I Matched! I Have A Job! Someone Will Pay Me Real Money!

Unfortunately I can’t outright tell you the specialty (sorry, everyone who’s asked!), because it’s just so small: there are only double-digit numbers of us, and I haven’t yet decided just how reckless I want to be with my internet pseudonymity.

But I can tell you that so far the Frequently Asked Questions include “Wait, that’s a specialty?”, “You can DO that?”, and “Isn’t that a fellowship? How did you match straight into a fellowship?” - so, you know, that’s fun. (Anyone super emotionally invested in my story can probably detective it out from there, but if you’re that invested, you deserve it.)

But – right, the important thing! I matched at my #2 program. And yes, as nice as it would have been to say “I matched at my #1 program”, the program I did match into has a much, much more recognizable / prestigious name – so, somewhat bizarrely, I think I’ve gotten way more sincere congratulations and impressed reactions from my friends than I would’ve the other way around.

(There is a tiny, possibly evil, part of me that enjoys that. It all works out, I guess.)

But – real talk: I’m going to miss med school. If you’re still a student, I have only one piece of advice for you:

Enjoy every irritating, terrifying, face-palmingly-stupid minute. 

God knows, I did.

Residency Interview Season 2013

The First Week After Submitting

staredown impatient

i expect nothing and i'm still let down

Getting That First Interview Invite

HELL YEAH

they broke up 2

uh-huh uh-huh uh-huh

… And That Program Earns A Special Place In Your Heart Forever.

kiss the screen

Especially Since No Other Program Seems To Like You

single mascara tear

… Until One Day…

chris rock holy crap you're dumb reaction gif

 When You Get 17 Interview Offers….

wait - what

… In 3 Hours.

oh god oh god oh god

i'm dead now gotta go

And You Try To Fit All Their Restrictive Interview Date “Choices” Into Your Calendar

excited typing

i got nothing

this is a nightmare

… But Mathematically, It Doesn’t Work.

that is not going to happen

QUICK: DECIDE YOUR LIFE PATH WITHOUT VISITING ANY OF THESE PLACES

yelling into pillow aaaaaaagh

And Now You Have To Write Horribly Complicated Emails Declining Those Precious Interviews

first of all i feel like an asshole

i am not good at saying no okay

And You Still Aren’t Guaranteed To Match

Kristen-Bell-Laughing-to-Crying

… Welcome To ERAS 2013-2014.

just slow clap it out

A Conversation With The New M1s (My People Skills Are Rusty)

M1s: Oh, child neurology? Cool! I heard in child neurology you just play with kids. True?

Me: Sort of, yeah! I mean, young kids don’t exactly follow commands, so to some extent you’re just watching them play and trying to elicit reactions from them with pen lights and toys.

M1s: Cool. But… child neuro is really sad, right? I mean, so many deaths.

Me: Sure. But their deaths are nowhere near as sad as those of the adults. Like, Internal Medicine. So sad.

M1s: … wait, how is Internal Medicine sad?

bambi

Me: Well… every day, you deal with people who have wasted their whole life without doing anything they set out to do. And now it’s too late. And that dawning realization, seeing them realize they’re at the end of their life and it was all futile – it’ll haunt you.

And when you’re not with them, you’re with patients who you know will die the same way, with the same regrets – except, they won’t follow your warnings, so there’s nothing you can do to stop them. You’re powerless against their naive optimism that they won’t die of a stroke, they won’t die of a heart attack, they won’t leave their family alone.

But they will.

As will you.

See – every day you are confronted with existential terror that overwhelms you until you can no longer comfortably ignore its hopelessness. It’s no longer in the periphery of your vision – it’s the focal spot. So, despite the occasional pinprick of brightnesss and good outcomes, the overbearing futility of living becomes like a dark black cancer on your soul that grows and grows until you no longer feel anything – just numbness.

Even the patients who thought they had meaningful lives – you will watch their memory fade as they become present less and less until there is nothing. And you will realize the futility of life: a truth you will never again escape.

