One day of freedom

I officially passed and completed my M2 year! Pre-clinical medical school is over! My reward is a single day off before 4.5 weeks of intense boards studying.

I decided this was insufficient and so allowed myself the following two additional indulgences:

1.) Oreo milkshake from Potbelly's. Amazing and delicious.

2.) A new pair of shoes. They are completely impractical but utterly fabulous. Who doesn't feel sexy in red peep-toe heels?

I drove this car (Mustang Bullitt) last night. It started raining and I spun it out (without hitting anything or hurting anyone). The owner was sitting next to me, totally nonplussed. He's going to let me drive it again.

It's good to be a girl.

Happy thoughts...

Dr. V on maternal mortality:

" That's about 6 jumbo jets per day that crash full of pregnant women and they all die."

Yesterday afternoon's class consisted of watching a video of a cesarean section and a second video of a vaginal birth (all the funnier because it was filmed in the '70s). You may be surprised to learn that I would still prefer a cesarean. Neither looks like fun so maybe .... no kids. But, accidents happen and in that case... I'll take the surgery.

The Good and the Bad... an update

Thumbs Up:

• I found a new apartment - a one bedroom - and will move in July
• M3 rotations are out, I got my first choice track
• No cavities at the dentist
• Passed my physical with flying colours
• My car is fixed and looks/smells new again
• Love my gym, really enjoying PT

Bummer:

• Grandma may need surgery
• A friend is sick (with something chronic)
• Research projects are lagging a bit
• Um... boards?

I will try to post something more substantial soon.

Evil Email

When you go to visit a medical school, especially one with pass/fail pre-clinical years, you inevitably hear a lot about how collaborative the students are. How they all want to help each other and work together because ultimately, medicine is a team discipline.

Reality check: Type A's don't change their spots overnight.

Exhibit 1: An email from A--- to our entire class:

Subject: I'm tired of people wearing jeans to MDC's

Text: [insert classmate's name]. Done.

Exhibit 2: 20 minutes later a second email from A--- to the whole class:

Subject: Re: I'm tired of people wearing jeans to MDC's

Text: And now sleeping during the MDC. Not cool. Way to be respectful.

You might think this kind of behavior is limited to students.

Reality check: Once a gunner, always a gunner.

Exhibit 3: Last night the entire class (!!) was accidently cc'd (do people really not notice when they hit reply all?) on this email from a pathology faculty member to a senior administrator:

Subject: GI handout

Text: Are you serious? A synopsis of Robbins textbook? Are medical students now incapable of reading, even reading stuff that may be wrong?

Exhibit 4: And then we were CC'd on the reply (apparently no one over the age of 30 can tell the difference between reply and reply-all):

Subject: Re: GI handout

Text: As a faculty member we/I cannot control what he does -that is why I sent the e-mail - he does it on his own - not a team player or collegial - he will be retired in August - just a heads up

Despite these outliers, most people are actually very friendly and collaborative. And drama-prone. Does high school ever really end?

Live from the OR

Once upon a time I did a post composed of live blogging from the ER. I thought I would replicate the concept tonight by giving you an idea of what a transplant case looks like for me.

11:07 - consent is obtained and I receive an email. I am now aware that a donor liver is expected to arrive for a patient and the surgery should occur sometime today.

17:48 - I find out the donor liver is not expected to arrive until after 10pm, that means an overnight surgery is likely.

21:11 - I call the main OR desk and they indicate a lines-in time of 11:30pm. That means the incision won't happen before 00:30am.

23:50 - I arrive at the hospital to change into clean scrubs, prep some dry ice for samples and start the paperwork.

00:18 - I head down to the OR to check on the progress. They are just finishing the echo and still have to place the radial line.

00:37 - Incision. I draw two purple tops and collect 10cc of urine. I leave the OR and head to the lab to centrifuge the samples and put them on dry ice.

01:26 - Back in the OR to observe

02:51 - Anhepatic phase begins. This is when the patient is no longer connected to his old liver and not yet connected to the new one. I draw samples and put them on ice to process later.

03:29 - Reperfusion. This is when the new liver is connected and circulation through the liver is restored. All the preservatives and biochemical waste from the new liver cause the patients heart to struggle briefly. When well-managed and with a little luck this can be short-lived and uneventful. Tonight, reperfusion goes smoothly.

03:59 - I draw samples and bring them and the pre-reperfusion samples up to the lab to process. Sometimes I stay in the OR until close, but tonight I'm hoping to catch a few hours sleep before class. If the close is within two hours of my shift ending, I will be able to draw the closing samples and leave. If not, I will have to stay until 2 hours post-op.

04:40 - The surgeons have closed, the operation is complete. This was a very short surgery, which is good for the patient, but bad for me. I now have to stay until 6:40 to do the 2 hour post-op samples.

