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.

Warrior

He was young for his type of cancer - squamous cell carcinoma of the larynx. I can't remember if he was a smoker or not, I don't think it matters, because those little details tend to deceive us into judging whether a patient "deserves" their cancer or not, and no one deserves a diagnosis of cancer. His tumor fell into the "organ preservation" limb of treatment, and he underwent weeks of grueling radiation and chemotherapy with his wife steadfastly by his side. The first few scans came back clean, then a year or so after treatment - recurrence. The cancer would prove to be a formidable enemy.

"Salvage laryngectomy" is the term we use when our first treatment has failed for voice box cancer and the ultimate decision is to be more aggressive and wield cold steel and hot cautery against our opponent. I think in some ways the term is quite poignant. It implies a battle of sorts raging within the body - treatments and human will versus the scourge of the malignancy infiltrating the tissues. Poetic interruptions aside, it meant the patient lost his ability to speak when we removed his larynx in an attempt to also in turn remove the cancer. Once again, a period of reprieve and healing. He became artful in speaking with the electrolarynx, attacking this new challenge the way he had all other challenges before then. But once again, the cancer returned with a ferocity, infiltrating the skin around where his airway now exited from his neck.

"Peristomal recurrence" is the term we use when the cancer returns in such a location. In general, it is considered a very poor prognostic sign. The type of sign where all you have to do is utter the term and those knowledgable to the lingo simply nod their head sadly, understanding that you're implying the chance cure is essentially zero.

And so it went on, another round of chemotherapy. More radiation. More chemotherapy. Experimental regimens that were so new or different they weren't even clinical trials yet. He lost a lot of weight. Nausea. A tube was placed through his skin into his stomach. His tumor grew larger. He was hospitalized. His tumor grew larger. He had bleeding. He spent time in the ICU. His tumor grew larger. He had abdominal pain. That earned him a surgery, and more pain, only to find that the cancer had further metastasized. His tumor grew larger. He would spend the last few months of his life in the hospital, until one night he quietly passed.

The unfortunate fact is that half of head & neck cancer patients in an academic institution will succumb to their cancer. His story, however, struck a chord with me.

Our team was frustrated with his care. We had tried many times to lay out prognosis to him, to arrange end of life care, to make him comfortable. But he would always talk about the next round of treatment. He would always talk about the day when his cancer would be gone for good. In fact, up until the end, he talked quite a bit. About his favorite football team and the upcoming season. About his rec sports league and the joy he got from the competition. He struck he as the scrappy small guy you hated to compete against but always wanted on your team. Ultimately, he always equated palliative care with quitting no matter how how we tried to frame the conversation. We, the team of residents caring for him, had trouble with transferring our own opinions onto his life. We saw the last few months spent in the hospital as time wasted, unnecessary pain and suffering. (And wasted healthcare dollars if you work in Washington). Some would paint his case as a failure of our medical system to navigate end of life care. Every day as we passed through his room we were left with a dampening of our spirits, a daily reminder of our own mortality, and the futility of our care at times. He was the other, more real, 50% of head & neck cancer patients.

I think when it comes down to it, he derived value and meaning from the fight. And I think he measured the worth of his life in the end by how hard he fought. He was a warrior. He outlived prediction after prediction. 6 months to live. 3 months to live. 1 month to live. He tolerated an inhumane amount of painful and debilitating treatments. He demonstrated the tenacity of human will.

And ultimately, I can't help but admire his story. In the end, I think, it was a good death. A death befitting a warrior.

Worrywort

There was this one moment I remember vividly from when I was a third year medical student. I had been working with one specific doctor all week in clinic, and we were talking about an interesting patient we had seen the day before.

"I worried about her all night," the attending said.

I remember reflecting on that line later that night. I remember it so vividly because I didn't worry about her at all. I went home that night, did some reading, mucked around on the internet, and had a blissful night's sleep. And I wondered why. Was it because I didn't understand the complexity of her case? Or was it, I really worried, because I didn't care about my patients enough?

That continued throughout the rest of medical school. I felt like I connected well with patients during the day. Empathized with them. Felt concern for them. But when I went home, I could unplug from that. And always in the background was this vague gnawing feeling tha maybe I didn't care enough.