M1s: …..

bad3

Me: Welp! Good luck on the first anatomy test! I recommend the practice questions – they’re great! See you later byyeeee.

bein cute

M1s: …..

we're taking a moment and we're done

Applying For Residency: In GIFs

Students Applying to Surgery

i will take what is mine with fire and blood

Students Applying to Medicine

little bit intimidating but i'm sure we'll live

Students Applying to Family Medicine

popcorn

Writing Your Personal Statement: Draft #1

it's so weird being my own role model

Writing Your Personal Statement: Draft #2

can we just take a moment to celebrate me

Writing Your Personal Statement: Draft #3

my place is here

Reminding Your LOR Writers That They Have Two Weeks no big deal it’s only my entire career on the line Oh God Please Write It Soon

staredown impatient

why what is taking so long

 

Finalizing Your ERAS Application

signing your life away

Posts I Have Started Writing But Ultimately Abandoned (for One Reason or Another)

Post Idea #1Advice for New M3s, via Quotes:

This one sort of worked. Easy and topical!  I’d argue that you can learn a lot about how to function on the wards from people like Anton Chekov (“Any idiot can face a crisis – it’s the day-to-day living that gets you down”), Will Rogers (“Never miss a good opportunity to shut up”), and Ron Swanson.

But I didn’t post it because after a 3 month absence, something this trite seemed like a weird re-entrance to blogging (“Okay.. an entry composed of nothing but quotes. So.. you’re not dead?”) – so instead I’ve just been letting it languish in my Drafts folder until I find something better to post first.

Ron Swanson.

Probably should’ve taken Ron Swanson’s advice on that myself.

Post Idea #2: Hey Guys, I’m Back!

I didn’t actually write it, but I thought about it.

And then I remembered that “Hey! I’m back! I’m SO sorry for the hiatus – been super busy!” posts always seem to be 1) boring as hell, 2) the death knell of blogging (once you see one apology post, you can bet good money it’ll be immediately followed by another, even longer absence) and 3) really self-involved. Even by blogging standards.

what do you want a medal

So I didn’t post this one because it’s a terrible idea. (Though I’m clearly writing a goofy, “self-aware”, meta version of it instead! Which is probably worse! Oh well.)

Post Idea #3: Links to fascinating articles about medical education.

This month I’ve been finishing up a lit review for a research project, and since the next step after “literature review” is “actually just submit the damned IRB protocol already” – I’ve… spent some extra time on that lit review.

Seriously, I’ve become completely obsessed with journals like Academic Medicine (the journal of the AAMC, where you can find out a lot of unexpected things about USMLE grading), Medical Education, and just generally link-diving into the PubMed abyss.

staging data

Theatrical data analysis in health policy: IT’S A THING.

In related news, I’m… very easily side-tracked.

I didn’t post this one because all the cool articles I’d want to link are behind equally uncool paywalls. And while I could say some snarky things about a couple of very poorly done studies, at least they actually finished theirs instead of just being stuck on the IRB proposal itself for an entire month. Glass houses, thrown stones, etc.

Post Idea #4: Step 2 CS Is The Dumbest Exam On Earth. So! Besides “research”, the other thing I’ve done this month is the CS exam – which isn’t news. Neither is the fact that the exam is widely considered to be worthless,

i don't like it no one likes it

Pictured: The medical community’s diverse spectrum of opinion on Step 2 CS.

But the point I kept trying to make while writing this was that it is beyond absurd for a Clinical Skills exam to not actually test Clinical Skills.  It is about whether you can go through the motions while speaking English and not alienating your patients.

… and also that any journalist could easily write an article exposing the US public’s misconception that their physicians are – at any point in their training – ever tested for their ability to actually notice findings during a physical exam.

Think about that for a second. The one thing a doctor is most trusted to do, and it’s never tested. People just assume that an “everything looks/sounds good!” after their yearly physical means something besides “well, you have no chief complaint and I went through the motions, so you’re set!” because, hey, doctors have to pass tests, right? And one of them must be on doctor skills, right?

Wrong. Sure, after all that clinical experience, your doctor can probably be trusted to notice a murmur. But isn’t it interesting that American doctors are tested on their ability to understand the phrase “abdominal bruit” or “cotton-wool spots bilaterally” – but never actually tested on their ability to actually recognize either one?

i mean is that too much to ask

Personally, I have some mild hearing loss (otosclerosis) and have always been a little self-conscious about the professional implications. So I use an amplified stethoscope and have like to think I’ve actually gotten pretty darned good at discerning soft murmurs – but, still: isn’t it sort of an uncomfortable truth that no one’s ever tested me on it? That no one ever will?

