I feel like a ping-pong ball

On Tuesday, from potential mentor #1:

"Oh you ABSOLUTELY MUST to an EM sub-i in addition to the medicine one. BEFORE you do your PhD so that you can do shifts in the ED while you're working on your dissertation. So you don't lose your clinical skills. Plus, you can't possibly know what EM is like until you've done a sub-i in it."

From Epi mentor, later that day:

"Yes, I think that's an EXCELLENT idea. Sign up for an EM sub-i plus your medicine sub-i. It's better than what you're currently signed up for."

So I go home, and write an email requesting April for that sub-i too. Feeling this sinking feeling since I really don't want to do two sub-is back to pretty much back. That I feel like I'd rather do something that would be more likely to help me figure out what to do research in. But of course, EM is one of those fields. It's just that it's in general easier for me to think of Health Econ topics to present upon than Onc topics because I know more about Health Econ than Onc at this point.

The thing is, of all the clerkships we do, EM is one that MOST resembles what it's like to be an EM doctor, despite what mentor #1 said about doing the sub-i. So what I'm not presenting directly to the attending as a 200 level student and would be as a 300 level one. It's not like I've never presented to an attending before.

So anyway, the next day I go to see the GRAND PUBA MD-PhD program advisor.

"Oh GOD no, you shouldn't do a month of EM. You should do a month of Heme-Onc in order to figure out if you want to do Oncology. Yes, plus your month of Rad Onc -- they're totally different. It may also help you think of a topic to pursue for your PhD. Sign up for Heme-Onc now. You can do clinical connections later this year (and all through next year and the year after....) to figure out what other types of things interest you and keep your skills fresh Doing EM shifts will only keep your skills fresh for *EM.* It won't help you in other fields and if you end up doing something else, it will end up being a complete waste of time."

Did I mention he's a hematologist?

Anyway, I get home and there is this email from the EM sub-i coordinator saying (basically),

"You can probably have April if you want."

ACK!!

Now I feel like I've put her out for no reason, and that if I say nevermind I'll be burning political capital in the ED. Why am I changing my mind AGAIN?? (I'd previously told her I was planning on doing this when I came back from my PhD.)

And plus, I know for a fact that the Psychiatry people I meet with next week are going to insist that doing a Psych rotation NOW would be imperative to doing a PhD in the subject. Even though I have my reservations about that as well.

So.

What should I do?

I could move Rad Onc from March to April and pick up the only available Heme-Onc slot for those two months.

I could pick up a Psych elective.

I could take the EM sub-i in April.

I kind of like option one or two the best (leaning towards one). I feel so totally pulled in multiple directions though. It's more stressful than studying for the boards. At this point? I really need these advisorly meetings to stop and to get a definitive, yet accurate answer from somebody.

Addendum: I remembered something about having to have your elective selections fixed the month before they started.... so I looked it up. It turns out we have 28 days, which gave me roughly until tomorrow to make a decision! So I decided to do Heme-Onc at Pennsy for March, and Rad Onc at HUP for April. SORRY EM PEOPLE!!! I am in the process of composing that email now. What a treat.

What do I want to do with my life? Some verbal diarrhea, please bear with me.....

I hate going to the MudPhud retreat every year. It's mostly basic science people talking about western blots and flow cytometry and whatever else they do. And nobody has a clue about epidemiology so I spend all day explaining myself to people who promptly glaze over and then walk away.

And then there are the round table discussions we have with various basic science faculty members. NOT ONE of whom ever has the foggiest idea what Epidemiology is or what a person can do with that degree. As for career advice? The best any of them could come up with was, "Oh, I know a person who has a masters in Epi. She is a full time clinician and does a little research in her spare time. You could do that."

Translation: She has been unable to get any grants to fund protected research time, and as such she is NOT a successful investigator. To put it bluntly, she has flopped. She has to see patients 5 days a week in order for the hospital to employ her. She will never get tenure.

And that's about the best it gets from the basic science people. Most of them find out what I'm doing, glaze over immediately, and direct their attention to the cell and molecular biology person who is sitting on their other side.

FYI -- The career I want is one in which I see patients 1/2 day per week and do research the other 90% of my time. I would probably quit medicine if I had to be a full time clinician. Why? Because it SUCKS. Seeing patients part time and spending the majority of time on research is far far far preferable.

Why am I bringing this up now? I met with the MD-PhD program advisor yesterday, and we talked about what I want my life to be like 10-15 years from now. And that I need to start learning how to package myself so that I'll be able to differentiate myself from all the people who get masters degrees in epi when they do their fellowships. So I don't end up a full time clinician.

Which means I need to figure out what I want to do with my life. STAT.

So I've narrowed it down to a couple of things based on the areas I'm interested in:

1. Oncology -- Via heme onc, rad onc, or surg onc (less likely -- it's really hard to do really good research as a surgeon)
What do I like about it? I like the way the doctors interact with their patients. I find tumor biology interesting. The changes in treatments and tumor marker specific targeting are completely revolutionizing how cancer is being treated. Plus the myriad of options available makes it hard for patients to decide which treatment to choose. Really interesting field with a lot of trailblazers ahead of me who have carved out research careers.
Downside: How do I think of a topic to study?

2. Neuroscience -- via Neurology or Psychiatry (my husband really wants me to be an ophthalmologist, but I just don't see it happening).
What do I like about it? I've always found behavior really interesting, and the pharmacology is fascinating. There is a huge amount of Epi research that needs to be done. I also liked the way the psychiatrists (less so the neurologists) talked with their patients. I think there are going to be a lot of advances in the understanding of mental illness and it would be nice to be on the leading edge of that research.
Downside: How do I think of a topic to study?

3. Health Services research -- via Emergency, or frankly anything else.
What do I like about it? You can do research that affects a large number of people and is immediately applicable to patients. I really enjoy economics and cost-effectiveness research, and I've done it before so it comes more easily to me than some of these other subjects.
Downside: The thing is, I'm not sure how excited I am to spend my career coming up with the algorithms (picture the one used to assess whether the patient has a PE) that doctors use to treat patients for the rest of my life. So, it's falling farther down on my list.

Everyone I talk with is like, "Come see me again once you've made a decision, and we'll talk more." Or, "Come see me when you've thought of a topic and we'll talk more."

Well, how the heck am I going to think of a topic when I am just beginning to learn about the field? There is just so much out there! How does anyone do it? Ugh. But of course coming up with a topic -- or the process of doing so -- is the secret of not ending up a full time clinician. It's also part of what I'm supposed to learn how to do as an MD-PhD student.

Hopefully I'll get there in the next year or so.

House

The hot Italian husband and I are thinking about buying a house. We're probably going to be here for at least 5 more years, and with the market tanking, it seems like the perfect time to buy.....

It's totally petrifying though.

I really don't know a lot about the process either, which makes it even more daunting. Still, we have an agent who a few other people in my program have used and been very happy with. And we can't buy until our CDs mature in July anyway, so we have some time.

But s***! We're becoming adults!

Scary.

If ANYONE has any advice, it would be most appreciated. About mortgages, neighborhoods, renovating houses..... ANYTHING.

Last Summer

Last summer during my O's rotations, I remember sitting with a gaggle of medical students for lunch. We were outside of one of the undergrad lunch places on campus which I usually avoid because it makes me feel old.

One of the MD-PhD boys made the offhand comment, "God I'm going to be AT LEAST 28 by the time I even get to *my* psych rotation."

I said, "Don't worry, you'll still be younger than I am now."

Third party interjected, "GOD OldMDGirl, STOP with the OLD talk. You're NOT EVEN that much older than WE ARE." (She was 24 at the time.) She then elaborated on how she was just as close in age to her intern as I was, and how it wasn't a big deal at all.