04:50 - Follow the patient up to the SICU to get immediate post-op samples. Run back to the lab to finish processing samples already collected.

05:30 - Email an update about the surgery and schedule for post-operative draws through POD4 to the research group.

06:30 - Head over to the SICU to check in with the nurse and get the 2 hour draw.

06:45 - Head back to the lab to leave the samples on ice (the girl coming in at 7 will process it), head home to catch a three hour nap before class at 11.

Swing performance!

Last night was the performance of the swing dance we've been working on for the last few months. We all landed our big breakout moves, which was awesome! Proof that med students do something other than study ;)

Smartest or Nicest?

The NYT ran an article recently on using personality tests as part of the criteria for medical school entrance. Apparently they gave personality tests to 600 students to look for which traits correlated with future success. Big surprise, those who stressed easily did poorly and those who were extroverted did well.

The thing is - I don't agree with their proposition that doctors all need to be super-nice people. Sure, a physician should treat you with respect and courtesy, but you're not there to make friends. When did it become an expectation that your doctor also be your confident and therapist?

Let's put this another way. If you found out tomorrow that you had cancer or HIV or needed a triple bypass - do you want the nicest kid in the class or the smartest?

I know what you're thinking, can't I have both? Sometimes yes. There are some very smart people who are also very friendly. But the traits that get you through training are not the traits that win friends. In medical school and residency you sacrifice a lot of your personal time to your training; thus your relationships are neglected. The divorce rate for doctors is above the national average. You have to be willing to study for hours alone - be independent and driven. The decisions you make and their consequences are weighty; they require detachment and objectivity.

Everyone's job has stress, but not everyone will find themselves leaving their son's baseball game because their pager went off. Your patient is in respiratory failure because they developed graft vs host disease after their bone marrow transplant, which you recommended and without which they would have died. And it's not just cancer doctors - it's the primary care physician whose patient has a hypertensive crisis or a stroke. It's the ER doctor that has to call the organ donation team when a 24 year old comes in from a motorcycle crash. It's the pediatrician who pronounces the unlucky child who got meningitis or the ob/gyn that tells a first-time mom that her baby has hydrocephalus. Every doctor sees these cases in training and no practice is immune from tragedy.

Why is the system built this way? Why do we make it such a stressful process to become a physician? Are we turning good people into bitter ones? I say no. I think we're pushed because there is a lot of medicine to learn and not enough time to learn it in. We spend two years in lecture halls learning biochemistry, anatomy, pharmacology and histology - no patients in sight - a lot of which we won't use in everyday practice. But those years are the difference between a doctor and everyone else on the medical team. They are they difference between memorizing a standard protocol to treat a disease and understanding on a molecular and cellular level how the disease and it's treatments work. You can't reassemble an engine if you don't understand how the parts work.

I promise that when I graduate and begin practicing that I will make every effort to treat you with respect. I will explain my reasoning and answer your questions. I will be professional and courteous. But I will not be your therapist or your best friend. I will not hold your hand or cry with you. It will have to be enough that you had the smartest kid in the class, trained in one of the best schools, using all of their intellect to save you.

Autologous surgery

Apparently, in 1961 a Russian surgeon did an appendectomy on himself in Antarctica. It's written up in the BMJ, complete with two intra-operative photos.

Thanks Andrew, for the link.

Pre-clinical years

I thought it would be interesting to total the number of exams I will take prior to my first clerkship in medical school.

M1 year: 37 written exams + 8 anatomy exams

M2: 15 written exams + Clinical Competency Exam (9 parts) + USMLE step 1

I've also had to write 15 essays and create an interpretive art project on chronic illness.

Hilarious

Those of you who read other medical blogs have probably see this, I know White Coat has re-posted this as well, but on Tales from Serenity Now there is a great story (with pictures) about a guy trying to escape the ED.

I can't wait for my fourth year ED rotation... I had a great time working in a PA ED during post-bacc and that was only 8 hours a week.

Best moment: my hand in an open chest.

Second: being barricaded in the ED because the gang fight followed the ambulance.

Being a positive deviant

I just finished writing a couple of essays for school. One of the assigned topics was on Atul Gawande's book Better. In the book, he lists his five suggestions for being a positive deviant; basically how to be Better.

1. Ask an unscripted question

2. Don't complain

3. Count something

4. Write

5. Change

I find it an intriguing list because it bears some similarity to the ideas I try to use to not just be better at what I do, but be a better person.

1. Ask more questions than you answer. I, like many extroverts, like to talk. It doesn't have to be about me, I like explaining things, I like reading out loud, I like debating - it's a hunger to participate. The risk, of course, is that with all the talking I find I've spent two hours with someone and I don't know their name, what they do or whether they've ever been West of the Mississippi. People have interesting stories and I can't hear them if I'm the one talking.

