X-ray Eyes, Hands, Shoulders...

(Radiologist): "I feel like hell. My shoulders and wrists are killing me..."

I've been a scut-dog. I was one of the junior staff of a hospital radiology department (for a short time) whose sole job was to serve the senior physicians with whatever they needed. And in radiology, that meant chasing films, finding films, locating jackets, checking in and checking out films and at the most critical time...find a lost film, STAT!!

Then it was necessary to put the film on a large, floor to ceiling box with rollers to "view" the film. It could take minutes, hours sometimes to have a film read and reported to the person ordering the x-ray test. It felt like so, so much work. And it was.

Zipppppppppppppppp...

Fast forward to today. I sit in a dark room, reading radiographs with a senior at lightening speed. And we sit for hours. No chasing films, no looking for jackets, no checking or checking out....those days are long gone. No more long term x-ray storage, processing, chemicals or accounting. We read hundreds of images today that would have taken weeks before. The efficiency of radiographic interpretation and the technology is one of the greatest revolutions in my long medical career. Picture archiving and communication systems (PACS) have taken over imaging. It's all about the computer.

 

Now, a radiologist can generate so much work, they can barely keep up with the demand. Computer overuse syndromes are so common among radiologists that some wonder about the value of the average $384,421 per year salary they can receive in exchange for the lifetime of pain in the shoulders, elbows, wrists and hands. The pace is fantastic and it's truly amazing to watch a modern radiologist "whir" through the day.

I walked away today, as other days, with a total "oh wow" experience and an ah ha moment that I could never sit in a dark room, for hours and hours on end, with little human contact, reading radiographs with little insightful information about a patients history, physical exam or differential diagnosis. And a little carpal tunnel to boot.

(Radiologist): "I feel like hell. My shoulders and wrists are killing me...but for $8,000 a week, I'll figure out a way to make this work"

Humbled, again

What a great day of learning!!

It's difficult to go very far in medicine, and not encounter people who are way more smart; filled with retained information, facts and experiences. It seems to happen regularly for me, but sometimes it's just more profound than usual.

Such was the other day, standing at the X-ray box.  And while it's not really a "box" anymore (my grasp at historical anchors), the experience is no less profound. Maybe more so given the technology and "wow" factor.

But the impressive thing to me is that I'll never have those 20-30 years of experience that create profound insight into a craft. That daily slog through medical care, and moreover, dealing with the failures and complications, brings a level of knowledge and skill that cannot be duplicated any other way.

And when one person who has attained this pinnacle shares it with me (or pimps me), I am so, so humbled. And so sad that I there aren't enough days in my career left to attain that. I should have started earlier is the only answer, but "shoulda" doesn't really cover it enough.

In any endeavor in life, practicing the craft is everything to becoming truly facile with the information and application. It's true of fine furniture makers, and true of physicians. The practice is what it's all about. And the more you practice, the more you have to give.

Great knowledge is learned at the X-ray box...uh, I mean the triple screen, color, high definition PACS display unit with the IPad controller and animated 3-D integration technology.

Matched

It's simple. It's straightforward. It's almost inane.

"Congratulations, you have matched".

That's mostly what it said and now we just wait until Friday to hear of the "where" of the equation. There's no telling where it'll be or when it'll start, but knowing that this phase is over is wonderful to know. It's been a strange, at time difficult, amazing journey so far these past 4 years, but it's literally the beginning of the second 1/2.

This is likely going to be an amazing time filled with new learning, new levels of responsibility and renewed view of the past, present and future. It's the thing we have been working for and what it's really all about.

But like any "match", it could be just the beginning of a new fire.

It's the Eve

So here I am, starting a new rotation and waiting on match results to find out where I'll be doing my residency, if any. It's frightening and exciting all the same. Nearing the end of the educational experience of medical school and holding the expectations of being able to move forward with great hope.

