What I hate most about the night float experience are the surprises.  When I show up in the evening, I get signout from 3 people who are exhausted from a long day’s work.  They want to get out of there so they fly through the events of the day.  If something happened that may happen again overnight I will ask about it, find out more, etc.–is the patient ok?  can this happen again?  what did you do for it?  did that work?  what did work?  who did you talk to about it? 

 This is good for me and good for the patient.  This is not good for the person who is trying to go home.  As a result, signouts go something like: patient x, nothing happened, doing great no worries; patient y, good day, nothing for you to do, etc.   The problem is when I get a signout like: patient z, “his creatinine bumped a little, has repeat electrolytes pending tonight, shouldn’t be a big deal, just check on them, and, oh yeah, his pressure was a little low so I gave him some fluid.  Not big deal, nothing for you to really do.”  [As an aside for those of you who don't know, creatinine is a reflection of kidney function and the higher it is, the worse that the kidney function is].  The next thing I know (of course, 15 minutes after the day guys have left), I get a page that the patient’s blood pressure is now 65/40 (very low–not good), having mental status changes (i.e. acting weird, suggesting not enough blood to the brain) and now his creatinine is 3.5 (not good at all) with a potassium of 6.2 (rather high, making the patient susceptible to fatal arrhythmias).  Oh, and did I mention the patient has a new oxygen requirement (needs supplemental oxygen–i.e. room air is not enough)?  Yeah, not good. 

I find that the night float resident is not too different from someone who goes out to buy a used car, while the day folks are the used car salesmen.  “Oh yeah, no problems!  No problems at all!  It’ll run perfectly smoothly!”  Uh huh.  My example is not typical, but it happens.  I wish you could blame the system but at the end of the day it comes down to apathetic residents who want to get the hell out of there and go home.  After a while you get to know these people so I know what to expect.  Then I still end up having to spend a decent portion of my night trying to find out what happened to these patients during the day so as to anticipate problems at night.  It really irritates me.  Don’t get me wrong, I want to go home too, but not at that expense. 

In any case, time for sleep in order to get ready for the big game tonight: 45 patients, 4 of them are really sick, 2 of them could die–try to figure out who they are!

The life of a resident.  Painful.

Enough–I’m going to bed now.

I was discussing with a co-intern of mine some of the things we learned this year and our mutually agreed upon top lesson learned was how to take abuse.  Again, I’m chuckling while I write this, but it really is true.  Don’t get me wrong, we did learn A LOT of medicine and number two on the list is how comfortable we all feel taking care of patients on the floor.  But, number one is definitely how to take abuse. 

In some ways, you have to train at it.   Taking abuse that is.  And that’s what part of this year is for I guess.  There’s always the possibility for getting chewed out.  Every day, there are at least 50 things that I do, which could earn me a major chew-out.  Not through any irresponsibility, not through any laziness, not for lack of caring, not stupidity but just because.  There is so much shit to sift through–all simultaneously–that you’re bound to get caught up on something.  Take for example the time I was presenting a newly admitted patient and I quoted some findings from a previous discharge summary dictated by a random attending who was not part of our team.  This attending just happened to be sitting within earshot, and screamed at me–interrupting our AM rounds–that the details of my presentation were totally wrong, that all interns are lazy, that I’m lazy, that I didn’t do any work, that I didn’t read his notes, etc.  Now, what he was yelling at me for being wrong about was stuff that I took directly out of his notes.  Makes no sense right?  No sense at all. 

So all at the same time, I was dealing with a random chew out, dealing with the embarassment of getting chewed out in front of my team and on top of that, dealing with an attending who was yelling at me for not doing what I actually did do.  All of this on total sleep deprivation and you about lose your mind.  I remember just standing there trying to make sense of it all, and just saying “yes sir, yes sir, yes sir” (always a safe response) until I figured out what had just happened.  Except by the time I realized that I was just nailed for no reason, everything was over.  In hindsight, there was nothing that would have been worth doing at that time except for saying “yes sir”.  This guy was a complete ass who was having a bad day and had his facts mixed up, which he took out on me.  Fair?  No.  Normal?  Kind of. 

These days, I take that stuff with a little more grace.  I still keep my mouth shut and absorb it but I don’t get flustered and I keep my poker face on.  What else can you do?  I’ve seen so many different permutations of being treated like shit that I’ve been there, done that for most of my intern-related chew outs these days. 

I know that I still know there’s a world of shit out there just waiting for me.   But I’m up to it.  I think.

As some of you know, I’ve been in the midst of intern year of my residency.  At some point in the winter, I backed off on the blog.  Too little “me” time.  Working as many hours as I had been (officially 80 hrs per week), there was little time to get any of my personal business done, let alone blog on a consistent basis.  But, I’m gonna try to get back into this.

Let’s try, shall we? 

More to come soon…  !

• accessibility: does the mentor have an open door and an approachable attitude?  is the mentor around or often away on trips/conferences?
• empathy: does the mentor have insight into what the trainee is experiencing?
• open-mindedness: does the mentor have respect for the trainee’s individuality, autonomy, working styles and career goals that may be different from mentor?
• consistency: is the mentor reliable in action and principles?
• patience: does the mentor understand that success can sometimes depend as much on luck as hard work?  does the mentor understand that people make mistakes and learn at their own rates?
• honesty: does the mentor communicate truth–whether good or bad–about the trainee’s work, the world and the trainee’s chances out there
• savvy: does the mentor have a sense (and communicates it) of the pragmatic aspects of career development?
• loyal: does the mentor value the trainee’s contributions and support as well as defend the trainee from outsiders trying to take advantage of the trainee?

I have previously written at length about finding a good mentor for both the research and medical careers and what a good mentor can mean.  I harp on this point over and over again because good mentorship is key to kicking off a successful career.  So if you are looking at a prospective mentor, try to hone in on these qualities and when talking to the mentor’s trainees in private, specifically ask.  Better to find out sooner rather than later when it may be too late.

Ever wonder why the smell of menthol can cause an enhanced feeling of air moving through your nose?  In another post on the use of nasal irrigation for allergies and sinus problems, I mentioned that nasal rinses with menthol may help with the symptoms of nasal congestion.  Why is that? 

The epithelial cells that comprise your nasal mucosa (the lining on the inside of your nose) have special temperature sensors on them, which belong to a family of proteins called TRP channels.  When you take a deep breath in, cooler air (than the warm air in your nose) whooshes over those receptors which sense “cold”.  This positive “cold” signal is relayed to your brain, which interprets it as “air is moving through my nose”.  Menthol is chemical that activates these receptors without requiring the cold air to move through your nose.  This is why when you are congested (i.e. not moving a lot of air through your nose), but you (for example) use either a nasal rinse with menthol or Vick’s vaporub, your nose feels as though it is opening up.  For more information, check out these studies by Lindemann et al (more clinical) and Bautista et al (more basic science).

Pretty neat, huh?  Now if I can only find something to relieve the sleep deprivation associated with residency.

Hmmm….

Although these days I’m not so sure that my white coat even has much power left.  Maybe it’s all the dirt and nastiness on it. 

You may have heard about the “white coat effect”–that patients tense up around physicians (e.g. in the doctor’s office) and their vital signs, like blood pressure, may be on the high side.  The last few times I’ve been in clinic and manually taken blood pressure on my patients, their pressures are just fine.  So either I have a calming effect or my patients aren’t taking me seriously.  My money is on the latter.

  Time moves quickly.  I’ve been going through the drill for about 4-5 months now and I’m sometimes so focused on surviving that it is easy to forget how many stories–interesting, tragic, or even annoying–happen everyday, for like a hundred years and to go on for even longer. 

  Makes me feel like a pimple on the ass of this hospital.  I’ll come and go.  Many came before and many will come after.  And maybe, just maybe, I’ll manage to turn into an abscess that needs to get drained and those who come after me will look at my scar and wonder what pain in the ass did that.

  Then I look down at the chart or an old note and see “end stage renal disease (ESRD)” and I know I’m screwed.  These patients are almost always quite sick with a lot of medical problems.  The reason is that people don’t typically lose their kidneys for no apparent reason.  And to lose significant kidney function usually requires a lot damage–in other words, a lot of chronic systemic diseases.  This usually means hypertension or diabetes.  Not so fast there because long term hypertension and diabetes cause a whole host of problems from heart disease, cerebrovascular disease and peripheral vascular disease in general–all of which make medical management much more painful.  Pain pain pain pain. 

  A patient that should be nicely and quickly tucked in becomes the dude you spend all night figuring out what to do with and then you are worrying about every second until you get your eyes on him again no matter how carefully you manage him. 

  Bottom line: don’t these people know that I need a break??!?!!?!?  Why do they have to be so sick? 

