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.

Cluster Headache

Pretty darn bad, apparently.

A cluster headache is one-sided head pain that may involve tearing of the eyes and a stuffy nose. Attacks occur regularly for 1 week to 1 year, separated by long pain-free periods that last at least 1 month.

They are "episodic" (most common) with 2 or 3 headaches a day for 1-2 months, brief HA free period and repeating pattern after that. The other type is "chronic" is about the same but without a period of sustained relief. Both are more common in men, and often feel like " an ice pick in the eye."

Of course it's always a good idea to see if the patient actually does have a pick in the eye before treating.

Sorta Just Snuck Up On Me

The patient struggled to the table. "This has been progressing for a few months and is getting worse. It just sort of snuck up on me, a little more each day, week.

I've had tingling over my body in different place. I'm numb here, here, here and here (pointing). I can't seem to keep my balance on uneven surfaces and have been falling a bunch. My legs and arms feel so weak and my vision is getting worse, almost daily. I've been seeing double and it's very blurry."

"How old? I'm 48 doc. I'm very active; at least I was. I drive a tuck for work and love to hike and bike with my wife and kids."

[pause]

"Lets get a MRI and see you back. I have an idea what this is all about, but I want to be sure."

"I'll want to run a few more tests but I'm sorry, it is what I thought. You have M.S., Multiple Sclerosis. I'm afraid you may not be driving anymore and while we have some treatments that will help control the episodes you have been having, this may get worse over time."

And that's how it is. One day young, active, hiking and biking...the next, struggling to get up from a chair or climb stairs.  And the presentation, signs and symptoms are as varied as the stories with many different nerve maladies affects:

Multiple sclerosis is an autoimmune disease that affects the brain and spinal cord (central nervous system). Symptoms vary, because the location and severity of each attack can be different. It usually happens in "episodes", period of time with symptoms and many patients can be kept in remission with various therapies, medications etc. Episodes can last for days, weeks, months....or forever.

For me, after my neurology rotation, it will always be the "just sorta snuck on me" disease.

Get rid of my headache doc, and I'll give you my daughter!

Migraine headaches suck! That would be an understatement to those really having them. Migraines create great dysfunction in life, work, relationships, mood, self esteem, eating habits, traveling habits and almost every other area of life.

So when a patient finds a cure, usually through a provider that's willing to walk the combinations of medications (both rescue and suppression), other therapies and time... patients are ecstatic. Now they don't normally give away daughters and other parts of their family, but they do make grand gestures.

"How are you headaches going Mr. Jones? We've had quite the challenge with these, haven't we?"

"Doc, they are GONE!! I love you!! That combination of [select from the buffet - Amerge, Axert, Frova, Imitrex, Maxalt, Sumavel, Treximet, Zomig, Botox, Migranal, Ergomar, Caffergot, Amitriptyline, Atenolol, Diltiazem, Doxepin, Verapamil...just to name a few] did the trick!"

"That's great Mr. Jones.I'm thrilled for you and that we could finally get you some relief. By the way, I love you watch. It's very nice. Ok, so I'll see you back in about 3 months to see how your doing."

"Sounds good doc. Here take the watch. It's just an old thing anyway. Enjoy it!" And with that, he handed the doc the watch, and walked out.

Thankful just doesn't cover the gesture.

Furiously Filling Fat Full Fast

I am so full of knowledge at this point, I'm afraid to learn anything new for fear that it will force something out that I might need later for exams, practice or human conversation. I don't think there is any room possible for any more. I'm almost completely full.

And just in time too. Nearly done with this phase of study and the next exam coming soon. It's anticipation and future relieve rolled into a tight package of anxiety. The ultimate performance anxiety.

I've met some interesting folks these past weeks of intensive study; all on the same mission. We all have our strategies for success and they couldn't be more different from each other. But the ultimate goal is the same. Fill up just enough to not push anything out the other side of our brains and promptly regurgitate what we know or think we know at the appropriate time, in the appropriate exam moment so we can onward to the next "Step".

