Not On My Body! The Dirty Secret of Surgical Training

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Retro

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

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

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

Sub-I... Check.

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

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

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

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

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

Reflections on Third Year

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

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

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

Normalizing.

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

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

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

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

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

Just a few things that are now normal to me.

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

You know you're in med school when... (VI)

Was riding up the hospital elevator up from the Starbucks in the lobby this morning with a classmate of mine. We were both clutching venti size coffees, and I turn to him and go:

"How much sleep did you get last night?"
"2 hours. You?"
"3, I was lucky."

A lady in the elevator with us suddenly laughs and says: "It builds character."

NEW. MOTTO.

Flying Solo

Few things represent the hierarchical and tradition-seeped natures of medicine better than the operating room. As many med students will attest, half of the battle of the general surgery rotation isn't learning the post-operative management of surgical patients or how to properly manage a wound infection - it's learning the ebb and flow of the operating room. Tales abound which serve to strike fear and trepidation into subsequent generations of medical students of students being yelled at for touching something, looking at something, breathing improperly, blinking improperly, etc, etc. There's a procedure and tradition for every minute detail of the choreography of the OR, and you are expected to know it all before you learn it all, which contributes to awkward or embarrassing moments aplenty for medical students as they rotate through. I remember when I got yelled at while participating in a patient transfer off the operating table. I was the one pulling the majority of the weight on the rollerboard, and assumed it was my responsibility to do the countdown. 3... 2... 1... I get glares. I'm told to step away from the patient and not touch anything anymore. Turns out it's always Anesthesia which does the countdown, which is logical as they are overseeing/moving the airway, everything that happens in the OR is logical, but how in the hell was I supposed to know that beforehand? Such is life sometimes for a medical student in the OR - expected to know these things, before anyone tells them. In my own limited time in the OR, I have collected a small bundle of mortifying anecdotes. The time I almost desterilized the entire instrument table with a sneeze, the time I put the SCDs on upside down, the time I almost face-planted into the operative field when I slipped on some sigmoidoscope-associated KY jelly which had dribbled onto the floor... the list goes on.

But this post isn't about embarrassment; it's about hierarchy. When standing around the surgical field, there's also a rigid structure to where one must place one's feet. Traditionally, to the upper right of the patient, by the patient's right armpit, stands the lead surgeon. The lead surgeon is, by virtue of the position, the individual in charge of directing and performing the majority of the operation. To the left of the lead surgeon stands the scrub nurse or scrub tech, whose job is to, among other things, maintain sterile technique during the operation, pass instruments to surgeon during procedure, and help perform counts of surgical instruments throughout the procedure. To the upper left of the patient resides the individual providing first assist to the operation - who, among other things, uses the bovie to cut vessels and tissues at the lead surgeon's discretion, helps provide traction to tissue planes to aid in dissection, etc. And to the right of the first assist lies the domain of the medical student: the position of second assist. Here one typically aids in the operation by holding retractors to open the operative view, use suction to remove smoke, fluid, and blood from the operative plane, and tightly covet the Mayo scissors that one uses to cut suture ties. But with the myriad of surgeries and surgical approaches out there, there's also a wide variety of places where the surgeon and assistants stand to get the best exposure into the surgical field. And just likes plays on a football field, its up to the medical student to learn where to proverbially 'line up' for the snap. In an academic institution like my own base of operations, typically a resident provides first assist during the operation and the medical student stands beside as second assist for the operation. But during chance opportunities, such as when the resident is taking the lead on a case, med students are given the opportunity to run first assist, which is infinitely more fun for obvious reasons - namely, being able to more actively participate in the case. Rarely, a med student is offered to take the lead on simple cases (appendectomies, cholecystectomies, etc), which is always something worthy of writing home about, no matter how mundane the case may be for everyone else in the OR.

So a couple weeks ago I was spending a day in the OR with the ENT surgeon who I'm doing research with and a third year resident. We were powering through several of the half dozen cases on the docket for the day and next up on the case list was a simple tonsillectomy. The resident gets called down to the ED for a consult, and suddenly the attending turns to me and says:

"Want to take a whack at it?"

The third year of med school is a lot like the game of golf. All too often, you find yourself feeling incompetent, frustrated, disheartened, or some combination of the three. As your shot out of the shrub grass careens off the tree and lands in the water hazard you didn't take into account, you begin to ask yourself why you even play this stupid game to begin with. But a handful of times during a round, the balls rises gracefully into the air and plops, like it should, down onto the green within spitting distance of that birdie. And before you know it, you're paying another set of green fees and are back for more. Likewise, third year is full of foibles and f*ckups, sometimes asking yourself why you're doing this for the rest of your life. But every once and a while, you get to see or do something incredibly cool that reminds you why you're in it in the first place. And you come back for more.