  Welcome-to-walmart-guy, M.D., Ph.D.

  That’s funny.  I’m going to bed now.

Mudphudder before graduate school

I’ve made out pretty well for myself but I am constantly reminded of choices that I could have made better.  Much better.

Examples: (have I complained about this stuff before?) an acquaintance for scored 3 articles in the C/N/S journals all in the same week.  If you added the impact factors of all of the journals I’ve published in (double digits), it wouldn’t come close to the impact factor of one of those journals.  Former co-graduate students who formed “alliances” with each other and now they all appear on all of each other’s papers.  I look at the author lines on those papers and I see 12 names but know that only 3 people did 99% of the work.  Bullshit.  Yeah yeah I know that those papers are just meaningless filler on the C.V. but when you have your work too, a few extra lines doesn’t hurt.  Bullshit.  I won’t even get into the social structure around the alliances in our old lab.  But it was there and now all of those wankers end up with like 10 extra papers for nothing.  Maybe I should’ve hung out with them more often. 

Mudphudder after he looks up old labmates on pubmed

Sigh, I definitely could’ve made better choices.

God, this looks like a retarded show.

Has anyone else noticed a recent slew of medical tv shows coming out?  So far I’ve noted several new tv shows about nurses and at least one about EMTs.  All (at least from the commercials) greatly romanticizing the roles of each group–here’s a line from a commercial for a TV show about EMTs called “Trauma”: “when everyone runs away from a disaster, they run towards it”.  Ahahahahahahahahahahahaha!!!!  Most of them are too out of shape to “run” towards a disaster.  AHAHAHAHAHAHAHAHAHA!!!!  I’ve met some pretty good and knowledgeable EMTs but I’ve met some really bumbling ones too.  My favorite was the one who walked out of the ED with an apple jammed in his mouth and the location of the chest pain patient’s EKG rhythm strip unknown (probably in his back pocket). 

I don’t remember any lines from the shows about nurses but I do remember a lot of nurses yelling at the

AHAHAHAHAHAHAHA!!!!

actors who are supposed to be the doctors.  Maybe I remember that because it hit so close to home.  I’m pretty sure that for TV viewers, like for me, watching nurses annoy the shit out of doctors will get old FAST.  I mean, how many different ways can the writers come up with for whining and complaining, interspersed with pages to the overtired, overworked resident at 3am that says: “FYI: pt XYZ’s BP- 120/70, HR- 76, T-98.6″.  IS THAT WHAT YOU WOKE ME UP FOR????  Arrrrggggghhhhh!!!!!!  (note those are all normal vital signs). 

The shows on TV about doctors are just as bad AND we’re portrayed as a bunch of bumbling malcontents (which, to be fair, may not be that far from the truth).  Sometimes I actually think the reality TV shows about doctors are the best because you get to see the real life dysfunction. 

Okay, let’s hold it for a second.  If it came across that way, my intention is not to hate on anyone.  Nurses, EMTs and doctors–there is a gradation of quality terrible to really great as well as a gradation in their aproach to work from just a job to a calling.  There’s nothing romantic about it.  In fact, the same person can be superstar or dud depending on the day of the week.  Take me for instance, there are days when I hate life and the rotation I’m on and then there are days when I’m a freakin’ inspired doctor.  Very much like the dude at your local footlocker who sometimes hates life because he sells shoes for a living but then sometimes takes the approach that his job is important because he helps people find comfortable shoes.  Whatever.  Most of the time I would think that medicine is not that interesting to the lay person.  Hell, I wouldn’t want to watch most of what I do on TV.   Fillng out paperwork, fighting with everyone from other doctors to phlebotomy to the freakin’ CT scan techs in order to get something done.  It’s usually the end product of a lot of uninteresting stuff that is cool–a patient who is healthier.  Note that I didn’t even say cured because there is very little that actually gets cured.  Does that sound interesting, dramatic or romantic to you?

This is residency incarnated and he wants to kick my ass.

lifestyle/job but sometimes it feels like that. There are days when I feel like there are older residents even nurses who have that look on their faces of “is this the day that he cracks”?  And mostly it feels like people are looking on in eager anticipation rather than in empathy.  I’m not saying that anyone purposefully does anything with the intention of causing one to cry (mostly at least–going through the process of residency has definitely fucked up a few people in the head).  But I’ve definitely gotten the evil smile. That would be the one I get in response to the look of abject terror when after AM rounds I look down at my census of 40 really sick patients each with a bunch of empty boxes next to their name that need to get checked off.
  I’ve come to the realization I’m living in a Rocky movie. (Note that whenever I need to find an explanation for the seemingly inexplicable, I turn to the universal wisdom of Rocky). In my version, residency is like Ivan Drago, where he stares Rocky down and he’s like, “I must break you”.  In fact, Ivan Drago says like 6 things in the course of that movie:

• “You will lose.”
• “I cannot be defeated” “I defeat all man.” 
• “If he dies, he dies.”
• “I must break you.”
• “To the end.”

 All of which suggests to me that residency is willing to go the distance and has only the singular goal of crushing me.  At least in my version, I’m Rocky.  Then again, Rocky did lose like half of the fights in his movies…

 Fibromyalgia, meaning muscle and connective tissue pain (also referred to as FM or FMS), is a medically unexplained syndrome characterized by chronic widespread pain and a heightened and painful response to pressure (allodynia). Other core symptoms are debilitating fatigue, sleep disturbance, and joint stiffness. Some patients may also report difficulty with swallowing, bowel and bladder abnormalities, numbness and tingling (paresthesia), and cognitive dysfunction.  Many patients diagnosed with fibromyalgia also have psychiatric disorders.  Because fibromyalgia involves more than just pain, the term “fibromyalgia syndrome” is often used; not all affected persons experience all associated symptoms.

Also, nor is this post meant to bash fibromyalgia.  However, if the disease process isn’t clear to you or you’re confused, then you’re starting to catch on.  Clinically, fibromyalgia is diagnosed with the following criteria (from the Mayo Clinic):

•  
  • Widespread pain lasting at least three months
  • At least 11 positive tender points — out of a total possible of 18

Seems kinda wierd to me.  But that’s probably the just the fear of the scientifically unknown coming out in me.  I’m not trying to be sarcastic either.  I believe that there is probably some pathophysiologic process underlying fibromyalgia but who the hell knows.  These patients are definitely experiencing “pain” but what is the source of that pain?  Is there even a tangible source?  When you think about it, pain is really just our subjective interpretation of noxious stimuli.  You can have noxious stimuli without pain (e.g. with anesthetic), and you can have pain without noxious stimuli (called allodynia). 

  I gotta be honest here, after all that I still don’t know what the hell this disease is.  I mean, I’ve been in constant pain since July and my whole body aches but I’m pretty sure that’s from getting my ass kicked on a near-daily basis and not fibromyalgia.   But I digress. 

  Anyway, is it just me or are most of these fibromyalgia patients a little weird?   (Losing readership losing readership… AHAHAHAHAHAHAHAHAHAHA)  NOTE: I did not say ALL–just most of these patients.  I don’t know if there’s some pathophysiologic connection between the cause of pain in these patients and weirdness (I mean like borderline schizotypal weird and not ”enjoys lobster-flavored ice cream” weird), but there you have it.  My personal “N” for seeing these patients is small but I’ve heard it from a lot of other physicians too.  Probably insensitive pricks like myself.  But to be fair, I don’t know if it’s on the patient or if it’s on the doctors.  Most of these patients’ doctors I think get so frustrated with their non-specific and recalcitrant symptoms that they end up putting these patients on so much pain killer and anxiolytics that it would be hard not to be nuts.  Actually, now that I think about it, everyone I’ve seen with fibromyalgia has been on a shit-load of meds so this could very well explain it. 

  Probably a little of both.  But find out for yourself.

As an MD/PhD student residency interviews tend to take a unique twist as there is the very obvious 4-6 year old elephant in the room, which clearly differentiates us from other candidates who went straight through medical school.  Below are some questions/issues that came up during my residency interviews and those of some fellow mudphudders that I felt were particularly specific to being an MD/PhD student.  (Note that while these questions/issues may be more likely to come up if you are an MD/PhD student, they may be likely to come up as well for medical students who’ve taken a year or two to do research). 

