I admitted 10 patients last night

Back in med school, I wondered how the interns wrote so many notes so quickly. It took me hours to do a good H&P, and in the process of writing it I would always remember something I forgot to ask or elicit.

Luckily, I’m now an intern, so I know the secret to writing lots of notes quickly:

Intern notes suck.

Even the best notes are only technically ‘good’ because we spent a couple extra minutes synthesizing the assessment and plan. Because, hey – the bright side to notes that suck is that nobody’s going to read a 3 paragraph HPI or a 4 paragraph history of someone’s back pain, and everyone’s just skimming your ROS and examination anyway, so what the hell, it’s okay that your family history consisted of two words.

(I used to bold the pertinent positives and negatives of the ROS and exam, but then one of my preceptors told me to knock it off because she likes to use bold for her own addendum. Which, okay, fine – I guess this way, at least no one will notice I didn’t check for cervical adenopathy in the kid with mono.)

The downside to notes that suck is that your original note will be repeatedly quoted in every consultant and social worker’s HPI, word-for-sucky-word.

I really can’t get over the fact that people actually read my notes now. (Or at least, copy and paste them). After 4 years of medical school, having a consultant specifically reference aspects of my HPI or assessment feels… wrong. And guilt-inducing.

Don’t you want to do your own assessment? Are you sure you want to rely on mine? I wrote this H&P in-between a rapid response, 3 “urgent” pages, the surgical fellow tapping his foot impatiently at the door, and sign-out.

But anyway, there you go: It used to take me 4 hours to write my weekly H&P, which would inevitably get ripped apart by the preceptor for not including tactile fremitus, CVA tenderness, a gait exam, and fifty additional ROS questions. This H&P would never, ever be read, because I was an M2.

Now I can write 10 H&Ps in a night, all of which will be quoted extensively by consultants who are relieved they don’t have to take the history themselves!

Something, something… patient safety.

Post-Match Paperwork: The 7 Stages of Grief

1. Denial. “WHOO! I MATCHED – I’M DONE!” 

The charming belief that because your CV, LORs, proof-of-identity, proof-of-USMLE scores, and photo were all uploaded into ERAS, your hospital employment will not make you find / beg for copies in order to upload them for its own pre-employment files.

Lasts up to 1 month.

2. Anger. “But they already HAVE all this stuff. It was all in ERAS.”

Yes, your residency program has your USMLE scores – but the hospital itself requires an official copy! Let’s hope you saved each individual score report, because the NBME ain’t Santa Claus – they want $75 per each “official transcript”.

Lasts up to ‘lingering resentment for the rest of your professional life’.

3. Bargaining. “Whatever, they won’t read it.”

They already hired you, didn’t they? The contract is signed. So you can probably get away with uploading screenshots for your USMLE scores, the draft of your Dean’s letter as a LOR, and your 3-years-out-of-date CV. There, you’ve helped your hospital check off some stupid boxes. Moving on.

4. Depression. “$300 to apply for a State Board of Medicine Training License? First and last month’s rent? No paycheck until July 31st?“

HAHAHAHAHA.

5. Acceptance. “Okay, private loans exist.”

Lasts until you discover that US law requires a 30-day “cooling off period” once you apply for one of these loans (to give you time to reconsider), so you aren’t getting your monopoly money anytime soon.

But hey – that’s okay, because you still have 3 weeks after you get your loan from when you need to move! Plenty of time to pack, buy a car, search for apartments, and – wait, hold on, check the calendar – oh god…

6. Graduation

… is poorly timed. You’ll have to stay in your current city so your proud relatives have somewhere to crash before they watch you walk across a crowded stage.

(Hope you remembered to order your comically colored robe and floppy hat! $800 to buy. You did remember to order them, right…?)

Okay, now you have 1 week to get your life in order before you need to move.

7. Magic.

[Presumably. I am not sure exactly what happens here but I am confident it involves a good story.]

Residency Interview Season 2013

The First Week After Submitting

Getting That First Interview Invite

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

Especially Since No Other Program Seems To Like You

… Until One Day…

 When You Get 17 Interview Offers….

… In 3 Hours.

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

… But Mathematically, It Doesn’t Work.

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

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

And You Still Aren’t Guaranteed To Match

… Welcome To ERAS 2013-2014.

USMLE Week 3 Update: WHY AM I HORRIBLE.

I’m at that terrifying point in the sigmoid curve where I should still be getting easy returns. Unfortunately, UWorld is refusing to score me higher than 68% on any given block – and to make it worse, it’s always clear uWorld was not only correct but also being relatively nice about it.