Well this moment was my proverbial 240 yard approach shot plopped down 6 inches from the pin. The first time I get to take the lead during an operation. I step into position above the patient's head and gaze down at the base of the mouth. Just as I get bovie in hand, the attending laughs and says: "Don't worry... the first tonsillectomy I ever scrubbed on, the patient lost 1800ml of blood. The bar's set pretty low." Great. My resting tremor kicks up a couple notches.

But before I know it, we're off. I go in alongside the anterior tonsillar pillar, find the capsule, and before I know it, the procedure is over. Less nervous than I thought I'd be, but still trying to contain the 8 year old inside of me jumping off the walls going "WOW! That was COOL! Let's do it AGAIN! WHEEEE!"

Yup, back for more.

Third Year and Dog Poop

It's well established in Medical Lore that the third year of medical school is the most taxing of the four. Over the past 4 months, I found myself doubting that assertion. Sure, the hours of third year are substantially longer and the clinical years require a more concerted effort to "bring it" every day, but I found myself having so much fun and time was passing so quickly that the days did not necessarily feel more "difficult."

Then I hit The Wall.

It hits your subtly. The fatigue from the chronic sleep deprivation becomes more pervasive. Your physiologic response to that third cup of coffee becomes less marked. The days drag on longer than you're used to. I was walking downtown the other morning, and unknowingly stepped in a pile of dog poop. I went the majority of my day ignorant to the fact that it was stuck to the bottom of my shoe until later in the day when I caught a firm whiff of it while charting at my station. Burn out is a lot like dog poop. It gets stuck to your shoe, lingers with you the whole day, and before your know it its stinking up your living room. When you finally smell it, its quite unpleasant.

So the days feel a lot more "difficult" lately. I know I'm burnt out, and just like the smell of dog poop, the sensation is quite unpleasant. Feeling tired all the time, feeling like you are just trying to survive your days, finding yourself feigning interest - it is not the ideal way one hopes to spend their days. And unlike the preclinical years, you are not afforded the luxury of being able to take a couple days or a weekend off to recharge your batteries. The alarm is going to go off at 5 AM tomorrow, rounds are going to start at 6:30, your first patient is going to show up in clinic at 8, your notes need to get done, you need to read up on your patients, you need to take that call night, whether you like it or not. That's the true challenge of third year and clinical medicine in general. Your patient's illnesses do not know nor care whether you are having a good day, a bad day; whether you're tired, or sick; whether you're rearing for a new day, or working for the weekend. Your responsibilities do not change with the color of your mood ring. Fatigue breeds complacency and apathy, both of which can be very dangerous, and the real difficulty in third year is learning how to suck it up and be at your best, even if you may not feel at your best.

Luckily, I have 2 1/2 weeks left on this rotation, then a week in the classroom and a 4 week block of research. The halfway point of third year. And a good time to wash off some dog poop.

Choosing a Medical Specialty (Part Dos/Deux/II/0b10)

As a continuation on my previous thoughts on picking a medical specialty, I've once again channeled my Dear Abby and have a new column up over at Headmirror.com.

Check it out here: Why ENT? Choosing a specialty and what drew me to ENT (navigate to Medical Students -> Blizzog)

On the road again

So I have to say, hindsight being 20/10, I ended up enjoying my psych rotation a lot more then I expected. I'll readily admit my preconceptions of patients with mental illness were too skewed by popular culture; I think I was expecting more of a Hannibal Lecter flavor. A "What are the voices in your head telling you Mr. Williams?" "TO KILL YOU!!!" sort of thing. But, fortunately, I found my interactions with patients to be generally pretty interesting and much more pleasant on the whole (exempting one interview with a drunk patient with narcissistic personality disorder). Especially gotta love the schizophrenic patients. Such a sad disease, but a rich source of some purely AWESOME conversations.

Anyways, like it happens time and time again during third year, just when you get comfortable in a rotation, the dean's office picks you up and plops you down in another unfamiliar location. For me, for the next 5 weeks, into a low income family practice clinic on the southeast side. It's been a tough adjustment coming from a rotation where I was afforded a great deal of autonomy and input into patient care, namely because the physician I'm working with has somehow come under the assumption I have the IQ of a sheet of dry wall. Cue one interaction I had today in clinic:
*MedZag, presenting patient to attending while in patient room (I know, awkward.)*
MedZag: Ms. Rogers is here today complaining of persistent worsening of allergies of the past 8 months. She states her main symptoms have been rhinorrhea, nasal stuffiness and sneezing, sore throat, and some intermittent wheezing. No sinus pain or pressure, no cough, no shortness of breath. She tried a trial of Claritin for 2 week...
Attending: So what brings you in today Ms. Rogers?
*Physician and patient proceed to start talking and cover all pertinent points I was about to distill in my presentation*
*Attending begins physical exam*
Attending: Now, if you see here MedZag, if you look up her nose you can see fluid.
*biting tongue*
Attending: You can also see swelling. This is very characteristic of allergies.
MedZag: Hmmm, yes, interesting. I also noticed that when I performed a physical exam (not so subtle hint). I had some ideas of an assessment and plan, would you like me to continue?
Attending: Oh no, that's ok. We'll just give her some Allegra.

