to tie thousands of knots in your lifetime. If you tie each one as well as humanly possible, you'll experience fewer complications. The big things in surgery depend on the little things.

I take heart from my fellow physicians who come to me when they themselves must suffer the knife. They know that Marion Stone will be as involved after the surgery as before and during. They know I have no use for surgical euphamisms such as "When in doubt, cut it out" or "Why wait when you can operate" other than for how reliably they reveal the shallowest intellects in our field. My father says "The operation with the best outcome is the one you decide not to do." Knowing when not to operate, knowing when I am in over my head-that kind of talent, that kind of "brilliance," goes unheralded.

I found the read quite inspiring as times. Too often in medical training, we get caught up in the drudgery of the day to day. Wake up, drink coffee, round, do work, go home, read, sleep. It's refreshing to feel inspired, because I can admit it is not often enough that I feel such as I trudge through my days.

Interviews are going well. Done with three, with four and five to come this week. My traveling karma has been good so far. No missed connections, flights on time. It's great to travel and experience new cities I haven't visited before. Gives me an appreciation for the vastness of America, but also for how similar we all are in ways that are not readily apparent. I'm also getting a better sense for what I am looking for in a program, but know that when it comes time to form a rank list, it's going to be insanely difficult.

That's it for now, off at the airport at 4:30am again tomorrow. Wake up, drink coffee, don suit, board plane... but then, luckily, I get a chance to reflect on where I am and what has brought me to this point. In the words of Dr. Verghese Life is like that. You live it forward, but understand it backward.

Leaving On A Jetplane

noreply@blogger.com (MedZag) — Fri, 19 Nov 2010 04:26:00 +0000

Last night, got to say adios to my plastics "sub-i" and scurry home to pack my belongings.

Today, I embarked on the interview trail that will take me (as of now) to 11 different states and several thousand miles. I won't see another patient until February of 2011 (which is weird to think about... 2 months in medical school without medicine?) Over the next 30 days, I'll spend 18 of them away from home. Then in January another 4 interviews. Whew.

I'm sure there will be some things learned the hard way along the way... I'll be sure to chronicle the foibles and follies here.

Sid Meier's Hospital

noreply@blogger.com (MedZag) — Mon, 01 Nov 2010 04:51:00 +0000

So I'm on Plastic Surgery this month. Excuse me, Plastic & RECONSTRUCTIVE Surgery. Though I think it's fair to say the department here earns that title as they do a fair bit of reconstruction amongst the stripperplasties and wrinkles-be-gonesies. It's strange being back on an academic surgical service after a break of over 3 months, but refreshing at the same time as the duties of the medical student on said services of academia (list updating, prerounding, hastily presenting, obscure pimping) are warm and familiar to me. Like a well worn sweatshirt or something. But the hours still suck.

We had a really interesting person on the census the past while - the whole package, interesting medical case and interesting personality. The guy was tackled by a buddy of his and broke a rib. Being the regular dust-on-the-boots American that he is, he didn't come to the ED but rather was just going to deal with the pain. Problem was, he was a nice guy, and since bad things only happen to nice guys, the rib pierced his pleura and soon enough he was in the hospital whether he liked it or not with a rip roaring empyema. One lobectomy, a lat flap, and a couple chest tubes later, he found himself parked on the floor slowly biding his time until he was given the blessings of the great doctors to go home. The healing was slow and he was nearing 2 months on service when I rotated on.

Of course he felt well enough, and rather than bore himself with watching his chest tube output, every day when we rolled through the room in the clusterfuck that is surgery rounds, he would be clicking away on his laptop, engrossed in a computer game. Now despite my rugged and masculine exterior, I am quite the computer nerd. Growing up in the glory days of DOS, I spent many an hour of my youth tinkering away at the computer keyboard with classics such as X-Wing, Doom, and Mechwarrior. Like like many things of youth, these hobbies have slowly been eroded away by the responsibilities of growing up. So on rounds we were much more focused on said chest tubes than what was on the computer screen.

Finally, after a few days on service, the chief resident glances up from the patient's incision and asks "Are you playing Civilization???"

The junior looks up from the chart to add "Hey, I love Civilization."

Intern: "What version? I haven't played 5 yet."

From my n=1 experience, I can now say that all medical students and residents have played Civilization. I'm not sure what that says about our demographic, but the computer nerd in me grinned internally.

