OK, I'm not actually an official MSIV (Med Student fourth year) yet. We haven't results back from our OSCE (observed patient exams) or MSIII finals on Wednesday and Friday, respectively. But I feel pretty good about both. It was a long week of studying for the latter with many of my classmates back in the cafeteria with the MSIIs (actually now MSIIIs) studying for Step 1 Boards.
So now it's a nice 3-day weekend (for Memorial Day) to work on my EM residency spreadsheet and try to nail down audition rotations. I've applied to several programs for Fall rotations, but only have August really nailed down. Arrowhead in Colton, CA is the only DO program I plan to apply to and it's in driving distance so I can see the family on the weekends. The others are out of state and, if I get all three, would mean another long season away from the family.
I'm also doing my best to get back into shape. Swimming is going well, other than missing Friday. I still have a few hours to get a workout in today. Biking is coming along slowly. I've been taking 25 mile rides once or twice a week plus spinning for 40 minutes her and there for about three weeks. Yesterday I pushed it up a notch and did a 52.5 miler solo. It was painful when I bonked at about 25 (only had a water and a glass of OJ prior) so I stopped for Gatorade and a snack. That really helped. I think I went through five 16oz water bottles in just over 3 hours at close to 100 degrees.
I'm loving my Garmin 305 even though I'm using less than half the features. It's cool to see your ride on the desktop software and then overlaid on Google maps. However, I went a little on the HR zone, speed and cadence alarms and those got a bit annoying.
It all must be doing something. I'm down to 208lbs from 220 in Fort Wayne 5-6 weeks ago. I've got nine more weeks until I rotate at Arrowhead. I hope to be back to my pre-med weight of 195 by then. Emergency is one those jock/granola/outdoorsy kinda of specialties where being in good shape will certainly help me feel like I belong.
Along with work on my EM program spreadsheet, I need to start thinking about Boards - and start using my online question bank (USMLEworld) to take practice tests. It's not nearly as stressful as Step 1 last year, but I'm aiming for 600 on COMLEX Step 2 and 230 on USMLE Step 2. The numbers are arbitrary but both represent about a Standard Deviation over the means. Improvements over my slightly lower but quite respectable Step 1 scores will look good for applications.
Back to my EM day dreaming...I mean research.
Sunday, May 27, 2007
Tuesday, May 22, 2007
Third year rotations over!
I finished RadOnc/Research last Friday and actually passed my Family "shelf" test the same day. I studied pretty hard for the latter and it paid off since it was a very hard test. Wish I had a better score, but passing is passing at this point.
RadOnc is for the most part off my radar. I like it, the lifestyle, income and tech is great. But Emergency is probably a better for me, and certainly for our family. So instead of studying for the Third Year Final on Friday, I've been working on EM spreadsheet and trying to finalize audition rotations for the Fall. I have a couple lined up, Arrowhead, CA in August and Christiana in November, but am still working on Tufts for October.
It's just so hard to get into studying anymore. I spend an hour or so reading EM posts on Studentdoctor.net this evening reliving the Match (March madness) for the Fourth years. Pretty scary and seems like EM is getting pretty competitive. Looks like I'll have to list a lot of schools to make sure I don't end up scrambling for a residency spot.
My diet is going pretty well. I'm under 210 for the first time in awhile. I'm swimming regularly and getting in decent shape. I'm also fitting in more than one road bike workout a week. I just installed the Garmin Edge 305 and am having a blast with it using a tenth of the functions (HR, GPS, cadence, etc.). It feels great to get out there and I can't wait to get my legs back after several years of studying. Only 15 or so pounds to go.
Time to get back to studying the 60 lectures were going to be tested on this Friday. At least its not as stressful. It just doesn't feel like grades matter at this point. I have my OSCE tomorrow which is a test of four patient encounters. The actors/patients grade us and then our chart notes are graded. I'm pretty much winging it. It I fail either, I just try again. No long term consequence for these. Step 2 in July is another story though...
RadOnc is for the most part off my radar. I like it, the lifestyle, income and tech is great. But Emergency is probably a better for me, and certainly for our family. So instead of studying for the Third Year Final on Friday, I've been working on EM spreadsheet and trying to finalize audition rotations for the Fall. I have a couple lined up, Arrowhead, CA in August and Christiana in November, but am still working on Tufts for October.
It's just so hard to get into studying anymore. I spend an hour or so reading EM posts on Studentdoctor.net this evening reliving the Match (March madness) for the Fourth years. Pretty scary and seems like EM is getting pretty competitive. Looks like I'll have to list a lot of schools to make sure I don't end up scrambling for a residency spot.
My diet is going pretty well. I'm under 210 for the first time in awhile. I'm swimming regularly and getting in decent shape. I'm also fitting in more than one road bike workout a week. I just installed the Garmin Edge 305 and am having a blast with it using a tenth of the functions (HR, GPS, cadence, etc.). It feels great to get out there and I can't wait to get my legs back after several years of studying. Only 15 or so pounds to go.
Time to get back to studying the 60 lectures were going to be tested on this Friday. At least its not as stressful. It just doesn't feel like grades matter at this point. I have my OSCE tomorrow which is a test of four patient encounters. The actors/patients grade us and then our chart notes are graded. I'm pretty much winging it. It I fail either, I just try again. No long term consequence for these. Step 2 in July is another story though...
Sunday, May 06, 2007
RadOnc
I took the first two days of this month's Radiation Oncology research rotation to nail the Surgery shelf test. They only told me that I passed, but I'm sure that I did much better this time. No stupid questions trying to redefine anatomy on this version of AZCOM's homemade tests.