This is going to be an interesting 5 weeks.

Hula Hoops

Jumping through hoops is a familiar feeling for any medical student. After all, it's something we have been doing at every level of our education. High school had its own set of hoops, filling college applications with National Honor Society merits, projects, AP classes, and the ilk. When time came to apply to medical school, there was a whole new set of hoops to tackle. Dean's lists, president's lists, scholarships, shadowing experience, personal statements, activities lists. Many experience a sense of relief on the arrival of that medical school acceptance letter. A feeling that you're finally reached the upper echelon of your training and the jumping of hoops is finished.

But alas, medical school brings its own new set of hoops. Anatomy, physiology, pathology. Step 1 and Step 2. Networking, schmoozing, research, clerkship grades. Once again, I will be pounding my head against a keyboard attempting to coherently produce a personal statement within the coming months. With my decision buck up and shoot for an ENT residency, the theme of the past month has most definitely been one of hoop jumping. I've been (somewhat) frantically trying to throw things together for a research elective coming up in November/December. Working on trying to network and get some clinical and OR experience in the process. Basically filling up my free time afforded to me by psych with numerous small projects all to play the game. Who wants to be bored anyways?

I tell myself this is the last time, but know that's just a personal delusion. But hey, I hear hula hooping is a great core workout.

MedZag Picks A Specialty.

There are few decisions more consternating to a medical student that choosing their eventual field. Sure, there's a few students born to be pediatricians or neurosurgeons or ED docs out there who know it, but the gross majority of us go through a great deal of waffling and procrastinating when it comes to deciding what more we want to be when we grow up besides the esoteric "I wanna be a doctor! Cause its cool!" Even those who were convinced they were going to go into x when they entered med school often do a complete 180 once they rotate through the clinical aspects and their face is to the table saw as they hover over the "submit" button on their ERAS residency application.

There's a certain progression to the process:
(1) Panic: The Lifestyle Specialties
When you first come into medical school, you have these idealistic views of what being a physician entails. Then you actually get into medical school, and a disenfranchised attending comes along, convinced the entire field of medicine now sucks, and blows that idealism into tiny, sparkly little pieces. You begin to become convinced that the only way you could possibly be happy is if you find your way into one of the highly-touted ROAD specialties: Radiology, Ophthalmology, Anesthesiology, or Dermatology. You begin to become convinced you could be happy staring at a computer screen all day, or rashes for that matter. After a while, you realize that all rashes look the same to you anyways, and you move on to...

(2) Resolve: Screw What Everyone Thinks
You encounter a doc who absolutely flippin' loves what they do. They tell you that it doesn't matter what area of medicine you go into, as long as you love what you do. You begin to convince yourself the same. You tell yourself that the disenfranchised attending from step 1 can go to hell, and you're going to go work for Doctors Without Borders as a surgically trained general practitioner. As medical school and the ongoing debate about healthcare reform progresses, you begin to notice that little "Total:" line on your student loans climbing at a otherworldly pace. You then move on to...

(3) Hopelessness: It All Sucks Anyways
Why does it matter anyways? In a few years, you're either going to be a government employee, and make peanuts, or privately employed, and make peanuts. Either way, you'll be working your glueteals off the rest of your life. You'll never pay off your loans. You're going to be driving that 1995 sentra for another 20 years. Your daughter is going to grow up with daddy issues because you'll never be home. You procrastinate thinking about what you want to do, because its no longer fun to think about it. Some stay in this stage perpetually, and become the attending referenced in Stage 1. If you're lucky you get to move on to...

(4) Chance: Your Specialty Picks You
The residents and attendings I've talked to who really enjoy what they do, and are pleasant people in turn, almost universally give the same advice about picking a specialty: get rid of your preconceptions, analyze your strengths and weaknesses, the things about practice which are important and unimportant to you, prune your list, then go out there and experience as many areas as you can. When you come across your specialty... you'll know. It'll be the one where you don't want to go home at the end of the day. Where you'll look and read about things not because you have to, but because you want to.