Sure enough, this past weekend we were rounding with the attending on call, and our fearless world leader slash conquerer was getting ready to be discharged home. We roll into the room and there he is, clicking away at his laptop like always. He's excited to go home. We make small talk. Finally, the attending was bent over glancing at the site of the last chest tube, when she comments "Is that Civilization? I love that game!"

Somewhere, Sid Meier is smiling.

These Healing Hands

noreply@blogger.com (MedZag) — Tue, 19 Oct 2010 02:03:00 +0000

It's a reality in medicine that sometimes your patients die, and patients generally do not take exception to this fact if they happen to be cared for by a medical student. Some deaths can be more difficult than others as a student, depending on how well you got to know the patient beforehand or the circumstances of their death. Throughout my third year of medical school, I had several patients who I was caring for pass away while I was on service. Generally, these deaths were of one of two varieties:
(1) A healthy individual crashes and burns, a code is called, and we try our damndest for hours to fight the inevitable tide of death. Eventually the code is called, the team collapses in exhaustion, but there is a certain amount of solace to be taken in knowing that we tried everything.

(2) An individual with end stage x disease, who has been playing ding-dong-ditch at Death's front door for far to long, finally catches Death as he/she is walking by the front door in a bath robe and passes quietly in the night. News of these deaths comes during the AM handoffs and is generally met with a general sense of "Damn." but part of your psyche had already begun stacking the sandbags, knowing full well that your dying patient was, well, dying.

I had another, unique experience with death while on my neurology rotation. We had been consulted on an elderly woman admitted with altered mental status, in the classic CYA consult "rule/out stroke" that elderly patients with AMS tend to collect as they pass through the ED. I originally went to examine her with my attending in the AM, to find a frail looking woman, eyes open staring directly at the ceiling, unresponsive to anything in the room around her. She was altered (frankly, encephalopathic), but we did a full exam anyways and determined that she most likely did not have a stroke. Her breathing was shallow, raspy, and moist, a death gurgle of sorts as she was having difficulty handling her secretions. Labs would show a CO2 of >150... the likely culprit of her current stuporous state.

We weighed in our opinion and were off to clinic for the day. When the late afternoon rolled around, I decided to check back up on her, anticipating that after the requisite therapy for her COPD exacerbation, she would be doing much better. Luckily, I decided to glance at the chart before entering the room, and found a note from the medicine team "Discussed situation and prognosis with family. Family wishes DNR/DNI, palliative care consult."

I enter to find her much as she was that morning. Eyes open, staring blankly at the ceiling, still unresponsive. The late afternoon tends to be quiet in this wing of the hospital, and it was just her and I and the setting sun through the hospital window. Her raspy breathing penetrated harshly through the serenity of the moment. Like a good medical student, I set to task repeating the neurological exam, looking for any differences from the morning. Dolls eye test. Corneal reflex. Tap on the tendons. Check tone. It is just as I remove her sock to perform a babinski exam that I notice a subtle change in the room. It takes me a moment to realize that the throaty death rattle, my patient's weakened attempts at oxygen exchange... had stopped.

The first thought to race across my mind was "Oh shit!" I don't know how, but I remembered at that moment her do-not-resuscitate status, which fortunately prevented me from running into the hallways like an idiot yelling "Call a code!!!!" I watched as the color rapidly drained from her face, and stepped out of the room to talk to the nurse. "Ms. R just passed away. I don't know the protocol for the hospital, do you need to page the attending? I'm just a medical student." She replies that it is ok, as the patient was on comfort care. "Just go listen to the heart and lungs to confirm."

As a medical student, you are not trusted to do a whole lot. In today's chaotic environment of CYA-medicine and medical malpractice, we mainly pretend we can do things while someone holds our hand, until intern year rolls around. And a task as simple as listening to a patient's heart & lungs and feeling for a pulse should be elementary for a fourth year medical student, who has felt hundreds of pulses and listened to hundreds if not thousands of hearts. Regardless, there was a certain amount of anxiety involved in confirming a patient's death. Placing a finality on a life, even a life known to be near it's end, felt like a heavy responsibility. "I'm just a medical student."

"Time of death 18:21."

There would be no code, no crowd of people in the room, no blood staining the gown from STAT blood draws. Just myself, and my patient - a patient I had never even talked to. This was a different death than what I was used to. Some would say a good death. But the intimacy of the moment, especially considering it happened while I was performing the physical exam, struck me.