2. Don't whine. This is essentially the same as don't complain, but he's right.

Whining is not attractive and let's face it, everyone could come up with something to whine about. Interesting people find things to be happy about. Really interesting people can radiate their optimism to others.

3. Move the goal posts. Having a purpose is important. It creates focus, creativity and energy. They key is to be flexible about goals and to have them in multiple spheres of life. For example, one of my goals is to graduate medical school, but another (more fun) goal is to get stamps from every continent on one passport. Goals are personal - it's about what you are passionate about and should reflect who you are and who you want to be.

4. Choose. It's easy to follow orders and do what's expected. It's far more fun to go out on a limb and find your own path. It's harder, to be sure, but you learn much more. That's not to say you can't go with convention, just make sure you choose it, rather than letting life or others choose it for you.

5. Try everything once. Okay, within reason. But experience is a great way to learn things and fear is a poor excuse for ending up 75 with a bucketload of regrets. Trust your ingenuity, your resourcefulness and your survival instinct - you'll live through it and you might even like it.

Why is it that I feel slightly foolish publishing my philosophy and Gawande confidently makes a fortune off of his? Oh yes, because I'm not yet an accomplished surgeon at a world-renowned hospital. Still, I don't think it's a bad list. Plus, I'm wearing two pagers and he's only wearing one...

Law of unintended consequences

From the New York Times:

Britain was planning on using full body scanners at airports to enhance security after the Christmas Day bombing attempt in Michigan. Apparently, these scanners create an image of the body being scanned, which includes the genitals and any *ahem* enhancements.

Clearly, someone didn't think this through because now they will need to pass laws to exempt security personnel from child pornography laws. Britain also has some of the world's most aggressive paparazzi - images created of celebrities as they enter the country would be worth a fortune. I can see the US Weekly now: which of your favorite actresses really has fake boobs? See page 15!

I'm in favour of making our airports actually safer (take your shoes off? 30z of liquid? please...), but I'm not sure turning everyone into a porn star is a good solution. First, why are the images saved? Second, couldn't they be auto-analysed and then only exceptions reviewed manually?And third, do we have any evidence (say, in the form of controlled trials) that shows full body scanners catch more than metal detectors and pat downs?

Prion power

I have never been allowed to donate blood in the United States. Having lived in England during the "mad cow years", I'm permanently banned from donating for fear of spreading prion disease. I've never really understood this because in order to get Creutzfeldt-Jacob disease you need to ingest contaminated brain matter (since that's where the prions are located).

A quick aside for those unfamiliar with infectious particles: there are bacteria (alive), viruses (not alive) and prions (also not alive). Bacteria are whole cells, viruses are essentially a little pod of either DNA or RNA and prions are naked proteins. These proteins are misfolded, however, and have a knack for causing normal proteins to also misfold and create aggregates in central nervous system neurons. Since prions live only in neurons, they cannot be transmitted by blood or air or droplets (coughing) like viruses and bacteria.

So basically, the US government is concerned that I am contaminated from prions but haven't shown disease yet and that somehow I will spread this via blood donation. Recent research is now showing - lucky me - that prions may actually be adaptive and develop drug resistance. This is alarming (for the obvious reasons) although currently Creutzfeldt-Jacob is a death sentence (within months) and to my knowledge we didn't think we had effective drugs.

There are several human prion diseases (no, CJD is not the only one) and all are fatal. Worse, standard sterilization procedures do not eliminate prions so it's a good thing they aren't easily transmitted. Adding drug resistance to their virulence is almost superfluous.

Please excuse the girl moment...

I bought myself a little christmas present in the post-holiday sale... the Kate Spade Opus bag. Now if only I could justify a BCBG dress...

I graduated high school a DECADE ago?!

This is a photo of me getting dressed for new years this year. It was a low-key affair with low expectations so it turned out to be an okay night. I wasn't quite back to myself -I'm still not- having just been traveling internationally. I always get a bit brooding when I return home. I don't like giving up the freedom of traveling - life is a bit too tied down and restricting for my taste. I wonder if I should have taken more time off - a whole year of traveling instead of just a few months? I also miss the person I am when I'm not here - I'm more confident, easygoing, in-the-present when I'm away.

I'm not usually very big on new year's resolutions, but this year I have a few. They are more reflections on self-improvement that stem from travel, but new years is as good an excuse as any.

1. I choose confidence. I choose to be okay with who I am. I will own it.

2. I will read more non-medical non-fiction.

3. I will stop using medical school as an excuse.

I'm going to head back to California for a couple of weeks in early April and then hopefully off to Turkey the first week of May. Hopefully that will sate the nomad in me until next December.