I came into medical school convinced I was going to be a surgeon. My friends told me as much, I told everyone as much, my ESTJ Meyers-Briggs personality evaluation told me as much. Now granted, my concept of "being a surgeon" wasn't all candycanes and lollipops - I had shadowed enough in undergrad to have a general idea - but I will be first to admit I had a very naive and limited view on the scope of medical practice and the proverbial "potpourri" of options afforded to me early in medical school. I found out in a hurry that telling people in the Real World™ that you want to go into surgery evokes an entirely different response to telling people in the medical field that you want to go into surgery. Namely, that instead of eliciting the token "Ooooo! Like Gray's Anatomy!" response, they instead try to scare you the hell out of considering the field. And granted, much of that behavior is grounded in either reality or stereotype of the field. And so began my progression of through the steps.

First was "what have I gotten myself into? I don't want to work 120 hour weeks for the rest of my life!" Followed "I'm going to do it anyways! It'll be fine!" I eventually just resigned to telling myself "you'll know when you rotate through surgery if its for you." But alas, my surgery rotation came and went, and by the end I was still just as on the fence about the whole surgery conundrum as before. So I began to break it down. I knew that there was nothing like being in the OR for me. That time flew when I was in it, and I missed it when I was out of it. But surgical clinic also left a bad taste in my mouth. I found myself enjoying the clinical aspect of medicine more than I anticipated, and I found clinic in general surgery too fixated on "to operate or not to operate?" Yet after leaving surgery and venturing into the realm of psychiatry, I found myself missing the faster paced lifestyle of the specialty.

ENT was a specialty that first caught my eye during second year. I had a small group doc who specialized in laryngeal surgery and speech therapy, and he really tried pushing us to take a look at the field. But at the time, I was too hung up on the "to surgery or to medicine?" that I never stopped and said to myself "self? how about both?" It was a field I kept on my list but never really investigated... namely, because I had no idea what in the hell an "otolaryngologist" was or did. With no frame of reference, I wasn't in a position to realistically examine the field. But the seed was there, and as third year started and I began to have more interaction with various specialties, I began to notice that I was really digging this ENT stuff. The more I read about the field, the more it seemed to jive with my expectations and desires for how I wanted to practice medicine. There was a monday morning report I went to that was presented by the ENT department... and instead of sleeping through it I found myself taking notes. I scrubbed on a pharyngolaryngectomy with a free jejunal transplant and even though I was on the colorectal service and was parked by the abdomen, supposed to be focused on the jejunal resection, I found myself fixated instead on the bilateral neck dissection. It was the small things that slowly roped me in, and after extensive email conversations and a few tall coffees with a couple members of the faculty, I've finally come to a decision. I said to myself: "Self, you're going to match into otolaryngology."

Along those lines, I'm going to be guest-posting about my experiences in discovering ENT, rotating through ENT, applying, and such over at headmirror.com (see the new side banner). If you're considering ENT, I suggest you check it out - there's a lot of great info on the site. All I can say is that its incredibly exciting to find that niche of medicine which really vibes with your persona. When I decided to commit myself to the field and really get after it, all I felt was this overwhelming sense of relief. I think that was really telling.

Till next time.

Surgery... Is Tough

The general consensus of the third year rotations is that surgery is the toughest rotation to get through. I didn't necessarily pooh-pooh this assertion, but I said to myself: "Self, you enjoy surgery. How bad can it really be?" After the first week of 3:30am mornings, walking home at 8pm realizing I need to be awake in 7 1/2 hours, still have to eat (since I haven't all day), and read up on my cases the next day, I have come to the conclusion that surgery... is tough.

This definitely creates a tension for me regarding my future. Surgery has been at the top of my list since the start of med school, and I've really enjoyed the rotation. I love being in the OR and time generally flies by while I'm in the hospital. But the moment you step outside those hospital doors, you realize just how tired you are and just how much your life sucks. There's been a lot of criticism of med school graduates choosing "lifestyle" as one of the major determining factors in choosing their future medical specialty. But when you're in the middle of a 96 hour week (sssshhhhh, we're only supposed to be working 80), watching the attendings crawl home at 7 or 8pm daily just as you are, you start to realize in a hurry just how much lifestyle can bolster or sink your happiness.

I'm on the colorectal surgery service. Which means obesity, obesity, and morbid obesity. I'm hoping to post some stories soon, because I've seen some crazy sh*t (no pun intended). But tomorrow is my birthday, so I plan to spend it how anyone would hope to spend it: On call on trauma service on a Friday night. Woooooo surgery!

The Bee Gees, Storage Closets, and Medical Education: A Thursday

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

It was my last day in the PICU and last day on pediatrics. I had come in at my usual time of 5:30 to pre-round on my patients. One I had carried for a week and was very familiar with and the other was a little boy with an epidural for who most of the heavy lifting had been done overnight. 7:30 came, I presented my last 2 patients, and rounds flew by, finishing ahead of time mostly due to our light census. It was looking like it was going to be a light last day, and that I would have time to fit in some much-needed studying for my shelf exam the next day. It was 8:30am and I had just settled down with a paper on PRVC ventilation when the voice on the overhead speaker system chimed on: "Code 99, 9th floor, room 4. Code 99, 9th floor, room 4."