I page my neuro attending to tell him the news. He breaks the mood with some levity: "Well don't go see of the other patients now... I thought they were supposed to be healing hands!"

I looked down at those healing hands.

Onwards and Upwards

noreply@blogger.com (MedZag) — Tue, 05 Oct 2010 04:30:00 +0000

Jeesh, I've been really slacking on this blogging thing. Probably because my life has been incredibly uninteresting the past month slaving away in honor to the boards gods. So I successfully (I think) navigated the travails of Step 2 and its assorted clinical vignettes and fake patients. The second romp with the Step exam was not nearly as stressful or interesting as the first go. More a matter of knowing what you have to do, then going and doing it. And yes, Step 2 CS is as big of a joke as everyone makes it out to be.

This month is neurology, which has turned out to be a quite the neurocation. Which means I've replaced qbank and first aid with monday night football and hulu. I'm already starting to feel that 4th year senioritis sink in.

First residency interview invite finally trickled in today. The residents warned me that in ENT things happen late, so while my classmates have been racking in the interviews I've been obsessively checking MyERAS to see "Available, but not yet retrieved" over and over again. After a month of hearing only crickets, it's nice to finally start getting some movement. So it's back to twiddling my thumbs and hitting refresh on my cell phone email every 30 minutes.

Btw, blog crossed 50,000 visitors this week. Pretty freaking surreal if you ask me. Thanks to all who follow this site and pretend to enjoy the content. Never thought when I started this thing it would generate such attention. Y'all are great!

Retro

noreply@blogger.com (MedZag) — Wed, 08 Sep 2010 04:34:00 +0000

So this month has been a blast from the past. Like all fourth year medical students in our fine nation, I've been spending the past week buffing, fluffing, proofreading, and shining my residency application. It brought back many a "fond" memory of 2006 when I was going through a similar process applying to medical school. And just like before, I'm stuck in that weird limbo now where everything is submitted, there's nothing left to do, and now it's a matter of waiting, and waiting, and waiting. As someone whose past four years have been filled with things to plan, things to do, things to prepare for... it's a strange feeling.

"Fortunately" I have Step 2 to keep me busy this month, which involves plenty of QBank and First Aid. It brings back many a "fond" memory of 2009 and preparing for Step 1. Luckily, none of the same anxieties this time around. But I'm back to my favorite spot at my favorite Starbucks, highlighters in hand. God knows how I did this for two whole years.

Luckily, only another 10 days of this then I'll literally be out of things to do. Who knows what I'll do then, I sure don't.

Empathy, Tragedy, and Progress

noreply@blogger.com (MedZag) — Fri, 13 Aug 2010 04:31:00 +0000

She was 28 years old when she first noticed the spot on her tongue.

Red and bleeding, it resembled a pinpoint ulcer along the left lateral border. She went to her doctor, with understandable concern. And he reassured her it looked like a small aphthous ulcer. He told her if it did not get better, or got larger, to come back and see him.

Shortly after that, she became pregnant with her third child. And as anyone would in that situation would likely do, concerns of small aphthous ulcers were placed into the back of her mind as her and her husband went about planning the new addition to their family. Months went by, until one day in her third trimester, she was brushing her teeth and noticed blood on the toothbrush. She took a look at her tongue again, only this time to find a large hard mass in place of the small red spot from before.

What followed was more doctors visits, biopsies, referrals, and a diagnosis... squamous cell carcinoma of the left lateral tongue. She was told there would need to be surgery, but not for another few weeks until her baby was safely delivered.

The baby was safely delivered.

It was the morning of her operation when our paths first crossed. I introduced myself to her, and the entirety of her large, supportive family in the pre-op room. I made small talk, and she spoke in articulate words with a slight British accent. I asked if she had any questions, and she shook her head no.

Back in the operating room, it was business as usual. Help transfer the patient to the OR table. SCDs on. Bovie pad on. Extra blanket on. Warm air circulating. She succumbs to the general anesthetic. Intubation successful. Rotate table 180 degrees. I go out to scrub with the attending and resident, yellow iodine dripping down my forearms into the sink. Sterile towel. Sterile gown. Gloves. Spin. Prep the operative field.

We are finally ready to begin, and we finally get a good look at the tumor. It it large, extending from the lateral edge nearly to the tip. Fingers of white parasite extending deeper into the tissue.