• The one issue that came up and I felt particularly annoyed about was how I would feel taking orders from people younger than me that may be more senior in the residency program.  I think I’ve written about this before, quite annoyed, in that this question quite frankly implies that MD/PhD students are all arrogant asses.
• You will get questions about your research.  This should in theory be really easy address since much of graduate school is spent describing ones research for presentations and in articles.  Most questions will require a superficial but eloquent answer/explanation but you will occasionally get quite in-depth or more involved questions.  The most involved question was actually a very open ended one where an interviewer asked me to describe one project that I worked one from start to finish.  The impression I got was that they wanted background, methods, etc.  So I just slammed them with my thesis seminar.  I had given that talk so many times (from previous lab meetings) that even though I hadn’t given it for about a year, I had it memorized stone cold.  Just know your research backwards and forwards.  This isn’t really something that you practice the night before the interview (although you should), this is just something that will come over time with practicing this over and over again.  Sounds painful but remarkably similar to what I’m going through in residency right now…
• You may be asked if you would want/willing to take time off during residency to do research.  This may be particularly important to some programs or residencies in general.  Know if this is the case and be prepared to respond as truthfully as possible because you will be held to your word.  If you don’t want to take more time off in the middle of residency, then you should explain why.  I’ve written about my personal opinion about research during residency before.  In short, I think it’s worthless for an MD/PhD student.  But you need to come up with your position and be able to eloquently explain/defend it. 
• One question I often got was regarding how my phd research would be applicable to my chosen clinical field.   In short, it didn’t superficially but the benefits of graduate school go so much deeper.  I think I’ve written about this before in response to a reader’s question.  Read on to be reminded of my annoyance. 
• You may occasionally get few comments on the quality of your publications.  Some good and some bad, meant to get a rise out of you.  Don’t fall for it and don’t take it personally.  You will spend/waste a good chunk of your scientific career having to defend your work against pointless criticism so get used to it.
• You may be asked about how your lab experience might be beneficial to your time on the wards.  This is a freebie so be ready to nail it.  I personally took the approach that many lab experiences can be used to illustrate my capacity to handle the wards.  For example, working in a team at all levels from a newbie to being a leader, dealing with problem coworkers, thinking on your feet, bringing different people together to solve a common problem, etc.  If you are lucky enough to get this softball, make sure you knock it out of the park. 

Here are some questions posed to me by the reader who’s pushed me most into writing this post:   

• Were you a prized possession?  Yes and no.  It really depended on who and where I was.  I think it definitely gives you an edge but then there some fields and some programs where everyone is a mudphudder so sometimes it doesn’t really seem to help much at all.   
• Or perhaps treated with bemused disinterest by non-reseach/clinical-only faculty? Sometimes.  But in my opinion, it’s then on YOU, the interviewee, to find a connection between you and the interviewer that will spark an interesting debate.  Once again, you will spend a good portion of your scientific career trying to get people to be excited about your work (i.e. see the significance of it) for funding, if for no other reason.  And, interviews, if nothing else, are a test of your ability to engage your interviewers in a positive way.  When I found myself in a situation where a clinical faculty member didn’t know too much about my area of research or just wasn’t interested, I tried to find a way of communicating the significance of the work in the bigger picture and relating it to something the interviewer may have been interested in.
• Were you ever challenged with specific questions about one of your publications or asked to give a formal presentation of your work (I know the latter has happened with people).  Yes–see above.
• Also, did you consider any of those PSTP programs that combine research with residency? Yes, but you need to be careful to weigh the pros and cons of these programs.  Namely, the advantage of getting to post-doc level research sooner vs. the hit that you will obviously take to your clinical training. 

If anyone has anymore questions regarding the mudphudder experience in residency interviews or if you any particular insights you’d like to share, feel free to leave a comment.

When I get home, I’m usually okay.  I’m wired from being awake for that long and I’m usually hungry so I’ll get something to eat.  I’ll get home and plop down on my couch, unwind with a little tv.  Usually it’s just the notion that I need to sleep that makes me go to bed rather than passing out.  That’s a little weird but I think I get pretty wired when I’m on overnight call.  Anyway, as soon as my head hits the pillow that’s when I realize how tired I am.  And then I’ll sleep for 3-5 hours before I’ll get up and take care of a few errands with the remaining hours in the day. 

Damn.

This is when the hangover hits you hard.  After the post-call nap or snooze.  You’re tired but you know you have to get up and do something.  Errands, go to the gym, goof off, whatever.  But you have to take advantage of being home early.  You’re a little anorexic from your internal clock getting thrown off and food doesn’t taste quite as good.  You’re just–off.  But for me, the most troubling part of the post-call hangover is what I call donkey dick breath.  It’s a bit of a misnomer in that it’s not really my breath but more a nasty taste in my mouth.  As though during the period that I was asleep, there was a donkey dick in my mouth the whole time.  (I will stipulate at this point that I don’t actually know what a donkey dick tastes like but I would imagine that it tastes something like this.)  Anyway, I’m not sure where the donkey dick breath comes from because I brush my teeth before and after sleeping and strangely it only happens after my post-call naps (or short naps after geing awake for a long time).  Someone has to know what I’m talking about.   It usually takes all day to shake.  I’m post call now and I’m still trying to shake it.  Yuck.   

So I write this post for two reasons.  1) To see if anyone has any advice regarding the donkey dick breath.  2) To empower others who also suffer from post-call donkey dick breath.  You are not alone.

  And, I just realized it’s that time of the year!  Yay!!!!!

  I think I wrote a number of posts about residency interviews last year, so if there are any interviewees interested in reading those, just search for “residency interviews” on the blog.  Otherwise, I will go on. 

  I have the benefit now of 4 months of internship under my belt to color my recollection of residency interviews.  I was pretty stressed out about them all.  And to some extent, rightfully so, I guess.  Internship is tough and you want to make sure you end up with good people.  Note I didn’t say good place.  I am on survival mode right now.  I hardly have time to give a shit where I’m at for residency.  What keeps me going and what I do think about (because it’s right up in my face) is who I’m working with.  I have to say that I’m with a great bunch of interns and I’m really happy for that.  My senior residents are also for the most part really awesome.  I think no matter where you go, you will find senior residents that have just been totally fucked up by the process of residency (perhaps I’ll turn into one of those people in a few years… or months).  But it makes life so much nicer when your seniors are awesome. 

  I think I’ve gained new appreciation for the importance of who your coworkers are.  I really didn’t give it any thought in medical school or graduate school.  Not sure why exactly.  I think medical school and graduate school are more solitary endeavors.  Plus, there’s never a question of “am I gonna make it past today?”, which happens on an almost daily basis for me now.  Having the support of good people is key.  On that day when you don’t know if it’ll all get done and you’re sure you’re gonna be there for 3 days straight, the last thing you want is some ass who is gonna pile more shit on you.  I’ve lucked out in that I haven’t had this happen to me (yet) but the thought has often crossed my mind and it makes me shiver.

  During my residency interviews, I didn’t pay so much attention to that.  At least, it wasn’t high on my priority list.  I will say though that when I interviewed where I’m at, I remember thinking to myself that I could really hang out and get along with these residents.  So I guess it played into my decision making but not as much as it probably should have. 

  So there you have, after all the glam and glitz of where you’re going for residency, you won’t even have the time to remember it.  Think about that.

  I recently finished a rotation after which I will never ever, ever ever, ever ever ever ever have to do another pelvic exam ever again.  For as long as I live.  Ever.  Never. Ever again. 

  Never ever.  Ever.

  I’m quite pleased with that fact.  No offense to the ladies, of course.  There are plenty of unpleasant physical exams (for both doctor and patient), including the male prostate exam.  This is all bourne out of my own ignorance with the pelvic physical exam. 

  Really it all comes down to the fact that I get really uncomfortable when I have to do something for a patient that I really don’t know how to do–much less to do with the yuck factor.  I hate doing rectals and prostate exams too but during medical school I ended up with an attending on one rotation who made me do a prostate exam on every freakin patient that came through his clinic.  By the end of that rotation I still hated doing rectals/prostate exams but at least I knew I how to do it.   In medical school I never got the chance to practice the actual pelvic physical exam all that much.  I did my ob/gyn rotation before graduate school (like 6 or 7 years ago) and even then most of the women seen in the clinics weren’t comfortable with a male medical student.  I guess I really can’t blame them.  But as a result, I spent most of my clinic time during that rotation checking email. 

  But here I am 6 or 7 years later except now I’m “doctor so-and-so” and I’m expected to know this stuff.  Can you say ”mudphudder is fucked”?  That’s what I was saying all through that last rotation. 