The PICU chief takes off running down the hallway, the team a few meters behind. We arrive up at the code in under a minute, finding ourselves the first responders due to the fact that most of the attendings and residents in the hospital were a building over in morning report. Our team would be running this code.

A code in real life is nothing like in the television shows (big surprise). It is a much more controlled chaos. There isn't any yelling, pounding on chests, doctors screaming "don't quit on me! DON'T QUIT ON ME!," or any of the other stereotypes that people think of when you say the words "code blue." We had actually had a mock code for the residents and students with a sim-patient the week before - our institution is big on assigned roles and closed loop communication. So I settled into my role of information gatherer and runner: finding the patient's most recent labs in her chart, getting ice to cool the patient's body, running blood gases down to the PICU, etc.

The patient was a 3 year old little girl who was actually set to be discharged later in the day. She had nephrotic syndrome and had spent half a day in the PICU earlier in the week with some mild pulmonary edema. Her labs looked completely normal and she hadn't had any issues besides intermittent hypertension. While her parents were showering her that morning in her hospital room, getting her clean for the ride home, she suddenly collapsed and became unresponsive. Within 4 minutes of that moment she was receiving chest compressions from the PICU chief.

137 minutes of chest compressions, 8 boluses of epinepherine, 4 boluses of atropine, 4 boluses of bicarbonate, 3 doses of calcium, 3 cardioversions, 2 boluses of ibutilide, 2 IO lines, and a bolus of insulin later, there still wasn't a pulse. Since she was a previously healthy child and was remarkably stable during the course of her hospital stay and had started getting chest compressions so soon after her event, the decision was made to get her down to the PICU and put her on ECMO (cardiopulmonary bypass) in hopes that giving the heart a break would allow it to snap back into rhythm. She was wheeled down the hallway with my resident straddling her on the bed, continuing to give compressions.

Down in the PICU, her room was converted into a field OR, and the cardiothoracic surgeons arrive to prepare to get her on ECMO. I am standing outside the room, looking for more opportunities to help and absorbing the controlled chaos, when the chief turns to me and says:

"MedZag, why don't you relieve David from compressions. He needs a break and I think it would be a good experience for you."

My adrenals dump a massive load of catecholamines into my system. I somehow find a way to utter "Yes, sir."

During our "Transition to Clerkship Week" at the beginning of MS3, we were forced to re-certify in our healthcare provider BLS (basic life support) training. Which basically entailed kneeing on the hard ground in dress clothes for 2 hours doing practice compressions on blue plastic mannequins which looked like they got misplaced from the set of I, Robot. There was no way I could predict that in 6 short weeks, my mannequin would suddenly morph into this brown-haired little girl.

I gown and glove up and go and relieve the fellow doing compressions. I was determined to do everything exactly correct - probably a delusional desire in the given circumstances, but I became fixated on a study I remember reading where residents and medical students who were instructed to do chest compressions to the beat of the Bee Gee's "Stayin' Alive" were much more likely to hit to target heart rate.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

The surgeons incise in her neck and begin to dissect down to the carotid artery, a difficult prospect as with every thrust of my palm down into the little girl's ribcage, her neck jerks and blood flies into the air.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

I become fascinated by how strong her ribcage is. Sweat begins to bead on my forehead, my respirations steadily quicken, and my arms begin to burn as the lactate accumulates in my muscle tissues.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

This little girl was going to make it. She was supposed to go home today. This will be a fantastic experience to look back upon. I had images of the thank you card the PICU will receive when she starts first grade - the little girl grinning in a photo, missing her front baby teeth. The little girl who nearly died but now has her entire life, a full and rich life, to look forward to.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

Bypass in on. Her body is once again receiving fully oxygenated blood. Chest x-ray shows everything is properly in place. Her heart regains a rhythm. Sinus. But 45 seconds later it fades. Asystole.

A repeat echocardiogram would eventually show a massive saddle embolus in her pulmonary arteries. You can't get blood to the body if blood can't get to the left heart. MRI and clinical exam showed absence of all reflexes and fixed, dilated pupils. There would be no first grade photograph.

I was in the room for the conference with the patients. Our chief explained what had happened. The scene felt surreal.

When stepping out of the room, one of the residents broke down in tears. The chief stares off into space. His words resonate in my head.

"Hope and pray that you never have to do that enough in your career that you get as good at it as I have."

Bypass was stopped 2 hours later. Within minutes, the brown-haired little girl, who should have been home watching cartoons, had passed on.