Victory!

As of May 2010, Michigan will go smoke-free. That means when I go out to restaurants, bars and clubs my hair and clothes will no longer reek of cigarettes! Even better, I won't be increasing my risk of practically every medical ailment for the sake of being social.

Joke's on me

I went on a date with a MBA student this weekend and during our conversation he asked how our classes work (since we don't really get electives or any control over our schedule at all). I honestly had never looked at how many credit hours we take because it never seemed relevant. So I looked it up. I also looked up the requirements for the MBAs for comparison.

Total credit hours in 2 years for b-school: 57
Total credit hours in 2 yrs (pre-clinical) for med school: 97

Years it takes an MBA to earn back the debt and lost salary: 5
Years it takes an MD to earn back the debt and lost salary: 20-40

The non-medicine side of medicine

The MI chapter of the American Academy of Pediatrics had an open forum meeting tonight, which I attended. It was interesting to attend a meeting of physicians that really had nothing to do with medicine or providing care. The two hours were spend discussing Medicaid reimbursement, disproportionate share payments and the requirements for re-certification; specifically the quality initiative requirement. I have strong opinions on all of these issues, but the one I will disucss now is re-certification.

Re-certification, which must be done every 10 years, requires four things:

1. Send in your license
2. Complete lifelong learning modules
3. Pass an exam
4. Complete an approved quality improvement project

An example of an improved quality improvement project is to plug data from 10 patients with asthma into some software which analyzes your management practices against accepted asthma guidelines. It will then suggest areas you could improve. You choose one, change your care appropriately and put the new data into the program. You can then look at how your patients are doing based on the change in your practice. The idea is to continually be evaluating your quality as a practitioner and actively identify and implement potential improvements.

My issue is this: it seems a lot like research without informed consent. The patient does not know they are part of this quality initiative. Their management is not being changed based on an individualized assessment by the physician, but by a national guideline or software program.

Apparently, if the intent is not publishing, it's not "research". I think this is an ethical gray area. Comparing your practices in a systematic way against the national guidelines is a good thing - it can help you identify ways to improve. But altering the treatment of your patients then merits thought about their individual case. I would like to believe that when my doctor makes a decision about my care, he has done so because he thinks it's best for me, not because he needs to meet his re-certification requirements. And as far as I'm concerned, if you run a systematic intervention with the intent of producing altered outcomes - that's research, published or not.

Lastly, patient outcomes are reliant on two (controllable) factors: the ability of the physician and the compliance of the patient. The physician can follow all the guidelines, run the right tests and prescribe the right meds, but if the patient doesn't take responsibility, the outcomes are still going to be poor. We should absolutely measure and track physicians performance, but we have to remember that the doctor cannot be there every day to put a pill in your mouth, put the ice cream away and get you out the door for a run.

For example, the pediatricians were discussing how they are held accountable for vaccination rates in their practices. Some parents simply don't make appointments and don't bring their kids in, so those kids hurt the physician's numbers (which hurts their reimbursement). The docs were seriously considering renting a van and going to the local school, rounding up the kids who hadn't shown for the vaccinations and vaccinating them. Are you kidding? In order to get paid for the services they provide the kids who do show up they have to track down all the rest and accost them at school? I'd rather fine the non-compliant parents. The money would help pay for child health insurance, incentivize care and remind the parents of a little thing called personal responsibility.

Wednesday night procrastination

My much-anticipated new shoes came - limited edition pinstripe Jack Purcells. I love them. Super preppy with a twist. So perfect. They took their inaugural walk to get me to IV clinic and back.

IV clinic is where the emergency department docs teach us how to place IVs and subsequently give us equipment to practice on each other. My friend J and I stuck each other three times. It turns out placing IVs in the hand is both more difficult and more painful than in the arm.

I watched the premiere of Scrubs season 9 and was disappointed. What the hell were all the first year medical students doing on rounds, in scrubs and working with patients? Your first two years (until you take and pass the boards) you are lucky if you shadow rounds - you are definitely not let loose in the hospital. Not to mention you would definitely not have a class called internal medicine before you've completed something as basic as anatomy. C'mon writers. Seriously.

Speaking of boards, I've turned in my registration for mine. I'm aiming for April 26... USMLE step 1 is officially on my radar.

I haven't been in the OR since Oct 14th, but I'm on call this Thurs-Sun. Here's hoping for a liver. Except maybe not Sat night (day is fine) because I have a date and I would kinda like to make it. Even if I have to show up with a pager and track marks (from IV clinic). Actually, Sat would be a good time to get my autopsy requirement out of the way. So here's hoping for a dead body and a life-saving liver, all in one weekend.