The rotation is radiology. Sitting in the dark, with another human being, for hours on end... reading the shadows. The unit secretary said it was "going to the dark side"...literally. But in those shadows is a crucial skill that many take for granted. X-ray, CT, MRI and U/S are extensions of the physical exam to peer inside. I'm excited about it.

Yet, sitting in the dark with another human seems so wrong too.

Good Black Monday Morning

"It's the morning of the match and all through the apartment, not a creature was stirring, not even a zatch."

Ok, so I'll never win any literary awards. But I sorta feel like a zatch at this point.

This is the day, like the NFL draft, that the world of medical students dread and anticipate. For the past 9-12 months the application process, interviews, paperwork etc have the activity level up. It peaks today with the announcement of what these last years of medical school have been all about...matching student preferences with residency program needs, wants and wishes. Today, we'll all get emails from the national match program saying you matched or you didn't.

I believe there are nearly 50,000 people vying for 24,000 some odd positions this year. Knowing that, some will not "match" and will enter the supplemental application process or SOAP for unfilled positions. Then on Friday, the world will hear of "where" we will actually go and train for the next 3-7 years (depending on specialty). But for now, I can only be sure my email and wireless work so I can get the Black Monday message at noon today.

If I "survive" it's a match. If I don't, drive thru at McDonalds seems like a good alternative.

And there you have it...

Four years, many class exams, 3 major national boards (and 2 more to come), lots of study, time, travel and nearly done with elective rotations....and we arrive at those tender, sanctified 3 annular weeks. It is time for "match"

Today, all applicants around the country (and perhaps the world) will submit to the match folks their "list" of preferences for programs. At the same time, the programs will submit their "ordered" list of students. Between now and the 12th of March, a batch of computers running a program that is more highly guarded than the formula for Coke, will make life decisions for everyone and "match" applicants with PGY1 residency slots and programs.

I can't tell you how much energy is expended on this process from the applicants end. I'm only 1/50,000 of the applicant bodies involved, each of us making a list and agonizing over each addition... the who, what, where, when and whys run like fluid through the brain. It's what these last 4 years have been about. And it's comforting to know that many of my brothers and sister MS-4's and graduates will get in with little more than high test scores, a cute smile and no healthcare experience.

Yet in the end, it'll be what it is and the more I release control, the more satisfied I am with my application at What-A-Burger.

Moments in Time - Coming and Going

There is so much activity inside the modern academic institution. Students, residents, fellows, attendings, nurses, clerks, technicians ...running around doing "their thing" in the hopes of curing and preventing illness. It's truly a marvel to hear, see and feel the "heartbeat" of the academic hospital "beast".

Yet in the moments of organized chaos and discombobulated focus there are moments of pause. That happens fairly regularly (for me at least) at my institution when the overhead speakers "click" on and we hear a short, just a few bars, music... Brahms "Lullaby" . It means that somewhere in the hospital a baby has been born. There is no announcement, no words, just the telephone-ringer-short-version of the lullaby.  I can't help it. I just stop or slow down my manic walk to the next assignment, listen and realize what's happening. I'm paying attention. A new life is coming aboard planet earth even as those leave us.

 

And so, it happened yesterday. There was a loudspeaker announcement of a "code blue, code blue, code blue,...room blah, blah, blah" as a patient arrested on the floor. Some doctor-looking folks jumped up from the conference room I was sitting in to run to the patients room.

And then, about 30 seconds later, the lullaby.  In under a minute, one patient "left" and one patient "entered". To me, a bit surreal. But I'll bet that most don't even notice such things.

Sometimes the hassle and bustle robs us of our humanity and really being present. I try not to let that happen. Or maybe I'm just sensitive to the fact that match is coming very soon and the rest of my life will reveal itself. So much easier to be "present" when I'm not studying for some major board exam.

And, there you have it!

"In every community, there is work to be done. In every nation, there are wounds to heal. In every heart, there is the power to do it." - Marianne Williamson

The season changes today from active pursuit to passive anxiety. The last of my interviews is over and rank order for "match" is due soon. I think I'll get mine out and certified today and be done with it until the match announcement on March 12 when "matched" and "unmatched" information is posted.  It's the end of this season and the wait begins.

