Flying to Fort Wayne today

Surgery ended just fine. Dr. Greco let me do more incisions, my sutures were looking better than ever and I wielded the Bovey decently. It's only been two days and I'm already missing the OR. There's something special about that place.

You, as the surgeon, are the boss as only a Navy Captain on the high seas can experience. The patient's wellbeing is your direct responsibility so you govern everything that happens. Unlike a Captain, you use your hands and mind to fix someone. You have to stay on top of meds, coags, fluids, nutrition, co-morbidities, H&H, pain, patient comfort (they can't feel abrasions) and more. And of course, it's fairly technical. There's some old tech (forceps, scissors) mixed in with a ton of new tech (Ligasure, GIA, A-grams, mesh, etc.).

I still believe the sacrifice is too great on family to go through five years of Jedi Knight/monk training (total dedication). Plus I'm long past my twenties. So it's kind of a sad farewell to the specialty. I may have rotations in surgery during Residency, and I may get opportunities to first assist for my patients in practice, but I'll never look through my mask/visor at my double-gloved hands in someone's abdomen with the sense that this could be my career.

The shelf test on Friday was ok, but some questions were ridiculous. As an example, one asked what anatomical anomaly causes hernias. Uhm, what kind of hernia? Incisional and spigellian are rectus sheath defects. Direct Inguinal are tranversalis fascia. Indirect Inguinal are from a patent process vaginalis. You get the idea...

I think I passed, and that's really all that matters. But I learned so much surgical knowledge and skills, I had hoped to do really well. Our Clinical Education is too amateurish for fair assessment, hence the Pass/Fail grading system.

The boys did very well in their first "real" swim meet yesterday. Now we have times for them to beat next season. In Phoenix the season ends in Spring because it's too hot to hold outdoor meets in the Summer! They really like their coach, so they will probably swim through the summer. This assumes Becky and I can work out childcare between her job, my didactics and Boards preparation and both of our work-out schedules. After the meet we prepared for Connor's 11th B-day sleepover. Any remaining time I've spent preparing for the Fort Wayne trip.

Becky and I are determined to get into better shape and lose some weight, but it's difficult with my travel. I read that there's a pool I can use in Fort Wayne, and I'll have a car. Plus the hours shouldn't be the 80+ schedule of surgery. Regardless is going to be a long month of hospital food, uncomfortable beds, new people and jobs, etc. I just hope that the three weeks of Family and one week of Emergency will give me the information and firsthand experience necessary to decide which specialty is the best fit.

I still have to finish the paperwork for my research rotation after Fort Wayne. I'm looking forward to the reduced hours, close proximity and return to some research. But I really hope the exposure to RadOnc will be enough to rule it out or make me 100% sure it's worth the effort to go for. The 70 or so spots across the country are so competitive you have to prepare extremely well for interviews and applications. I just heard that one of our MSIV classmates was thinking Psych and changed to RadOnc late, then matched at a great program! I have to find out who it is and talk to this person.

Almost forgot, I spent time with the radiologist in Show Low checking out what they do. I love the interventional part of it. Placing tubes, running A-grams and nuclear studies, placing rads guided markers and lines, etc. But they spend a lot of time in dark rooms with big screens rapidly talking into their microphones. Procedures with actual patients are their breaks. They try to dictate 100+ studies per day. I'm too much of a people person to be happy in Rads.

Of course Rads has reasonable hours and makes a truckload of dough. I think Rads, Derm and Anesthesia are examples of overpaid specialties. They all make more than surgeons while surgeons have more responsibility, at least as long residencies, higher malpractice, worse hours and more stress. And Medicare wants to reduce their compensation 25% in the next few years! That just doesn't make any sense at all.

An hour or so until we drive to the airport. I sure hope this month is going to be worth it...

One year to go for the Match

The MSIV medical students from around the country received the results of the Match last week. Actually the military, married and osteopathic students had earlier matches, but by now everyone should know where they are going come June.

That means the countdown for my class has begun. As usual I'm having a hard time studying for my Surgery shelf test on Friday because my tunnel vision is focused on residency programs. I have my EM draft spreadsheet, but need to research the programs so I can rank them. Even though I'm not decided on Emergency Medicine (EM) I have one audition rotation scheduled in September at an Osteopathic program. Now I need to schedule another EM rotation at an East Coast allopathic program. Along with EM at Maricopa County in Phoenix, that will give me a well-rounded CV with a good assortment of Letters of Recommendation (LORs).