And, she's right sort of. Except that when she starts residency, she'll be 27. I will be 37. And last I heard a decade was not an insignificant amount of time.

But why did this grate on her so much? I did feel like she was giving me a bit of a bum rap. I have tried to keep the condescending remarks about how all the problems of 23 year olds are trivial and they will grow out of them in 5 years or so to a minimum. But it can be hard. Sometimes when you hear them complain about how miserable they are, or how they are "wasting the best years of their lives in med school," you want to say, "You know, your i-banker friends aren't that happy either. Lots of people are unhappy when they first get out of college, and hate their first jobs. It can be a tough transition to make."

Because even though you remember acutely just how horrible you felt FOR 4 WHOLE FREAKING YEARS after you graduated, and you want to make them feel better by empathizing, saying anything of that nature is inevitably going to come off as condescending. I would have been annoyed too if someone had said that to me when I was 24.

It's really better to sit back and watch the pyrotechnics, and be supportive. Unless your advice is actively solicited, which rarely if ever happens.

Similarly it's easy to start hating the skinny beautiful 20 year olds at the gym, and to be annoyed by their adolescent conversations. I used to sit there rolling my eyes when listening to the stories about the parties and the boys and the dorm-life drama. "SLUTS!" you think. "SO INAPPROPRIATE AND LOUD!!" Then you look at the young woman who could really be a model and you think, "I'm SURE she's anorexic. Just look at those ribs!"

And then you realize that your irritation is just a defense mechanism for your own insecurities. When these things happen now, I try to remember what it was like for me when I was 20 and the conversations I had with my friends. I think, "Wow, that is a really beautiful woman," and concentrate on getting my swimsuit on. I really don't want to be that preachy old appropriateness police hag that so many women become when they start seeing that they aren't the young vixens they once were, having forgotten what it was like to be that age.

Well, I try to be good anyway. When I'm able to, listening to them makes me smile with the memories.

I hope when I have kids I won't be one of those people who says to others, "Well, you couldn't possibly understand...." or, "When I was single and childless....."

I think it will be hard to become that person surrounded with all the young characters that fill my life. Especially if they keep calling me out when I do it.

;-)

Losing empathy

I remember my first patient on Trauma. It was an old man who had shot himself in the head. I remember thinking that there was surprisingly little blood, and that he was very very pale. The back of his head had been blown off, but the pressure of his skull on the gurney had tamponaded the bleeding mostly.

I also remember feeling paralyzed and numb and unable to function. Fortunately, I wasn't the primary survey person. My only job was to call the CT scanner if it was determined he needed to be scanned.

He didn't. A few minutes later he was pronounced dead.

All these thoughts ran through my head. Why did he kill himself? Was his life so bad? His foot had been guillotined.... did he have health problems? A family? Money problems? Had he been suffering for a long time, wondering when the right moment would be to put the gun in his mouth and pull the trigger? Had he practiced? Written a note?

Would anyone even notice that he was gone?

It was hard not to cry, but I didn't.

And then I looked around me. Nobody else seemed upset. The EMTs and some nurses just put him in the black body bag and mopped his blood off the floor while prattling on about what they'd done over the past weekend and how they were buying a new house.

The doctors were similarly unphased.

I wondered if they had been born tougher than I was, or if they were just used to it. One of told me that she didn't find it upsetting at all. That it seemed a rational decision. His choice.

Anyhow, as the month of trauma progressed, I became more involved on the team, doing primary surveys, chest compressions, taking histories, sewing people up. When a patient was announced overhead in the ED, or your trauma pager went off, you'd just run from wherever you were in the hospital to the trauma bay so you'd get to be a part of the action.

Which ever medical student got there first got to to the primary survey if one of us wasn't in the OR on some other case.

*******

My last day of trauma ended the same way that my time on the service began. With an old man who had shot himself in the head. This time, the EMTs were doing compressions on him as they wheeled him through the door. He wasn't actually dead yet, and we ended up doing a whole bunch of procedures on him in the hopes that we might keep him alive long enough to use some of his organs for another patient.

I ran the primary on him, and did compressions. We never really got past "C" (of the ABCs) and after about 30 minutes we pronounced him.

My emotional response this time?

Meh.

After we'd bagged him, I sat and thought about this for a bit. It really didn't bother me. There were no almost-tears, and I was ready for another one. I had been able to function and do my job without any problems. I noted that his body was still warm as we zipped the bag over his head, and scurried around the bay filling out paperwork and getting work done.

But this lack of feeling.... I wondered if it would be a problem in other ways. Would I lose my ability to empathize with people? I feel like this happens a lot to doctors. They see so many tragic, intense things that they stop being able to feel. They can't understand why a patient would be upset by some illness that has befallen them because they have seen worse. They have lost the ability to feel what the patient feels. To see the world through the patient's eyes.

Why is this patient taking up so much of my time?

Whiners.

On the other hand, it's probably necessary that this happen to them for them to be good at their jobs.

Do they become unfeeling and hard in their lives outside the hospital too?

I don't know.

If they do, is it worth it?

Ah, Medicine

I was on campus to turn in my receipt for step 1 to the MD-PhD office. We get reimbursed! Yay! Well, for step 1 only, but I'll take what I can get.

Anyway, I ran into a classmate of mine. Not one I normally talk to, but a nice enough-seeming guy. Since I hadn't spoken to anyone besides my parents or my husband in approximately three days, I decided to say hi. He didn't look overwhelmingly busy.

It turned out he was going into medicine. This was interesting to me, as I had always pegged him as a surgery person. I asked him why. He said he really loved coming up with a differential diagnosis. On rounds, the team would stand outside the patients' rooms discussing what the problem could be and what they were going to do to narrow things down, and collaboratively come up with a plan. Then they would continue said discussion with whatever consultants they had decided to call that day.

He had also loved peds, but didn't really enjoy babies (they couldn't talk), and liked patients who were a bit more complex. Peds patients seemed to have only one problem at a time, and he found this less interesting.

Ah, yes. This is what medicine is supposed to be. Sounds appealing, right?

I congratulated him on his choice. I think he'll do great in that field. Hopefully he won't succumb to the medicine malaise that plagues many residents, or the asperger's-like way of communicating with patients that so many of the medicine residents I worked with had. But I doubt either of these things will happen to him.

I reflected on my own experiences. And you know, he was right in some ways. Coming up with the differential was cool. When it happened. We'd do this in small group sessions every Friday afternoon, and I can say that I had a lot of fun with this. I could also see my knowledge base grow, as well as heightened sophistication in the way in which I approached the problems.

The problem was that when it came to actual patients, I cannot recall one time that we actually sat down and developed a differential. The vast majority of the patients were already differentiated, and those that weren't usually remained a mystery. And when they didn't? Well, usually that happened when three days into their hospital stay, the Lupus patient just happened to mention that UTI they had last week for which they were given bactrim.

And all of a sudden, the acute-onset thrombocytopenia was magically explained.

Those times, you could just sit there and watch your resident and attending look at each other knowingly and make mental notes: Med student failed to take complete history the first time. Med student is incompetent. Reducing "History Taking" portion of evaluation from 7 to 5.

(Med student is scapegoat for all oversights by rest of team.)

I would have LOVED it if teaching and developing a differential were goals of my team. Instead their goal seemed to be to identify flaws so they could give me a lower grade.