I also spent a lot of time catching up with classmates while suffering through on campus didactics. I sure didn't miss the boring lectures during the last four months. However, it was great to hear how everyone is doing, what they are planning on going into, rotation experiences, etc.
Then I was pleasantly surprised to learn that my Preceptor this month is letting me see interesting patients and get in on the cool procedures. I even got to see how a dosimetry plan is generated by the physists for external beam treatment of breast cancer. The best part so far though was helping to insert brachytherapy catheters into guys' perineums and womens' breasts. We then deposited (temporarily or permanently) radioactive sources like Iodine131 into specific catheters at specific locations in the lesions. They actually had most of the surgical "cool" factor to them, but no suturing or Bovey aroma. On the most recent no urologist was present, so I did their job of placing all the catheters.
Most of my time though is spent reading through patient records and filling out research surveys for each one. We are trying to publish the largest post-prostatectomy external beam radiation therapy study to date. So it's a lot of paperwork, but I have the opportunity to get my name on a published study. The office is the largest private RadOnc group in the country and they enter more patients into studies than any RadOnc group in the country, including Universities! So I think they know what they are doing.
This Friday I'm going the St. Joe's office to see their Gamma and Cyber Knife systems. That will be awesome, and it will allow me a chance to ask the Attending what is happening with the paper I submitted to him a few months ago for publishing. I had a minor contribution with a classmate, but any published papers look good.
After almost two weeks doing RadOnc and learning that one of our fourth year students matched RadOnc at Drexel, I think it is much more doable. It would mean 60+ applications, hopefully 5-10 interviews and then a move to who knows where. But the Docs in my office feel I have a shot at RadOnc and should go for it.
At this point, I'm trying to decide whether to try for both RadOnc and EM in the Match or just EM. Going after both means more applications, more expensive interviews and probably listing a couple RadOnc programs as my first and second choices then seeing what happens next March. If I stick with EM, I might be able to get an early contract at a DO program and skip all the time, expense and stress of the Match. The Arrowhead, CA program I'm going to rotate at in August may just work into that plan. However, the income, technology and patient contact of RadOnc is very attractive. I'm tempted to try for RadOnc to see what happens with EM as my backup.
I just finished a bike ride with my attending this morning. We started at his brand new 3800sf house in North Scottdale. What a place! According to Zillow.com, nothing in his zip code goes for less than a million, even the lots start at $500k. And he's less than two years out of residency! He laid out how his contract works with two years guaranteed income then full partner. It's a pretty good gig, and the Docs all say that likely changes to medical reimbursement shouldn't have a huge negative impact on RadOnc. I have a hard time believing there won't be some decreases when procedures can easily run from $100k to $200k, but even a 10% decrease in reimbursements would leave RadOncs as some of the best paid Docs in medicine.
My thinking at the moment is to audition at Arrowhead in August, hopefully Maricopa ER in September and a RadOnc program in October (one that has 2+ slots for non MD/PHDs, if such a thing exists). I may need to double book November with both a RadOnc and an EM program, doing the RadOnc rotation if it's still in the running.
I hate to make things so complicated, but I'm not ready to up on a shot at RadOnc yet either. Two more weeks to go on this rotation along with a lot of studying for the Family shelf test. There's always a chance, however slight, that things will become clearer.
I also spent a lot of time catching up with classmates while suffering through on campus didactics. I sure didn't miss the boring lectures during the last four months. However, it was great to hear how everyone is doing, what they are planning on going into, rotation experiences, etc.
Then I was pleasantly surprised to learn that my Preceptor this month is letting me see interesting patients and get in on the cool procedures. I even got to see how a dosimetry plan is generated by the physists for external beam treatment of breast cancer. The best part so far though was helping to insert brachytherapy catheters into guys' perineums and womens' breasts. We then deposited (temporarily or permanently) radioactive sources like Iodine131 into specific catheters at specific locations in the lesions. They actually had most of the surgical "cool" factor to them, but no suturing or Bovey aroma. On the most recent no urologist was present, so I did their job of placing all the catheters.
Most of my time though is spent reading through patient records and filling out research surveys for each one. We are trying to publish the largest post-prostatectomy external beam radiation therapy study to date. So it's a lot of paperwork, but I have the opportunity to get my name on a published study. The office is the largest private RadOnc group in the country and they enter more patients into studies than any RadOnc group in the country, including Universities! So I think they know what they are doing.
This Friday I'm going the St. Joe's office to see their Gamma and Cyber Knife systems. That will be awesome, and it will allow me a chance to ask the Attending what is happening with the paper I submitted to him a few months ago for publishing. I had a minor contribution with a classmate, but any published papers look good.
After almost two weeks doing RadOnc and learning that one of our fourth year students matched RadOnc at Drexel, I think it is much more doable. It would mean 60+ applications, hopefully 5-10 interviews and then a move to who knows where. But the Docs in my office feel I have a shot at RadOnc and should go for it.
At this point, I'm trying to decide whether to try for both RadOnc and EM in the Match or just EM. Going after both means more applications, more expensive interviews and probably listing a couple RadOnc programs as my first and second choices then seeing what happens next March. If I stick with EM, I might be able to get an early contract at a DO program and skip all the time, expense and stress of the Match. The Arrowhead, CA program I'm going to rotate at in August may just work into that plan. However, the income, technology and patient contact of RadOnc is very attractive. I'm tempted to try for RadOnc to see what happens with EM as my backup.
I just finished a bike ride with my attending this morning. We started at his brand new 3800sf house in North Scottdale. What a place! According to Zillow.com, nothing in his zip code goes for less than a million, even the lots start at $500k. And he's less than two years out of residency! He laid out how his contract works with two years guaranteed income then full partner. It's a pretty good gig, and the Docs all say that likely changes to medical reimbursement shouldn't have a huge negative impact on RadOnc. I have a hard time believing there won't be some decreases when procedures can easily run from $100k to $200k, but even a 10% decrease in reimbursements would leave RadOncs as some of the best paid Docs in medicine.