Calmly, the operation commences. According to the pre-operative MRI, it looked like the tumor did not creep too deep. The hope was to get in, get clean margins, and close primarily, leaving her enough residual tissue that her speech and swallowing would be largely unaffected. The dissection proceeds around the mass, and finally the bovie tip penetrates out the opposite side. Frozen sections are sent off to pathology, and we breathe a sigh of relief for the moment. We sit and absorb ourselves in the BB King playing from the iPod. We have a discussion about how much we enjoy the blues.

The phone rings, pathology on the other end. "Frozen sections show margin passing through tumor." In the passing 3 hours, more tissue was taken, more sections were sent, more phones ring, and more swear words penetrate the soft, solemn blues of BB King wafting through the air. The partial glossectomy transforms itself into a hemoglossectomy, which creeps towards a near total glossectomy with each positive margin. Finally, margins are clear and we close, folding the thin strip of remaining tongue over onto itself and securing it with the appropriate number of half hitches.

I am reminded on my last question to her before the operation, when she simply shook her head and smiled. What brings me back to that moment is that for the next few days, her sole mode of communication involves those same left-right, upwards-downwards motions. Any pain? Shake no. Comfortable? Shake yes. Ok, more of the same today. Try to get out of the bed. She turns out to be quite lucky in some ways. Her swallowing was intact. And she will eventually speak again, though not without a heavy lisp and not until the burns of the radiation therapy subside and many months of speech therapy are completed.

There were two things that stuck out to me as particularly profound about this case, about this mother of three.

First occurred during those nauseating hours in the OR as frozen section after frozen section returned with tumor as we burrowed deeper into tongue tissue. With each subsequent resection, I could not shake the feeling of how horribly I felt for the patient, that we were slowly robbing her of her chance at a normal life. Part of that is good, I think. It means these past four years of medical school have not robbed me of those intimate emotions, of the ability to feel empathy for the person prepped and draped in front of me. But I was also struck by how calmly and confidently the attending surgeon, a man I greatly respect and admire, went back to work with each setback... steadfastly marching with tenacity towards negative margins. He knew the data, but more importantly he had lived the data in his many years of practice. He knew that if we did not get clear margins, this woman in front of us would be robbed of her chance to see her children grow old. So he could bury those emotions in order to do what is necessary. Me, I could not yet detach myself from those feelings of horror, because I was not yet convinced it was necessary. Quite bluntly, I have not seen enough people die to be convinced.

It reminded me how much time and space still yet separate myself, inquisitive pitiful fourth year medical student, from the title of surgeon. Because in that situation, I'm not sure I could have done what was necessary. That was humbling to realize.

The second profound moment came the next week in clinic when the attending, chief resident, and myself saw the name of a 32 year of woman on the schedule for follow-up. She too had developed a tongue cancer noticed after becoming pregnant. She too required an operation and radiation. We got to talking, and the chief resident remembered another young woman from her second year of residency who had a tongue squamous cell. We look at her chart and notice she was pregnant. "Interesting," the attending states, and we go to see our follow-up patient. Somehow the conversation turned to what we were discussing earlier, and the patient states she also knew another young woman in the south part of the state who had tongue squamous cell. The momentum of the conversation between the three of us accelerated throughout the day. By the end of clinic, we had assembled a list of 9 young pregnant women with tongue cancer who had been operated on in the past several years. Questions floated about to the tune of the scientific method. Why pregnancy? Why are we seeing more of these tumors? What's different about these tumors? Are there unique ways of approaching treating them?

And so a hypothesis was born. And a plan. There would be a study. IRB protocols and special stains and information databases and eventually a publication. And hopefully... progress. And I thought that all is not so horrible after all.

She's high maintenance.

noreply@blogger.com (MedZag) — Thu, 05 Aug 2010 03:08:00 +0000

There's a dangerous new mistress in my life that's been sucking up all my time I would have been writing on here, and her name is "ERAS". I know, sexy.

Anyways, promise more stuff is coming soon.

Sub-I... Check.

noreply@blogger.com (MedZag) — Fri, 09 Jul 2010 01:51:00 +0000

Man, time flies when you're having fun, I guess. My four weeks on my otolaryngology sub-i were over in a flash. I have to admit, I was a bit nervous coming into the rotation. I felt like I had a fair amount of exposure to the field of otolaryngology, but any time you're making a decision to enter a field when you haven't spent dedicated time rotating through the specialty, you have to wonder if you'll end up enjoying it as much as you think you will. Luckily, I found a great experience during my rotation that reaffirmed rather than undermined my decision.