That Step 2 CS wouldn’t let me use my electronic stethoscope – but it was totally okay because there weren’t any murmurs to find anyway?

stethoscope on cs

Since the NBME already went to all the trouble of setting up the national Clinical Skills Centers – and several European countries appear to have already figured out the logistics of netting Standardized Patients with real diseases and physical findings – why not just go the extra step? Actually test clinical skills?

Or at least give me back my $1,500.

I didn’t publish this one because it sounded really defensive, almost angry. Besides, it was both way too long and somehow still over-simplified.  It’s probably a better topic for a book than a blog post.

i got nothing

Post Idea #5: Just posting bits from all the entries I started and why I ultimately decided against them. This one’s been languishing in my ‘drafts’ folder for the last week because it’s incredibly long – too long. I bet you just skimmed the last 5 paragraphs. (A safe bet, since that’s what I did while trying to edit it.)

I actually DID finally post this one because a commenter on the last post (Hi, Barney!) asked whether I had changed careers. Which… is both a reasonable assumption (given how depressing that last entry was), and a good indication I should suck it up and just hit “publish” on something.

So – here I am! Still alive, definitely still in medicine, definitely still over-thinking things as simple as “is this really worth posting?” – but here, all the same.

 

12 Things I’ve Learned On Pediatric Radiology

1.  Stupid Thymus Ruins Everything. At least, it ruins everything that I already knew about adult x-rays – which was already largely limited to “where’s the air”, “can I use the word ‘hazy’ to describe this”, and “no evidence of cardiomegaly”

But NOT WITH KIDS. With kids, I’ve learned the correct answer to even simple stuff like “is that cardiomegaly?” is No. No, it’s not. It’s probably just a dumb thymus.  (Except for the cases where it totally IS cardiomegaly, in which case it will look exactly the same.)

Goddamn it, thymus, MOVE. You are in a highly inconvenient location.

2.  When In Doubt, The Answer is “Moderate”. Lymphadenopathy in the pelvis? Sure, I see it – it’s ‘moderate’. Quality of the fibrosis in the portal tract? Moderate. Suspiciousness of that periosteal lesion? MODERATE.

i tried and therefore no one should criticize me

(I mean, not really-  if they’re bothering to ask you, that means the most correct answer is either “very subtle” or “OH MY GOD” – but better to err on the side of “lacks experience” than “is not able to discern basic anatomical structures”.)

3.  Radiologists are geniuses. Every time I start feeling confident about my pattern recognition or image-reading skills (“I could totally sit in a cushy chair and read images all day! This is the best!”), I end up in one of their oral boards review sessions watching them all get grilled on isotopes, ochem diagrams, and physics.

I bet I would’ve loved radiology if I were born 50 years ago when everything was just plain films. Or if I had gone to medical school straight out of high school, before taking so many college pre-reqs.  But I didn’t, so now I’m old and cynical and my general attitude about studying “converging collimeters” in radionucleide scans is stuck somewhere between “THOSE WORDS AREN’T REAL” and “YOU CAN’T MAKE ME.”

4.  Sitting in the dark all day is dangerously relaxing.  My Red Bull consumption is nearing an all-time high, which is sort of disconcerting, since this rotation is basically 5 hours a day, 5 days a week. (I’ve lost my edge! I’ve gone soft.)

5.  Reading a radiograph: The “helpfully point out structures” approach that worked so damned well with the attendings last year does not, somehow, impress the radiologists. (“And what do you think of the vasculature?” “Well, that right there is the IVC. And, uh… it is.. not enlarged. So… it is looking good. … or possibly not good? … Hey, look – it’s patent!”)

yes thank you for your input

6-12.  Fact dump: The newborn liver should always be less lucent than the heart – free air would make it brighter. Ovarian torsion is super difficult to rule in or out with imaging alone. Current wisdom is that “shaken” baby syndrome actually involves impact. The bone equivalent of “hazy” (in the lungs) is “broad transitional zone” and it signifies diffuse disease characteristic of malignancy.

Bone ages are fun to determine, but many radiologists believe the “11 year old” and “12 year old” male standards should be switched, the standard deviations are broad and not, in fact, actually standardized, and it’s all based on cohort data from like 50 years ago.

If the neonate’s ossification centers are visible, it was likely a full-term child, because those come in at 42 +/- 2 weeks. Germinal matrix hemorrhage is echogenicity seen anterior to the caudothalamic groove on ultrasound, as opposed to the echogenic choroid plexus posteriorly.

… best rotation ever.