My thinking at the moment is to audition at Arrowhead in August, hopefully Maricopa ER in September and a RadOnc program in October (one that has 2+ slots for non MD/PHDs, if such a thing exists). I may need to double book November with both a RadOnc and an EM program, doing the RadOnc rotation if it's still in the running.
I hate to make things so complicated, but I'm not ready to up on a shot at RadOnc yet either. Two more weeks to go on this rotation along with a lot of studying for the Family shelf test. There's always a chance, however slight, that things will become clearer.
Friday, April 20, 2007
Fort Wayne Emergency Medicine
Finished up my week in the ER yesterday with the best day of the week. It started slow like the rest of the week, but about 10 am we had four ambulances arrive with fifteen minutes. We had some interesting cases like a 14 year old gymnast that had fractured her back and a guy that almost cut the tip of his finger off. I was able to suture the latter back together after injecting a bunch of anesthetic (big hands).
The best part though, was talking to a couple of the ER Docs I hadn't worked with until yesterday. I learned some very interesting things about ER and medicine in general. First, ER Docs typically make what they can bill the hospital for. So a Doc serving a poor population is going to make far less than a Doc serving a fully insured population - like half as much! So ER is in a very good position to benefit from any national health care plan. Even $20 or $30 per patient is better than the $0 they get today from those patients.
On a more scary note, a few ER Docs that have made a killing in the past by "owning" the hospital contracts with busy trauma hospitals. They then created partnerships and locked out any other Docs. By selling ownership into partnerships or just hiring ER Docs on salary and skimming off the top, a few made millions at the expense of their fellow EM Docs! Sounds like EM Residents need to watch out for secretive and closed book partnerships - especially in this age of mega-partnerships of EM Docs.
One of the two Docs finished his EM Residency then decided to do an Anesthesia Residency. After practicing a couple of years, he decided the overnight call every third night or so and poor lifestyle were too much of a sacrifice and went back to working ER! That was eye opening.
The other Doc works pseudo-Locum Tenens: he works odd shifts at four of five hospitals in a couple of Midwest states. His advice was that EM is great because it still allows you to do so different things. Not only do you have a controllable lifestyle, you aren't trapped (as I had assumed) into being a hospital ER employee for ever. Like a lot of creative Family Docs are doing, you can open a "wellness center", do cosmetic or low income medicine, etc. That is, if you don't fill your off time with hobbies like travel, investments, missions or sports you can start a profitable part0time business. It was very exciting to learn that there are still many opportunities opened in medicine if I get burned out or bored with shift work.
The last thing we discussed was Osteopathic EM Board certification versus Allopathic. It sounds like Osteopathic Residency programs allow you to sit for either Board test. So I could do the four year program at Arrowhead's Osteopathic Residency program, but sit for the Allopathic Boards. The difference between them is that the Allopathic Boards is more recognized internationally and probably required to teach at any Allopathic Medical school. The Osteopathic Boards would be required to teach at any Osteopathic school presumably. However, either allows to you practice anywhere in the U.S.
The first three days this week were in the Dupont ER were slow. Felt like an urgent care clinic with the ability to admit the most serious patients. I basically just did a lot of history taking, looking at labs and X-rays/CTs and hoping to see something interesting coming in on the monitors. Yesterday was a nice change and really peaked my interest in EM again.
This happened at the same time I was having great dinners with the Family residents courtesy of local drug reps. Wednesday we had a ton of pretty good sushi at the "best" sushi place in town. Lat night it was a top-rated steak place. The shrimp was ok. And I only got a few strange looks for being the only one of about 50 people not ordering red meat. The residents here are great people, so it was hard to admit my preference for EM as they were soft selling the program to me.
Today I slept in and am just getting started studying surgery. Less than 24 hours left in Fort Wayne. Kind of bittersweet. I can't wait to see the family, but I like the people here and am facing a very hard three months upon my return. We got our Clinical Education schedule from AZCOM this week and I can definitely see why the previous med classes despise the Department. My early summary of tests was a bit optimistic. I have Surgery and Family shelf tests, then a week later third year finals - one written and one with standardized patients. Then we get three weeks of 8 to 5 didactics immediately followed by our fourth year written final! The following four weeks I get to cram for the Osteopathic and Allopathic Boards. Seven tests in about 12 weeks.
My opinion during first year that Clinical Ed is probably the worst run Department at AZCOM has only been reinforced over the last year. Speaking of, before I study for these tests I have to make up (i.e. Lie) my logs for this rotation by inputting a bunch of ICM-9 and CPT codes on Clin Ed's worthless intranet site. They take up so much of our time and teach us nothing. And after ten years they still can't get us decent clinical rotations. The only redeeming value is a few superstars like Linda, the MSIII rotation coordinator who works her butt off for us.
The best part though, was talking to a couple of the ER Docs I hadn't worked with until yesterday. I learned some very interesting things about ER and medicine in general. First, ER Docs typically make what they can bill the hospital for. So a Doc serving a poor population is going to make far less than a Doc serving a fully insured population - like half as much! So ER is in a very good position to benefit from any national health care plan. Even $20 or $30 per patient is better than the $0 they get today from those patients.
On a more scary note, a few ER Docs that have made a killing in the past by "owning" the hospital contracts with busy trauma hospitals. They then created partnerships and locked out any other Docs. By selling ownership into partnerships or just hiring ER Docs on salary and skimming off the top, a few made millions at the expense of their fellow EM Docs! Sounds like EM Residents need to watch out for secretive and closed book partnerships - especially in this age of mega-partnerships of EM Docs.