 With a pelvic exam, there’s a particular set up (i.e. you don’t want to have to run out of the room looking for stuff in the middle of the exam), there’s a whole formality to it, and then there’s the actual exam: you have to use a speculum, find the cervix, identify discharges…  1) half the time I can even find the cervix.  2) When I do find it, what the hell does a normal cervix look like anyway?  Sort of like a pink cherio?  But sometimes it’s normal for it to be a little red.  Maybe.  I’m not sure.  3) Discharge?  There are normal discharges (which at least to me don’t look that normal) and then there are a gazillion different abnormal discharges.  Do you know what an expelled fetus looks like?  I don’t and I don’t want to know.  I’ve heard it looks mucousy, like snot.  This is what someone named ”doctor” told me.  SNOT?!?!  It all looks like snot!  What the fuck?  4) And then, what the hell am I supposed to do with a discharge? Culture it maybe.  I don’t know.   5) And then you have random things that pop-up.  Like, one time when I was all, what the hell is that string?  And then I found out what that string was for. 

  This is making my head hurt.  Is my level of discomfort palpable?  Yes.  I think it is. 

  Never ever.  Ever again.  Ever ever ever.  Done.

Ouch ouch ouch ouch ouch. Ouch. (courtesy of eMedicine)

  I saw a patient who was complaining of a “swollen penis”.  There are about a million jokes I or you could throw in here, so let’s everyone pause for a minute, think about your favorite “swollen penis” joke and insert here
–> <–.

  So I took a look at this patient’s penis and it took all of my restraint to keep from saying “DAAAMMMNNNN”.  This patient had what is called a paraphimosis.  For those of you who aren’t familiar (hopefully there aren’t too many of you who are familiar), a paraphimosis is when the foreskin of an uncircumcised man is pushed back too far, gets stuck and acts like a rubber band around the penis preventing return of venous blood from the head of the penis (“the glans” for the sake of making this sound somewhat doctorly)–note that arterial blood continues to pump into the glans because arterial pressure is usually high enough to overcome the restraint of the paraphimosis.  So with continued arterial inflow and obstructed venous outflow, it’s not hard to imagine that one ends up with vascular congestion and swelling distal to the paraphimosis, which makes it even more painful and harder to fix (pull the foreskin back over the glans).  If a paraphimosis goes unfixed it can become a urologic emergency since once the pressure in the glans grows very high from the congestion and swelling, eventually arterial blood can no longer enter and the glans necroses from lack of blood supply.  I.e., the head of the penis rots off.  Not a good thing. 

  Anyway, this dude’s penis was majorly swollen (like in the picture).  We contemplated calling urology but the decision was made that I should try to reduce it first.  The objective in reducing a paraphimosis is to somehow reduce the swelling in the glans so that the foreskin can be pulled back over and therefore eliminate the rubberband-effect.  Unfortunately, when you look online at how these things are reduced, they often get bloody–many times involving a tear or cut in the foreskin to accomodate it over the glans.  I was hoping to avoid this.  Using a combination of thought and guy-knowledge, here’s what I did. 

  I wrapped my patient’s penis with an ACE bandage.  Starting from the top and working downwards, wrapping it quite tight in order to use the constant pressure from the bandage to push the pooling blood past the foreskin but leaving the base of the penis uncovered.  Once wrapped, I went over it once more with another ACE, this time a little more tightly.  Then I summoned a little thing that all men know as shrinkage.  I grabbed a couple of ice packs and had my patient hold them on his penis for about 30 minutes.  

BOOM. That's the sound of Mudphudder dropping the bomb on that paraphimosis (courtesy of eMedicine)

  When I took the ice packs off, unwrapped the bandages, I was able to pull my patient’s foreskin back over and he felt much better.  Interestingly, so did I.  I came out of the patient’s room and everyone heard the good news, and it was like something else.  Let’s just say there were a lot of high-fiving going on.  Yup, as my attending (also a guy) said, “score ‘one’ for the home team”.  You said it brother.

All I can think about in those situations is the worst case scenario for each day.  And then I imagine having to deal with that worst case scenario day after day after day.  It never turns out that badly but of course the one time that I assume it won’t turn out that badly, it will. 

Or even a far more benign thing like a good day on the wards.  You know that by the law of averages, it’s only a matter of time before you get the clinical equivalent of a sack of bricks upside the head.  The bad day is coming. 

Yeah yeah, I’m just being neurotic but I’ve heard this from more than a few other co-interns: the anticipation will kill you.

This wasn’t a patient of mine but rather one of those times where you see another group of doctors around a computer looking at an x-ray and collectively hear them say “DAAAAAAAMMMMMMMNNNNNNNN” so out of morbid curiosity you have to go over and see what the fuss is all about.   

Everyone together now--DAAAAAMMMMMMMNNNNNNN

I present to you a patient who fell poorly on the right ankle and destroyed it.  At least that’s the story.  You question my skepticism?  Look at that film–that’s pretty bad for a fall. 

Anyway, you see all of those red arrows I added to show all of the different places where this patient’s ankle was broken?  That’s not normal.  That’s not even the typical ankle fracture.  And I caught a glimpse of the patient.  This patient was in a world of hurt.  A world of hurt. 

So this would be a comminuted tibia/fibula (tib/fib) fracture.  It’s not an “open” fracture since the bone wasn’t sticking out of the skin but it was close.  Like bone right under the skin close.  But, I’m not an orthopedic surgeon so I won’t even pretend to know much about different fracture types, etc. so I will refer you to wikipedia…  In any case, this patient’s ankle is a bag of bones at the moment and will be going to the OR in the very near future.  And, will likely have a very difficult recovery ahead. 

One thing I will say about medicine is that just when you think your day was about as bad as it could possibly get, you see something like this and you realize things can always be worse.  Like having to manage 25 really sick patients, do 3 admissions and discharge 8 patients on a shattered ankle.  Although, on a more serious note, I will say in hindsight that there were days in graduate school where if you had taken an x-ray of my dreams/hopes/desires/career prospects, it would have looked something like this.  Who knows what I’m talking about?  That’s right, everyone with a PhD should be raising their hand.

I have a few buddies who are going through this process now and applying for many of these.  For those of you who aren’t up to this point yet, it may be useful to get familiar with some of these grants–at least know what they are referring to.  You will hear these terms being thrown around a lot in conversation and more importantly, it won’t be too long before this will be useful information for you to know. 

If any of the readers have had experience with these grants or applying for them, please share your experience or any tips that you may have to offer in the comments…

To quote from the CRISP website:

CRISP (Computer Retrieval of Information on Scientific Projects) is a searchable database of federally funded biomedical research projects conducted at universities, hospitals, and other research institutions. The database, maintained by the Office of Extramural Research at the National Institutes of Health, includes projects funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Health Care Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH). Users, including the public, can use the CRISP interface to search for scientific concepts, emerging trends and techniques, or identify specific projects and/or investigators.

So you can use this database to spy on any investigator’s NIH funding status.  But in all seriousness, the CRISP database can be a really useful tool if you are thinking of writing a grant or even starting a new project because you can see if someone is already funded to work on your project.  It can potentially save you a lot of time in not writing a grant that someone else already has (or at least give you an opportunity to sufficiently distinguish your own grant).  Moreover, by knowing who else is working on a similar project, you can either know who to contact for collaboration or help (if you need it) or in contrast, you’ll know who to hide your work from…

Addendum:

Thanks to the readers who pointed out that CRISP is no longer up and running.  But, for those of you who still have the morbid curiosity to see which cocksuckers have NIH funding while you languish away barely making ends-meet on foundation grants, there is the RePORT Expenditures and Results query tool at: http://projectreporter.nih.gov/reporter.cfm

Most of you know what I’m talking about when I say “problem patient” and most of us have been a problem patient at one time or another (probably more frequently for those of us in health care).  As I said, there are many flavors of the problem patient so it is hard to define, but you know one when you see one. 

• If the patient is admitted to the hospital without any medical indication for inpatient care because he/she knows an attending, you might have a problem patient on your hands.
• If you get 5 pages over the course of 4 hours just regarding the patient’s request for you to change the pain medication dose from 4 to 6 to 4 to 6 to 4-6, you might have a problem patient on your hands.
• If the patient writes down the name of every doctor who comes into the room, you might have a problem patient on your hands. 
• If the patient wants to have the doctor confirm in person every order he has placed (note: not explain, just confirm that he ordered it), then you might have a problem patient on your hands.
• If the patient has nausea and dry heaving without vomiting every time he/she is told that they can be discharged today and then goes on to have a full dinner when he/she is told they can stay for tonight, you might have a problem patient on your hands. 
• If the patient says, I’m not leaving until I’m back to 100% my normal self even if it takes 6 months, you may have a problem patient on your hands.
• If the attending is yelling at the patient, then you might have a problem patient on your hands.
• If the patient tells you that he/she is deciding which oral pain medication he/she will have you switch him/her to, then you might have a problem patient on your hands.
• If the patient tells you that it is ridiculous to be discharged from the hospital at 4pm in the afternoon, you might have a problem patient on your hands. 
• If the nurse–the freakin’ nurse!!!–is fed up with the patient and prefaces every phone call with “I’m sorry to be calling again”, then you DEFINITELY have a problem patient on your hands.  (this one has 100% specificity)

Again, these are just some signs.  They are not 100% sensitive or specific (except for that last one) but they can be indicative.  Moreover, this list is not nearly comprehensive but I think you get the point.