Med student says that NSAIDS are the most common cause of acute interstitial nephritis, when everyone KNOWS it's penicillin. Stupid med student. Poor fund of knowledge.

or

Med student WASTED THE TEAM'S TIME today by introducing the team to the patient before she interviewed her in front of us. God, didn't she see me do this ten minutes before? God. Med student totally unaware of her surroundings.

or

Med student failed to realize that the ONLY THING IN THE DIFFERENTIAL WORTH CONSIDERING in a patient whose chief complaint is "pulsating neck vein" is a ROMI.* Even though patient has a medical history complicated by multiple endocrinopathies and domestic violence. Incompetent medical student.

or

Med student asked patient whether she had ever been pregnant, and then later if she'd had any miscarriages. Doesn't she KNOW that a miscarriage is a pregnancy.... SO PATRONIZING!! (Then later.) Med student used acronym "STD" with patient. Doesn't she KNOW that patients might not know what that means?

See, it wasn't the feedback. I expect not to know everything. I expect not to be perfect. I expect to improve over the course of a clerkship. The thing was, every time you did something that wasn't completely perfect, they'd give each other these knowing looks. You could just see your grade slowly swirling down the drain. It shouldn't be about that, but that's what they made it into.

And then there is the problem with the work environment. On every other rotation, I felt it was ok to have a personality. To kid around. Be a person. On medicine, whenever I laughed or smiled I felt like I had to look over my shoulder. I was sure that someone would think I was being unprofessional. They really love that word on the medicine service. The sad truth is that one of the reasons I liked surgery was that they actually laughed at my jokes and seemed to enjoy having me around.

And then there is the fundamental problem with general medicine for me. While I think working up DVTs, MIs, COPD, diabetic ketoacidosis, anemia, and non-acute abdominal pain would be interesting for a while, I could not imagine feeling fulfilled if my entire career was comprised of nothing but that. The interesting things happen so rarely. If I did do medicine I know that I would have to specialize.

I once made the joke that the medicine people need to come up with this blown up differential so that they can make themselves feel better about the fact that nothing exciting ever happens. It's like, "Well this ROMI turned out to be just a panic attack, but if the patient had had an MI two weeks ago it could have been DRESSLER'S SYNDROME!!! Quick, medical student -- how would you treat that?"

Or, "That ulcer turned out to be due to h. pylori, but if his gastrin level had been higher, it COULD have been Zollinger Ellison syndrome! Quick, medical student -- what other conditions is that associated with?"



Plus, I like making decisions and then going with it rather than pontificating for hours with 15 consult teams (did I mention the constant "touching base*")about all the possibilities. And hand-writing notes the length of War and Peace is just not my cup of tea.

Sigh. I'm glad that my classmate enjoyed his experience in medicine. I only wish I could have said the same about mine.



*ROMI = rule out MI
*I wish I could say I was making these examples up. Sadly the examples have been modified only slightly in order to protect patient confidentiality. PS -- Dr. M, you are truly a loathsome person.
*Frankly, some people on my team seemed like they could have used some base touching of their own.... Oh wait, that was unprofessional. Forget I said that. :-)

Nightmare

Last night I had a nightmare. It wasn't of the usual Industrial Supply Company From Hell flavor either.

I dreamed I was pregnant.

Actually, the dream was about the birth itself. See, I had started to try pushing, and the Ob/Gyn resident (the one one of the ones who was a total bitch to me on my rotation) comes in and tells me to lie down.

Then she starts cutting me open to do a c-section without actually telling me what's going on. My husband is standing there with his jaw on the floor.

And I'm thinking, well at least I don't have to worry about becoming incontinent this time around!

But instead of doing the c-section, she decides to use her hand as leverage to push the baby out the bottom.

Anyhow, at that point I fall asleep and then I wake up sewn up and in pain, still at the hospital, and my husband is at work. All I want to do is go home, but nobody will come to my room. Well, actually there is another patient next to me whose family is there, but nobody is there for me. So I decide to get up and wander the halls.

Eventually I give up. But I don't get to go home.

When I do get to go home, I have to take a taxi across town with two strangers that want to split the fare. Somehow I've translocated to Manhattan here, and we're driving from the West Side through Central Park to the East Side. But then the cab starts going south and I ask them if they're going to the Village or something and they say yes.

So I tell them to stop the cab. I get out, and I then walk home 3 miles. It was cold and I was still in my hospital negligee.

*******

So guys..... what does this one mean?

Actually, don't go there. I really don't want to know. The workings of my subconscious are obviously too warped for me to understand, I shouldn't bother anyone else with this.

But geeze.

Maybe tonight I'll get to dream about happy things like rainbows and teddy bears.

Today

It's 9:15 and I've already finished a set of questions. It turns out that I've actually learned some microbio these past few days.

Thank GOD.

Now I'm going to finish immuno and do some more questions.

BEFORE LUNCH.

It's going to be a productive day.

I promise.

Did I mention it's going to get up to 45 degrees today?

Meetings

My meetings with Epi people have gone very well thus far. Most of them seem to understand that I'm in the beginning stages of deciding a specialty and figuring out what I want my PhD to be on. They've all been very encouraging and very receptive, and have given me good information.

That is until today.

It wasn't that the person I was supposed to meet today got a call two minutes into the meeting about a lecture he had wanted to attend, but had forgotten about, that was happening NOW, so he had to reschedule.

I think it was that the first words out of his mouth were, "Oh, you're one of the students on the list of people who are definitely interested in Emergency Medicine."

I.e. He had no idea what the meeting was supposed to be about.

And just to clarify for your purposes (dear readers), the meeting was about Epidemiological/Health Services Research in Emergency Medicine. The pros the cons. What kinds of people has he mentored before? What kinds of projects did they do? What are other people he knows in EM doing research on? How feasible is it do do research and EM?

That sort of thing.

And it was totally obvious that the man had not even glanced at my CV.

I think my objection was: He treated me like any other jackass medical student who wants to suck up a little and do a BS research project in order to get a plum residency. Not as a potential future mentee/colleague.

I wondered if he realized he was being interviewed as much as the other way around....

We ended up headed in the same direction as he walked to his lecture, and I walked to my recruiting session. As we talked there was this problem: he had a way of making cost-effectiveness research seem incredibly boring and unappealing. And this is the kind of research I used to do and love before medical school.

Maybe it was the fact that he had an MBA (I am revealing my anti-MBA bias here -- please don't hold it against me.)?

He also had this stereotyped male EM attending ADD that outside of the ED is highly off-putting, but which seems to be ubiquitous around here. It comes across as though the person is either a) high on coke, b) not paying attention, or c) both.

Anyhow. I rescheduled with him for next Tuesday. He has a long way to go to make me interested in working with him however.

Thus pushing EM further down on my list.

Maybe by that point he'll have managed to look at my CV....

Basically dead

I was up in the MICU doing a trach and peg consult for the trauma service. The patient had suffered an at home cardiac arrest and had been resuscitated by EMS after having been down for 15 minutes.

She had anoxic brain injury. She was never going to wake up. Probably, she was never going to be off the vent either.

I had been told by my resident to speak to the MICU resident who was on to make sure there was nothing about the history that I had missed in my review of her chart, and to see if there was anything else I needed to know.

And what did the MICU resident say to me?

"Um, I'm the SAR.* That means I don't care about anything besides that patient's code status."

She continued.

"And?" she said, waving the signout in my face, "If it's not on this sheet I don't know about it."

O.k. I thought.

Finally I got some information out of her. But mostly I just verified what I already knew.

And then I said, "Gosh, sometimes I wonder if it weren't better if they hadn't been able to resuscitate her. What kind of quality of life is she going to have now?"

(Note: My mistake for engaging the troll resident in conversation given how she'd been up until that point.)

Apparently, we medical students are not permitted to utter such things as she then decided to tear into me about how one mustn't ever talk about such things, and that not everyone feels that way, and blah blah blah.*

So really? The truth? Everybody else on the trauma team felt the exact same way as I did. In fact, several attendings, residents, and fellows uttered the very phrase I had just uttered myself not 20 minutes later as I was presenting the case to them.

