Big Boy Pants

Intern year is a weird limbo of sorts. In some ways, you're still like a medical student(+). Your activities consist some days mostly of carrying out other peoples orders throughout the day. The things you do handle independently are mostly algorithmic. Manage this patient's pain regimen. Work up this patient's chest pain. Evaluate this patient's shortness of breath. Put in this patient's admission orders. Anything beyond that, you are generally encouraged to page up the food chain to residents above you (or discouraged from handling these things on your own, depending on how you look at it).

But the other day I had to put on my big boy pants.

Due to a combination of the chief resident being out of town, one of our residents being post call, and the last one being in the OR all day, I was gifted with the responsibility of handling the otolaryngology consult pager for the day. The ENT consult pager is an interesting beast. Most of the time, our consults are something very benign and not particularly time-sensitive. The little old lady with an incidental mass found on imaging when she presented with stroke symptoms. The level 3 trauma with the mandible fracture. The cheek laceration in the motor vehicle accident. But the consult pager is also a terrifying thing, because it is also the emergent airway pager. These are very rare, but present. So every time the pager goes off your heart rate jumps a couple clicks.

Luckily, I escaped without an airway emergencies. However, I did pick up an emergency department consult later in the afternoon. It was supposed to be a curbside consult. "We have a patient with sinusitis and I was wondering whats the best imaging test to order." I ask to hear more about the patient, and there was enough concerning bits about the story I say "you know, we should probably formally consult and lay eyes on this patient." Go to evaluate the patient. Run the story by the chief on call, who is already home for the day. Get the imaging ordered. Read through the images with the chief, and decide the patient has to go to the OR. Immediately. Staff with the attending on call. Get the case booked, talk to the ED resident, explain the findings to the patient, answer questions, get the consent.

As the patient is being wheeled into the OR, the chief and attending still have not shown up, and I realize... I'm the only person who has physically seen this patient.

The necessary powers show up. The attending sits at the computer checking email and the chief ends up taking me through the case in its entirety. Whether it was luck or whatever may be, I end up being right, the operation was appropriate, and everything goes smoothly. With the case complete, I put in the admission orders and go and talk to the family.

When I finally get home later that evening, I think back on the whole sequence of events. It was a fairly straightforward consult. But I was the one who decided we needed to formally consult. I was the one who saw the patient, took the history, performed the physical exam, performed the endoscopy, and ordered the imaging. I was the one who talked to the patient about the findings, talked about the implications, obtained consent, booked the operation, performed the surgery, and talked to the family afterwards. From the patient's perspective, and from the family's, I was the only person they had seen and talked to. I was their doctor.

That was a profound feeling.

I know that is the endpoint for residency, to be able to independently evaluate and treat patients who come under you care. And I know that my chief and attending had my back, and if it wasn't something straightforward, they would have been there to see things over in person. But for someone still so green at all of this, it was a refreshing (and, in some ways, terrifying) experience to be the point person for everything.

The patient did great and went home the next day. I saw him on morning rounds, staffed with the attending by phone, and put in his discharge orders. He is scheduled to follow-up with the attending surgeon in two weeks for post-operative care. And part of me wonders what he will think when he shows up for his appointment and my attending, a person he never met, opens the door to the exam room.

I think I'll try to be there.

*ahem*

I am alive. I am loving residency. I have lots to write about.

Soon.

So are you going to be doing my surgery?

Residency is very different from medical school.

(Thanks, Captain Obvious.)

I had a flashback this week to our "orientation to the clinical years" just before beginning my third year of medical school. I remember the out-going third year trying to coach us on various things - like writing a good note, making a good presentation, etc. I remember asking "So, what does do you do as a third year?" He gave some answer involving "helping with floor work, updating the list, faxing for records, following up on labs, ad infinum", and I remember thinking by the end of is "Yeah... but what do you DO?". I ahd not tangible mental image of what my days would be like. As I discovered over the next few weeks, you can't really understand it until you have to do it.

I think the same goes for residency. Sure, you have a lot of interaction with residents as a student and you get a sense of their responsibilities and how a resident's day is structured. But you don't really understand until you have to do it. A few of the key differences I've found include:
1) There's way more things competing for your time than you have as a student. At any given time, this includes: managing patients on the floor, discharges, seeing patients in clinic, logging procedures, prepping for conferences or tumor board, teaching time, self-guided reading time, prepping for OR cases, didactics, preparing a presentation, practicing basic surgical skills, graded laparoscopic assignments, and maybe a research project or two. As a student, you also had some of these requirements, but if you skimped a bit someone may or may not notice, and no harm no foul. As a resident, if you don't do them, they don't get done, and someone always notices.

2) As a student, you try to know everything about your patients. As a resident, you need to know everything about your patients. There's redundancy in teams to help mitigate this, but there's always the possibility that you may be the only person to follow-up on a lab or check a vital during the day. And that may end up being critical to the patient. It requires a great deal of focus throughout the day to remember to follow-up on things when there's a myriad of other issues continually competing for your focus and attempting to distract you.

3) As a student, you study a lot, but your primary motivation is often your grade. Sure, you convince yourself to read sometimes because "you need to know this for the future" but that often becomes much less of a motivator than impressing those that will evaluate you or an upcoming shelf exam. You also jump around every month, so you reading often will be a sample platter rather than a 4 course meal. As a resident, you read because you need to know the information. Not just because its expected of you, but for the good of your patients. Reading is more intensive on given topics and can feel more exhausting - I feel like I need to hang on to everything that passes in front of me because it is all important, and I feel like there's so much to learn and retain and I want to tackle it all at once.

4) Your skills explode by sheer repetition. As a student, you develop certain skillsets, but the next month you're on to a new discipline and most things you learned pertinent to a specific field fade away. As a resident, the skills you need to learn how to do are the things you are doing every day, and you do them over and over again.

5) The attendings really do rely on you. There was talk at my medical school that a good student is always "value added" on a service. As a resident, you are "value needed."

I think it all comes down to a switch in the manner of your responsibility. As a student, you try to take on as much responsibility as possible. But a lot of it is faux-responsibility (both for medicolegal and practical reasons). As a resident, you continually accrue more and more responsibility over the care of your patient.

I was in clinic the other day with a pleasant patient. I went through a lot of the things I had practiced in medical school - took a history, did a physical exam, developed a plan, went and presented the patient to the attending. The attending came and whirled through the room, checked a few things, talked to the patient about surgery, then left me with the patient to consent them for the procedure.

As I shook his hand as he walked out the door he asked, genuinely: "So are you going to be doing my surgery?"

I think that encapsulates the big switch that occurs in residency. You turn from purely a student into a provider of care. Over the coming years, I will read about the patient's condition, I will learn how to do his surgery, I will learn how to manage patients like him post-operatively. And I will do it not just to provide care, but the best care possible for that patient. Residency is about living that mantra.

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.

Still alive, on Q3 call.

In the surgical and trauma ICU. So busy I haven't even submitted a preliminary rank list yet. Gulp.

Will recap interview season soon. Sounds like a good call night project, as long the patients stop trying to die.

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.