5 Things I’ve Learned On Primary Care

Actually, I’ve already done primary care. There’s a complicated explanation behind why this extra month exists in Metropolis-world, but to simplify it for blogging:

You know how all of Daylight Savings Time’s well-thought-out reasons for existing were ultimately overshadowed by the awkwardness of creating an extra hour?

Well, picture that, but with an extra month.

Personally, I don’t mind. Primary care is fun, and doing an extra few weeks just means I don’t have to study. It’s the perfect post-Step 1 / first 4th year rotation.

Sure is a tough life.

Sure is a tough life. Somehow, I’m powering through the burn.

1.  When our med school lecturers joked that “50% of what we teach you today will turn out to be wrong”, I should not have laughed. I always assumed that aphorism was meant more  “over the course of a career” than “over the course itself” – which makes the joke less “funny” and more “immediately alarming”.

(Seriously, forget about niacin for cardiovascular end-point improvement, statins for primary prevention in women, and beta blockers for isolated hypertension in anyone. Lies, damned lies, and statistics.)

2. Insurance companies DO care – about electrolytes. The health of my patients has truly never been as prioritized and cared about as it is during the 10 minutes immediately after attempting to order a calcium level.

phone 2

Yes, THANK THE DEAR LORD you insurance companies have risen up to protect us against the abominable scourge of lab-draws for patients with generalized bone pain; thus forcing us to go straight to the much more fiscally-responsible full-body bone scan.

WELL DONE, YOU. Slow claps all around.

getting off the phone idiot

(Yes, I did read the Time article. And all the immediately preceding identical articles that, for whatever reason, never blew up the same way despite containing the exact same information. Seriously, healthcare spending has been a mess for far longer than Time Magazine has been in existence, and while the attempts at fixing it have changed, the underlying reasons have 1) not, and 2) never really centered on ionized calcium, to the best of my knowledge.)

3. How to present a healthy patient, with no complaints, with an unremarkable annual physical.

there is no news

“So… in conclusion, my plan is to shake their hand and wish them a good year.”

4.  Career-wise, I am a cheap date.  My preceptor gave me my own office for the month. It has a phone line! And a desk! And a window!

And that was the moment I knew I was going into primary care.

(I’m kidding. Still, it’s amazing the difference a desk can make: call me power mad, but the last time I had my own office I was 8, and it was a re-purposed Fisher-Price box.)

5. Fine, Geriatrics really DOES deserve to be a specialty. I’ll admit it – I was never convinced the Science of Old People ran much deeper than “\dose adjustment” and “avoid the hell out of anticholinergics”.

“This specialty’s inability to take itself seriously is reflected in its inability to find a title that it’s comfortable with. ‘Geriatrics’ was discarded because many practitioners resented being a ‘geriatric consultant’. ‘Gerontology’ was toyed with, as it made their discipline sound much more scientific. However, this was dismissed as inappropriate for exactly that reason.”

- John Larkin, Cynical Acumen

But I’ll give this to them: pain control in the elderly is a nightmare.  NSAIDs are right off the table, opiates and trazodone are great recipes for broken hips and delirium, gabapentin isn’t exactly the drug of choice for arthritic pain, and it’s hard to muster up the untempered enthusiasm to encourage daily acetaminophen use.

USMLE Step 1: The End

It was hard.

I mean, I knew that already – but I wasn’t 100% sure until I became formally acquainted with the “5-minute warning” pop-up.  (Oh, we spent some quality time together that day, “5-minute warning” and I.)

But the time pressure felt bizarrely reassuring, because I knew – having gathered some solid evidence from taking all 7 NBMEs in the preceding 7 days – the easier I find a test, the more patently obvious it is I’m missing something.

(And by “something”, I mean, “roughly twenty questions more than usual”. Dumb, sleep-deprived, face-palming mistakes on the order of repeatedly trying to swipe your driver’s license at the check-out till).

In fact, the only two practice NBMEs I was just SURE I had nailed were, ultimately, my two lowest scores (by a downright embarrassing margin). And the only two that had me reduced to tears, seconds away from dialing the Office of Student Affairs to sound the Official “Help, I’m A Risk to Our Pass Rate” Alarm? Those two scores were twenty points higher than the rest.

So, right – test was clearly hard, so I felt good. I went back to my hotel room, wikipedia’ed all the questions I was unsure about (common sense be damned, I was curious as hell), marathon-ed half a season of House of Cards, and moved on.

it's gone it's done

But now its one week later, and while I haven’t thought much about the test, I no longer feel “fantastic” about it: After a week of feeling cheerful, my mental pendulum has slowly swung to the opposite conclusion: “if you felt so good about the test, you definitely bombed it”.

