You could cut the irony with a knife

I’ve been off my Lexapro for a month and it turns out that’s bad.

Sometimes my patients have crippling anxiety.

When they do, I’ll take a few minutes to rule out other causes, report it to my preceptor, and they’ll breezily tell me “Fine – write a prescription for Zoloft, Lexapro, or Prozac – whatever you feel comfortable with. Do you know the dosing?”

Lady, you have no idea. By the way, I would also like a refill for myself.

… but for the life of me, I can’t find someone to take 10 seconds to write one for me.

I don’t feel it’s alarmist to say this is a problem.

I’ve been pretty open about my anxiety / depression. It’s been a non-issue for the last 4 years because my med school had outside psychiatrists.

But I’m not in med school anymore, and there are only a certain number of times you can refill a prescription from out-of-state without a visit – and I’ve gone way beyond that.

So now what?

I could set up an appointment at my current hospital, but I have to do a psychiatry rotation with these same attendings, so that seems… short-sighted.

I could call around at one of the competitor hospitals, but they’re all far enough away that I’d have to ask off work for “medical reasons”, which is a bit of a death knell. And why would they even accept our health insurance?

They probably don’t.

(Or maybe that’s just me making lame excuses? I honestly don’t know. My anxiety has ramped up to the point where the thought of just finding a phone number and calling someone is so mentally and emotionally exhausting that it’s impossible to tell.)

The thing that kills me (and the reason I’m writing this blog post at all) is that I know I’m not the only resident with this problem. I can’t be. Depression and anxiety are way too common – and the 80-hour work week and infeasibility of accessing your own hospital’s psychiatrists have to make this a global problem.

In the mean-time, there I am: taking a total of 10 seconds to jot down a prescription, then sitting in the corner anxiously twirling my pen and grinding my teeth.

Medicine sure can be stupid.

I’m Not (Yet?) Proud Of Graduating Med School

Sometimes I take a 5 hour bus ride to a different campus. And as bad as “5 hour bus ride” sounds, I actually like these rides: the buses are nice, the route goes through the mountains, it takes me to a nice place where I did all my clinical rotations, it’s usually quiet.

I even go so far as to sit in the front, so the bus driver will personally give a polite “shut up” to anyone in my general vicinity who dares to talk on the phone. (It’s so liberating, being able to sleep on public transit!)

But on Saturday I took my usual 5 hour bus ride and found myself sitting behind this loud, eager old man who would not. stop. talking.

The first moment he had a chance, he started engaging the bus driver with questions: “Where’d you get that booster seat?” “Oh? Which Wal-Mart? I’m always looking for a better one! Because – ”  (and here his voice swelled with pride) “I’m a bus driver too!”

And for some reason, I immediately felt guilty for sending “shut up” vibes his way.

They went on to have a 3 hour conversation about the E-17 bus models, the federal regulations, the weird thing that sometimes happens with the steering, the hilarious antics of the county transit supervisor.

That man was so proud of his job. Something about his tone of voice made me not mind the 3 hour conversation that interrupted my nice, quiet bus ride.

Why was I on that bus? To attend a small, unofficial graduation ceremony* for medical school. Because soon, I’m graduating medical school. That’s a thing, apparently. A thing that’s legit happening.

And I don’t feel proud at all.

It’s weird. I feel a lot of other things: sad to leave my friends behind, happy to have a job, irritated about the bureaucratic machine behind my “graduation to-do list”, downright panicked about moving, nostalgic about all the good times and the class bonding…

But I have yet to think “I have an MD! I made it! Good for me!”

Which is pretty stupid, because just this morning I felt proud for getting up at Totally Reasonable O’Clock to attend a mandatory meeting. I was like, “Yes! Look at me! Awake! Facing the day! SOMEBODY GIVE ME AN AWARD.”

I felt even prouder for taking out the trash last night. I didn’t have to do that! No one was visiting! Look at me, adulting!

Anyway, so I took the bus to the graduation ceremony. And I listened to two bus drivers talk shop for hours. And I somehow wasn’t as annoyed by it as I would normally have been.