Interviews have been absolutely fascinating. In a very short period of time, usually minutes, you have to summarize your life, education, and experience, respond to questions and concerns, and do it with a cool, calm and collected demeanor. Piece of cake!

So now, rotations continue toward graduation in the very near future. Rank order will be submitted to the God of the Match. And life will continue as if nothing is happening behind the current that Carol Merril is standing in front of. Off to the gym, where the weights don't care what I did on boards.

Entitlement

I'm daily made aware of a subsystem of medical education in the U.S. that is predicated on access, sense of entitlement and money. There are many such examples in the South where students from private, for profit institutions like Krass University and others pay exorbitant fees that amount to bribes, to practices and centers to exclusively allow only their students to attend clinical rotations and receive education thus excluding other students, programs and schools.

This sense of entitlement, bought and paid for with huge tuition, has the students feeling they have the right to be given something which others believe should be obtained through effort. This extends into match and residency as well for many of these students who become unrealistic with expectations of favorable treatment or automatic compliance with theirexpectations. But they are a cheerful bunch, willing to bad mouth and step on any other student in their way.

Lovely huh? Perpetuation of the competitive, almost manic, approach to medical education unlikely to promote anything but more entitled doctors with no sense of team work. It is nearly impossible to create an empathic, caring physician under these conditions.

The U.S. medical education system is drastically in need of review, overall and possibly trashing. But I sense nobody is willing or able to live beyond the system that seems to have a life of it's own...open to payoffs, lured by money, entranced by funding. And further privatization of the medical system is not the answer. It is in fact, part of the problem.

Eating for Health

I just watched a man down lunch at Burger Prince. I guessed he was 6 foot and about 250# based on gross comparison with my own frame. He ordered a meal while I was behind him on line (I got a diet soda to help down my vitamin pack). He ordered 3 items including a triple whopping burger, a large potato fry and a large brown soda. Being in health care and being very curious about and actively seeking information on nutrition and health, I looked up his meal to calculate his intake.

Besides the incredibly high amount of salt, his meal was over 2000 calories. I'm currently on a program that allows 1500 cals for the whole day and he downed more in one setting. His triple burger alone was worth 1250 calories all by itself.

So I started a conversation with him about his company (insignia on his jacket) and introduced myself. His company is locally famous and I was fascinated with their success, policies and such. I wanted to know more (really). Somehow I got him interested in me in some meaningless way and he asked me to join him while he finished off his voracious attack.

The niceties of what we did, our holidays and New Year's progressed to resolutions. He told me he wanted to lose weight and get into the gym. Shocking, right? So when I noted to him that my diet soda was part of a larger plan (and caffeine injection) and a goal of 10 pound weight loss, he was interested. His face turned to stone when I told him about his now almost finished ingestion of over 2000 calories and such, and I didn't even include the 6 ketchup packs (filled with sugar) he doused his fries with.

We are just used to big everything and think it less value if we don't get it. And when we get it, we convince ourselves we have to eat it. Now at the price per calorie his meal was an incredible value, but to what end? I made a friend and potentially a future patient today, but I know he's going to think twice before he stops for that "value meal" again. At least that is my prevention hope. I'm confident though that the drive-thru will lure some unsuspecting traveler another day.

Job security, even if nobody can pay for the work. Except perhaps the very profitable Burger Prince.

The Last Christmas

 

 

I'm not sure when it happened, but sometime during the 2nd year of medical school, I began to map out my trek on 3 very large, picture calendars. You know the kind...photos of national parks, huge vistas that you ad to your bucket list as you flip the pages. Awesome to look at as I moved onward.

As I progressed, I marked key dates, deadlines and points of interest in this process called medical school. I remember looking at December 2012 back then and marveling that it would be the last holiday break before graduation if everything went on time and schedule. And while there have been some blips, it came.