As for the rotation, it's going very well. I hung out with one of the radiologists yesterday afternoon, and while I love the money and lifestyle, I couldn't do it. They fly through imaging consults, dictations and studies in the "pit" (e.g. dungeon) with too few patient encounters for procedures in between. Dr. Greco called me in late for an acute appendicitis. It was a great case of a week long ruptured appendix. He let me cut, suture and break-up some of the nasty pus pockets. She had a lot of co-morbidities but she should do just fine after a week of ventilation, antibiotics and open abdominal wound packing. I love surgery. It's just too bad it's such a sacrifice lifestyle-wise. I might even overlook my somewhat advanced age if it wasn't an all consuming profession. 5am until 6pm on normal days with overnight call once or twice a week is just too much.

I went home over the weekend. The family and I went to Body Worlds 3 on Saturday and had a great time. Colton got bored after an hour and a half of my detailed explanations on the anatomy, physiology and pathology of the cadaveric displays, but Connor pretended to be interested for another hour or so. Colton summed it up by saying; "being a surgeon would be pretty cool." While there I ran into a couple AZCOM fourth years. They had a big post-Match party Friday and most students were very happy. Twelve had to scramble for residencies, but it sounded like many of them didn't list enough choices and "blackholed" themselves.

We then enjoyed a 96 degree March afternoon in Phoenix and went to dinner at some friends' house. We had Tucker and his family over on Sunday for a relaxing day of barbequing and chatting.

I drove back to Show Low on Monday taking the long route through Globe and was again amazed by the beautiful scenery. Until you see Sedona and the eastern mountain ranges (Superstition, Mongollan, White) you have no idea how beautiful a state this is. Phoenix is really one of the ugliest places in this state.

Finally, I officially changed my last rotation of this year from rural family here in Show Low to research with Dr. Reed, the RadOnc I shadowed in second year. He's doing some research with the help of one of my classmates and mentioned could use mine too. It will be close to home, an easy schedule (convenient for Step 2 Boards studying) and give me a chance to ask Dr. Kresl if he's ever going to publish the case study I did with a fourth year classmate on Gamma Knife therapy. The only downside is that I have to go back to campus for didactics every other Tuesday. Oh well...

Career schizophrenia

Today was another decent day medically. Assisted on bilateral inguinal hernia repairs in a one-year-old boy. Scoped a true Ulcerative Colitis.

Even heard a good joke related to specialties. Where do you hide a dollar bill from a:

Internist... taped to his patient
Surgeon... with his wife
Orthopod... in a book
Plastic Surgeon... no where, he'll find it anywhere

I'm still coming back from yesterday's disappointment's. Had a long conversation with one of my preceptors about specialties and the future of medicine. If you spend any time looking at the numbers you can get very pessimistic. I'm starting to feel a little jaded just as many Docs and professors predicted would happen during third and fourth year. My biggest angst at the moment is that I don't feel any specialty truly "fits" and I've got start making some plans for fourth year audition rotations quickly.

I hope it comes to me quickly...

More fun in Show Low

It's been a great two and a half weeks in Show Low. I like the place and it's been a valuable learning experience. Moreover, it's been pretty relaxing. I haven't spent much time in clinic or rounding on patients here at the hospital. On slow days, like yesterday, I've been able to spend some time in the ER learning more about Emergency Medicine.

EM in this rural environment is interesting. You get to know the locals well (too well in some cases) and do a lot of procedures. I think compensation is pretty good as well. The specialty "feels" pretty good. But I'm not totally convinced. I still have questions about burnout, why none of the EM docs like to do procedures and how the EM "business" is set up. I had a conversation regarding the latter yesterday and was surprised to hear the Docs here have their own businesses and charge the hospital for their services. There's almost no overhead, so the compensation is higher than, say, Family Medicine. But I'm not sure who sets wages, how vacation time, overtime (extra shifts) and retirement benefits are set.

Yesterday was fine educationally, but a real downer career wise. I thought I had an EM rotation set up at UCSD for the last rotation of the year. I even talked with the EM coordinator and she said the Program Director was fine with my rotation, so it was a "done deal". Then I got a voice mail a few hours later that the UC bureaucrats nixed the rotation because I am only a third year student. I grabbed the FP rotation here in Show Low I had previously scheduled. But I'm disappointed that I'm going to spend my one elective this year in Family Medicine. I'll have three Family rotations under my belt already and no exposure to EM, anesthesia or radiology!