That being said, talk about a crash course of an experience. Doing a sub-i in a field that is only peripherally covered by the third year rotations, I found myself having to read quite a bit every night just to stay on top of the topics I may see in the clinic or OR the next day. Luckily, I got to rotate through a different service each week, so I could focus each week on learning one specific aspect of the field, be it head & neck, rhinology, peds, or facial plastics. That being said, I felt like the rotation was much less about showing what I knew and much more about showing my willingness to learn. Definitely a different experience than some of my friends who were doing sub-i's in general surgery, internal medicine, etc where you're expected to have mastered basic principles as a third year and graduated on to more patient management.

That being said, being a sub-i kicks butt compared to being a third year. The attendings know you are entering their field, and are much more willing to tolerate your presence and teach. You're given more hands-on opportunities. You're seen more as part of the team and less as a stranger passing through for a few weeks. Good times abound.

Some highlights from the four weeks:
- First assisting an entire anterior lateral thigh free flap
- Getting to perform a trachesotomy on my own
- Pulling a popcorn kernel out of a 3 year old kiddo's ear
- Draining 350cc's of pus out of a patient's neck who has a post-op infection (I'm afraid to admit... I love I&D's)
- Becoming known as "the PEG man" on service, and being paged specifically to come put one in
- First assisting an entire rhinoplasty with rib cartilage harvest
- First time getting to use the microdebrider
- First time getting to play with the DaVinci robot
- First time getting to shoot the laser

But, all good things must come to an end. My sub-i wrapped up and now I'm off on an away rotation. Living in a different, large city with only a small furniture-less room and a twin sized bed to call home. But still otolaryngology, so I can't complain. Grin.

Reflections on Third Year

noreply@blogger.com (MedZag) — Sun, 13 Jun 2010 17:27:00 +0000

So third year ended 2 weeks ago for me, and I've yet to write about it. You think after an "accomplishment" such a surviving third year I'd be bursting with feeeeeelings about the matter. After all, I briefly delved into the realm of the introspective when I finished first year, and I got damn near teary-eyed after taking down Step 1. After third year, I don't know. I don't have that same sense of accomplishment, and the same sense of transitioning onto something new. Am I glad I no longer have to rotate through specialties I have no interest in showing faux-interest along the way? You betcha. But I didn't wake up the day after my OB/Gyn shelf feeling any older or wiser. I think part of that is because the transition to the next level of competency tends to come throughout third year rather than after it. Before my last shelf exam, I was thinking a lot about my first rotation on peds and the student I was then was very different from the student I am now. But that change was a slow process that had little to do with the MS label after my name. Basically, I can see the progress I made this year, but don't really feel like I "survived" anything. Maybe it's because I really enjoyed third year and the things that are historically dreaded about it weren't that big of a deal to me. Maybe it's because I'm going into a surgical field and I know my days of sleep deprivation, early mornings, and busy days are far from over. And you know what, I'm cool with that.

That being said, good riddance to the third year label. It'll be nice to not have people automatically assume you know nothing and can do nothing just because you're a third year medical student.

Anyways, it was a good week off, and now I'm on to the greener pastures of fourth year, the "best year of medical school."

Normalizing.

noreply@blogger.com (MedZag) — Sat, 08 May 2010 03:18:00 +0000

I had an interesting conversation with a friend in the military the other day about the things we do for work and how they become so mundane to us, that we lose sense of what's normal. As third year draws to a close and I look back at the experiences of the past 12 months, I realize how much I have seen and experienced that to many (or most) people would be vasovagal-inducing, nauseating, disturbing, masochistic, macabre, or just plain strange which has simply become... normal, to me. It is normal to be covered in blood or various other bodily fluids. It is normal for the workplace to smell of feces and urine. It is normal to work 15 hours a day. It is normal to stick your hand into various bodily orifices, natural or artificial. It is normal to disassemble the human body, intervene in a problem, then reassemble using silk, nylon, and stainless steel. It is normal to discuss bowel habits, suicidal thoughts, and sexual activity the first time you meet a person.

Back when I was in undergrad, I remember some of the jokes about certain medical specialties. Proctology. Who would want to deal with butts all day? Urology. Who would want to touch penises all day? Gynecology. Who would want to stare down vaginas all day? C'mon man, that's gross. Seriously, who would want to do that for a living? Especially a guy.