What are the common denominators here?  1) the desire to not leave the hospital despite being medically cleared and 2) the desire to micromanage health care. 

On some level, I can understand both of these underlying issues.  Before I knew more about how nasty hospitals are, when I was sick, I’d want to be in the hospital and when I had surgery I wanted to stay there until I was all better.  What people I think fail to realize sometimes is that hospitals are just filthy places.  And that’s understandable in my opinion since hospitals are where SICK people go.  And not sick–my belly is ow-y sick, but I’m talking more like I have C. Diff colitis and blowing diarrhea all over the place sick or I have disseminated MRSA septicemia sick.  We can discuss the role of the health care providers in spreading the nastiness another time but no matter how it is spread around, hospitals are not clean places.  Sometimes I sort of feel like the guy who works at burger king and knows what goes on behind the counter so he can never bring himself to eat there ever again.  So the end result of people who don’t want to leave the hospital is inevitably a nosocomial infection.  I’ve seen it happen and it kills me every time.  A patient delays leaving, delays leaving and just when it is about to happen, comes down with a nasty infection.  It kills me.

Some of you cynics may have the thought that my main reason for getting on patients who want to stay longer than necessary is out my desire to have less patients to deal with.   This is not correct.  In fact, the opposite is true.  Patients who stay beyond the necessary amount of time typically have the fewest real or pressing problems to deal with because they are healthier than most other patients.  On days when you are getting 3 pages at the same time: #1- patient x having acute change in mental status, #2- patient y having fever of 105 and #3- patient z wants to talk to MD about his/her lab values from this AM, it is really easy how to triage at least one of those pages.  And, with a limited number of beds, filling them up with patients who could have been home, means less work for me.  It’s the senior residents and attendings I feel bad for.  They have to figure out ways of getting these peoples home because when the patient gets pissed at me for telling him/her that it’s time to go home, it’s then the higher-ups’ job to step in and convince the patient.  And, it’s the higher-ups who spend the mornings determining these patients’ plans. 

The other aspect of the problem patient is the desire to micromanage their health care.  Medicine is based on the principle of maintaining hte patient’s autonomy.  That is, we inform the patient and the patient makes the choice.  And that continues to be true but when patients abandon trust in the physician’s expertise/knowledge and exercise this autonomy to the level of small details, it can become a logistical nightmare.  It would be ideal that I could explain to every patient why they are on drug x vs. y for each and every problem but there just isn’t enough time.   I try my best–but for some routine things, like pain medications, it’s impossible, or at least it’ll take some time.  I have no problems meeting patient’s requests for things that are not dangerous but it can be brutal on busy days.  I made all of the changes requested by the patient who wanted dosing on his/her pain medication changed from 4 to 6 to 4 to 6 to 4-6.   The other patient, however, who no longer wanted to take his/her antibiotics because he/she didn’t feel like it anymore, on the otherhand, I had to take a good hour of time to explain why this was not a possibility.   I mean it’s all good of course and I’m happy to do it but when it’s just me dealing with the entire floor and everything from the emergencies to admits to discharges, this kind of stuff can really slow the pace of the day. 

Unfortunately, there’s no solution to any of this.  I’d tell patient’s to trust their doctors more often but then there are enough dumbass doctors out there that it’s probably worth it for patients to have a healthy degree of skepticism and to ask questions.  I guess the only thing to impress on people is that the hospital is not where you want to be–it’s nasty–where sick people go.  With that one point understood, I guess we the residents will just have to keep on keepin’ on.

One thing that I’m not used to nor will I ever be used is rudeness from coworkers–be it nurses, residents or attendings.  I think it’s most hurtful from residents and fellows since I can clearly sympathize with the fact that no one wants to turn around and drive back into the hospital at 10:30pm, especially when they just got home, for a consult that is borderline questionable but needs to be done anyway.  I know it sucks.  Believe me I know the pain of sleep deprivation–or at least I know a little and will find out more later.  In any case, I can sympathize.  Plus we’re all in the same boat–I have no ill will for other residents or fellows–why would I put them through pain if I (or more likely my attending) didn’t think it necessary? 

I hate it when consult residents get pissed off at me because I have a sick patient that needs their attention.  I’m like, what the hell else am I supposed to do?  If the patient needs a consult, then the patient needs a consult.  Am I right or am I right?  I mean, what the hell?

Then what’s even worse is when I get a run-around and then I have to spend half an hour of my time trying to cut through the bull shit only to realize that yes, the patient still needs the consult.  Trust me, I prepare before calling consults.  I’m not one of those people who calls consults without knowing anything about my patient.  I’m on top of it.  But there have been times when I’m asked certain highly unexpected questions by the consults, the answers to which I don’t have, and then I’m told how inappropriate my phone call is without knowing X, Y or Z only to later realize that X, Y or Z has nothing to do with anything.  Seriously, I don’t know what goes on–are people trying to play tricks or are we just having some miscommunication?  It could be a little of both but there are definitely times when I’m sure I’m being fucked with and it really pisses me off.  Especially since I’m an intern and most consults know it and if I feel like an older, more experienced resident or fellow is taking advantage of my inexperience and wasting my time so they can sleep during their call night, then I get royally pissed off.  It’s a fucking call night–you’re supposed to get called!!!!!  It’s just not cool to be mean to the intern.

As a personal side note, I start every phone call with “hi, thanks for returning my call” and “how are you?”  Isn’t that fucking nice?  Geez, how are you gonna be mean to me after that?  And then I end my calls with “thanks again for your time”.  How the hell is someone just gonna hang up on me after that?  Even at 3 in the morning I do that.  I know you’re annoyed, but come on now. 

Well, whatever.  I’m not gonna change.  I’m just gonna keep on being sweet, collegial mudphudder.  And if you got a problem with that then, well, you can just have a nice day. 

Asshole.

While for cynical me the experience was just another reminder of how cruel life can be and that everything good eventually comes to an end, Pascale has chosen to take a more practical approach and attempts to extract something useful from her experience as she reminds us that while Denver the wondercat died peacefully in his sleep, many people do not have that luxury and that we should specify advanced directives and/or discuss these end of life issues (e.g. whether to have life support–CPR, intubation, etc.) with our doctors ahead of time.  This is, of course, a hot topic item in light of recent health care reform discussions and the fact that Medicare does not cover the cost for patients to meet with their physicians to have such discussions.  I say “of course” but of course I have minimal insight on the matter as I spend most of my time as an intern and only recently found out that there even was a health care reform discussion. 

But I digress.  Pascale, you are so practical.  Time to grieve but I understand.  So in a show of solidarity and in support of Pascale as well as toward a lasting legacy of Denver the wondercat if we can get even one person to plan ahead, I too will make the pitch.  However, I am not quite as warm and fuzzy as Pascale so I will do it in my own cynical, bitter way. 

Here’s why people need to have these discussions.  1) Because they can and 2) because I don’t want to be the one making these decisions. 

I always feel especially bad when intelligent animals die.  They know and understand so much, and yet my feeling is that in the end they don’t really have an understanding of what’s about to happen.  In fact I don’t know that they have any understanding of death at all (note: animal people, DO NOT send me emails about how this species or that species does understand death–I’m speaking in generalities here).  Anyway, maybe that’s all for the best.  My cat understood health and life and enjoyed both.  You could tell from his reaction to illness and how he would seek out help from us when he was previously ill.  But at the end, I don’t think he understood the untreatable nature of his demise.  That was the hardest part for me to deal with.   He wanted help–you could tell–but there was nothing to be done.  I suspect it was similar with Denver the wondercat.  My suspicion is that if my cat or Denver had understood the impending end of the road, they would have made plans and requests in terms of how to be cared for at the end to best suit their comfort needs.  Cats are very responsible and self-centered in that way.  Of course we tried our best, but one never knows.  Only the cat did. 

Now, with people it’s a different story.  From about the time we’re 4 years old we know and understand that we will die.  It sucks but there’s no escaping it.  It’s like the direct admission that comes in 2 minutes before my shift is up every night–the one that keeps me there 3 hours past when I was supposed to go home.  It’s inevitable.  I pray that it won’t, bargain with God or Admitting (one and the same sometimes) but sure enough that direct admit will show up just as I am about to go home. 