When I read an answer I missed I’m like “oh shit, they shouldn’t have even let me into med school – that was obvious and I am terrible, I will take this embarrassing secret with me to the grave“.  But then when I read an answer I got right I’m like “oh and look at me not even knowing why half the wrong answers were wrong WHY DON’T I JUST MOVE TO ALBERTA AND BECOME A MOOSE GODDAMNIT”  – so even though I feel so close to that goddamned 70% average I can taste it, it’s all beginning to feel a little dire and claustrophobic.

The fun, light-hearted comedy of my study month which was supposed to star a young Natalie Portman Discovering Her True Potential Despite Being Beset By Wacky-Yet-Understandable Hijinks has slowly morphed into more of a black-and-white, subtitled feature about Pensive Looks and Slow Motion Espresso Pours headlined by a down-on-his-luck, alcoholic Kevin Bacon and directed by Woody Allen for some reason.

Guys.  Down-on-his-luck, subtitled Kevin Bacon is not going to get a good Step 1 score. Zany-yet-hopeful Natalie Portman was totally going to overcome those wacky hijinks and blow Step 1 out of the park, but somehow my life is no longer the musical comedy it was when I took the MCAT.  It is now gross and unrelenting in its awfulness.  It could even be nominated for an Oscar despite widespread critical distaste – just because it’s THAT DEPRESSING –that’s how bad the cinemized version of my Step 1 studying has become.

I have 2.5 weeks left.  It is now or never. I can either continue holding true to the “First Aid + UWorld = guaranteed 230 minimum” mantra touted across SDN and every 240+ test-taker of the past decade, or I can square my shoulders, say “screw you,” shake my fist at the sky, and try something radically different because I am applying to pediatrics, goddamn it, and in exchange for no glory or disgustingly excessive paychecks whatsoever for the rest of my professional life, I will bravely risk claiming my rightful (gasp!) average score.

Hopefully it doesn’t come to that, though.  Hopefully this story will end with the kind of moral you’d feel comfortable instilling in your bright-eyed, bushy-tailed pre-med friends: “See? If you just try hard and stay flexible, you too can go from being a marginally amusing, 2nd-tier med blogger to a genuine holder of a 230+ score!”

Anyway, I’m beginning a new, revolutionary plan.  A plan so revolutionary you will have second thoughts – regardless of the outcome – of so much as mentioning its very name in front of bright-eyed pre-meds, because you know in your heart that 1) they should not follow it and 2) it is just a terrible name.

It’s called – quite eloquently, I think –  The 3 week “Screw All Of You, I Hate The World So I’m Going To Study What I Wish I’d Learned Better The First Time Around” Plan.

Instead of more UWorld questions and more First Aid passes, I’m going to watch the Kaplan pharm and path videos, take notes, carefully speed through pathoma, make sure I know fetal anatomy & physiology like the back of my hand, and memorize the genetic disorders in a way where I understand them somewhat logically.

I’ll make sure I keep what I know of immuno and micro well-memorized, but I’ll probably have to watch the Kaplan videos for those as well, because let’s not kid ourselves – without cytoarchitecture, I don’t know a Kuppfer cell from a damned histiocyte.

Everything else, the rest of my stubbornly-still-not-230 knowledge base, can just STAY WHERE IT IS FOR ALL I CARE.  I’M NOT TALKING TO YOU. LALALALALALA, biochem.

To review:  UWorld + FA is not working for me because I am either a) an idiot or b) doing it wrong.  This merits a brand new plan, and it is as nonsensical and all-over-the-place as UWorld + FA is sensible and complete.

Luckily, if nothing changes, I do seem to be well on track for a solidly 220ish number, so I think it’s worth the risk to try to redeem these study hours on a Hail Mary pass towards the 230s.

Action Potential, out.

How to Be Phoneless

1.  Lose your phone.  This is undoubtedly the best part of the process, so I advise you enjoy it.

2.  Berate yourself over it for at least 2 weeks.  After all, the last time you lost a phone, it was a brick-sized Nokia, and your mom found it under the seat of her minivan 20 minutes later.  This “smartphone” shit is decidedly more damaging to your finances – especially since your finances can’t even be called “finances” with a straight face until the Financial Aid Fairy intervenes.

3.  Sheepishly discover you could actually get a replacement phone for free.  This information was in something called a “contract”, which you were apparently supposed to read before signing.

Still, no problem!  Your friendly phone company Customer Service Representative is happy to assure you he just needs the case number for your lost phone, and he’ll send you the replacement in a jiffy!

… you did file a case with the police department, right?

Right?  

4.  Spend as many days as humanly possible making up excuses for why you cannot go to the police department, because, c’mon – who wants to go to a police station?  Who wants that to be on their daily to-do list?  Especially to get a case number for the extremely professional reasons of “losing phone while drunk at bar.”