From the other side, I can see it was because you are so well protected as a student. Sure, you dabble in independence. One night as a fourth year student we were being hammered on call. The resident was busy with our 8th trauma ICU admission of the night and a big case just got out of the operating room. The resident sent me to evaluate the patient and come back and tell me "stable or spiraling" (i.e. is this a patient I need to see now, or in an hour when the traumas are done). I remember the anxiety of that moment standing in the ICU room alone with the patient - looking at monitors, drains, and drips and trying to get the overall gestalt of the situation. But by the end of the night, the resident had come and seen the patient, and had agreed with my assessment. I went home and had a worry-free nights sleep.

In some ways, moving from student to resident is like being a sheltered teenager that suddenly graduates high school and moves away to college, thrown into a crazy world where dangerous things lurk around the corner.

I worry about my patients now.

The patient I just operated on with post-op tachycardia and EKG changes. I do an assessment, order labs, look at her old EKG, and make the determination that her heart rate is secondary to pain and she ends up going home. I worry that she is doing OK, and I didn't miss her heart attack.

The patient whose feeding tube comes out prior to discharge. I place a new one, order the xray, and see it isn't comfortably into the stomach. Go, advance the tube, and re-order the scan. Somehow the patient gets discharged before he follow-up x-ray is taken, and I worry all night that the tube is in the right place.

The patient with shortness of breath after an operation where you SHOULD feel some shortness of breath, and I worry that her symptoms are covering up something more insidious.

There's a few things that I mull over about this newfound worrywort quality of mine:
1. I wonder if it is because I don't want to "get caught" doing something "wrong." I think that may be part of it, because all of us in medicine tend to have a perfectionistic quality. And I recognize that, as a person who didn't really get "into trouble" as a child growing up, I retain some of that quality in adulthood even now as a resident where I don't want to be in "trouble."
2. That being said, most of my focus is on my patients. The worst thoughts I have are of my patient at home, suffering, because of something I did or something I missed. So I think my worry comes from a good place, because my focus is on keeping my patients well.
3. I'm learning that its good to have worry. It keeps you vigilant. But you have to be able to turn it off. You have to be able to trust your colleagues to handle issues for you. You have to be comfortable with uncertainty and trust that if things begin to go downhill, the patient will let you know.
4. I'm also learning that perfection is a noble and good goal but not an attainable reality. You will make mistakes. There are mechanisms in place to pick up on mistakes. And, to use a cheap sports analogy, you have to forget about the botched play and get ready for the next one.

I think back to those days of medical school when I worried that I didn't worry enough and I smile. It's always fun to reflect on your own naïveté.

Residency, huh?

First of all, apologies for leaving the blog hanging in the wind like a bad M. Night Shyamalan cliffhanger for the past 3 months. You may (or may not) have noticed I dusted off some of the things around here and updated the header to note than I am no longer a short-coat-wearing, deer-in-headlights, hopelessly-clueless medical student. Since our last interaction, dear reader, I have shed the shackles of medical school, packed up all of my "stuff", drove 2,353 miles across the country, and settled down in a small city with a very big medical center where I have spent the last week preparing to be a long-coat-wearing, deer-in-headlights, hopelessly-clueless... intern.

Progress.

I debated for a long time what the fate of this little corner of the interweb would be when I would be forced to stop writing about medical school. For a long time, I was content to let it ride on out into obscurity like many medical student blogs before me. Less time during residency (especially a surgical residency), the changing face of medical social media, and increasingly stringent institutional policies would all stack up and make it easier to just stop writing altogether.

But a few things changed my mind. First, I remembered a conversation I had with a good friend of mine who is in a *wink* elite *nudge* branch of the military. During our conversation, we talked about unique and stressful experiences and how it is important to take time to reflect on those experiences to learn and grow from them. I know myself well enough to know that unless I'm writing it on this blog, I won't take the time to write it at all (I don't know what that says about me as a person... but moving on). Secondly, as I nostalgically romped through the end of medical school, I decided to go back and read this whole damn blog in its entirety. Reading posts was like reliving experiences all over again, and I was surprised by how much of those memories had already began to seep away into the dark recesses of my brain. Finally, during a conversation with one of my new co-interns, I discovered that he both read my blog and liked it, despite the fact that we never interacted on the interview trail and hailed from states on different ends of the continental time zone. I was reminded about the common thread of the medical student experience and how many comments in the past have remarked "I'm glad you're writing about this." These things have led me to the conclusion that:

Remembering the process is important.

Over the 4 rapid years of medical school, this blog has evolved from something analogous to a teenage chick flick, to a place for me wax sophomoric about my "difficult" life, to a place to reflect on the incredibly powerful moments laced into and around my chosen profession. But what this blog is is far less important than the purpose is serves... to remember the process.