So people have no excuse.  Don’t people want to be prepared for the end?  Is it carelessness or a selfish need to avoid an unpleasant truth?  In either case it’s plain irresponsible.  Plus, people are largely responsible for their own deaths.  Yeah, you, the dude who’s eating a big mac while reading this, I’m talking to you.  And I’m talking to me because I too am eating a big mac while writing this.   But seriously, when you think of the major causes of death, many of them are preventable (for the most part).  Heart disease, cancer (some types, e.g. lung), accidents, diabetes (type II), etc.   I don’t personally have any of these problems but I definitely see myself working towards at least 3 if not all 4.  In any case, we’re all killing ourselves slowly, so we might as well be prepared for when it happens.  Death is not a dignified process–better to make it as painless and orderly as possible. 

Which brings me to my next point.   I don’t want to be the one who has to make these decisions for you.  A lot of disorder and chaos is ensues when a patient codes and family members are arguing back and forth over how far to take the resuscitation effort.  It’s no good.  A doctor is always going to err on the side of saving a patient if advanced directives are not clear but I don’t think any doctor wants to put a patient through a lot of possible pain and discomfort during resuscitation if it’s not the patient’s wishes.  I don’t know, call us selfish or whatever, but we’d rather you made up your own mind.  You know what I’m saying? 

In any case, Pascale brings up a good point.  Think about it people and tell others to think about it too. 

Pascale, feel better my friend.

Those kids don’t even know what’s waiting for them.  Well not entirely.  Some them probably do, but most have no idea.  The scary thing is, I still don’t have any idea.  I talk to people with kids, people who are practicing doctors, people who are researchers, people who do all three, I have no idea.  I wonder if in another 10 years I’ll look back on these days and sigh and say that I had no idea.  Probably.

Beautiful. Just beautiful.

But anyway, I made the best of the situation and headed up to Maine–Acadia National Park for a week of relaxation. As a side note to anyone up in the north east who hasn’t been to Maine yet–it’s nice. Real nice. I enjoyed it tremendously. I’m used to my annual trips to south carolina but I suspect that Acadia will make a nice substitute for those years when I can’t find the time for the trip down south.  

Anyway, I think the keys to a good vacation are good relaxation and good eats.  And I got plenty of both.  It’s hard not to relax with scenary like this. 

5 pounds of lobster. Onion rings. Budweiser. Does it get any better?

And, I was reminded why Maine is known for lobster.  I think I averaged >2 pounds of lobster per day while I was there.  As a side note, did anyone else know that lobster is really cheap this year?  I’m not quite sure why but apparently it is.  In Maine, I was paying $8 to $9 per pound.  Not too shabby.  I think it’s probably a little more expensive outside of Maine or the north east, but maybe not by too much. Anyways, I digress.  Good eats and good relaxation.  Those are the key.  I made the mistake of going hiking.  Now, hiking on it’s own can be relaxing and provide much needed personal satisfaction.  But, when you’ve spent almost every waking  moment of the last two months walking/running around the wards, up and down stairs, perhaps hiking up and down moutains is not the best idea for rest.  I kid you guys not, the medial aspect of both of my big toes are completely numb.  I’m not sure why but it’s been a gradual onset and I suspect it has something to do with running around/up and down stairs so much.  In any case, I probably should have considered this on my first day of vacation before I

At this point I was wonder if it would be more painful to jump or to continue the hike.

went hiking.  Up and down 2 mountains.  For 5 hours.  With one small bottle of water.   And you know what the worst part of it all is?  When you get to the point where you know it will take you 2 or 3 hrs to finish the hike regardless of whether you turn back or keep going forward.  Painful.  Just painful.  But, all grumpiness aside, the hiking in Acadia is amazing.  I even went hiking every day I was there.  But it just helps if you’re well rested and have food/water. 

In all, it was a good intern year vacation.  It took some game-time adjustments in my activity, eating and sleeping, but I’ve come away well rested and ready to hit the wards again.  Not bad at all.

Hey Mudpudder….I am in a combined BS/MD program in NYC and I really need your advice. I am asking you for advice because you are one of the few physicians I have encountered that are honest and open about their profession.  As mentioned before, I am in a BS/MD program that allows me to complete my undergrad and 2 years of my medical education at a University and the last 2 years of my medical education (rounds) have to be completed at a participating medical school. Now I just finished interviewing at SUNY Downstate, SUNY Stony brook, and NYU. They all have their pro’s and con’s.  My main goal for the last 2 years of medical school is to learn as much as I can from the wards, so that I can really decide what type of residency to apply for. Essentially, I want experience so that I can make the best decision regarding the residency to pursue. However, I am not too sure which medical college is right for me.
 NYU med is a world renowned institution with a lot of NIH funding, prominent faculty, with high tech facilities, etc. Most of all it is in NYC, so I will be exposed to a diverse population with different medical needs. However, it is a really expensive school and affiliated with mostly private hospitals. I do not know if I would really get a chance to practice my clinical skills in a private hospital. I have heard that private hospitals limit medical student/patient interactions because we are a liability. Is this true? SUNY Downstate is located in an underserved community in Brooklyn.  In addition, it is affiliated with mostly city hospitals and most of the hospitals are understaffed, so I know I will get a lot of experience. However, Downstate does not have as good of a reputation as NYU or Stony Brook in terms of research funding, facilities, etc. I am afraid that the reputation of my medical school I attend may negatively affect my residency match process in the long run. I want to do my residency in an institution that is renowned for whatever residency I choose. Does the name of your medical college have a big impact on your match process? As for Stony Brook, it is a great school that is expanding drastically in terms of research and is making a big push to attract prominent faculty. However, it is in the middle of nowhere and its affiliated hospitals serve a racially homogenous population. So I do not think I will be able to experience as many clinically diverse medical cases as I would as in an urban hospital. Now that I told you about all the factors revolving around my decision, what advice can you give me? If you were in my shoes, which medical college would you pick? And why?

First of all, I won’t tell you which medical school to pick, only what kind of logic I’d use to make the decision. 

What is the purpose of medical school?  In my opinion, to 1) prepare you for residency and 2) get you to residency. 

Your question touches on both of these points.  Let’s tackle number 1 first.  Where would you get the best preparation for residency?  Well that’s broken up in two parts too: the academic training and the clinical training.  You seem to be focusing more on the clinical training part.  Yes it is true that medical students (as do residents) get less hands-on experience at private hospitals compared to academic or low-income community hospitals.  Think about it this way, the more that patients pay, the more they expect the attending to do and the more they get pissed off when a medical student sticks them 5 times to get an IV in.  You know what I mean? 

However, it is my personal feeling based on my experience and those of friends as well as other residents is that the clinical training you get in medical school is, in general, pretty minimal.  Really.  Sure there are differences between the experience you get at different schools, but how big are those differences?  So you get to do a few more procedures at one place vs. another.  So what?  Putting in one central line vs. five or ten as a medical student under supervision of a resident still equates to zero when you start internship and you become submerged in that stuff all of the time.  There may be varying degrees of comfort between interns at the start, based on where they went to medical school, but those differences become virtually indistinguishable after one to two weeks of internship.  It’s actually quite interesting.  At no medical school will you be the intern or the resident.  Simply because you will be a medical student.  You will not spend your days doing procedures anywhere because the residents will be doing them since they need the experience more than you will as a medical student.  Make sense?  You will occasionally get thrown a bone as a medical student, which may depend on where you are training (e.g. community hospital vs. academic hospital) but again, I wouldn’t put this too high on my list of factors determining where I go to medical school.  In terms of procedures, the only thing I can think of that you should be sort of comfortable with after finishing medical school is suturing/tying knots and that’s only because you will have to do it to some degree in every residency.  Again, you don’t even need to be good at it–no one I know was good at it at the beginning of internship–just be familiar with it. 

When you start internship and you have to do pleural taps, put in central lines, suture, etc, you will do it so many times (initially under supervision) that it really won’t matter where you went to medical school.  If you want to get good at some of these things during medical school, it will mostly fall on you to practice (what you can) outside of school.  So to put it more directly, I don’t believe that going to any one of those schools that you named will give you any significant additional exposure to doing procedures.  Where the quality of your medical school plays a role in these procedures is in terms of what kinds of colleagues and residents you will have around you to teach you or to bounce ideas off of.   I learned a lot of useful tips from my residents or other medical students.

More along this route, the facts you need to learn are pretty much the same no matter where you go to school, right?  The side effects of an ACE inhibitor are the same whether you go to school A or B.  And you will have to work equally hard to memorize all of that stuff.  However, the more collegial the environment and the higher quality of medical students/residents that you surround yourself with, the more likely it is that you will get tipped off on that useful pnemonic or website that will help you to learn X, Y or Z. 