(Actually I think their exact words were, "Family's not ready to pull the plug on 'er yet, huh?" Not that it matters.)

I thought maybe it was just my audience. Perhaps that resident was just particularly unpleasant? But then it happened again on a different patient with a different resident. This time, the resident opined on how "lucky" the patient had been to suffer cardiac arrest on the hospital premises (he'd still been down for God knows how long before he was found), since we had gotten to him in time to rescussitate him, and he was still ALIVE.

Albeit unconscious and unresponsive.

I said I didn't know if "lucky" was the word I'd use to describe permanent anoxic brain injury.

So I guess the moral of the story? If you're a medical student, keep all opinions about everything to yourself. Always. Even though it can be tempting to join in if you're functioning as part of the team and everyone else is talking about it. Nobody cares what you think, and it will only come back to bite you.

And also, some residents are idiots.




SAR = Senior Asshole Resident
*Generally speaking, the assertion that "You know, not everyone shares your opinion," incredibly patronizing. Because DUH!! Of course they don't. It's like they think I'm going to say, "Really? You mean everyone else isn't exactly the same as I am? Wow. That is really profound. Thank you SAR for revolutionizing the way I look at the world."

Commence slow process of going berserk

So, I've already moved my boards back once -- to Feb 16th, which will give me exactly 6 weeks. I feel this is reasonable, given all the advisorly-type meetings I've scheduled for myself, and thus all the extra reading of papers lest I make an ass of myself, that I must do in addition to studying for the boards.

And now I present to you my typical boards studying day. Which really is every day since I am not so efficient as to deserve a REAL day off yet. (Maybe this is part of the problem? Hm.)

7AM alarm goes off. hit snooze
7:09 hit snooze again
7:18 arise, go to computer
check email, read news
8AM Shit it's 8 already? Better get studying.
9AM I'm hungry. I'll eat cereal while checking email. Again.
9:30 resume studying
11AM I've only read 30 pages so far this morning!?!? I'm supposed to get through 150 today!! Shit shit shit.
12noon OMG I have to leave the house. Can no longer sit still. Am going crazy.
12:30 (having managed to eat lunch) head to campus for swim/meeting/change of venue
3:30 where did all my time go? better check email
4PM um, maybe I should start studying again?
7PM arrival of husband
7:30 commence Kaplan questions
8PM Oh husband? Why do they keep asking me which virulence factors are transmitted by phage? Is that *really* important?
9PM Am getting sleepy.....
10PM Bed

As you can see, not nearly as productive as one might hope. Probably I get a solid 5-6 hours of actual reading/ note taking done per day -- which I might add is BARELY adequate to stay on schedule. And also there are the questions. Which some days are good! And some days, not.

And then there are the meetings. Which have been very useful from a career standpoint, but not so much from a step 1 standpoint.

Not sure what to do about the daily freakouts at noon. Whence I can no longer sit still. Remedied only by a workout. Workout always longer than necessary and then followed by intense guilt for having not studied the past three hours. The working out seems to help a lot with the insanity though.

I guess on the plus side, I'm getting my muscles back!

Ok back to viruses.

Who says doctors are smart

1 year = 52 weeks = 13 sets of 4 weeks

Right?

Except according to my old Chicago primary care doctor, 1 year = 52 weeks = 12 sets.

That's how she filled my birth control prescriptions anyway. And I didn't even notice really until after a few years I realized my annual exam appointment fell a month earlier than it had the year before.

So that year, I decided to say something.

"Can you please give me 12 refills, rather than the 11 you usually give me?" I asked.

"No. There are 12 months in the year," she said, "You only need 11 refills and then you have to COME BACK FOR YOUR YEARLY PAP SMEAR."

She was obsessed with this. One year I had gotten my pap smear done at student health for FREE (as opposed to for $100 bucks -- thank you deductible!) downstairs from my office, and she was convinced that I had just skipped a year. Even though I told her I had gotten it done there and why. She asked me repeatedly why I hadn't come in that year. REPEATEDLY. As though she thought I was lying.

She also asked me repeatedly whether I'd ever had an abortion. At the same visit. This is not something I will ever understand.

Anyhow, back to the original story.

When she told me that 12 packs of pills was adequate for the year I said, "That only covers me for 48 weeks, and there are 52 weeks in a year. 52 divided by 4 equals 13."

"No," she said, "There are 12 months in the year."

"Are you trying to tell me that 52 divided by 4 equals 12?" I asked her.

She furrowed her brow and thought really hard.

In the end I got my 12 refills.

I still don't know if her 11 refills was a ploy to get me to come in more often, or if she really was that bad at math.

All I know is that I never should have had to escalate to that level of conflict in order to get her to do the math correctly. It was tres awkward.

The next time I came in was my last visit before I moved to Philadelphia. I told her I was going to medical school. She seemed intrigued. I then told her I was doing an MD-PhD program.

"Those MD-PhDs are the WORST doctors in the residency program I teach at," she said.

"That's nice," I thought. "But I'll bet they're a lot better at math than you are."

And she is just one of the reasons that I don't trust doctors.

Anatomy

Well, one thing is clear: I know NOTHING about anatomy.

I sincerely hope the Kaplan questions are much harder than what is on the real thing....

EDIT: I should add, I do know *something* about it.... it's just when they ask you which fascial layer they suck during liposuction? How the heck should I know?

But I digress....

I think they must find us very annoying

Our medical school has made it possible for us to view our evaluations online. Which is kind of nice. Now I can show my husband all my glowing reviews, and when express dislike for a particular hospital staff member, I can also show him the comments provided by that person.

It's a lovely system really. Pretty much all the evals are up now, except for Surgery (it's not done yet), Peds (too early in the year?), and Medicine (because they're special).

And so it was, that in a rare* moment of procrastination, I was perusing through the evals for a particular rotation in which I did very well.

The comments had me rolling on the floor laughing my ass off.

"Medical student did not get in the way."
Translation: I wasn't horribly slowed down by the medical student's exhaustive history taking and retarded questions.


"Medical student was not annoying."
Translation: The medical student spoke only when spoken to, did not try to make friends.


"Medical student showed good judgment about when to call for help."
Translation: The medical student could tell when a patient was about to die. I didn't have to see every patient first after I discovered this.


"Medical student graciously accepted feedback and applied it successfully."
Translation: The medical student did not try to debate the feedback I gave.

All this for a grade of Honors.* I hate to think what they said about the students they DIDN'T like.

Oh well.

Someone told me that the old adage was that a "good" medical student was one that only slowed you down by 50%.

I guess it just sucks to be a resident. And also, medical students are a giant pain in the butt.


*Ok fine, these moments are not rare. You caught me.
*I don't usually like to broadcast my grades, but it's not SO far fetched to believe that I got honors in at least ONE rotation this year, is it?

MY Barriers

As I take my breakfast break this fine fine morning, I thought I'd share with you my plans for February.

Of course, the first third I'll be studying. For the boards. Feb 11th is the tentative big day barring massive freakout/sudden realization that I already know everything (ha!). After that....

Well, I'd like to take some sort of mini-vacation. Preferably to someplace warm.

And I'd like to work on that paper I've been putting off for a year and a half now.

The paper. Oh yes. The paper.

It occurred to me that it would be helpful if I remembered what it was about. So I gave it some thought the other day. Hmmmm.....

As it turns out, there are all sorts of other barriers besides not remembering the topic that come to mind. Including but not limited to:

1) What was it about again?
2) My computer expired a year ago and I haven't replaced it yet
3) I need to purchase a new computer and put all the important programs (SAS,STATA) on it
4) I need to remember how to use SAS and STATA. I'm actually pretty concerned about this one.
5) I need to remember how to write formally, since I haven't done that in 2 years almost.
6) Literature review? Hm.

