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.]

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

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: …..

Applying For Residency: In GIFs

Students Applying to Surgery

Students Applying to Medicine

Students Applying to Family Medicine

Writing Your Personal Statement: Draft #1

Writing Your Personal Statement: Draft #2

Writing Your Personal Statement: Draft #3

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

 

Finalizing Your ERAS Application

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

Post Idea #1: Advice 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.

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.

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.

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,

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?

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?

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.

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 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.

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.