Finally, the name of your medical school does make a difference for residency applications.  It’s kind of bullshit that it should, but on some level it makes sense.  It’s bullshit because, in my opinion, the top performers at any medical school can usually always compete with each other (i.e. the top medical student at small medical school is usually in the same league as the top medical student at big-time medical school).  So I find it unfortunate when top medical students from smaller schools are passed over, especially for lesser students at bigger medical schools.  It happens.  More practically, if you are a “good” student, which most of us are, are a big school, then you will definitely get more looks during residency interviews than a “good” student at a small medical school.  It may be unpleasant to think about but it’s true. 

You mentioned the fact that one institution you are looking at may have better research and science, etc.  I’ve argued before that this doesn’t make much of a difference for medical training.  And, I stand by that.  However, being around smart people–clinical or research–is always good.  A lot of intangible characteristics get rubbed off on you just by being around them.  So while you may not “learn” anything about the side effects of ACE inhibitors from being around top notch scientists, you will however pick up lesser appreciated/unrecognized pearls such examples of how to look at problems in different ways, how to balance clinical and research careers, how to be a collegial participant in academics, etc. (some of these will apply more than others). 

Okay, so there you have it.  I think I’ve addressed the concerns you brought up and it’s probably pretty clear which way I lean, but I think it’s more important that you see my reasoning.  Maybe you agree or disagree with some or all of my points but then you can take that into account as you make your decision. 

Moreover, if any of the readers have any thoughts, please offer them.  I’m sure this reader will appreciate it.

If you are the interviewee: ideally you should just answer these questions honestly, on the spot in a very impromptu fashion (well, you should always answer questions honestly).  But sometimes these questions can catch you off guard and then you spend 10 minutes trying to remember what is a time when you had a conflict with a lab mate (at least an episode you can tell the interviewer about–leave out the fist fights).  So I’ve found that it can be really helpful to go over some sample questions before hand in order to jog my memory. 

If you are the interviewer: then you need to figure out what questions will be important in flushing out the applicants qualities, which you think are most important.

As I mentioned in the last post, with experience you will notice the same questions (in one shape or another) being recycled between interviews.  This is probably because these questions are good at bringing out the various qualities of applicants.  As a resource to you, below are some questions that I found in a pamphlet I got a while go, written for the Burroughs Wellcome Fund and Howard Hughes Medical Institute:

For evaluating experience and skills:

• what is (are) your most significant accomplishment(s)
• describe the part you played in conducting a specific project or implementing a new approach or technology in your lab
• I see you have worked with [a specific technology or technique].  Tell me about its features and its benefits

For evaluating commitment and initiative:

• why do you want to work in this lab?
• where do you see yourself in 5 (or 10) years?
• what kinds of projects do you want to do?  Why?
• tell me how you stay current in your field?
• describe a time when you were in charge of a project and what you feel you accomplished.
• describe a project or situation in which you took initiative

For evaluating working and learning styles:

• what motivates you to work?
• would you rather work on several projects at a time or on one project?
• do you learn better from books, hands-on experience or other people?
• describe a time or project when you had to work as a part of a team?  What was the outcome of the team’s effort?
• how would you feel about a leaving a project for a few hours to help someone else?
• if you encountered a problem in lab, would you ask someone for help or would you try to deal with it yourself?
• would it be a problem to work after hours or on the weekends, should the project need it?

For evaluating time management:

• how do you prioritize your work?
• how do you deal with multiple priorities competing for your time?

For evaluating decision making and problem solving:

• what is the biggest challenge in your current job?  how are you dealing with it?
• describe a time when you had to make a decision that resulted in unintended (or unexpected) consequences (either good or bad)?
• describe a situation where you found it necessary to gather other opinions before you made a decision 

For evaluating interpersonal skills:

• how important is it to you to be liked by your colleagues and why?
• if you heard through the grapevine that someone didn’t care for you, what would you do, if anything?
• describe a situation in which your work was criticized–how did you react to and address the situation?
• name a scientist whom you like and respect.  What qualities do you like about this person?

There are several styles of interviewing, some of which most P.I.s might find too manipulative and distasteful.  For example, stress interviewing subjects candidates to difficult and hostile questioning to test their reaction to thinking under stress.  Other techniques are more useful and can be incorporated in your interviewing protocol.  Behavioral interviewing assumes that, if you can really find out what happened in the past, you can predict the future.  Asking questions about how candidates dealt with a difficult project or with other people at a previous job can suggest how they will act in your lab, and these types of questions will probably form the basis for your interview.

Personality profiling attempts to define candidates’ underlying personality by analyzing their responses to questions about real or theoretical situations.  An example of this would be to ask, ‘Upon finding out that a close colleague had fudged data, would you approach the person or go directly to the P.I.?’

Another technique that is actually part of many postdoc interviews is the situational interview, when the candidate is placed in a situation that might actually be on the job.  Giving a seminar and having to field questions about one’s own experiments much as are done day to day, is an example of this.  Some P.I.s do give a test or request a demonstration of a technique from candidate technicians.

The only kind of interview that has had any consistent success in predicting performance in the workplace is the structured interview, in which all applicants are subjected to the same questions and are rated according to predetermined objective scoring (Gladwell 2000).  The questions should examine past or present behavior to try to define the candidate’s ability to do the job and to predict future performance in the lab. 

excerpted from  At The Helm: A Laboratory Navigatorby Kathy Barker, p. 88-90

In the course of interviews, though, you may use or experience (depending on which side of the interview you are on) any of these approaches.  In my experience, the stress testing has largely fallen out of favor as it usually turns applicants off and can result in interviewers losing a lot of good applicants for the job.  If you are the interviewer, consider what kinds of approaches (and in what situations) you will take.  If you are going for interviews, consider how you will react to these various approaches. 

In stress interviews I’ve found that questions are often based on fallacies or they are just illogical.  So, as the interviewee, you just have to pick out that fallacy or the breakdown in logic and calmly answer the question by addressing those weaknesses in the question.  When it comes to personality profiling, I’ve found that you just have to be yourself.  There often is no right or wrong answer to these questions so it’s best to just say what you would actually do.  With these types of questions, I sometimes will ask the interviewer what he/she would do.  With experience you may notice that most people seem to expect one particular answer to a specific question.  Whether you agree or not, it’s up to you to decide how that should impact your own opinion.  The situational interview can sometimes be “interesting”.  You are basically called upon to do your everyday activities but this time you’re being evaluated!  It’s weird, when you’re doing your everyday work, sometimes you just “do” but when you’re being watched there’s a greater component of “think” that’s included, which can throw you off of your rhythm.  So before you go on your interviews, try preparing by practicing some of your everyday activities (or at least those you would be expected to do on the new job) with the mindset that someone is watching you–i.e. really think through what you are doing rather than letting muscle memory take you through it. 

Finally, the only way to prepare for the structured interview is really to think about as many questions as possible that could be asked.  After you’ve conducted or been on a few interviews, it becomes pretty obvious that there are subset of questions (still a long list) that are often adapted in one way or another to every interview.  I will address these in the next post… 

That’s right–always keeping you hungry for more! HAHAHAHAHAHAHAHA!!!!!!

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I don’t know, has anyone who has done this or is in it now, ever had the thought, “I’m only ONE person”? I have that thought like 50 times a day. Today it was like a thousand times. I tweeted today that I felt like I was gonna cry. The old school doctors are all about telling us residents how weak we are, etc. but the fact of the matter is the amount of work that needs to get done hasn’t decreased since the introduction of work hours, etc. In fact, it has probably increased. The expectation is just that now we’re expected to get it all done in a limited amount of time. And that’s it. Get it done. Don’t ask, don’t make excuses, just get it done. I got des-troyed today. A huge service, discharged 7, admitted 3. Plus anything that could go wrong did. Patients changing their minds about wanting to take their medications, patients who were doing great yesterday were feeling like crap today or having intractable pain. And of course I’m the one all the nurses come to.  Pages all fucking day. My favorite is the two-fer. That’s when two pages come in at the same time and the pager makes an especially high-pitched squeal. It’s good stuff the way that a rusty nail is good stuff to step on.  

I mean some of the stuff that comes my way is ridiculous. I was dealing with a patient who wanted to do harm to himself (without getting too specific) and received 3 pages from one nurse, each increasingly angrier than the last about giving an other stable patient something for gas. And then when I went to call back, I got a ton of attitude. I gotta tell you, on some level that hurts. I really think that the worst is when you kicked while you’re down. For me personally, that’s why I always try to be nice. You just never know when you’ll run into someone who is having a miserable day and that niceness will actually do some good. Attitude, meanness and being an asshole do not Mudphudder a happy camper make when he is getting crushed. But, what can I do?  It’s not my style to really retalliate or get into it so I just do my thing and hope that my work gets done. 