It was a great holiday with many wonderful memories created with family, friends and places. But it did feel different. It was the first one I wasn't studying for something in earnest. And it's that pensive time before Match is announced. It was a time of reflection too...have I done everything I need to do? Is there anything I need to do? Are my last rotations all set? It's been a very busy 2011.

And so this part of the process will end very, very soon. It's the last of the clerkships and laid back learning. I wish I could figure out how to do 4-8 week rotations for the rest of my life, but alas it doesn't pay well :) It's a great time to hone skills, be truly present with patients and get better at communication and decision making. It's a great time to reflect on the experiences thus far and try to envision the future to come. It's an exciting time.

And while I may have been out of my mind to jump off into this abyss, it's been a great experience and I'm looking forward to the next stage. And that will be here before I know it. I can see the light at the end of the tunnel and graduation is on the horizon.

And the congregation said "yea".

Now, if I could only get my preceptor assignment for Monday.

A Numbers Game

The frightening thing is the information doesn't seem to be out there. It's gone largely noticed as I talk to established physicians. The reality? As medical school class sizes grew and new medical school opened on top of more foreign medical students applying...many will NOT match in 2012.

Expectation - There will be approximately 24,000 PGY1 positions available this year in ALL specialties. There will be nearly 50,000 applicants this year (U.S. and FMGs plus graduate MD's from other countries). There are going to be over 25,000 U.S. grads alone....more than the number of PGY1 slots. Any with funding questions swirling, there may be less positions even as the number of applicants increases.

The Problem: A tremendous need for primary care physicians in this country (pediatrics, geriatrics, community internal medicine, general surgery, family practice, women's health, etc)

The Myth: Expansion of medical schools will increase physicians, particularly in primary care. This is the biggest lie of the entire health care discussion, and medical school have largely bought into the idea by increasing class sizes and opening new programs. Physicians are "built" in residency, NOT medical school.

A Simple Solution: Unmatched graduate MDs and DOs want to continue training and practice medicine...being part of the solution.

How about providing a route for all unmatched physicians who have passed Step 1 and Step 2 enter into a "apprenticeship" agreement for training with any licensed physician? In exchange "training reimbursement" through Medicare, Medicaid, Insurance etc including payment for services as if the trainee was a physician.

Why is this so outlandish? A Physician Assistant can graduate PA school after 2 years, and enter into a work agreement to "practice medicine with supervision" right away. Why shouldn't a 4 year trained physician be allowed to do the same? It make so much sense to create this alternate pathway to create primary care and needed specialty physicians as a methodology to create the solutions health care really needs in this country.

The question, is there anyone in medical leadership willing to champion the effort. Are Boards of Medicine willing to be creative enough to fulfill the needs of it's citizenry as physicians retire, leave medicine, and refuse to accept Medicare and other payment programs?

We really need solutions, not more roadblocks. How about bringing the community apprenticeship training model back? It's worth looking at!

Emerging from the Rabbit Hole

Time flies when you are having fun or doing interviews for residency. I was doing the latter. Doesn't seem to matter how many times I sit across a table from another human being for an interview, it never gets any easier. I'm sure my facade is glowing calm, but my insides are churning of sweat and sheer panic.  I realize that it's not supposed to be that way, but the pressure of presenting yourself to one person or another in a short amount of time is brain busting. Combining a rather long history with honesty and trying to highlight the important qualities that fit the setting = nerves. At least the suit looked good.

But then, once in awhile there is a merging of the minds, a synchronous dance of perfect symbiosis and "Tsaheylu" is formed. I jump up and down inside when that happens. It's a moment in the interview time, place continuum when you know you are answering the questions easily, appropriately and becoming one with the interviewer. The portal into this rabbit hole could be something simple like a highlight from your past that fits their future view of the program. It could be a shared venture outside of medicine or a key word or phrase. It could be a testing struggle you both shared. And there doesn't seem to be any rhyme or reason and certainly no way to Google it in advance.