You know what? As I’m writing this, I think I’ve realized why I don’t feel “proud”: whenever I pictured myself graduating / becoming a ‘doctor’, I sort of pictured myself as… a doctor. Someone with secret, insider medical knowledge. Someone who can fix people!

But it’s been 4 years, I’m getting that magical “M.D.”, and yet…. nada. In fact, I feel approximately as legit as this guy:

So how can I walk across the stage and feel the sense of pride when I always pictured that pride being accompanied by… I don’t know… actual doctoriness? Or doctor skills? Or even just general knowledge?

But the clock’s ticking, because after so many graduation celebrations, my actual graduation – For Real Graduation, We Mean It This Time, You’re Wearing A Floppy Hat And Everything – is on Wednesday. And to be honest, I’m still not feeling anything.

Except ‘broke’.

(Seriously, the wizard robes and floppy hat set me back $260. To rent. To RENT.)

(I THOUGHT THIS WAS AMERICA.)

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.]

‘Perfect’ is the LOWEST standard

because you’ll never meet it. It’s a way of copping out.

Aim for better than ‘perfect’: aim for ‘pretty darned good’.

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.

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?

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: …..

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

M1s: …..

I Wanted To But I Didn’t: Part 2

… Oh Wait No, I Totally Did

So yeah, you could say my research month is treating me pretty well.

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 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!”)

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.

Step 1 Score: Two-hundred-and-majorly-relieved

My score came out! And despite a lot of post-hoc rationalization of just how much i did not allegedly care, as soon as I actually had the option of clicking “View Score Report”, I no longer wanted to.

Like, at all. Ever.

Even after mustering up the courage to at least click the damned link, I still spent an embarrassing amount of time avoiding the screen and just generally attempting to evaporate due to Internal Conflict overload.

The internal conflict, to be fair, started about 2 months ago with the seriously depressing disparity between my original “go, fight, win!” optimism and the resulting elaborate series of nervous breakdowns when practice test after practice test revealed a reality that didn’t match up.  

Which, ultimately, I blame on 1) not actually being a secret genius (DAMNIT I was counting on that), and 2) seriously underestimating the workload required to meet the “average” maximal effort concerted by thousands of medical students who have lived their entire lives in the 95th percentile and are not about to release their unholy death grip on it now.

(Honestly, if I learned one thing while studying, it was that a 224 should be greeted with nothing but respect. An “average” score is a freaking achievement.)

Weirdly, after the Abject Despair of taking my dare-to-be-great expectations and pasting them onto a dare-to-be-average reality, I started scoring higher.

In the end, my NBME practice test scores ranged from roughly 21X – 24X, with a baseline of 207 and one UWorld score of 250 thrown in as hyper-emotional outliers.

So, right, that’s why I was sitting in front of my laptop, eyes shut, throwing around the idea of just never, ever checking my score – or at least just closing my eyes and humming loudly whenever it was brought up.

After all, wouldn’t it be nice to live in a world where the 250 was forever a possibility?  A world where it would forever be possible that I definitely did not slide back down Average Mountain to my baseline, thus negating all 6 weeks of blood, sweat, and tears?

But right, my point is: eventually, I looked.

And surprisingly, it did. not. suck

Step 1 score: 23X!  Which is great news! (To me! For my particular goals and study habits! Without making any judgement calls on it as a score in general!)

(For the lucky people reading this who aren’t familiar with USMLE scoring, this score falls right between the National average and the Metropolis Med average. So I can safely justify either “PARTY ON” or “I have brought great shame upon my family” depending on my goals – which luckily, as I said before, are not high.)

Incidentally, I really do respect the Sacred Med Student Moratorium On Score-Talk in real life. It’s an excellent unwritten rule that prevents all manner of med student psychopathy and drama.

But online social codes are different (where would any of us be without pseudonymous score reports?), and I don’t want to post a non-numerical entry that’s just EXCITED YELLING and risk misleading any future orthopods out there into thinking my relative happiness means I actually killed the test and should be listened to.

I mean, tempting as that implication may be (Action Potential, QUEEN OF THE ORTHOPODS) – the fact remains: M2s, if you want to actually kill Step 1, you’re going to want a better role model.

And possibly also – I don’t know, an actual study plan. (More on that later.)

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. 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.

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.

(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.

“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.