I pray for no leakage of any vital information, including my name.

His story, Her story

Everyone has a story. Everyone has tales of woe and triumph about this abortive process called medical training. The stories are all about the trials and tribulations, the attendings, the rotations, the schools, the classmates, the exams, the sleep (or lack thereof), the process, the residencies, the hours, the longer hours, the memory (lapses). And we all seem to have the same response on any given day...one day at a time, moving closer to the goal, whatever that is for you. It's a daily slog.

And it's so great to find those of use who relish, thrive and look forward to the learning day. There are great mental triumphs and "oh wow" experiences of eureka, mind blowing understandings of new, or newly incorporated knowledge. And it's those that force people to answer the question, "how are you?" with "I'm EXCELLENT!" :) and really mean it.

The process can be a great challenge.

But, today, I'm EXCELLENT.

Thanks Ceriman, the waiter, for reminding me of that simple fact. It's not what happens to us, but how we respond to what happens.

Mortality

I've learned to equate "clinical trials" of medications on people with illness as a terminal event, one step closer to death. It's just the places I've hung around, people I've worked with and things I've seen, but the the two -- Clinical trials & terminal -- just seem to go hand in hand.

One of my friends from way back when I was too smart for my own good, just told me she's in a "clinical trial". I felt sick...for her, and her family. She's so upbeat, so positive, so able to move through the day with a huge smile on her face. That same smile way back when, won her awards. Now they hide the sad fact that disease is ravaging her body.

I'll pray, I'll hope, I'll stay positive for her when we speak. But I've become acquainted again with mortality.

One, more, STEP

Seems like I've been studying medicine my whole life. Oh wait, I have! And it seems that it really all comes down to this set of two exams...Step2 "clinical knowledge" CK, and Step2 "clinical skills" CS. The entire reason for being comes down to two day of exams, one live with patient actors (and I use that term very loosely), and one "dead" day with a computer for 9 hours. Then sometime this fall, two email messages, and attached PDF's announcing the fate...Yay, or nay, to have the opportunity to graduate, get the MD in hand and move forward into the next part of training, the residency.

Rotations have been great. I'm in my element. I love the patient, the clinic, the learning, the relationships with staff, the smells, sounds and activity around healthcare. Lots of people are disgruntled in the field of healthcare, but I largely ignore them. Rotations are signs of things to come, residency and practice beyond. This really is the essence of why I did this in the first place. I am encouraged.

I thought she said "your ass" when I first heard the description of "what next" from one of my classmates. Actually E-R-A-S (residency) application. It is truly time consuming, but a necessary evil and it too continues getting ready for the 2012 match with 35,000 close medical friends who will also apply. Letters, documentation, work history, blah, blah, blah. Seems like I've been filing paperwork my whole life too. Oh wait; I HAVE!

So I study, and study, and study some more. It's a race against time, knowledge attrition, creeping dementia, boredom, mind numbing fear and a touch of ADHD. It's a balance between sitting for long hours, exercise, sleep, eating right and knowing just how much caffeine I can bear without overdosing.  It's keeping an eye on the prize and doing what it takes, even if I should have found "another career" (- career counselor, 1977). This 2nd step isn't the last step, but it's the one that really counts and "bookends" the process of the past 4 years. It's exhilarating, and frightening in one well wrapped package. My date with destiny coming very soon. Emails forthcoming.

The Cycle Begins

It's that time of the year that those shooting for Match 2012 in March begin the cycle of paperwork, processes, letters of recommendation, applications and interviews begins. The cycle starts now, in July, and ends the day the "matches" are announced in March.

It's worth reflecting how the process ended in 2011. Match Day 2011 there were 30,589 "active" applicants, and 23,421 PGY-1 slots available. Over 7,000 walked away with nothing after many years of hard work and the effort. Many will apply again this cycle, but likely many will walk away into other fields of work and study.