I was sent home to study for my shelf exam. I sat starting at my question book, but no studying would be happening that night. I logged onto the EMR and looked at her chart again. I looked at her echo again. I read the note I had written on her earlier in the week when she had been in the PICU. We had been instilled with the proper fear of a saddle embolus during our first two years of med school, but this was the first time I had seen one clinically and wanted to make sure all the information about the situation was seared into my brain. But mostly I simply sat there. And thought. I couldn't shake the feeling of guilt clawing at my stomach. This will be one of those centennial moments of my medical training: the first time I actively participated in a code, the first time I performed CPR on a patient, the first time I witnessed a truly horrific conference with parents, the first time I saw a member of the team collapse in tears, the first time I watched a patient die without forewarning. This was an important day in my medical career. But it is a sadistic reality that my education requires bad things to happen to good people.

So, to the patients of that little brown-haired girl: Thank you. Through your tragedy, I gained valuable experience that one day may perhaps enable me to save someone else's life. And know that I would gladly exchange all that experience for a picture of your daughter, clutching her pink backpack, grinning with her missing front teeth, on her way to start the first grade.

Balls.

So during our pre-clinical years we had this wonderful class called "Principles of Clinical Medicine" which was "designed" to impart onto us all the skills we need to survive in the clinical world that you don't learn out of a basic science textbook. We had lectures on giving bad news. Lectures on disaster preparedness. Lectures on healthcare reform. Lectures on "adapting to a chronic illness." The culmination of the class was something called the (Group) Objective Standardized Clinical Examination (GOSCE if as a group, OSCE if solo), where you had to perform a history/physical exam on fake patients often with one of the "difficult" issues lectured on, such as substance abuse, non-compliance, divulging a medical error, etc and graded in checkbox style on whether you washed your hands, shed appropriate tears, preserved modesty whilst sticking a finger up a man's inguinal canal, and such. Did it help me prepare for my clinical years? Yeah, I think so. But as far as preparing me for what I do 75% of my day, it didn't help squat. So instead, in order to better prepare MS1s and MS2s for what the wards are actually like, I propose the OSCE be replaced with... the SACK (Subjectively Arbitrary Clinical Klusterf*ck - with a K 'cause SACK is a way cooler acronym than SACC)

Here is how it would be conducted. 10 students would be unleashed into a mock ward with 1 patient assigned to each of them. There is a workroom with computers. The student must:
(1) Log onto the records system on a computer terminal to read up on the full H&P, course, vitals, labs, and imaging of their patient and commit them in some form to memory
(2) Go see their patient and get overnight updates/perform a physical exam
(3) Go talk to the nurse for the patient to find out what really happened overnight
(4) Come back to computer terminal and write a progress note complete with assessment and plan with a "well thought out and thorough" differential and relatively accurate plan
Now the rules of the exam:
--The student must perform all of the above tasks on a timer of 120 minutes. At the end of the 120 minutes, the student must present their patient while individuals in long white coats stand around, shuffle their feet, and clear their throats
--Even though there are 10 students and 10 patients, there are 8 computers in the work room. Additionally, throughout the course of the 60 minutes, 8 individuals in long coats representing consults, attendings, and residents will come in and sit at terminals to check their google mail and book airline tickets to exotic tropical places. The students have no choice but to defer to hierarchy and rescind a computer terminal if needed by said individuals. Said individuals can sit at any station as long as they want, and if all 8 individuals decide to use computers, students have no choice but to stand there wasting precious time
--There will be 5 nurses for the 10 patients. At any moment 2 of the 5 nurses will be missing and no one knows where they are.
--60 minutes into the exam, the students will all be herded into a room and forced to listen to "morning report" for 30 minutes, denying them access to patient, work room, or computer terminal and cutting their effective work time down to 90 minutes
--Patients will either be too tired to give a good history of last nights events or physical exam, too cranky to give a good history of last nights events or physical exam, or too drugged to give a good history of last nights events or physical exam.
--You are allowed to print your notes for aid in your presentation at the end, but only 2 of the 8 computers will send to the printer

Now that's real wards experience.

BTW... saw my first code today. A parent of a patient seized and collapsed in the hallway right outside our workroom. He hit his head on a counter, cracked his skull open, and went apneic. I stayed out of the way, since simply observing the carts and the medical supplies and the pooled blood on the floor was way too much for me. But good lord, within minutes of the code being called there were 50 docs and nurses all in that narrow little hallway while people tried to get supplies and a stretcher to the patient. It was like pigeons at a bird feed sale.

Cryptococcus!
(You might be a med student if you get that joke.)

The Aftermath

I survived Step 1.

It still seems surreal to say it. That the seemingly insurmountable task that has been hovering over my head for such a long time is now over and done. In the past.