One of the two Docs finished his EM Residency then decided to do an Anesthesia Residency. After practicing a couple of years, he decided the overnight call every third night or so and poor lifestyle were too much of a sacrifice and went back to working ER! That was eye opening.
The other Doc works pseudo-Locum Tenens: he works odd shifts at four of five hospitals in a couple of Midwest states. His advice was that EM is great because it still allows you to do so different things. Not only do you have a controllable lifestyle, you aren't trapped (as I had assumed) into being a hospital ER employee for ever. Like a lot of creative Family Docs are doing, you can open a "wellness center", do cosmetic or low income medicine, etc. That is, if you don't fill your off time with hobbies like travel, investments, missions or sports you can start a profitable part0time business. It was very exciting to learn that there are still many opportunities opened in medicine if I get burned out or bored with shift work.
The last thing we discussed was Osteopathic EM Board certification versus Allopathic. It sounds like Osteopathic Residency programs allow you to sit for either Board test. So I could do the four year program at Arrowhead's Osteopathic Residency program, but sit for the Allopathic Boards. The difference between them is that the Allopathic Boards is more recognized internationally and probably required to teach at any Allopathic Medical school. The Osteopathic Boards would be required to teach at any Osteopathic school presumably. However, either allows to you practice anywhere in the U.S.
The first three days this week were in the Dupont ER were slow. Felt like an urgent care clinic with the ability to admit the most serious patients. I basically just did a lot of history taking, looking at labs and X-rays/CTs and hoping to see something interesting coming in on the monitors. Yesterday was a nice change and really peaked my interest in EM again.
This happened at the same time I was having great dinners with the Family residents courtesy of local drug reps. Wednesday we had a ton of pretty good sushi at the "best" sushi place in town. Lat night it was a top-rated steak place. The shrimp was ok. And I only got a few strange looks for being the only one of about 50 people not ordering red meat. The residents here are great people, so it was hard to admit my preference for EM as they were soft selling the program to me.
Today I slept in and am just getting started studying surgery. Less than 24 hours left in Fort Wayne. Kind of bittersweet. I can't wait to see the family, but I like the people here and am facing a very hard three months upon my return. We got our Clinical Education schedule from AZCOM this week and I can definitely see why the previous med classes despise the Department. My early summary of tests was a bit optimistic. I have Surgery and Family shelf tests, then a week later third year finals - one written and one with standardized patients. Then we get three weeks of 8 to 5 didactics immediately followed by our fourth year written final! The following four weeks I get to cram for the Osteopathic and Allopathic Boards. Seven tests in about 12 weeks.
My opinion during first year that Clinical Ed is probably the worst run Department at AZCOM has only been reinforced over the last year. Speaking of, before I study for these tests I have to make up (i.e. Lie) my logs for this rotation by inputting a bunch of ICM-9 and CPT codes on Clin Ed's worthless intranet site. They take up so much of our time and teach us nothing. And after ten years they still can't get us decent clinical rotations. The only redeeming value is a few superstars like Linda, the MSIII rotation coordinator who works her butt off for us.
Sunday, April 15, 2007
Fort Wayne Family Residency
The second week of inpatient family went great. I can't say enough great things about Dr. Connerly and the FP residency program here at Fort Wayne. I'm surprised it's not a lot more competitive than it is. Everyone talks about the Memorial program in South Bend as the big competition, but the only reason they are competitive is that they pay $11,000 a year more than Fort Wayne! And Fort Wayne pays relatively well, it's just that Memorial is the top paying FP program in the country. Oh, and you do sports medicine with the Notre Dame football team :).
Fort Wayne is better, from what I can tell, in terms of didactics, Night Float, hours for moonlighting, opportunities for moonlighting and pathology (tertiary ctr vs. community ctr). The Residents are trying to address the pay difference. And the Program will have a brand new 30,000 sf clinic open next May and a new regional hospital they will be moving into starting next year and completing in 2011. I even got on local TV this week with a few Residents, the Program director, hospital CEO and Mayor to announce the new building project at a press conference.
Speaking of pathology though, I saw the worst case of lymphedema ever here. It was elephantitis like we saw in Path class from photos taken in Third World countries. Oh, it also smelled like necrosis. We eventually got 19 liters of fluid off him so he could walk again! That's about 45 pounds off one leg! It still probably weighed 80 to 100 pounds, but he could get around with a walker when I left the service.
This is an environment where I could feel comfortable learning inpatient medicine. No comparison with the VA hospital.
Last week I was at St. Joe's hospital for OB/Gyn. It has been a great refresher. I delivered a couple babies, did lots of pelvic exams, did a couple circumcisions, got in on one C-section and rounded on lots of new moms and babies. I saw 14 year olds give birth, nuchal cords and even got to suture a very large second degree tear. We even had one nuchal cord rupture, one shoulder dystocia (with a fractured clavicle) and one muconium aspiration. As at Parkview over the past two weeks, the Residents and Attendings have been terrific. The main Attending, Dr. Pebble, is an admitted dinosaur.
Dr. Pebble is a Family physician that does general anesthesia, general surgery, Gyn surgery, OB and has his own family practice! He's like a walking legend. I bet there's less than a dozen docs like him left in the country. Heck, he even does anesthesia for friends doing heart surgery and learned laproscopic surgery on his own! Oh, did I mention he's also very cool and a great teacher?