My fourth year rotation schedule came through yesterday as well. I only recognized two names from the list I submitted for the lottery last month. In talking with a classmate, I'm not the only one feeling screwed. Moreover, I received a reminder that my LORs for Maricopa County rotations are now late and may jeopardize those fourth year rotations. Ugh! Time to hound my Docs about the LORs they promised. And possibly time to start calling EM (or gas/rads) Docs about simply shadowing them for my last rotation this year.

As for surgery, the week and a half since my last post has been great. I've burned three gallbladders off patients' livers. I've intubated a few times and run into a couple very challenging anatomies. I've assisted in three thyroidectomies now, three more than last month. I was given the opportunity to remove an appendix so I got some firsthand experience with a GIA - a VERY fancy stapler that laparascopically places four rows of staples and then cuts down the middle of the rows. If surgery didn't have such an awful lifestyle, torturous residency and mediocre pay it would be very enticing. If I was ten years younger, you still couldn't keep me away.

Oh, in the ER I even stitched up a young lesbian's forearm after a self-inflicted serrated knife wound through part of her brachioradialis muscle. Fun stuff!

Finally, the wife and kids spent the weekend here with me. We had a good time hanging out Saturday and skiing Sunday. The skiing here was a bit icy in the morning and slushy in the late afternoon, but quite respectable. Connor took a little longer to remember how to balance, but by lunch both boys were bombing down the mountain. Dr. Greco, my preceptor, even managed to find me on one of my solo runs from the top. I think he's the best boarder I've seen so far. Even with his iTunes going and Bluetooth earpiece ready to pick-up any emergencies (he was on call!) he flew down the mountain with amazing grace. Typical surgeon, he doesn't do anything halfway!

This weekend we take the kids to BodyWorlds and I get a year older. If I can keep swimming 3-4 times per week and lose a few pounds, maybe the birthdays won't be such a downer. I love not having traffic here in rural Show Low. I get up at 6am, am in the water by 6:20, out by 7:10 and back at the hospital in scrubs ready for surgery by 7:30am! At 6500 ft above sea level, I can only do 1800 yards, but hope to get up to 2k in the same time by next week without sucking air too badly.

First week in Show Low

Just got back to the family in Phoenix after a great week in Show Low, AZ.

First, the town is great. One of those hidden gems that you know will be overgrown in the next few years, but is the ideal size now. It's 3-4 hours outside of Phoenix with weather like Colorado: lots of sunny days, seasons, trees/vegetation, and skiing/mountains nearby. Only thing missing is the ocean, but even that is only 7 or so hours away (Rocky Point, Mexico).

The medical training is great as well. The surgeons are laid back, and because I've had some surgery now, they are letting me do a ton. It also helps that there's no other students or interns to share procedures with. The highlight of the week is 4 intubations, Lap dissection of a gallbladder from the liver and first assisting on some cool surgeries like Lap Nissens (wrapping the stomach around the esophagus to eliminate hiatal hernias). I'm also getting much better on my knots. Interupted knots are second nature and I'm getting the hand of fancy buried-knot, subcutaneous sutures.

I'm not managing patients or doing much clinic time, so it's mostly just OR time and reading on my own. The staff at the hospital, outpatient surgery clinic and surgeons' office are great. Even the apartment is a huge improvement over Toledo. Becky and the boys are planning to join me next weekend in Show Low to see the town and get in a day of skiing. I think Becky will love the drive. It's so scenic you begin think Arizona is a beautiful state and Sedona isn't an accident.

Lots are errands to finish up this weekend: logs, test schedules, evals and possibly a change in my last rotation this year. I'm looking pretty hard at Emergency Medicine and would like to change my last rotation, rural Family here in Show Low, to an EM rotation. My roommate is doing the rural FP rotation and I just don't think I will learn as much regarding specialty choices versus spending a month in an ER. I may even get to do a couple ER shifts in Show Low this month, then in Ft. Wayne next month to get a taste of the job.

I've had some great conversations with classmates regarding FP versus EM. My roommate this month and one of my class friends (whose wife happens to be my kids' piano teacher) are both in the same position, trying to decide between specialties and individual programs. I need to get started on the spreadsheet and phone calls regarding about 6 western and 6-10 eastern EM programs that look intriguing at first glance.

Maybe the best thing about this rotation is that I have a car and can drive to a pool every morning. I found out about it on Tuesday so only got in two swims, at a very reasonable $2 per session. But I feel so much better with even a meager two workouts. The swims felt awful (I'm horribly out of shape) but I felt great afterwards. Without mornings free until the first surgery (around 8am usually) and a car, I should be able to get in 3-4 weekday swims plus some kind of activity on the weekend.

Time to get some rest back in my own bed.