So I plan to keep on writing. I have no idea how this space will change, only that it will change along with me. Hard to believe over 60,000 of you have been here to this point, but hopefully a few of you stick around for the next chapter. Because tomorrow I'll put on a long white coat for the first time, walk into the hospital, and get to be Dr. MedZag. And I'm sure it'll be a process.

Survey says...

Oh, hello. Didn't notice you there. Been distracted with this thing called "life" the past 2 1/2 months. Amazing how as my clinical responsibilities tail off, other things find a way to take their place.

Anyways, time to share the verdict. As I had said before, I was a late switch onto the ENT track (during the first half of my third year) and I approached the match process with more than a bit of apprehension. I was a good student, sure. I had the necessary board scores. But I hadn't set up any free clinics in Africa or presidented any associations or covered my walls with awards from medical school. I think I can fairly call myself a fairly "average" ENT applicant. That being said, I believe myself to be a very likable person, a hard worker, have a good rapport with patients, and I tend to be efficient & pick up things fairly quickly. As a result, I feel like the feedback I received from residents was that I was someone they would absolutely love to work with, and that I would interview very well. I think my LORs represented that fairly well.

I think it was difficult for me coming from a medical school in which a lot of students go into primary care and very few (4 in the last 5 years) go into ENT. I felt like I didn't have a good roadmap paved by former grads like some of my classmates did. I applied to 45 programs, which felt like an extraordinary amount of programs compared to my peds/FM/IM classmates who were applying to 15-20. In hindsight, I probably would have applied to 15-20 more.

In the end, I was probably lucky, but I net a good number of interview offers, and attended 11 interviews. The ones I did not attend were primarily due to conflict with other interview dates and inability to get to the destination program on time. So I basically accepted all comers. I ranked all 11 programs I interviewed at, because, on a whole, I was blown away by the quality of ENT programs across the board - seems like there really are no bad programs out there.

Making the rank list was incredibly difficult. I felt like I was perseverating over minor shades of gray concerning issues that really aren't that important for the quality of your training. But you need to sort out programs in some way, so I had to choose some points which were more important to me than others. The most important thing driving my rank list was the surgical volume and quality of surgical training. Overall, when I asked myself "what is my real goal in residency?", being comfortable with performing the breadth of ENT procedures was my #1 priority. Along those lines, I also ranked programs higher if they had a well rounded faculty and a good track record of sending graduates into both fellowship and private practicen and departments that were stable and growing. Second most important was the intangible camaraderie I felt amongst the residents and with the residents and staff. I favored programs where I could see myself having fun at work over programs where the residents tended to work then go home to their lives. The size and atmosphere of the city of the program also played a factor. Less important to me was weather, distance from home, cost of living, call schedule, etc.

I consider myself a fairly even-keeled person, and I didn't work myself up too much over the whole match process. But the week before match week, my id kicked in. I had nightmares I didn't match because I didn't certify my rank order list. Dreams I matched at my #1. Nightmares I matched at my home program but was failing as a resident. The subconscious is a crazy thing. The Monday of match week was one of the most nauseating mornings of my life. I'm lucky I am on a clinical rotation and had rounds to distract me, but from 8:30-9am, I was dreading the buzz of my iPhone on my belt. Finally, the buzz came and it took me a good 30 seconds to work up the courage to open the email.

"Congratulations, you have successfully matched!"

I don't know if what I felt at that moment was elation, excitement, or relief - probably a combination of all three. But it felt like a huge weight had been lifted off my shoulders. I didn't care where I ended up - I had matched into ENT. The rest of the week was a blur. I actually slept like a baby Wednesday night, unlike some of my classmates. But when Thursday morning arrived, the nausea returned. Turns out, I DID care where I would be spending the next half a decade plus of my life. The 30 minutes between 9 and 9:30am, mingling with friends and classmates, felt like 3 hours.

The moment came, and they opened the door to our "match room" where all our envelopes were located. I got my envelope and shimmied out of the cattle drive. I held the envelope for what felt like several minutes, then opened it slowly.

I had matched at my #2 program.

My response went somewhat in the sequence of shock -> excitement -> shock -> doubt -> shock -> excitement & doubt. I hadn't really considered the possibility of matching to my #2 program a whole lot, because I saw it as somewhat of a reach for an applicant of my stature. Frankly, it seemed out of my league. So, internalizing the reality that - (1) I had matched there (2) I was actually going there (3) I was moving there in 3 months - took more than a while to process. Frankly, I think I am still processing it. But the more it sinks in, the more excited I become.