I started getting gentle pressure to apply to the program if I decide on Family. I also attended a drug rep dinner and a welcome back party for one of the Docs returning from Iraq. It was a chance to meet many of the existing Residents and some of the new ones coming on next year. Everyone was very friendly. I also had a chance to hear more about ER work as a family doc. One of the Family Residents has an offer for $126 an hour plus benefits as a hospital employee in a small community. No call, no pager, 36 hours a week and a reasonable mix of day and night shifts. Not bad!
I'm presently studying for my second try at the surgery shelf exam. I missed passing the last one by two questions. After a conference call with the Dean, I would have passed if I hadn't changed some answers! I didn't criticize him for the poorly written questions, mostly because these results don't play into our Residency applications. It's just pass or fail. Kinda sucks anyway, because I had hoped to be studying Emergency for next week and/or Boards which will help for my last shelf exam - Family Medicine. I now have to take that after the last rotation.
In the next three months, I have two shelf exams, one standardized patient exam, third year finals and two sets of Step 2 Boards! Gotta love medical school, especially as a D.O. I had planned on just taking our required Osteopathic COMLEX Step 2 Board exam, but fourth year friends who just matched said that we need to take the Allopathic version (USMLE Step 2) if we are planning to apply for anything vaguely competitive, such as Emergency. So that's more stress, more time and another $500! This D.O. thing is sure getting expensive and time consuming. I mean I like OMM (manipulative medicine), but twice the Board tests, about twice the money (private vs. a state school) and 200+ extra lecture hours is adding up.
On the plus side, I did get to do some soft tissue techniques and HVLA on a couple of the MD Residents, which they loved. It's a handy skill for family, friends and patients but I'm not sure it's worth the cost at this point.
I forgot to mention the weather. It's been snowing the last few days! Very wet and windy. We finally got some sun this weekend. One of the Docs mentioned Fort Wayne is in a convergence zone of the Great Lake and Canadian weather patterns so it actually has fewer sunny days than Seattle! They made a new record earlier this year with 96 days of cloudy weather - yuck!
One more week in the ER. I'm sure missing the family, especially over the weekends. At the same time I'm concerned one week in the ER just isn't enough time to make a 20-year career decision. By the time I get to EM audition rotations in the Fall, changing directions will be much more difficult. I'm just going to try to make the most of next week, starting Monday at 9am...
Fort Wayne is better, from what I can tell, in terms of didactics, Night Float, hours for moonlighting, opportunities for moonlighting and pathology (tertiary ctr vs. community ctr). The Residents are trying to address the pay difference. And the Program will have a brand new 30,000 sf clinic open next May and a new regional hospital they will be moving into starting next year and completing in 2011. I even got on local TV this week with a few Residents, the Program director, hospital CEO and Mayor to announce the new building project at a press conference.
Speaking of pathology though, I saw the worst case of lymphedema ever here. It was elephantitis like we saw in Path class from photos taken in Third World countries. Oh, it also smelled like necrosis. We eventually got 19 liters of fluid off him so he could walk again! That's about 45 pounds off one leg! It still probably weighed 80 to 100 pounds, but he could get around with a walker when I left the service.
This is an environment where I could feel comfortable learning inpatient medicine. No comparison with the VA hospital.
Last week I was at St. Joe's hospital for OB/Gyn. It has been a great refresher. I delivered a couple babies, did lots of pelvic exams, did a couple circumcisions, got in on one C-section and rounded on lots of new moms and babies. I saw 14 year olds give birth, nuchal cords and even got to suture a very large second degree tear. We even had one nuchal cord rupture, one shoulder dystocia (with a fractured clavicle) and one muconium aspiration. As at Parkview over the past two weeks, the Residents and Attendings have been terrific. The main Attending, Dr. Pebble, is an admitted dinosaur.
Dr. Pebble is a Family physician that does general anesthesia, general surgery, Gyn surgery, OB and has his own family practice! He's like a walking legend. I bet there's less than a dozen docs like him left in the country. Heck, he even does anesthesia for friends doing heart surgery and learned laproscopic surgery on his own! Oh, did I mention he's also very cool and a great teacher?
I started getting gentle pressure to apply to the program if I decide on Family. I also attended a drug rep dinner and a welcome back party for one of the Docs returning from Iraq. It was a chance to meet many of the existing Residents and some of the new ones coming on next year. Everyone was very friendly. I also had a chance to hear more about ER work as a family doc. One of the Family Residents has an offer for $126 an hour plus benefits as a hospital employee in a small community. No call, no pager, 36 hours a week and a reasonable mix of day and night shifts. Not bad!
I'm presently studying for my second try at the surgery shelf exam. I missed passing the last one by two questions. After a conference call with the Dean, I would have passed if I hadn't changed some answers! I didn't criticize him for the poorly written questions, mostly because these results don't play into our Residency applications. It's just pass or fail. Kinda sucks anyway, because I had hoped to be studying Emergency for next week and/or Boards which will help for my last shelf exam - Family Medicine. I now have to take that after the last rotation.
In the next three months, I have two shelf exams, one standardized patient exam, third year finals and two sets of Step 2 Boards! Gotta love medical school, especially as a D.O. I had planned on just taking our required Osteopathic COMLEX Step 2 Board exam, but fourth year friends who just matched said that we need to take the Allopathic version (USMLE Step 2) if we are planning to apply for anything vaguely competitive, such as Emergency. So that's more stress, more time and another $500! This D.O. thing is sure getting expensive and time consuming. I mean I like OMM (manipulative medicine), but twice the Board tests, about twice the money (private vs. a state school) and 200+ extra lecture hours is adding up.
On the plus side, I did get to do some soft tissue techniques and HVLA on a couple of the MD Residents, which they loved. It's a handy skill for family, friends and patients but I'm not sure it's worth the cost at this point.