Well, after two weeks on OB/Gyn and numerous sterile speculum exams, the field has become... normalized. And really, once the pelvic exam stops being weird and starts being just one more physical exam you "do" to get information, you begin to see what's cool about the field. It's fast paced and busy, where things can go from reassuring to tenuous quickly. A good balance of medicine and surgery. Good outcomes for the patient in most circumstances, and a chance to significantly improve outcomes in cases where things are more dire. A sense of participating in an important moment in the patient's life.

But yes, all "that" stuff about OB/Gyn is now nothing unusual. So much so that when I do a pelvic exam now, all the anxieties I felt before about an exam that seemed so "gross" and inappropriate before just seems like another part of my job. My main concerns are more for the patient and how she may feel about a baby-faced male doctor-to-be performing an exam that is uncomfortable and in principle socially taboo. I am still very much in tune with that, and still struggle with balancing patient discomfort with my own education. But as far as it seeming gross, or unusual, those feelings are gone. I already find myself forgetting what it was like to know nothing about obstetrics. The 17 year old nulliparous patient who has no idea it is normal to defecate the bed during delivery. The couple who just welcomed their first child into the world who have a brief look of horror when the resident says she is now "using suture to reapproximate the vaginal wall." The 28 year old new mother who glances down in horror after we "remove" 300cc's of clot from her uterus post-partum. I forget how strange these things must seem.

During a c-section earlier in the week, the anesthesiology resident was comforting the patient during the procedure, talking her through the steps of the procedure. We had just finished closing the hysterotomy, and the resident says flatly "they just finished closing the uterus, you may feel some discomfort as they return the uterus to inside the body." I can imagine the patient's eyes growing wide, but all I hear over the drape is "WHAT!?!???" A large part of me cannot find fault in his faux pas, as these things seem routine to us. There is nothing strange about removing the uterus and placing it on the stomach to better sew the incision.

Just a few things that are now normal to me.

Ironically, 3 of the first 8 image results for the keyword "normal" in google images are of genitalia.

Livin' in a woman's world.

noreply@blogger.com (MedZag) — Mon, 03 May 2010 01:47:00 +0000

So I'm a week into OB/Gyn, which has traditionally been labeled as the estrogen-charged girls club of the third year rotations. I've heard some horror stories from a few members of my class of the male gender, so I had a few trepidations heading into the rotation.

I was standing in the workroom doing board rounds last week when the conversation of the room turned to hair straighteners. Believe me when I tell you I now know more about hair straighteners than I ever cared to know. My intern turned to me and mouths "sor-ry", and someone makes a comment about how I was the only guy in a room of 9 women. The funny thing is, I didn't even bat an eye at the entire situation. Hell, I didn't even notice the female predominance of the room until someone pointed it out. It seems like I've been working on female dominated teams more of the year, so I decided to do a formal count.

And of the 40 residents and attendings I've worked under this year... 33 have been women.

Maybe this has conferred some inherent advantage on this rotation, because things have gone swimmingly well so far. After all, we're all just living in a woman's world.

4 weeks left in third year.

Character approved.

noreply@blogger.com (MedZag) — Fri, 09 Apr 2010 05:20:00 +0000

So one of the fun things of this rural rotation is that I get to know a lot of the docs in the hospital, just by virtue of its small size (40 beds). I've been scrubbing a couple cases with "the" general surgeon on staff who's a real character. Pushing 70 years old, 5 ft and change, originally from Brooklyn. Which means he's a little ADD, a little senile, lacks any sort of social filter, and is a helluva surgeon. Kinda like Tommy DeVito from Goodfellas, except Jewish, and minus the mean streak.

Example of an exchange we had:

"So its my 40th wedding anniversary this weekend"
"Congratulations! That's quite the accomplishment! Any big plans?"
"Well, it's actually our 39th. But I'm telling the wife its the 40th so I can take her to Switzerland at the end of the month. That way we get to do it twice. The broad doesn't have a fuckin' clue how long its been, but god do I love 'er."
"Haha, that's brilliant."

Anyways, earlier this week I scrubbed on a "soft tissue mass excision", which was basically excising an abscess. The thing had been I&D'd a couple times and always recurred, and since it sat squarely in the patient's perineum (3 cm or so lateral to the anal triangle, almost right over his ischial tuberosity... yeowch), it was a painful sucker.

