Little m, big P

It occurs to me that I haven't really talked about residency applications, which actually comprise a lot of time and mental energy during the beginning of M4 year. I'm applying for a medicine-pediatrics residency. It's a four year program, at the end of which you sit the boards for both internal medicine and pediatrics. You are then eligible for any fellowship in either medicine or pediatrics, though 60% of graduates go into primary care. Not me - of course - I will be headed to fellowship.

There aren't very many med-peds residency programs, and each one takes very few candidates. Thus, this residency is competitive because demand outstrips supply. Nevertheless, my advisors tell me I will match.

For those of you who don't have relatives in medicine, I will briefly mention what "the match" is. Basically, as a 4th year you apply to some residencies. The ones interested in you will invite you to interview. You rank all the places you interviewed. The hospitals rank all the people they interviewed. It goes into a big computer program called the NRMP. In March you get an email telling you where you matched - not all the places, just the one place you will go to. It's not a choice and you are not guaranteed to be chosen anywhere. Rather appropriately, this process causes a tremendous amount of anxiety - will I match at all? Will I match somewhere I actually want to go?

Right, so I've been told I will match, it's just a question of where. My current list of programs is 19 deep and I hope to get 10 interviews. I've had to get four letters of recommendation, two of which must come from the chair of the peds dept. and the chair of the internal medicine dept. I have to get a letter of endorsement from the dean of the medical school as well. I have to put my CV and all my publications into the online program (one item at a time). I have to provide transcripts and copies of my USMLE step 1 and 2 scores. I have to write a personal statement and include a photo. I have to pay money (of course). All of this gets submitted September 1st, so you can imagine the past three months have been spent getting all of this together. But soon - so soon - I hit submit and then... I wait. Wait and hope. Hope for interviews.

I will keep you updated.

Heartbreak cardiomyopathy

This month I had a patient with an interesting and rare condition called TakoTsubo Cardiomyopathy, also known as "broken heart syndrome." It involves myocardial stunning after a highly stressful event such as the death of a spouse or a natural disaster. Basically, you are so overwhelmed that you literally go into heart failure. The physiologic mechanism is incompletely understood, but leading theories revolve around catecholamine release. Thankfully, the significant majority of people recover their full heart function in days to weeks. It is most commonly seen in Japanese post-menopausal women, however it has been described in the US and Europe as well. It can be accompanied by an NSTEMI (heart attack) and frequently QT prolongation (repolarization abnormality - sorry, I don't know how to translate that better without a tutorial on EKGs).

It gets its name from Japanese octopus traps. Why? Because this particular heart failure displays what we call "apical ballooning." Basically, the upper and middle parts of the ventricle contract, but the apex (the point) of the heart does not. That means that blood, which is ordinarily squeezed from the bottom of the heart towards the top, is now being simultaneously pushed up and down. the down-going blood has nowhere to go so the tip of the heart balloons out (see diagram).

My patient began recovering heart function very quickly, but her QT prolongation was impressive. Almost write-it-up-in-a-journal impressive. Thankfully, that also resolved quickly. We never got a good sense of what her precipitating event was, but I suppose all stress is relative.