Anyway, I guess these barriers are not insurmountable, but they did keep me from getting anything done on this godforsaken paper for a year and a half now. Maybe when I start working on it, I'll remember what I'm doing again?

Let's hope so.

It was COLD today

The temperature didn't get above (drum roll please....)

25 degrees!

It was actually 20 when I walked into school today, with a wind chill of 9.

I wore my long down jacket and was snug as a bug. I felt the cold pinch at my cheeks, ears, and nose, and the clean(ish) crisp air fill my lungs.

It was AWESOME.

I miss Chicago weather. Well, maybe not the ZERO degree weather. But 20-25 is nice.

....

Further evidence that I am not normal.

More Facebook Stuff

I learned yesterday that it is "pathetic" and "stalker-ish" to friend people on facebook just to find out what they've done with their lives for the past 15 years.

Oops.

Apparently, COOL people use facebook to share pictures with their friends and as a communal message board on which they keep their loved ones apprised of what they are up to. As an online community, if you will.

Oh, and people who have, "like, over 400 friends, you know," are obviously just lame and trying to show everybody how cool they are.

Hmmm... Me thinks a bit too much thought has gone into this. I wonder what my life would be like if I spent time worrying whether I was perceived as "pathetic" because of how I used facebook.

Bizarre. I daresay it seems rather lame and pathetic to me to assess someone else's lameness and patheticness by how they use a social networking website. But that's just me.

Maybe I'm really a giant loser and just haven't figured it out yet.

Nah. I totally figured THAT out years ago.

Sign that maybe it's time for lunch

While reading about alkaptonuria, a disease of the tyrosine degradation pathway (homogentistic acid oxidase deficiency) I stumbled upon the following sentence:

"Urine darkens upon standing."

First thought? Why would an error of metabolism affect a patient only when he pees standing up?

Second thought? You could write your name in the snow with your urine. Cool.

Hm.

I'm going to make a burrito now......

So it turns out....

My MD-PhD program is trying to attract more students in the Epidemiology department.

BUDDING EPIDEMIOLOGISTS -- PLEASE APPLY TO PENN!!!

My school has always been interested in non-traditional MD-PhDs, in such fields as Sociology, Anthropology, History and Sociology of Science, Health Care Systems, Psychology, etc. But when I came along for my interviews back in early 2006, only one other person had done an MD-PhD in Epidemiology at my school. And he was already a fellow.

That is to say: it had been a while.

Oh, and I was the only Epi applicant.

But now.... NOW?

There is another Epi student 2 who is a first year now, and several more who are applying now.

WHHHHAAAAAAA!!!!

I liked it when I was the only one. :-P

To add insult to injury, the new Epi student already has a project for the summer. Whereas my summer project between 1st and 2nd years? I figured out what I was doing in June.

Wait, who looks like a f*** up?

Of course, I could just look at this as: They're learning from me. All the difficulties I had, they're fixing. And it looks like they're getting better at processing the Epi students. Which is a good thing, right?

Sucks to be the trailblazer's all I have to say.

Now I'm being asked required to participate in recruiting, which I might add I've shied away from in the past on the basis of my age and interests. It seems that 21 year old basic science/engineering applicants really want to talk to 23 and 24 year olds in basic science fields. Not 31 year olds in Epidemiology. Hell, most of them don't even know what Epidemiology is. And I can't say I blame them.

But....

After getting comments along the lines of, "What IS that? (nose wrinkle)" or, "The only people who do post-bacs are the ones who got crappy grades in college," or, "You're HOW OLD? Wait, you're going to be 37 when you're DONE? (shaking head and walking away)" I decided that my presence at these events was not needed. Plus, talking about basic science with a bunch of kiddies who think their PhD thesis is going to win them a Nobel Prize? Not my idea of a good time.

In two weeks, I have to do this Epi recruitment panel in which I tell applicants about the research I'm doing. Huh? What research? I still don't know what I want to do with my life... and I'm still looking for a mentor. Even the first year student has SOMETHING.

Who's going to look like a f*** up again.

Gah.

Not fun, and not looking forward to it.

If you feel like your doctor may not like you.....

You're probably right.

This was one of the most disturbing things that I learned this year.

Furthermore, if she hates you, she is likely blaming you for the problem. YOU'RE difficult. YOU ask too many questions. YOU'RE non-compliant. YOU take too much of her time. YOU think you know everything already.

And she will be complaining about you to her support staff before she enters the exam room. Telling them how difficult you are, how neurotic and crazy. Rolling her eyes and thrilling at the story the nurses aid tells about how you got annoyed when she snagged your sweater with the blood pressure cuff.

How dare you!

You have an attitude problem.

Well, maybe she's right. Maybe you are difficult.

But so what.

Maybe SHE'S difficult too. She once was a pre-med after all. This is not a far fetched idea.

But still, she dreads seeing you and she wants you to go away.

So do both of you a favor and go find a doctor who doesn't give you the "I hate you" vibe.

Maternity

Someone asked a few weeks ago about what medical students/residents did about having babies.

Here is what I know about the people I know who have had/are having babies in medical school/residency:

One person took 3 months. She was an MD-PhD and had just defended. She postponed going into the clinics a little longer. Her in-laws helped for the first 6 months and now she sends her child to day-care. She anticipates playing the in-law card again during residency.

One resident was planning on taking 4 weeks. Her in-laws were coming to help.

One resident and his resident wife had 4 babies. They took out loans to pay for their childcare. One is an MD-PhD (thus no med school loans) becoming a surgeon, and the other is an anesthesiology resident. Both will make beaucoup $.

One of my attendings with 4 kids shipped her mom from overseas to take care of her kids.

One had a husband who worked from home as a computer programmer who also took care of the kids (they have 2 now I think).

Another decided she wanted 4 kids and opted to work for a pharma company instead. But, she hated medicine anyway.

A lot wait until fellowship.

A male classmate has a wife with an easy job who brings the kids to work with her while he goes to med school.

*******

Which brings me to another quickie.

I was in the locker room a few days ago listening eavesdropping on a conversation between an older woman (I'm sure she'd be upset if she knew I thought that -- HA) and her middle aged work colleague. The older woman was a doctor (let's just call her Hag, shall we?) and was grousing about one of her other colleagues.

Apparently, her work colleague didn't have to take call on the weekends.

Why was that, you might ask?

"Childcare." Apparently she couldn't get childcare on the weekends, and as a condition of her return to work post maternity leave she had negotiated having weekends off. And yes, Hag actually used air quotes when she said the word childcare.

Then asked sarcastically what this woman's problem was. SURELY she could find childcare on the weekends. They're called HUSBANDS.

Of course, I don't know if this woman-doc even had a husband. Maybe she was (gasp!) a single parent. Maybe her husband worked weekends. Maybe she was just a damn good negotiator.

Hag went on to describe how the practice must have been desperate to cut such a deal with her. She told her friend how she had gone to HR to complain about the unfairness of this arrangement. And she was eagerly awaiting the outcome. No, she didn't want weekends off herself. She wanted this other woman to HAVE to take call, just like she did.

Well anyway, I guess it's obvious how Hag came across to me. Way to spit in the soup on behalf of womankind. Maybe she was just bitter that she didn't get to/think to negotiate when/if she ever had kids.

Maybe she just sucked at negotiating.

Maybe she just sucked.

Anyhow, I thought I'd share that one to illustrate how we ladies need to stick together. Because one bad apple could spoil it for the rest of us.

Studying

Does it make me weird if I say that I'm kind of enjoying studying for the boards?

I get up in the morning when I want, which is usually 7 anyway. But could be later if I desired....