All that remains is the aftermath. My First Aid binder with pages ripped through their 3 hole punches, hanging out like a dog's tongue after chasing one too many frisbees. Dead highlighters on my desk. Sheets full of self-made diagrams and flowcharts. Sentences underlined in red with "QUESTION!" written next to them. My Goljan book, with its binding cracked down the middle and the second half of the "Hepatobiliary and Pancreatic Disorders" chapter hastily scotch taped back in. 3,400 QBank questions tucked somewhere in my cranium. 2,400 notecards sitting no longer of use on my laptop.

I'll post more about my experiences with my progress doing questions, taking NBMEs, and the like when I get my actual score back and know how accurately it actually projected how I'd do. But I thought I'd talk a bit about the experience of the test. My actual test day went pretty well. My immune system made one last rally and with my prophylactic DayQuil in hand I kept the congestion and runny nose at bay throughout the day. I arrived for the test a half hour early, and found myself starting the exam early at 7:40am. All those hours doing questions paid off and I found my stamina was good enough that I could bang out two hours of question blocks at a time between breaks. Time goes VERY quickly while you're taking the test. You find yourself so focused on each question that blocks can seem to fly by, and hours of the day silently tick away. Before I knew it, block 7 rolled around and I clicked that final "End Block" button and half-assed my way through the survey at the end.

What does it feel like when you step out of the testing center? It's a strange combination of exhaustion, exhilaration, and denial. It didn't sink in for almost two days that I was done. That there was no more studying to do. The day itself almost felt like just a long day of doing USMLEWorld, as the interface, pacing, and question prompts were all so similar.

But it does finally sink in. And its a great feeling when its over. The sheer amount of concentrated will it takes to study endlessly, day after day without reprieve, was honestly something I wasn't sure I had in me. Its a time filled with highs and lows. Lots of lows. Frustrations, and sometimes despair. You realize you have gone days without talking to another human being, and find yourself unable to engage in normal conversation when you do. You become robotic in your routine. Wake up, study. Eat only because you have to. Study. Sleep. Repeat.

I think if I had to sum up the entire experience it would be: I would never want to repeat it. But I'm damn glad I went through it. And now its time to sleep.

So you want to go to med school, huh?

Well, to survive the first two years, all you need to do is memorize this information in 74 weeks:


5 wood and manatee for comparison. Manatee may or may not be to scale. Tape measure reads just over 4 feet tall (1.21 meters) tall.

Done with second year. Wooo.

Happy Day!

Every medical student has his or her own unique challenges as they progress through training. For some, its social anxieties fostered by years of seclusion in the library. Others its the constant berating by superiors. Fear of needles. Aversion to blood. Painful memories of gurneys. Dislike of the color white. Latex allergy. For me, I've had my own Everest I've had to climb.

I have a baby face.

Now I know. I'll be laughing when I'm 40. I'll miss the days when I get carded by Brutus on Monday $1 pint night (or carded for rated R movies... still happens!). But unfortunately I kind of need to learn this medicine thing now not later, and getting a 45 year old man to talk to me about his sexual history or confide possibly socially taboo behavior when I look like I should be playing on his 12 year old son's little league team just doesn't seem to fly.

There has been several (unsuccessful) attempts at growing a beard, but the battle against genetics has proven a futile one. Wearing glasses helps a little. Then patients just ask what college I go to instead of what high school (no exaggeration). White coat or not, patients are always observing "So you're following this doctor around today? How fun! Well do well in college and maybe you'll get into medical school!" Sorry lady. Jumped the gun on that one. Let me just put away your chart with your full medical history in it and go work on my English homework.

The best? A patient who told me I look just like Richie from Happy days (see above).

Maybe I should embrace it. It'll only take a couple months before I could grow a mean comb-over.

And change my name to Doogie.


Anyone got any good ideas on how to look older? That doesn't involve illicit drug use or alternative medicine?

Tom Hanks will kill you.

An article on CNN.com caught my eye the other day:

Man designing Camry hybrid works self to death

One of the main highlights of the short article is the following blurb:

"The man who died was aged 45 and had been under severe pressure as the lead engineer in developing a hybrid version of Toyota's blockbuster Camry line, said Mikio Mizuno, the lawyer representing his wife. The man's identity is being withheld at the request of his family, who continue to live in Toyota City where the company is based.

In the two months up to his death, the man averaged more than 80 hours of overtime per month, according to Mizuno."

This is not a unique occurrence in Japan. It happens with enough frequency that they actually have a term for it: Karōshi... occupational sudden death from overworking.

Now time for some basic arithmetic. Assuming they are talking about 80 hours of overtime a month in accordance with the Japanese work week (46 hours per week, thank you wikipedia), that means that the unfortunate Toyota employee from the article worked (46/7)*30 + 80 hours a month... ~277 hours.