So back to my original point, I really think that each day things are made a little tougher than the previous day just to see if that’s what pushes me over the edge. I know that’s really paranoid sounding and I don’t believe it either but it sure feels that way. I got some help down the stretch today from some students on our service in getting things ready and together for evening rounds. And we just barely made it. Not only in time for evening rounds but also making it through evening rounds. After rounds I thanked the students (you gotta do that–they work so hard and you just can’t forget what it was like to be a med student) and I expressed how I felt that today our little team was very much like a rickety old boat held together by duct tape and with bubble gum plugging the leaks. We were seaworthy, but just barely, and we wouldn’t have made it without every single little contribution. It was close. Sometimes I wonder how one person can be expected to do everything in one day. Sometimes it can be ridiculous. But somehow it (usually) all gets done. 

I don’t know, maybe I’m just whining too much. I’m definitely learning a lot. Not so much through active effort (too little energy and time) but because I have to do the same crazy stuff so many freakin times that it’s hard to forget. I’ve actually started dreaming about my patients and discharging them. It’s so sad–I used to dream about other things. Right now I’ll just settle for some sleep. 

Well, now I can go and get some sleep. This weekend I work over saturday night, so I can at least sleep in tomorrow. Hopefully it won’t be too bad but it probably will be. Whatever, though. If I didn’t cry today, I won’t cry tomorrow either–probably because I won’t have the time to.

Anyway, the short answer is, No. At least in my opinion. A lot of people assume that your field of research in graduate school does make a difference and there are even residency interviewers as well as more senior/important people who will argue with you that it does.
I am someone whose PhD topic did not obviously match with my residency field, without getting into too many specifics. There are also many mudphudders who do their PhDs in biochemistry, etc. So just because their chosen field of medicine doesn’t have to do with folded proteins, does that mean the PhD was a waste? Heck no. Let’s start with the very obvious fact that graduate school is meant to teach you how to become an independent investigator. That training is valuable to any field of medicine. As someone who has gone through graduate school–without quitting–you have demonstrated that you not only can survive but also thrive in the face of scientific/research adversity. Second, I would argue that you would be more of an asset to a field by bringing skills from a completely different background. Case in point, some of the best biologists I know have PhDs in physics. Some even were physics professors! Finally, you can always find a connection between things you learned in graduate school, if not your specific field of research, with what whatever field of medicine you want to go to.
In this regard, it’s really easy for mudphudders with translational research PhDs to apply into residences that are directly related to their research. However I sometimes wonder how many of these mudphudders actually go that route because it’s safe. Don’t get me wrong, most mudphudders I know seem to have a real love for what they’re doing but I really do wonder about that sometimes. I also wonder how many of these mudphudders didn’t let themselves explore other fields, just because their research matches so well with a field that they may have interest in.
Anyway, the short of it is that in my opinion, the topic of your phd research doesn’t make a huge difference on future career aspirations/ residency. The point of graduate school is to become a professional, independent researcher who can develop interesting questions and then answer them. If you can learn to do that, then your graduate school experience will be an asset to any field of medicine that you go into.

My suspicion is that there will be days when I will rescind this post and say that I have been cast into residency Hell and there will likely be days when I will be in residency Heaven. I guess we’ll take those times one day at a time. In the meantime, with the benefit of the clear thought that comes from a golden weekend, I’ll just stick with “mehhh”.

http://grants.nih.gov/grants/funding/ac_search_results.htm

Sooner or later if you stay in academia, you’re gonna have to get awfully familiar with these grants…

Where I spent four years of graduate school.

Not too long ago, someone happened onto the mudphudder blog by searching:

are med school and grad school the same

on ask.com. 

Are med school and grad school the same?  No.

Having been through both now, the best way I can put it is that medical school is like a four year jail sentence: you go in knowing you have to put in four years of hard time and along the way you take it up the ass occasionally.  Graduate school, on the other hand, is like solitary confinement: you’re wandering around in the dark, not knowing how much time has gone by or even what year it is, slowly losing your sanity until one day someone opens the door, you see the light and you’re out–smelly and a shell of your former self.  And you still have to take it up the ass occassionally.

Yum

I think what I miss most about my previous life is fresh air.  These days I get mostly stuffy hospital air, with occasional whiffs of disinfectant.  This weekend is my golden weekend and I’m taking full advantage.  I’ve spent hours outside today.  I walked Back Bay, Coolidge Corner, Brookline Village and even a little in the West End.  And what a beautiful day.  After 2 weeks of rain, we finally got a sunny day.  I sort of wished I had been a little more productive with chores, but who cares?  I got some rest and spent some time being completely mindless.  I had dinner outdoors at a tapas restaurant on Newbury Street.  It was good.  And, I got some fresh air.

I’m not normal and my life clearly is not normal. I live in the hospital except for the few hours of sleep I get every night. I get my vitamin k  vitamin D (or lack there of) from fluorescent lights.  I’m wriing this entry as I stand in line in the hospital cafeteria for a grilled cheese sandwich. I wear pajamas all day long at work.  In my profession 80 hrs is the lower limit of acceptable time spent workig in a week. Actually, I don’t think the word “acceptable” is even accurate.

But in any case I am of the opinion that sometimes it’s nice, even therapeutic, to feel normal. So I do two things everyday to feel normal: 1) I come to work in jeans and a tshirt (ie civilian clothing) everyday. There’s something really relaxing, almost cathartic after 15 hrs in the hospital to put on a pair of jeans and go home.  It only adds an extra 4 minutes to both ends of my day to change, but it’s worth it. 2) I try to take 5 or 10 minutes everyday to sit outisde either in a hospital courtyard or even out in front of the hospital. I’ll get an iced tea +/- a chocolate chip cookie and just take in some fresh air.  It’s nice and also very normal feeling. As a sidenote, I’m not sure yet how I’ll adapt this to Boston winters but I’m thinking about it now. 

I know a lot of residents who deny themselves the chance to feel normal, either out of arrogance or feeling like they don’t have the time, but I thnk that’s a bad idea. My sense of normality is one of the ways through which I relate to my patients.  Everyone wants to be “normal” sometimes and everyone wants to relate to normal.  It’s why despite sleepiness and a list of boxes that need to get checked off pages long, I love sitting down to talk baseball with a patient.  It’s also why the same patient with untreatable cancer, for a even period of 5 minutes, will baseball with me.  Everyone wants to be normal sometimes.  Finally, occasional normalcy is also a reason why I haven’t and hopefully won’t turn into a complete asshole when the going gets tough (although some may disagree with my assessment that I’m ready not an asshole).  In any case, I should say when the going get tougher.  Plus, trying to be a little normal really doesn’t take that much time.  And as I like to say: even in medicine, 10 minutes never killled anyone, unless of course it was a code.

One of the realizations I’ve had in the last two weeks is that internship isn’t too too bad if you don’t have much of a life to begin with.  Luckily for me, I didn’t.  I mean think about it, I spend close to 15 hrs a day in the hospital on average, which leaves me about an hour in the morning and an hour in the evening. 

I guess it’s all good though.  Someone once told me that the purpose of residency was to become a doctor not to have fun.  So be it

But I’m still lookin forward to this weekend.  I’ve worked everyday since since two fridays ago and I’m tired.  Just tired.  Last weekend I got destroyed.  It was the closest I’ve come to crying in public.  There was just so much stuff to do in each of my “12 hr” wink wink shifts that I didn’t think I’d get it all done even if I had 20 hr shifts.  It was brutal but I somehow pulled it off.  God knows how. 

But now I’m tired and I could really use a couple of days off.  My first day off of residency.  Good stuff.  I want to reward myself so I thought I’d buy some electronics or something but then the first paragraph of this post hit me–i.e. not having a life outside of the hospital–and I decided to do a spa day instead.  Yeah it’s a little soft but I think I’ll get a lot more out of a good back rub and maybe  a pedicure than an xbox, which will collect dust.  In fact I think the xbox would have the opposite effect and actually depress me each night when I came home to see it but not have time to use it.

Anyway, I better go and get some sleep now.  I hope everyone is doing well. 

More this weekend when I actually have some time.

Take it all in: it’s Final Countdown by Europe.

Yum.

I am adjusting to the fast pace of most everything–racing to get everything done at work, then racing to get home so I can have a few minutes of free time to unwind before going to sleep.  Yeah it’s crazy but it’s worth it.  I’m learning a lot everyday and it’s all practical knowledge–not random minutiae that I’ll never use.  Patient’s potassium is low, how much to replete with?  How long to bridge a patient starting on coumadin with lovenox?  It’s pretty useful. 

Anyway, I’ll write more in a bit when I have a few more hours consecutively off.  I hope you are all doing well. 

MP

Mudphudder out.