I forgot to mention the weather. It's been snowing the last few days! Very wet and windy. We finally got some sun this weekend. One of the Docs mentioned Fort Wayne is in a convergence zone of the Great Lake and Canadian weather patterns so it actually has fewer sunny days than Seattle! They made a new record earlier this year with 96 days of cloudy weather - yuck!
One more week in the ER. I'm sure missing the family, especially over the weekends. At the same time I'm concerned one week in the ER just isn't enough time to make a 20-year career decision. By the time I get to EM audition rotations in the Fall, changing directions will be much more difficult. I'm just going to try to make the most of next week, starting Monday at 9am...
Sunday, April 01, 2007
First week in Fort Wayne
Yup, people are nicer in rural America. Fort Wayne isn't small, at about 250,000, but it has a small town feel. As with most of the Midwest, it lacks the outdoor activities I'm used to, but it's a nice size. And whereas the music was scene in Toledo was Country and Ghetto, here it's just Country. Not my favorite, but it's easier to overlook than awful traffic, mean people and outrageous home prices.
As for the medicine, the Residents and Attendings are some of the best I've worked with so far. I'm really impressed by this Family program so far. A PYGII (2nd year Resident) wants to do OB/Gyn when she's finished. The Program has managed to get her 69 C-sections so far!! Her husband wants to do Emergency. The two understand they will have to live in a small community, probably under 50,000, most likely. But it's an attractive plan.
The hospital, Parkview, is a tertiary care (Trauma Level II) center for a big area and even here Family Medicine Docs handle much of the ER. There's an acute care ER where they have to have an EM Boarded Doc on at all times. But five FM graduates of this program help to staff the three ERs.
Yes, my schizophrenia has returned and I seem to change my mind a couple times a day. But when we take new admits in the afternoon and I do an H&P in the ER I always up thinking EM. In fact, I've got Arrowhead's EM program lined for a September "audition rotation". And I filled out my paperwork for Maricopa's ER rotation before anyone else so I should be able to get August there. One more ER rotation in October or November at an East Coast program, like Christiana or Augusta, should do the trick. Then I'll just have to apply to 30 or so Programs and interview at no less than 12 to "guarantee" a spot without scrambling.
We usually get together around 7am, divy up new patients and get updates on our ongoing patients from the Night Float Resident. Then we see patients and round until 10am when we have Attending Rounds. These are relaxed and great educational lessons by Dr. Connerly. We then have a quick lunch and put in our new orders (from Dr. Connerly's input) before two of the three Residents head to Clinic. The other student and I stay with the Resident on "Call" taking new admits until 6pm when the Night Float Resident comes in for turnover. Night Float is a great system!
This is how to learn about Medicine! I have no desire to be a Hospitalist, but this program really teaches FPs how to be Docs. They only have two half days of clinic first year, then a day and a half second and third years, but they still acquire way more than the required number of patient encounters for the FP Boards. The time most programs spend in Clinic, these guys spend learning procedures, internal medicine and electives in OB, ER, scopes, etc. And for students it's great as well. We even get to write orders and dictate notes. This is my first opportunity at either, and it feels like a huge head start on Internship.
Finally, I'm really glad to have a car. It's required since my apartment is a few miles from the hospital and I'm going to be doing OB and ER in different hospitals. But regardless, I don't want to be trapped like I was in Toledo again. I'm studying in a coffee shop with free WiFi at the moment. Had time to get a haircut and drop off dry cleaning yesterday. And a few days a week I'm swimming at a local pool for about $1.50 a session.
As for the medicine, the Residents and Attendings are some of the best I've worked with so far. I'm really impressed by this Family program so far. A PYGII (2nd year Resident) wants to do OB/Gyn when she's finished. The Program has managed to get her 69 C-sections so far!! Her husband wants to do Emergency. The two understand they will have to live in a small community, probably under 50,000, most likely. But it's an attractive plan.
The hospital, Parkview, is a tertiary care (Trauma Level II) center for a big area and even here Family Medicine Docs handle much of the ER. There's an acute care ER where they have to have an EM Boarded Doc on at all times. But five FM graduates of this program help to staff the three ERs.
Yes, my schizophrenia has returned and I seem to change my mind a couple times a day. But when we take new admits in the afternoon and I do an H&P in the ER I always up thinking EM. In fact, I've got Arrowhead's EM program lined for a September "audition rotation". And I filled out my paperwork for Maricopa's ER rotation before anyone else so I should be able to get August there. One more ER rotation in October or November at an East Coast program, like Christiana or Augusta, should do the trick. Then I'll just have to apply to 30 or so Programs and interview at no less than 12 to "guarantee" a spot without scrambling.
We usually get together around 7am, divy up new patients and get updates on our ongoing patients from the Night Float Resident. Then we see patients and round until 10am when we have Attending Rounds. These are relaxed and great educational lessons by Dr. Connerly. We then have a quick lunch and put in our new orders (from Dr. Connerly's input) before two of the three Residents head to Clinic. The other student and I stay with the Resident on "Call" taking new admits until 6pm when the Night Float Resident comes in for turnover. Night Float is a great system!
This is how to learn about Medicine! I have no desire to be a Hospitalist, but this program really teaches FPs how to be Docs. They only have two half days of clinic first year, then a day and a half second and third years, but they still acquire way more than the required number of patient encounters for the FP Boards. The time most programs spend in Clinic, these guys spend learning procedures, internal medicine and electives in OB, ER, scopes, etc. And for students it's great as well. We even get to write orders and dictate notes. This is my first opportunity at either, and it feels like a huge head start on Internship.
