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.

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.