I read about things that are interesting. For instance, I am actually enjoying biochem. I feel like enzyme kinetics finally makes sense. I'm getting a chance to review stuff that I always wish I knew better.

I get to work out every day. I've set things up so I study most of the morning (7:30-12 or so with an hour off to eat/procrastinate), then a short break for lunch, and then I study in the afternoon, and THEN GO EXERCISE, and then come back and study some more. I take a practice test (48 questions) between 7 and 9PM and then go to bed.

Some days I have a meeting. That messes things up since I usually run into people and desire to talk to them..... but on the days I'm at home I get about 10h of studying in/day. When I have a meeting, it's more like 7/8.

And on the weekends, I have my adorable husband to make me food and entertain me during my breaks.

Did I mention I get to make my own schedule?

It's really nice. I think I'm going to like graduate school.

:-)

See, TV CAN be useful..... sometimes

Direct quote from my biochem text:

Obtaining O2 from the atmosphere solely by diffusion greatly limits the size of organisms. Circulatory systems overcome this, but transport molecules such as hemoglobin are also required because O2 is only slightly soluble in aquaeous solutions such as blood.

It reminded me of a show I saw on the discovery channel about prehistoric times. I've never known the various eras/ ages/ whathaveyou of the dinosaurs and stuff, but in this episode I remember GIANT DRAGONFLIES that ATE DINOSAURS.... and small mammals.

These puppies were 8 feet long.

How can this be? Bugs have an open circulatory system (no blood vessels). I don't know if they have hemoglobin or not... I'm thinking no.... when was the last time you saw red when you squashed a bug. And I'm not counting mosquitos -- that's your blood!). But 8 feet?

Gosh, spiders can only get to be 1 foot in diameter these days. Or so.

Well I learned on that TV show that at that time, it is thought that there was a higher concentration of O2 in the atmosphere.

And ta. da. You get big bugs.

I'm quite frankly happy that we don't have to worry about such things these days on our walks to work.

So, yay hemoglobin!

Professionalism

In the hospital I noticed two types of people.

On group (in a non-patient area) would express their irritation about certain patients.

They'd say, "That patient really annoys me."

Or, "GOD they suck up so much of my TIME!"

The other group (by contrast -- in the hallways outside patient's rooms), they'd say, "God that patient was so difficult."

Or, "That patient has a personality disorder. She's SO borderline."

Or, "They are totally just drug seeking."

They seem to be saying the same thing, but notice the difference: In the first example, people acknowledged how patients made them feel. They allowed themselves to be annoyed, admitted that they were frustrated and tired, could make jokes about the irony of certain situations. Then they moved on with their work.

In the second example by contrast, everything was the patient's fault. The doctor? Not a chance. They're too professional for that. Then they'd go into the patient's room and act passive aggressive towards them. Nothing flagrant, though. Because they are professional, and don't do that sort of thing.

Note that group one is often told by group two that their private expressions of annoyance and frustration are unprofessional. Even though their patient's don't ever know that they were annoyed in the first place.

Do you want to make a guess as to which group is medicine and which is surgery?

I guess maybe I must be crazy

I remember talking with a co-3rd-year medical student sometime last year about Psychiatry. She HATED it.

I loved it.

I've talked about my reasons for this in other posts, so I won't belabor them now.

I was more interested in why she hated it. Vehemently.

She told me that she had a really hard time relating to patient's illnesses. That she could more easily relate to what it must be like to have a chronic disease like diabetes or heart failure, or cancer, than to be depressed.

She couldn't imagine what depression, or any other psychiatric illness for that matter, would be like to live with.

I was stunned.

First off, it seemed to me that having diabetes/cancer/other terrible illnesses probably feels a lot like.... depression? Or at least is a giant pain in the ass to deal with, altering the way in which you think about yourself.

But really, how can someone, ANYONE, not be able to imagine what depression must be like?? Schizophrenia, Bipolar, maybe less obvious (but I'll get into that in a moment). Haven't they ever felt sad about ANYTHING? All you have to do is imagine what you felt like at your most crappy and hopeless, and then think about what it would be like to feel that way every day for months at a time, with no end in sight.

Fact is, I didn't believe her. Nobody goes through life feeling that good all the time. But still, she insisted that she couldn't relate.

I wondered if she was one of those people who couldn't understand why depressed people couldn't just "snap out of it."

Anyway, it got me to thinking what it must be like to have schizophrenia or the manic phase of bipolar.

And I concluded, with schizophrenia you hear things that aren't there, and have beliefs that can't be true. You feel that people are after you. You tell people about these things that you hear, or these special messages you're receiving from the tv, and they look at you like you're nuts. BUT YOU STILL HEAR THE VOICES and see the messages and feel people are after you. So you try to block them out.

It must be horrible to walk around not knowing what's real and what isn't. Having people tell you that you're imagining the reality that you live in and treating you like you're nuts. Feeling like others are out to get them all the time. Having other people shake their heads and try to get away from you as fast as possible. BECAUSE YOU'RE CRAZY.

As for being manic, I guess just imagine feeling really good. 100x better than you've ever felt before. And feeling like you have superpowers. It must feel incredible. No wonder people with bipolar illness don't want to take their medications. But then you do come down. And you now have to atone for all the stupid things you did when you felt invincible. Not a good feeling, I'd imagine.

Anyway, the classmate is going into Internal Medicine. And it's probably a good fit. I guess I'm not really surprised given how bad at psychiatry the medicine docs I saw were, and the lack of introspection they displayed (but somehow at the same time, so very interested in discussing professionalism).*

Touche!

Well whatever. Maybe I'm wrong about what it must be like to have different categories of mental illness. But at least I gave empathy a try.

Do any readers have better insight as to what these things are like for patients to live with?



*I'm being a little flip here. Deal with it.

Some Drugs Create Awesome Knockers

That's for the drugs that cause gynecomastia as a side effect. And they are:

Spironolactone
Digitalis
Cimetidine
Alcohol
Ketoconazole

Pants yesterday commented that we at Penn are lucky in that we get to take our boards after our clerkships. Because we've just spent the whole year doing pathophys on patients. Which kinda makes it stick better than reading it out of a book.

Though, I gotta say, it does put us a WHOLE EXTRA YEAR away from things like.... Biochemistry! Pharmacology! Those kinds of things. I mean, I could tell you 5,000 different B-blockers. But Guanethidine? Seriously? Reserpine? Metyrodopablahblahblah?

Exactly.

And I'm also sort of like.... DNA polymerase? Right. That was more than 5 years ago. Yep, my med school skips all that. Which is probably fine but still. I keep thinking that it might have been nice to have a few more easy weeks during first year to review all that stuff. Or to learn anything about biochemistry.

Or maybe not.

Ha.

I'm hoping that when I actually GET to the pathophys section, I will be like, CLEARLY, OBVIOUSLY, I DON'T NEED TO REVIEW THIS TRIPE!!

Somehow I doubt that will occur.

Ok, anyway. Back to learning about Hurler syndrome.*

*If you want to know what it is (but seriously? WHY??), look it up

Anxiety Blogging

In T-1h I will be in my first meeting with an Epi person. I am petrified.

She does really cool work..... ON THINGS I DON'T KNOW ANYTHING ABOUT. Hell, I learned what Friedrich's Ataxia was by reading a paper by her on the subject three days ago. Add to that, what if she asks me to talk about my previous research? Ack! It's been three years! I feel like I barely remember what I was doing last week, let alone what the outcomes were on my various papers of yore!

I did review them this morning.... which helped. But I still know NOTHING about neuro-ophthalmology.

What if she thinks I'm an idiot?

Worse, what if she thinks I've wasted her time?