Finally, I'm really glad to have a car. It's required since my apartment is a few miles from the hospital and I'm going to be doing OB and ER in different hospitals. But regardless, I don't want to be trapped like I was in Toledo again. I'm studying in a coffee shop with free WiFi at the moment. Had time to get a haircut and drop off dry cleaning yesterday. And a few days a week I'm swimming at a local pool for about $1.50 a session.
Sunday, March 25, 2007
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...
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...
Wednesday, March 21, 2007
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...
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...
Thursday, March 15, 2007
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...
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.
Friday, March 02, 2007
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.
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.
Saturday, February 24, 2007
Back home...finally
The trip home wasn't too eventful. I gained even more appreciation for the book Surgical Recall, a pocket-sized 700-page book in Q&A style that really covers a lot of basic surgery territory. Even with all the hours in the air I've only read about 200 pages, but hopefully I'll get more read in the next few weeks.
It was sure nice to get home and see the family. We just hung out and didn't worry too much about chores, homework (mine or the kids) or packing. Got caught up on Gray's Anatomy and I hope the weird afterlife scenes are over.
So now it's Sunday and I have to start on the To Do list: new tires, wash, packing and all the post rotation logs and evals. I've had enough time to think back on the last month now that I sum up the experience as a good rotation, where I learned a lot (got my tuition's worth) but one I probably could have done equally well closer to home. I'm still miffed about my Maricopa paperwork mix-up that resulted in my losing that rotation. However, that whole situation is what allowed to have the excellent Peds ER rotation. I'm not sure I would be looking so closely at EM if had gone as planned.
The surgery rotation ended with a few good surgeries, more office hours and a couple in office I&D type procedures. The Attendings and Resident were very complementary in their feedback and interested in our feedback. I'm fairly confident of getting a decent evaluation.
Tomorrow is day one on a new job again. I drive to Show Low (on new tires I hope) at 6am for rural surgery. We see how well the last month prepared me to step in and really start participating in surgeries. Every indication I gotten from the three surgeons I'll be working with is that I should be able to do a lot more than just cut sutures, staple and steri-strip.
It was sure nice to get home and see the family. We just hung out and didn't worry too much about chores, homework (mine or the kids) or packing. Got caught up on Gray's Anatomy and I hope the weird afterlife scenes are over.
So now it's Sunday and I have to start on the To Do list: new tires, wash, packing and all the post rotation logs and evals. I've had enough time to think back on the last month now that I sum up the experience as a good rotation, where I learned a lot (got my tuition's worth) but one I probably could have done equally well closer to home. I'm still miffed about my Maricopa paperwork mix-up that resulted in my losing that rotation. However, that whole situation is what allowed to have the excellent Peds ER rotation. I'm not sure I would be looking so closely at EM if had gone as planned.
The surgery rotation ended with a few good surgeries, more office hours and a couple in office I&D type procedures. The Attendings and Resident were very complementary in their feedback and interested in our feedback. I'm fairly confident of getting a decent evaluation.
Tomorrow is day one on a new job again. I drive to Show Low (on new tires I hope) at 6am for rural surgery. We see how well the last month prepared me to step in and really start participating in surgeries. Every indication I gotten from the three surgeons I'll be working with is that I should be able to do a lot more than just cut sutures, staple and steri-strip.
Sunday, February 18, 2007
One week left in Toledo
Last week was even more routine than week two. We had some interesting surgeries that I mentioned a couple posts ago, but nothing too unusual. I'm getting pretty familiar with the typical general surgical procedures like gallbladder removal, inguinal and abdominal wall hernia repair and appendectomies. I also got to first assist on a Lap Chole which was a nice change from holding the camera. I hope that next month, my rural surgery rotation will be more varied and allow me to first assist more.
The lady with the necrotizing fasciitis was scheduled to go to surgery for another debridement. I wanted to watch the surgery on Friday, but had to head to one of the other hospitals. It will be interesting to see how she's fairing tomorrow, Monday. I think I've mentioned Streptococcus Decapitii to half the students on the Wards.
Now it's time to catch up on some reading and get my LOR stuff ready to send out.
The lady with the necrotizing fasciitis was scheduled to go to surgery for another debridement. I wanted to watch the surgery on Friday, but had to head to one of the other hospitals. It will be interesting to see how she's fairing tomorrow, Monday. I think I've mentioned Streptococcus Decapitii to half the students on the Wards.
Now it's time to catch up on some reading and get my LOR stuff ready to send out.
Match is one year away!
It was an exciting week for the MSIVs. The Osteopaths got the results of their Match and the Allopaths had to submit their Match lists. The latter's results won't be out until the middle of March. I wonder how many AZCOM MSIVs were scrambling for Residencies on campus this last week?
All this talk of Residency has made me reflect on FP pretty hard. So be forewarned, this post is more about another week of soul searching than medicine.
I believe I would be good at rural FP and the job would be thoroughly satisfying. My lingering doubts are around whether the family would like living in a rural town and being stuck there once we establish ourselves. Becky won't have many careers options other than helping to run my practice. Maybe she find a foundation to run or get elected to something, but not much need for a CFO.
At this is my justification for not reading much the last two days. I've spending most of my time researching Emergency Medicine, Anesthesia and Surgery residencies to see what options are out there and how they "feel" as I try to envision those specialties as careers. Yes, I've made a couple of spreadsheets.
The timing is getting pretty important now because there's still a possibility of changing of my last rotation this year. I also need to start applying for audition rotations the beginning of my fourth year in order to reserve openings. I may just start and double book myself to be prepared.
EM is nice in that you work reasonable hours. Typical schedules include 4 x 12 hrs for three weeks then the fourth week off, or 7 x 12 hours every other week. Those hours are usually very busy and can be quite stressful. But when you're off, you're off (no call). You make more than FP and do lots of procedures. You make good money from day one and can readily move to a different hospital with no drop in income. The down-sides are screwing with your circadian rhythms (night shifts), no continuity of care (triage-stabilize-move on) and always working in an ER environment.