It is the bottleneck. It is the part of the system that is the real problem with the system. Medical schools are expanding their class sizes even as new programs are created for new students, both D.O. and M.D. But the sad fact is that the number of positions in residency are not increasing as fast. Thus, more and more physician graduates will not have post graduate residency positions to enter. And the problem is only exacerbated by the number of physicians immigrating into the U.S. each year, also in the hunt for those positions.

And so the environment I enter now. I'm so impressed how little information is out there that is consistent to help make the many decisions that have to be made in the next months. I'm on a haywire way up high without a net. This "fly by wire" is a rush, but it be the first step back to waiting tables too!

Education of the Un-schooled Kind

I was really frightened many years ago, helping take care of my first cerebral palsy (CP) patient. There was this really grotesque looking and acting child with muscle spasms, head shakes, twitches and writing sitting in a wheel chair. I thought he would break. I thought I might break. But that was many 10's of 100's of patients ago and I've heard and taken care of CP, cerebral palsy, patients forever. It's not a new name or category of care for me. But I've been schooled this past month. I really didn't know CP at all.  

Then I met and really hung out with a bunch of CP affected folks and their families. I really appreciate the experience and am so grateful for being able to hang with some of the most phenomenal but individually different CP folks ever. Everyone different from the next. Somewhere during the last few weeks in that experience there was a "click" of information (my anatomy, physiology and neurology) with reality. And after this intense month of talking with and experiencing these amazing young people, I now realize how diverse this group of patients is.

Cerebral palsy is considered a condition but it's really a waste basket term for everyone suffering from injury (usually some form of anoxia, low oxygen, at birth). It's more often thought of as a group of disorders that involves injury to the brain. But the problem is that the physical manifestation of the damage depends on which part of the brain and it's pathways are damaged. As a result, no two patients present the same and have differing combinations of functional deficits in movement, learning, hearing, seeing, and thinking. Each one is different.

The brain is huge and has between 10 billion to 100 billion neurons organized into cortices, pathways, areas and regions. Imagine all the different combinations of connections between those neurons and you have a number that is representative of the true nature of CP and the number of possible presentations.

So the first patient may have sight problems and motor control on the left side of his/her body. The next patient may have lower extremity problems and normal above the waist up. The next may have speech creating deficits and be unable to walk or hold a fork in the right hand but can with the left...and on, and on, and on go the variations.

But what I really learned I learned by hanging out with them and hearing their stories, successes, triumphs and fears. They are creative, fast thinking, smart for the most part with incredible senses of humor about themselves and others. They are dedicated, and grateful since they don't know what they don't have...they never had it. They are sincere, loving, hard working and diligent to find their niche in life while serving others. They really are, as one mother put it, incredible kids often trapped in bodies that just don't work. I really have been schooled...and I really am a better student, provider and person for having done so.

Tis the Season

Tis the season, not to be jolly, but to apply. And so it begins...the 2012 Match ERAS season. This is the start of what will be the long months leading to the that fateful March date when everyone I know will be fighting for residency positions and hoping someone says to them..."we want you". I don't know if I'll make the 2012 match, but I'm going to give it my best shot.

It's a frightening process filled with more sources of information, speculation, advice, land mines and unknowns than I care to envision. All the elements must fall together in a pattern of "presentation" so the director of said residency programs feels you are a "match" with his/her vision of his/her specialty in his/her community. Dean's letters, letters of recommendations, tokens, Step 1 scores, supplemental  applications, Step 2 CK and CS scores, grades and evaluations from rotations, etc etc. And then how to decide which specialty, at what program, where in the world?

Having watched good friends go through this process, it's really awful. It's not a system that really matches proportionally to the many factors that a person has. In many cases, your personality and bedside manner never see the light of day if you are a struggling test taker. Getting the interview..that's really the goal. And hopefully figuring out where your best chances of "match" are before you click "send" the applications out to the many programs.

And so it begins. I'll try to figure out this process and hope that each day I'll inch toward that letter of "we want you" and it'll be a place I really want to be. Marriage was easier. Actually, pulling that ice pick out of my leg was easier.