So, yeah. All those hours spent slaving away over syllabi the first two years. The grueling days spent studying for Step 1. The mindless times spent crunching charts of research in front of my laptop. The long days and late nights of third year. My sub-i and aways. The pre-rounds, rounds, and presentations. The writeups and scut. That f'ing personal statement. The countless hours spent on airplanes and countless nights spent in hotel rooms. All of it brought me to this point. The finality of it is daunting, in a way. But in 3 months, I will be moving thousands of miles away from my home, my friends and family, to start the process of becoming a physician and surgeon for the next half decade of my life. There is something incredibly intimidating and exhilarating about that reality.

2k11: Things I've Learned On The Interview Trail

Long hiatus from blogging. Hard to find time for much on the interview trail when you're constantly switching time zones, packing/repacking the suitcase, and hustling to catch the next flight. I took a true "vacation" over the holidays and checked out from anything academic... first time in over 2 years.

Anyways, with a month spent traveling, thought I'd past along some tips from my own experiences and experiences of classmates and fellow applicants:
1. If at all humanly possible, downsize to only a check on bag
Yes, checked luggage does get lost, and it does happen to medical students. The risk of your luggage going lost increases exponentially if your flight gets delayed, or you have 1+ connections, and the last thing you want is to arrive in a city without your suit. Trust me, it happens every year and it happened to a few people I know this year. So go to the store and get those little 3 oz toiletries, and make it work. If you're having trouble fitting everything, wear your suit on the plane. The peace of mind is worth it.

2. TripIt.com
Interviews can be a logistical nightmare with all the airline flights, hotel confirmations, car rentals, etc. I was lucky I stumbled across this little gem, tripit.com. It allows you to create individual "trips" for each of your interviews and keep track off all your flight information, confirmation codes, addresses of interview dinners, and even gives you maps. They have an iPhone and Droid and you can access it online from any Smartphone or laptop. Plus it syncs so you don't need web access to retrieve your info. It's been a lifesaver as far as keeping everything in one place and being able to pull it up at a moment's notice. Plus it's free.

3. Research your hotels
The "recommended" hotels provided by programs are not all nice places to stay (learned that the hard way), and often are not the cheapest or closest places. Before you book anywhere, google the hotel and read some of the reviews to weed out the stinkers. You also want to make sure you are at a place with an iron (so you aren't crumpled on interview day) and internet access (for checking into flights and for sanity). If you have a rental car or there are limited hotels in the area around your interview, you can often get away with using hotline.com to get a deal as well. At one interview, there was only one hotel by the medical campus, and even with the "medical discount" it was still $100+ a night. I did a hotline search for the area, found the hotel (even though it was hidden, I knew it was the one) and was able to book for $68 a night. These little savings add up in an expensive endeavor.

4. When possible, book extra time in a city when you visit
It's impossible to get a feel for a city when you're around only for your interview day. When possible, I'd try to get in earlier the day before or stay the night after and see the city a bit. Plus, this whole process is supposed to be kind of FUN. It's way more fun when you have time to explore a bit and try out some cool little restaurants or walk around a downtown of a city you've never been in before.

Along the same lines, if you have an opportunity to stay with friends, take it up in a heartbeat. On one trek, I had a 4 day layoff between two interviews and didn't want to fly the 2000 miles home in between, so I made a quick jump up to a city 500 miles north and stayed with a friend I hadn't seen in 7 years. Made the trip much more enjoyable and I saved some money on airfare in the process.

5. If you're going to drink, tread carefully.
Many of the social dinners are open bars, and occasionally the residents and/or faculty will take you out beyond that. Don't be afraid to have fun, but also tread carefully. The last thing you want to be known as is the applicant who was sloppy or did something inappropriate. I have seen this happen at several of the social events. Interviews are exhausting and stressful, so feel free to have a drink or two, but know your limits.

6. Take notes
After a couple of interviews, the places start to blend together. Use the flight out of the city as an excuse to take 30 minutes and go stream-of-consciousness on a tablet of paper. It helps when you're trying to remember your impressions from places weeks later. It gets old, but at the same time I have no idea who I'd make me rank list without it.

7. Exercise and hydrate
When changing time zones a lot, your body gets really confused. When sitting on planes a lot, your muscles atrophy. When eating airport food and drinking airport coffee, you gain weight and get dehydrated. Bring along some running shoes and workout clothes and hit the pavement or the hotel gym when possible. You'll feel better and sleep better. And trust me, you want to be rested for your interview day. I've had two interviews already where I was absolutely exhausted the day of and between the powerpoint presentations and repetitive questions, it was very, very difficult to stay locked in. Do everything you can to help your energy level.