5.  Listen to the police officer explain that 2 months is a little late to report a lost phone. Especially when you lost it in another county entirely.  Agree with him that, yes, that would be logical, to a logical person.

6.  Flirt with police officer.  Obtain case number.  Mentally apologize to feminist forebearers who are undoubtedly glowering down at you from Liberal Heaven.  Remind yourself that you make up for this by always asking your patients very progressive questions like, “Do you have sex with men, women, or both?” and occasionally wearing a little rainbow caduceus pin.

7.  Get new phone in mail!  SUCCESS!  All one needs to do now is charge it for 18 hours, then call the convenient number on the packaging that you just threw away!

8.  Turns out you only use your phone for e-mail and medical apps, so you forget to find the packaging and call the number to activate it.  Whatever.  It’s fine.

9.  Realize it’s been 1 month and you have not activated your phone.  It just, sort of… seemed like an improvement to not get interrupted constantly by the “pay attention to me!” ringing thing it does, you know?

10.  Okay, fine.  Interrupted intermittently by the “pay attention to me!” ringing thing it does.  God.

11.  Finally call activation number, though only after actually asking someone to call you without realizing it will in no way work.

12.  Fail.  It has been too long.  You only get some weird recording about being “unable to reach” the phone company, presumably because they are all too busy laughing.  This happens 4 days in a row.  You have missed your chance.

13.  Congratulations!  You are now a Phoneless Person.

Good luck explaining this to any of your friends without scrunching up your face and getting confused about how to explain any of it without resorting to the elegant phrase, “Well – you see – it’s like this: I am an idiot.”

The Neurologist Explains EEGs To Me

“:Here’s a great example of an EEG.  Let’s work through it together so you can start learning to interpret.

First, we look at the first run.  See, all 10-11 and d4-6 low voltage.  So that’s okay, right?  And here we have some occipital slowing – probably not going to get to show you a vertex sharp wave, but – OH!  A sharp transient!  More on the right, reflected on the left… See?  Might be artifactual, thouigh – you don’t want to overread.

So to localize further, obviously we need to check back to the double banana .  And see how we’ve got a sharpish transient with some 3-4 in the parietal?  Nothing too exciting, clearly.  And here – see, the hypnagogic hypersensitivity – wow – that just comes right out and says “young person going to sleep”, doesn’t it?

That is, of course, unless the patient is still hyperventilating.  I don’t know, could go either way.  What do you think?”

 

“Try a rubber mallet first, and, whatever might happen, keep a cool head.”

I’m buying a filing cabinet!

… Unfortunately, most of the Amazon reviews are… worrisome.

…

A couple of things

1.  Sometimes people are the absolute best.

I just.. hold on.

Allergies. I just... allergies. I'M ALLERGIC TO LOVE.

2.  Sometimes I come up with multi-million dollar marketing plans in the shower.

Remember when you used to be able to just use face wash?  But now “facial care” is a 3 step process:  1. Exfoliate, 2. Clean, 3.  Moisturize.  You need 3 products.  (We’ll ignore the fact that I’m pretty sure Dermatology has taught me that exfoliating is a gigantic waste of time, money, and protective layer of stratum corneum cells.)

(Oh, also, I totally have my Dermatology test in 2 hours.  You can tell it’s real important to me.)

We could do the same thing for the haircare industry – increase profits by 33%.  After all, does anyone only buy shampoo, or only buy conditioner?  No.  We need a 3rd product everyone has to buy. (And by “we”, I mean “the haircare industry, if I was involved and got a payday out of this”.)

My ad campaign.

The Commercial:  “If you’re only using Shampoo and Conditioner, you’re missing out on a crucial 3rd step.  Take a look at any shower in France, and you’ll find a 3rd product – Pre-Conditioner.”

The actual name of the product isn’t important.  It just has to have a vaguely plausible sounding scientific gimmick like “providing a surface for conditioner to fully enter the hair shaft – because without it, conditioner only sticks to the outside and is mostly rinsed away!”  (Since 90% of the scientific stuff in hair commercials is made-up, this should be legally ok.)

If I were in charge of this ad campaign, I’d pin this “secret” on the French, because – at least in America – we seem to be willing to believe anything about the French, including that they’re all skinny and effortless.  Perfect hair goes with the territory.

If the hair-care industry successfully plant the seed of doubt in people’s mind that shampoo and conditioner are not enough, they could get $6 out of most of the women in the USA, and probably half of the men.  Millions of dollars.

No, I don’t know how tongue-in-cheek this idea is.  I hope you don’t either.  

How to be a med student with a mental illness

Someone just posted a great, yet heart-breaking comment in response to a post I wrote on another site about my anxiety – and I need to address it.

I have had “becoming a great physician” at the top of my life goals for about 4 years now. I have also been struggling with finding myself to be ‘mentally interesting.’ These mental quirks as they were have, however, really tried throttle my medical school ambitions. I am terrified of talking to a physician about my problems.