I'd like to point out, that this concern was NOT alleviated by my other Epi advisor whom I asked to alert people that I was interested in possibly maybe working with them. See, most Masters students enter the program with a specific advisor in mind. PhD students get to pick later. And I got a whole bunch of faculty asking me, "Aren't you already supposed to have picked someone?" Which is hard to explain away when you're a first year medical student.

He said, "If I email them, you have to go prepared! Don't make me look bad!"

Thanks.... I needed the extra pressure. Really.

And let's not even get started on the boards studying. With my Drs appt and various errands yesterday, I did 7 hours of actual solid studying. For a grand total of 60 pages of First Aid and 60 Kaplan questions. The studying itself felt pretty good actually, and it was high quality. It just wasn't nearly enough time. I had really wanted to do at least 100 pages.

For those who suggest cutting blogging, just know that each post takes about 15 min. Not a huge time sink in the grand scheme of things.

So, we repeat again. I guess I could be studying *now* but I really feel I should be going over this woman's research so I don't look like an ass an hour from now.

Gah!

Hopefully it will all work out.


Update: The meeting went well! I didn't come off as an idiot (I think)! I could actually work for her. Now, all I have to do is meet with 5K other people and then make my decision. Thanks for all your good luck/you're a goddess sentiments (totally not true, but appreciated nonetheless).

Next up: Critical Care Man #1.

Oh joy, oh rapture

Well, I'm about to head out the door for my annual cervix scraping.* I really hate going to the doctor,* and I especially dislike student health services (You broke your arm? Do you think you could have chlamydia?). I'm thirty-freaking-one, ok? I'm in med school. Do you think you could talk to me as though I had a brain?

Alas, there are no male doctors in woman care (OMG why do they have to call it that?), but this time I specifically requested a doctor rather than a nurse practitioner. Because the NPs I've had the past two years have been oh so delightful.

We'll see if it makes a difference.

I have my doubts.

Update: The appointment went fine. Not sure if it's because she was better than my previous NPs or because I didn't ask her anything. Notable quote of the visit was, "You're 31?!?!?!? You don't look it AT ALL," which won her big points. I'm realistic though. It's easy to be contextually youthfully appearing when the average age of her patients is 20. Also, let's be honest here -- I was wearing a t-shirt with skulls on it. Not exactly the outfit du jour for your average 30+ woman on the go.

Of note, the appointment was in the *new* student health facility, and the "woman care" exam rooms were carefully segregated from all other patient care areas on the floor. They were, in fact, on THE OTHER SIDE OF THE BUILDING. It was as though they were trying to keep the icky vaginas from contaminating anything else in there.


*Pap smear
*Medical school has only enhanced my hatred and distrust of doctors

From a few months back

My Family Medicine rotation was one on which I got to spend a lot of time talking to my patients, most of which whom were relatively healthy, a lot of whom were there for well-checks. Most of the time the conversation was pleasant enough. Occasionally, when it drifted towards my hair color, it became mildly annoying.

More rarely, thank God, when it drifted towards my career choice, it became downright offensive.

It was always the wealthy little old ladies who would dish on how wonderful things were back in the good ole' 1950s. And they were always so pleasant when they did it.

"You know," one of them told me, "Things were so much better in the 50s when all a woman had to do was get married and have children," one such patient told me one morning.

She continued.

"Her husband would take care of her, and she and her girlfriends could get together and have lunch everyday, with their children playing in the background. She didn't have to worry about anything."

Oh wait. There was more.

"There wasn't any of this concern about things like careers," said as though the word "career" tasted foul and slimy in her mouth, "Girls could just get married, and all their problems would be solved. There was none of this worry about what they should do with their lives. The husband could do his thing and she could just have fun with her babies."

Now, what is there for a budding young doctor-ette to say but, "Uh-huh Mrs. Anderson.* Now can you please take a few nice deep breaths so I can listen to your lungs."

And then I said, sweetly and with a smile on my face, "I'm so happy things worked out so well for you with your family, and that you have such fond memories.... Not everyone is as fortunate as you are."

She nodded, "Yes, I suppose that's true," she said.

I'm really grateful that I've had the opportunity to use something other than my uterus to make a life for myself. I love using my brain, and I can't imagine where I'd be without it.

I really wanted to ask her what she was trying to prove by telling me this.

Perhaps I have finally learned some diplomacy?

Nah.

*Not her real name.

Three words

Yay New Jersey!

Going to the grocery store in Philadelphia makes me want to punch someone in the face

When I lived in Chicago, I loved to cook. Every weekend, I'd look up a couple new recipes that I wanted to try, and take a short walk down the street to the fresh produce mart to get some fresh and cheap vegetables. Then I'd go to the co-op next door, which while overpriced and not fantastic quality, always had what I needed.

And then I would go home and make bean salads, guacamole, meat dishes. And Luca and I would sit on the couch sipping wine and watching movies while eating my latest concoction.

This activity is actually impossible to do in Philadelphia. Even with advance planning. Even if you allocate the whole day just to grocery shopping.

Let me walk you through a typical day in which I have decided I want to make something requiring specific, but not particularly special, ingredients.

Last Wednesday, I decided that I would cook something special for my husband for New Year's Eve dinner. He had specifically requested scallops, and I thought it might be nice to finally make this Tuscan White Bean dish with sweet sausage and red peppers.

I knew that I wouldn't be able to find all the ingredients I needed at Trader Joe's (the most loathsome grocery store ever invented -- the depths to which I hate this grocery store are unsurpassed -- did you know that their business model actually involves intentionally selling a % of food that is rotten?), so I decided to go to Whole Foods, which is a mile and half from my house.

My husband had the car, so I decided, what the heck, I'm on vacation. I'll walk.

The weather wasn't even that cold, and by the time I arrived there I was actually pretty toasty.

First I got my produce. Never mind that half of what I was buying was not labeled with a price tag. Never mind that the ONLY items with prices on them were the "organic" items. All of which were !!ON SALE!! Looky! You can get a pound of red bell peppers for $3.99/lb compared to the usual of $4.99/lb!! It MUST be a good deal. Oh, there are some other peppers over there.... but they don't have a price on them. I guess I'll have to get the "organic" ones so I don't end up inadvertently getting raped in the checkout line.

And then we get to the seafood section. And oh look. No scallops.

So I called my husband. "Honey, there are no scallops at Whole Foods. Do you want some other kind of fish?" I started receiving dirty looks from some of the other customers. The person behind me actually started leaning against me, trying to shove me out of his way. I might add, I was pulled off to the side, waiting in the fish line. Out of the way of the flow of traffic.

You read that right. The other customer pushed me out of his way.

If I had been wearing heels, it might have been nice to accidentally on purpose step on his foot with them. Alas, I was not. Had it been nice out, perhaps I could have been wearing a pony-tail, and accidentally on purpose slapped him in the face with it. Alas. I am not a large person. Overt acts of aggression are not a good idea for me, anyway. Plus I don't want to get shot. Since that is something that happens here not infrequently.

We decided that scallops were going to have to be purchased at Trader Joe's. Frozen. So much for a special treat for New Year's! So much for advance planning!

Did you know that Whole Foods doesn't carry dried white beans? Lentils yes, white beans, no. I didn't know that either. No sweet sausage either. Only hot. Which I don't mind, but my husband does.

I ended up buying them anyway so as not to feel like I wasted a trip.

I then resigned myself to having to go to another grocery store later that day in order to get the ingredients I needed. Mind you, these weren't the random spices that I couldn't happen to find. These were the MAIN INGREDIENTS for the dishes I was planning to prepare.

And so it was, that I found myself in the checkout line, looking down at what I was about to buy, thinking, "Wonderful. Now I am paying twice as much as I ought to be for parmesan cheese and tomatoes. I think. Since the tomatoes didn't have a price tag on their rack."