8. Relax
90% of my interviews have been very casual and very conversational. Even the more difficult ones have been because of interesting personalities or "behavior-based" questions. Even the curveballs have been fairly soft, so try to relax when the interviews come up. After the first couple interviews, you'll be in a flow and already have a rote response for 90% of the questions that will come your way.

Four interviews left then it's time to create my rank list. CRAZY.

Friendly Reminders

One of the nice things about traveling so much is it has afforded me the opportunity to read-for-pleasure for the first time in several years. I just finished digesting this 500 page behemoth:

A fictional tale of twins born to a disgraced nun slash scrub nurse in Ethiopia, the tale follows the narrative of one of the boys as he grew up in Ethiopia to two physician parents working in a small mission hospital. The protagonist follows in his parents footsteps of medicine, ultimately coming to America to train as a general surgeon.

The novel is penned by Dr. Verghese, an infectious disease doctor at Stanford who, like his characters, was also born in Ethiopia. A powerful read, with an very engaging plot and many poignant moments intertwined into the story.

Perhaps the most interesting parts of the story for me where when the main character was himself on the path of medical training, both in his youth and then in medical school proper. There were some very profound statements Verghese used to describe the "transformation into a physician" and his own personal viewpoint on care of the patient. I found most of them surprisingly on-point despite the fact that the author is not a surgeon himself.

To be a good surgeon, you need to commit to being a good surgeon. It's as simple as that. You need to be meticulous in the small things, not just in the operating room, but outside. A good surgeon would want to redo this knot. You're going to tie thousands of knots in your lifetime. If you tie each one as well as humanly possible, you'll experience fewer complications. The big things in surgery depend on the little things.

I take heart from my fellow physicians who come to me when they themselves must suffer the knife. They know that Marion Stone will be as involved after the surgery as before and during. They know I have no use for surgical euphamisms such as "When in doubt, cut it out" or "Why wait when you can operate" other than for how reliably they reveal the shallowest intellects in our field. My father says "The operation with the best outcome is the one you decide not to do." Knowing when not to operate, knowing when I am in over my head-that kind of talent, that kind of "brilliance," goes unheralded.

I found the read quite inspiring as times. Too often in medical training, we get caught up in the drudgery of the day to day. Wake up, drink coffee, round, do work, go home, read, sleep. It's refreshing to feel inspired, because I can admit it is not often enough that I feel such as I trudge through my days.

Interviews are going well. Done with three, with four and five to come this week. My traveling karma has been good so far. No missed connections, flights on time. It's great to travel and experience new cities I haven't visited before. Gives me an appreciation for the vastness of America, but also for how similar we all are in ways that are not readily apparent. I'm also getting a better sense for what I am looking for in a program, but know that when it comes time to form a rank list, it's going to be insanely difficult.

That's it for now, off at the airport at 4:30am again tomorrow. Wake up, drink coffee, don suit, board plane... but then, luckily, I get a chance to reflect on where I am and what has brought me to this point. In the words of Dr. Verghese Life is like that. You live it forward, but understand it backward.

Onwards and Upwards

Jeesh, I've been really slacking on this blogging thing. Probably because my life has been incredibly uninteresting the past month slaving away in honor to the boards gods. So I successfully (I think) navigated the travails of Step 2 and its assorted clinical vignettes and fake patients. The second romp with the Step exam was not nearly as stressful or interesting as the first go. More a matter of knowing what you have to do, then going and doing it. And yes, Step 2 CS is as big of a joke as everyone makes it out to be.

This month is neurology, which has turned out to be a quite the neurocation. Which means I've replaced qbank and first aid with monday night football and hulu. I'm already starting to feel that 4th year senioritis sink in.

First residency interview invite finally trickled in today. The residents warned me that in ENT things happen late, so while my classmates have been racking in the interviews I've been obsessively checking MyERAS to see "Available, but not yet retrieved" over and over again. After a month of hearing only crickets, it's nice to finally start getting some movement. So it's back to twiddling my thumbs and hitting refresh on my cell phone email every 30 minutes.

Btw, blog crossed 50,000 visitors this week. Pretty freaking surreal if you ask me. Thanks to all who follow this site and pretend to enjoy the content. Never thought when I started this thing it would generate such attention. Y'all are great!