So we're about to start the case and Dr. DeVito turns to me and says "I was gonna let you cut, but I'm gonna try to get this sucker out without piercing the abscess. Y'know, keep the pus out of the wound and we might be able to close him up and save him a lot of trouble." We get the site draped, eyeball/palpate the abscess, and draw a nice clear margin on the skin. I'm ready with suction in hand, Dr. DeVito makes the first cut, and... almost immediately pus pours out of the incision all over the surgical site, sprung free from a pocket of the abscess that was tracking laterally under the skin.

"Well, shit. Might as well let you take over."

He turns, hands me the 10 blade, and grins.

"The Look."

noreply@blogger.com (MedZag) — Sun, 28 Mar 2010 18:23:00 +0000

As part of our internal medicine rotation, we were required to spend 5 weeks at a hospital out in the community. The hospital I was sent to was a fairly large medical center with close to 500 licensed beds, and part of my hospital was a large tower of a structure dedicated as the "cancer center". The problem with the cancer center is that it was built as an addition to the hospital, which meant to get access to the beds within the tower, you had to go up to the 3rd floor of the regular hospital, through this back hallway attached to the corner stairwell, go through a tiny side door, which brought you to a back elevator shaft. You then went up the curiously slow elevator, through a set of double doors, then up another set of stairs, just to get to the beds in the tower. As a result, the tower had been nicknamed the "Death Star", because every time a code or rapid response was called in the tower it took several minutes to respond simply by virtue of its reclusive location. While rotating at the site, I worked with a senior resident who took the code pager very, very seriously. Whether it was a code blue or a rapid response, we. were. running.

One day on short call, we had an afternoon where the code pager would not shut up. As a result, we were running all over the hospital to various locations within the hospital, always at an aggressive jog with my 30 pound white coat flapping around me and sweat beading on my forehead. All the codes that morning ended up being fairly well controlled situations... a patient in the post-op area of the day surgery who got too much narcotic, a code blue called on a patient already in the cath lab, a patient who had an an RRT called simply because the attending wanted a stat ECG. We had just finished up our 5th code of the morning when the code pager started blaring again, this time for a patient in the Death Star. "Crap." my senior muttered, and off we took, up to corner stairwell, down the back hallway, through the tiny side door, to the elevator. Wait for it. Wait for it. Wait for it. Up the elevator. Through the double doors. Up the stairwell. Down another hallway.

When we arrived the scene was fairly chaotic. An elderly woman was sitting tensely up in bed. Nursing staff was trying, quite unsuccessfully, to get an ABG, and blood was spotted all over her arm and hospital gown. The ECG showed new-onset a-fib and the patient was satting 70% on 12 liters of oxygen through a rebreather mask. But what struck me most profoundly was the look on the poor woman's face. She had what we called "the look": sitting rigidly upright, arms locked with hands grasping onto her sheets, desperately trying to breath with eyes wide and an expression of impending doom on her face.

There's only a few things that give someone "the look," and in an elderly bed-ridden hospital patient, we knew even before the labs came back that she had thrown a clot to her lungs. She was wheeled down the hallway, down the elevator, through the lobby, up another set of elevators, and into the ICU. Luckily, she did quite well and survived her PE with only a scare. The Death Star had been defeated that day. But I'll forever be imprinted with that look she had the moment we walked through the door. It's one of those indelible moments that are sprinkled throughout the third year of medical school - when what you learn in textbooks manifests itself in a living, breathing human being tenuously placed in front of you.

The unrelenting March of time.

noreply@blogger.com (MedZag) — Tue, 23 Mar 2010 04:37:00 +0000

Apologies for the lack of posts recently. Spent the last weeks of my internal med rotation scrambling to study for the shelf exam, which definitely lived up to it's billing as a ridiculous exam. That was followed by a week of continuity curriculum, with The Greatest Day of the Year thrown in mid-week (and copious consumption of Guinness in celebration). Followed by The Greatest Weekend of the Year (aka March Madness). Little time for frivolous things like blogging, you know.

Anyways, just started on my rural medicine clerkship. I'm nestled in a small coastal town, living in a small loft apartment without television. Should be interesting. I'll keep the updates coming more frequently. Got some good stories from the end of medicine, including a couple dramatic codes and my first intubation! Stay tuned.