I put the cheese back. $18/lb is definitely too much for cheese that you put on your pasta.

Later that day, I swung by Trader Joe's to try to find the frozen scallops. And I did find them. Of course the grocery store was packed with people who wander aimlessly and cut you off without noticing. Then they will stand in front of what you need to grab for what seems like hours. Later, as you're waiting behind some person who is doing something similar in another aisle, these same people will sigh heavily and give you dirty looks because you're in THEIR way.

Oh and also, another pet peeve of mine is when these yuppies won't unload their own cart at the checkout line or pack their own grocery bags. When the store is literally EXPLODING with customers and the checkout lines reach halfway down the aisles. They stand there in line, bitching to each other about how slow things are moving, giving the other customers the stink eye. Then when it's their turn to pay, they glaze over and stick their thumbs in their asses. It's completely infuriating to watch.

At least nobody laid their hands on me at Trader Joe's.

But I digress. Trader Joe's didn't end up having the dried beans either. I had to send my husband to the grocery store in suburbs on his way home from work, thus eliminating my ability to prepare food for him before he arrived home. By the time the shopping was finally finished, we had spent too much money and found half the things we needed. I didn't want to cook anymore.

But I did anyway. And we drank a lot of wine. Because we deserved it.

Sadly, this is typical of food shopping every week in this godforsaken city. I still hate it here, and this is one of the reasons why.

Boards

Technically, my vacation will be coming to an end on Monday.

Technically, I will start studying for step 1* at that time.

Technically, I have had 2 weeks of vacation.

Technically, even after I take the boards, I will have the whole month of February off too.

Technically, I will be finishing working on a paper during February.

Technically, I will be meeting with various faculty in an attempt to figure out who I want to work with for my PhD.



So if I have all this work coming up, why does it still feel like I have two months of vacation ahead of me?

Oh I know why. It's because I don't actually have go be anywhere during the day. Sure, I may have mountains of reading to do, but if I don't have to set my alarm for 5:30AM, it seems like vacation to me.

It will be interesting to see whether I still feel this way after I've started studying. I haven't had so much unstructured time since.... ever I think.

I was thinking about how I told myself I was ready to start studying last Monday. And I WAS. I was beginning to get antsy. But I am very happy that I took the extra week off. It's not often that one has the chance to just lie around with one's husband and do nothing for a whole week. I don't expect this will be happening again.... ever, and I'm glad I took advantage.



*My med school has us take the boards after core rotations, which we finish up halfway through third year. Say what you will about how horrible it is that I don't have to take them before clerkships (I've heard this from a surprising number of people who seem to think I have some kind of control over the process.), that's how it is. Supposedly this is to enable us to have more time for research and electives.

Dinosaurs

I did 4 LPs* during my core clerkships this past year. I even got the first one!

Alas, it was all downhill after that. My only consolation is that whenever I missed, so did at least one resident too. So I know that I can't *possibly* suck that much.

:-)

Anyhow, while attempting to do a particularly challenging LP this past block under the tutelage of a resident who LOVED teaching (almost TOO much, if that is possible) he started going into great detail about the anatomy of the spine. He said, "You just have to picture in your mind what the vertebrae look like when you position your needle."

And well, it's true.

The only thing is, every time I think about the anatomy of the spine while doing an LP, I think of stegosaurus.



Now, compare the spinous processes (the big plates on his back) of the giant lizard to those on our spine. The projections that stick out on the left side of the photograph below.



See the similarities?

Though I ultimately failed at this LP (as did the next resident who tried)*, I couldn't erase the comparison from my mind.

Who says there's no such thing as evolution!


*Lumbar Punctures
*Yes we made multiple attempts at sticking a needle into this patient's back. He was unconscious. I don't think he ever woke up.

Locked In

Learning about various drugs during anesthesia, I was struck by the way vecuronium worked. It is a depolarizing neuromuscular blocking agents, i.e. it makes you unable to move while preserving awareness. It was discovered by natives South Americans who would poison their arrow tips with the stuff and go hunting.

The prey dies of respiratory failure. Well, in reality, they probably got clubbed to death after they stopped being able to move. But still, at the time I couldn't really think of many worse ways to go.

It still ranks up there.

In The Diving Bell and the Butterfly, we see a man who has a pontine stroke wake up and then live out the last months of his life in the hospital. He is unable to move any muscle in his body except the ones needed to blink his eyes, but has complete function of his cerebral cortex. Total awareness with complete paralysis. He is in what is known as a "Locked In" state. One of the nurses finds him interesting and they develop a method of communication based on him blinking, and together they write a book.

I can't remember what the book is about, but ultimately the patient dies of pneumonia or something. Not infected bedsores though, I remember that much. At the various nursing homes I've seen around Philadelphia, I have no doubt that is what would do in a patient here. Or maybe urosepsis from a catheter left in place for months at a time.

They were in France, though. And not to wave a huge stereotype in the face of everyone, but WHERE ELSE would someone have the time and inclination to sit with someone who can't even talk for hours upon hours every day -- uncompensated -- to transcribe a book he is writing by blinking.

I do remember one thing: at the beginning of the movie, the patient feels depressed. Quite understandably. The first words he blinks out are, "Kill me." By the end of the movie, he has made amends with his former lover and their three children (ah, France), and many of his friends. He isn't depressed anymore.

Other illnesses can cause complete paralysis as well of everything except the bulbar muscles.* In central pontine myelinosis (now called osmotic demylenation syndrome), a patient's hyponatremia has been corrected too quickly. It is associated with alcoholism.

Somehow I doubt that many of these patients are lucky enough to have someone take interest in them and decide to spend hours with them every day.

When I was on my neurology rotation, I remember a patient who had ALS on our service. I remember standing during rounds for what must have been 30 minutes by the patient's bedside, the attending talking to her and her husband. She couldn't move anything below the neck, and she was planned for a tracheostomy the next day to help with her breathing. Then we were planning on sending her to a SNF. She was very afraid.

I remember standing at the foot of the bed, straining (and failing) to hear what she was saying. I remember my back hurt from standing for so long. I remember wanting to move on to the next patient.

After her surgery she came back to a different service with a different attending and a different group of residents. It was a busier service with sicker patients. We used to rush by her room every morning. "Nothing to do!" we'd say. "Recovering well post surgery. We're just waiting for a SNF to accept her."

When the team would march in and out of her room every morning, she would mouth stuff to us, now that she was unable to talk because of the trach. The team would say, "What? What?" and then say, "I'm sorry I don't understand," and then walk out the door. We'd stand outside the room for about five seconds and look at each other. Maybe write down some palliative measure we were planning to do for her that day.

Then we'd move on the the next patient. One we could hopefully fix, or at very least one who could complain to us.

Once she had mouthed, "I'm cold," and the other medical student and I had gotten her a blanket after the team had said, "What?" and walked out the door.

After a few days, we stopped even going into her room during rounds.

From the nursing standpoint, I guess she was probably relatively easy to take care of. Never able to pull out a line or a tube.... Never able to complain.... Never able to press her call button....

Nobody was available to take the time to come say hi, or to even sit with her for a few minutes a day. Her husband stopped coming in as often. Many days I would plan to go see her in the afternoon, but each day something would come up and I wouldn't end up going. Even I as a medical student, supposedly the one with the most time in the world, didn't have time for her.

On the last day of my rotation, she wasn't in her room anymore. She'd been transferred to SNF I guess, but all I know for sure is that we never talked about her again. 8 months later, she may well be dead by now.

I'm still haunted by guilt over my laziness. I should have gone in to say hi on my own at least once. I wonder if I will ever be able to atone for that wrong. To myself if not to her.



*Those you use to blink