Now take your average US resident. Under the new work week restrictions, US residents are "limited" to 80 hours per week (though many work more secretly to gain more experience or due to underlying program expectations... SSSSSHHHHHHH). (80/7)*30 hours a month... ~343 hours.

Note this post is in no way meant to belittle the unfortunate tragedy of this man's death. But it does offer a unique insight into the under-the-radar life that people in medicine live. Everyone I talk to outside of medicine understands and sympathizes on some level with the long hours of the field and realizes that a 36 hour shift is not good for the decision making processes. But if a resident were to die from overworking, I don't think it would illicit more than a curious yawn from the general public. Everyone I talk to outside of medicine also expects perfection from their doctors. At first glance these two things, sympathy to mistakes and expectations of perfection, seem utterly incompatible.

Of course the conundrum is that residents do not work so many hours simply as some form of primitive medicinal hazing ritual. Residents work so much because they have to. The Medical Knowledge Ocean is vast, and a single resident but a small speck upon a life raft on it (Wilson sometimes accompanying). Even cutting resident hours down to 80 hours per week, which some professions would be considered ridiculous, we have already seen a greater amount of graduating residents seeking fellowship feeling that they have not had enough training to enter individual practice on their own. With talk of a further reduced 56 hour work week for residents, the debate between the "enough hours to stay sane" vs. "enough hours to not become Dr. Death" debate has gained even further ammunition. The benefits of work hour restriction are obvious. More balanced and well adjusted residents. Less medical mistakes due to sleep deprivation. Candy canes and bubbles and rainbows and shit. The drawbacks are perhaps less obvious but just as important. Necessary longer periods of training on an already exhausting path. Losing the lessons learned from being in the hospital to follow patients from admission all the way through the course of treatment. More time with that "interest" ticker steadily clicking away on student loans.

Personally, since I am firmly plopped on the "baby" end of the medical student age spectrum, the idea of extending residency another 1-2 years in favor of more sane working hours appeals to a certain side of me. After all, whether I am 29 or 31 when I leave residency is apples and apples to me. But the path of medical training is a long and arduous path, and I can certainly sympathize with my older classmates who find the idea of even 12 more months of residency truly gross. And 56 hours doesn't seem like enough time a week to learn what you need to in medicine.

Of course, its easy to spin the wheels in the ol' noggin about this topic when my days still consist of a schedule largely under my own control. It will be interesting to see how my opinions change as I'm thrown into said Medical Knowledge Ocean and told to survive, with the nearest island far enough away it will take 80 hours of paddling a day to reach it in 5 years.

But the idea of residents dropping dead in the hallways, being picked off like flies, in an epidemic of karōshi is a funny image to think of. In a morbid, real kind of way.

Med School Poker

If there's one thing that every medical student knows, its that medical school is really just a bunch of humbling experiences all strewn together under the ruse of "education." Most people out there know that doctors are smart. And that they know lots of stuff. But I don't think anyone can truly realize how much there is to know and how much practicing physicians DO know as part of their daily functioning. I have studied day and night for 8 straight months and still am barely able to interact on a fairly elementary level. And just when you start to forget that and start to think you might actually be making progress on this whole doctor thing, bam, along come some attending wielding his massive sword of knowledge, striking you down from your high horse to go mingle again with the peasants.

Take for example today in clinic. I was talking with a pediatric hematologist about an interesting patient I was about to see with him - a 17 year old patient with Blackfan-Diamond Anemia. The typical first line of treatment for this disease (a erythroid progenitor disease that prevents red blood cells from properly maturing) is steroids in hopes of resuscitating the patient's own marrow's ability to pump out those cute little RBCs. So the physician was discussing the various steroid treatments they have tried on this patient and asks me "do you know what some common clinically pertinent adverse effects to steroids?" I proceeded to stare at him like a stoned pufferfish.

Now, deep in my brain somewhere, I actually know some "common clinically pertinent adverse effects of steroids." They include weight gain, hypertension, osteopenia, and psychosis. But like 99.9% of the things I've learned this year, they were stuffed into my tired and overfilled brain and subsequently left to dissolve back into this bizarre long term memory twilight zone where they come back to me during weird moments like when I'm watching Futurama on a Monday night (read: now), but never when I actually need them.

Massive Sword of Knowledge: 1
Me: 0

Of course, I currently hold the ultimate wild card: the totally awesome "I'm a first year" card. Play this card in any situation and the attending will smile with a fond reminiscence at you, reward you for demonstrating any shred of medical knowledge whatsoever, and then proceed to explain things to you at the level of a first grader. If you've been there, you know what its like, and its truly hilarious.

But like all good things, the totally awesome "I'm a first year" card will come to an end. In exactly 10 weeks (not like I'm counting) I will graduate from a cute little first year to a second year. And then I might be actually expected to know something.

Uh oh.