But I'm not asking for much, just a chance. A chance to show how passionate I am about medicine and patient care. A chance to prove beyond my average test scores that my clinical skills, honors rotations evaluations and experience means something beyond the sheer numbers. Match is what this last 4 years has been all about, and it's about to happen; As soon as these interviews are all over and the rank order lists are submitted. This is the nerve wracking season of medical education for MS-4's and graduate MD/DO's everywhere.

Since the 80's the number of applicants for the Match is growing at a faster pace than the number of spots available. This leaves the clear picture to many that residency is not possible. Everyone doesn't match. So more and more applicants are vying for a proportionally smaller number of post graduate training program spots. That's a recipe for a nervous interview season.

And so it goes. About 3 months after the holiday season, everyone will know their fate and where they'll be going come July 1. Could be family medicine in Florida, surgery in South Dakota or dermatology in Des Moines. The future of medicine is in the hands of a few powerful men and women interviewing a few very nervous applicants.

The Stream is VERY Full!

When you have a hammer, everything looks like a nail. when you are in the match, everyone around you looks like a match applicant.

Recent article in the news applauded medical schools for increasing the number of first year medical students; Up almost 2,000 slots this year. That means in 4 years there will be 2,000 more students in the match process for residency positions.

But once again, the truth of the news is lost in the tragedy of the ineffectiveness of the process in the U.S. There were NOT 2,000 more residency slots created to accommodate those graduates. Add to that number the increase in foreign medical graduates like me, and the number of immigrant physicians who want to practice in the U.S. (all required for the most part to do residencies) and you see the bottleneck.

The fact is that there is a rapidly expanding disconnect between graduate medical education (residency) and the medical school "feeder" system. There is much money in expanding medical school and ERAS residency application slots, but not much made available to programs to expand residency positions. This is only going to get worse in the coming years as the new medical students graduate. It's a real problem as the U.S. tries to solve the primary care crunch as the baby boomers age.

I just want to practice "hang the shingle" primary care adult medicine. Why is this so hard? It shouldn't be at this stage.

Well, I've made it this far

Just heard! I have officially passed Step 1, Step 2 CK and Step 2 CS. I now can graduate and get the coveted MD degree. Now that and $1.95 may get me a cup of coffee at McDonald's (maybe), but it is done...and that's a GREAT feeling!

Next step...3 sometime in the next couple of years. In the meantime, residency apps, interviews (hopefully) and placement. It's a long road, with many twists and turns, but I can see the light.

Could be a train, but I see the light.

Waiting for Scores

Another Step, Stepped Upon

"Father, into your hands I commit my spirit."   - Med Student speaking to the ceiling fan with vague reference to NBME

"Boy, that was worth it. Such value in learning and educational assessment. $2 per answer!"
-Med Student III to me

"Remember what you learned for Step 1 and Step 2? Now forget it. It's useless, meaningless and has no place in this house of healing!"
- Residency director to new PGY-1s at orientation

Now just have to wait for the results.
Just in case, application to What a Burger submitted.

"Hey boy, you want fries with that??"

Sucking Sound

That sucking sound you'll hear is a large medical testing organization insuring I have nothing left.

Today is the day

The next "step" happens today. Step 2, part 2. This day marks the end of a long process that, while not quite over, was the pinnacle I could see off in the distance.

When I return, it will be done.

Tomorrow, onward to Internal Medicine.

Terms Everywhere

It's all about vocabulary.

Anything protected from outsiders must have a code that only the insiders know. That vocabulary of terms is the "fair maiden", protected in the towers by the knights in white smocks with black rubber tubes of grail around their necks and in their ears. To know "the words" is to be a member of the secret society of potions and spells that few are permitted to use or allowed entry.

 

And when the attacks at the gates by nurse practitioners, physician assistants, chiropractors, pharmacists and the many "non-knights" becomes too brutal, the knights convene and invent new words, new exams, new "steps", new rules, new regs, newances...and they smile broadly.

Pneumonoultramicroscopicsilicovolcanoconiosis

Mu ha ha!!

That'll keep them to the other side of the mote.

The fair maiden is protected again.