Dear commentor:  I’ve been there.  I felt incredibly alone. The feeling of “oh god, but I’m a future physician – I’m not allowed to have a psych problem” was worse than my panic disorder itself, because I had no role models – no physicians, no med students who knew how I felt.  I had nobody to look to for help.

So as much as I dread the idea of airing what was a pretty dark time in my life in a public forum, I have to write this.  I may not be the best med-student-with-a-psych-history in the world, but I’m one of the few with a blog.  So, hell – here I am.

“I have “toughed it out” as it were for years now, mostly since I started college. I am afraid I can’t do it any longer. I feel like a failure for even thinking about getting “help.” You managed to get into medical school before finding what worked for you. Does this mean I am just not up for it?”

First, I’ve given you the wrong impression by not talking about this.  I absolutely should have gotten help in undergrad.  In fact, I tried – I actually called my University’s mental health service after a horrible panic attack.  And I made an appointment.

But I never showed up. I never showed up, because I was having a panic attack about seeking treatment for my panic attacks.

… So, no, I wasn’t the best at logic.  But hey, I was the best at organic chemistry!  And physics!  And studying alone for hours!

But I was also the best at denial.  The fact that I rarely wanted to hang out with friends?  That just means I’m introverted. It’s totally normal for introverts to be too nervous to go out.  And the fact that I’d break down crying at the worst moments, over the smallest perceived slight?  Genetic. I’m just a crier. Sucks, but it’s how I am.

Neither of those rationalizations was true.  And I had absolutely no idea.  I knew I had panic attacks, but I had no idea that there was anything else wrong.  No idea until a psychiatrist asked me to examine my life, no idea until 10mg of Lexapro lifted 100 lbs of unhappiness off my back.

“I really want to go to medical school, but my thoughts are “How can you possibly survive medical school when you have these anxiety problems NOW?”

Here’s the thing:  No matter who you are, med school forces you to confront your anxiety.

I know an extremely competent, high-achieving med student who has been in 4-times-a-week psychotherapy for the past 12 years.  You’d never guess it.  Some of the most socially outgoing and fun people at my school see psychiatrists.  And a couple of the most outrageously anxious people I know have never set foot in a therapist’s office.

But you don’t have to wait until you’re overwhelmed.  Sure, I waited until med school – but I also wasted a lot of time in undergrad locked in my room or crying in a corner. You can survive by seeking help, doing the work, confronting your anxiety now.  I promise, you wouldn’t be alone.

So there’s no rule, no pattern to “who can handle it and who can’t”.  In the end, the only important thing is this: are you willing to learn how to handle the anxiety?  Therapy can teach you.  It won’t happen overnight, and it’ll take work.  But it can happen.

Just know this:  There’s no First Place Award for “toughing it out”.  There’s no medal, no praise, nothing you get to add to your CV for being 100%-certified Therapy-Free.

And that’s why you should seek help.  Life can be so much easier.  When you’re anxious or depressed, you don’t even know how hard life is for you – and it doesn’t have to be that way.

It doesn’t.

• Choosing A Psychiatrist
• Choosing The Right Mental Health Therapist
• Find A Psychiatrist
• Find A Therapist.
• Depression Screening Test.
• Crazy Meds: Forum for the Mentally Interesting

How to Have A Class Meeting About 3rd Year

Welcome!  Good morning!  Take your seats!

I’m so glad you could all be here for this mandatory meeting.  Now, you may have heard some rumors about 3rd year – rumors that it’s filled with soul-crushing paperwork, vague directions, and a surgeon who has driven at least 2 students to suicide.  We hope to set the record straight that those rumors are all absolutely true.

… Just kidding!  Haha, jeez, lighten up everyone.  No, those bodies were in too many pieces to be legally identified.

Let’s get right to it:  How to schedule your rotations.  It’s a simple process, really:

While we don’t have time to go through it in detail, if you’d like a closer look, this chart is on our website.

Oh, the young woman in the back – a question?  Yes?

… Where on the website?  It’s not, uh… well, I’m not quite.. Hmm.

Okay, look, it’s not there right this instant, per se.  The IT guys are redesigning the site because “it’s impossible to navigate”, and I guess we’ll get it back online when they’re done?  It should be soon, though – maybe a few weeks.  One year, tops.

Still,  I want to let you know that my entire office is here for you during the transition period. I know it’s difficult to schedule your life and med school at the same time.

So if you’re planning on having an important family event – such as a graduation, marriage, or tragic death – just give me a call!  I can easily sit down with you and discuss how best to schedule this event so that it coincides with your vacation week.

But most importantly, remember:

Meeting dismissed.