It’s a dumb paradox, but there it is: I wouldn’t be surprised if I got >240, so I wouldn’t be surprised if I got < 220

The truth is, whether I bombed it or not, my score will be 10 points higher than I deserve. I lucked out with my test. It played to my strengths: very, very minimal biochem (4-5 questions total), tons of genetics and neuroanatomy (my two best subjects by far), what appeared to be the entirety of the OB/GYN shelf (?), and even a couple of questions that I could’ve sworn were on Step 2.

So as much as I love complaining about the NBME – if my score sucks, it’s on me. I couldn’t have asked for a better test, and that fact makes the waiting bearable.

(Meanwhile, I started my Family Medicine rotation. So far, Family Medicine seems to be 50% constant awesomeness, 40% riding a bus, and 10% getting up at 4:50am to catch it. The 4:50 am part is pretty inflexible, so I’ll call it quits on this entry for now. Thanks again for all the well wishes!)

USMLE Week 5: Eh, Good Enough.

So after that mini-mental-breakdown of a practice test, I regrouped.  I montage-ed.  I set out to target my lowest-scoring subjects, grudgingly relearned them from scratch, ultimately spent more time alone in my room listening to morose music than I did during my last major break-up, and then proceeded to score, on two separate tests, just flat-out ridiculously higher.

… which – thanks in part to my newly-acquired Biostats knowledge (see: “lowest-scoring subjects” above) – I now know says more about just how poorly designed this test truly is than it does about how talented I may or may not be at short-term memorization.

(Okay, calling the USMLE “poorly designed” might sound a little harsh and high-minded – but when the NBME is purposefully distancing themselves from the notion that it’s an “achievement” test - in other words, that the exact scores mean anything – preferring instead to categorize it as “minimum competence”, and then still steadfastly reporting 3 significant figures?  At the steep end?  All while knowing that they’re handing out these career-determining judgements to the most self-absorbed, breakdown-prone students in the world?

… if that’s not poorly-designed, it’s at the very least disturbingly cold-hearted.)

And while I’m relieved as hell about scoring better, the relief is transient and the tiredness is a slow burn.  I’m forgetting more and more while caring less and less.

The result of adding this kind of burn-out to the general theme of my Step 1 study plan (which, FYI, would be most appropriately titled “Ways In Which I Helpfully Verified Common Wisdom By Ignoring It Entirely” - subtitle, “Somehow, It Went Poorly”) is a schedule for the last three days that looks something like “do stuff, but not too much or too little”.

I guess I will probably go through my flashcards again.  Or my notes?  Or re-listen to the recording I made of me reading First Aid.  Or learn to juggle.

I DON’T KNOW.  THERE ARE OPTIONS.  It’ll work out – and someday, as a commenter recently reminded me, there will be happiness again.  (Seriously, thanks for reading/tolerating self-absorbed posts like this, you guys.  Thursday can’t come soon enough.)

Meanwhile, Here Are Some Awesome Step 1 Resources Buried Deep In The Depths of The Internet: 

USMLE Week 4: A Light Update


day4
day3

nbme

… So that happened.

For my more visually-challenged readers, that disturbing sound you just heard was the sound of an NBME practice test exploding me into tiny bits of sub-par, clearly less-than-average, horrifyingly-close-to-my-pre-studying score self.

IT’S LIKE THE NBME DOESN’T EVEN CARE THAT UWORLD THINKS I’M SMART.

IT’S ALMOST LIKE THEY’RE RUN BY TWO SEPARATE COMPANIES OR SOMETHING.

hitting door frustration

(Yeah, I know statistical variation is a thing.. but I’m not willing to attribute a difference of almost 40 points to it.)

Luckily, even though I’m studying in the middle of Abandoned Rural America, I had a friend who was willing to listen to my hysterical panic attack and help point me towards a rational plan for the next few days.

So instead of following my regularly-scheduled Gut Instinct of Crazy (crying, staying awake for 120 hours straight, emailing the dean, and then pushing back my test date) I will instead follow her advice and spend the next few days addressing specific areas of weakness in a logical order.

Like a smart person would.

you have failed me brain

All of this to say: This blog will be taking a minor “crisis-mode” break until the 21st.