Anesthesiologists work longer hours, have an additional year of residency and have job that can be very boring (punctuated by moments of terror). They do a fair amount of procedures, have some patient interaction and make a very nice living.
Both of these have one big negative I just discovered. The residency options aren't very good. EM has few Western US programs, but tons of DO programs in the Midwest. Anesthesia just has programs spread out everywhere. Both are fairly competitive, but the latter even more so. We would probably have to be willing to move where ever I got accepted. With FP I feel pretty confident I can pick three top programs in nice places to live and get one for sure.
Surgery worries me because residency and practice hours suck. You have to love the ER because it's your mistress. And there's my age factor. I know surgeons that operate into their 70's but that is the exception. That's why rural FP is so appealing. You can do minor surgeries (still great fun!) but they don't dictate your lifestyle and you can stop whenever you choose.
Becky is also doing a bit of soul searching herself while spending the weekend with the kids at my Dad's place in SD. Maybe he'll have some words of wisdom for her. Her careers desires may very well be the deciding factor on my specialty.
My uncle form Ann Arbor is on his way down to pick me up. I've never seen his place. It will be nice to get away for a few hours and talk this out myself. His daughter, my cousin, just started medical school at U. of Washington so he may have more interest seeing as how his daughter will be going through this in a couple of years.
All this talk of Residency has made me reflect on FP pretty hard. So be forewarned, this post is more about another week of soul searching than medicine.
I believe I would be good at rural FP and the job would be thoroughly satisfying. My lingering doubts are around whether the family would like living in a rural town and being stuck there once we establish ourselves. Becky won't have many careers options other than helping to run my practice. Maybe she find a foundation to run or get elected to something, but not much need for a CFO.
At this is my justification for not reading much the last two days. I've spending most of my time researching Emergency Medicine, Anesthesia and Surgery residencies to see what options are out there and how they "feel" as I try to envision those specialties as careers. Yes, I've made a couple of spreadsheets.
The timing is getting pretty important now because there's still a possibility of changing of my last rotation this year. I also need to start applying for audition rotations the beginning of my fourth year in order to reserve openings. I may just start and double book myself to be prepared.
EM is nice in that you work reasonable hours. Typical schedules include 4 x 12 hrs for three weeks then the fourth week off, or 7 x 12 hours every other week. Those hours are usually very busy and can be quite stressful. But when you're off, you're off (no call). You make more than FP and do lots of procedures. You make good money from day one and can readily move to a different hospital with no drop in income. The down-sides are screwing with your circadian rhythms (night shifts), no continuity of care (triage-stabilize-move on) and always working in an ER environment.
Anesthesiologists work longer hours, have an additional year of residency and have job that can be very boring (punctuated by moments of terror). They do a fair amount of procedures, have some patient interaction and make a very nice living.
Both of these have one big negative I just discovered. The residency options aren't very good. EM has few Western US programs, but tons of DO programs in the Midwest. Anesthesia just has programs spread out everywhere. Both are fairly competitive, but the latter even more so. We would probably have to be willing to move where ever I got accepted. With FP I feel pretty confident I can pick three top programs in nice places to live and get one for sure.
Surgery worries me because residency and practice hours suck. You have to love the ER because it's your mistress. And there's my age factor. I know surgeons that operate into their 70's but that is the exception. That's why rural FP is so appealing. You can do minor surgeries (still great fun!) but they don't dictate your lifestyle and you can stop whenever you choose.
Becky is also doing a bit of soul searching herself while spending the weekend with the kids at my Dad's place in SD. Maybe he'll have some words of wisdom for her. Her careers desires may very well be the deciding factor on my specialty.
My uncle form Ann Arbor is on his way down to pick me up. I've never seen his place. It will be nice to get away for a few hours and talk this out myself. His daughter, my cousin, just started medical school at U. of Washington so he may have more interest seeing as how his daughter will be going through this in a couple of years.
Wednesday, February 14, 2007
Snowed In
We had at least eight inches fall last night. This morning they called it a Level III emergency so non-Healthcare folks could be ticketed for driving on the roads. The schools have been out all week. Some of the drifts this morning were waist high.
Our Chief made it in late, but Jason didn't, so the two of us did rounds at a fairly lazy pace. The morning procedures had been canceled. And while in the ICU visiting my favorite patient at the moment (a repeat ventral hernia repair) we came across a pretty fascinating ID case.
A 41 year old woman came down with Strep throat along with two family members. However, her infection progressed to necrotizing fasciitis. I couldn't see much since her neck was completely covered with dressings and a trach tube, but the nurse said ENT has had to debride her neck twice. She's almost been decapitated by Strep throat!! Obviously she has to have some co-morbidity like Diabetes or an immune-compromised condition. The infection is still spreading down her trunk, so it doesn't look like any antibiotics can save her at this point.
Even if she did survive, they had to remove all her neck muscles, so her trachea and jugulars are exposed. She'd never be able to move head on her own again. The whole thing is morbidly fascinating.
I didn't feel well around lunch, so I let Jason, the third student and our Chief John head over to the hospital where one of our Attnedings did an inguinal hernia, a Lap Chole and a Lap Chole that had to be converted to an open surgery. Attendings have only so much patience for removing big gallstones stuck in ducts with laprascopic tools before cutting the patient open. I missed some good scrub time, but I feel better after a long nap. And Jason just got home so it was a long afternoon in scrubs.
Tomorrow is Thursday, we have our half day a week of didactics starting at 7am. That means fast rounds starting at 6am. Hopefully I can peak in on the woman with no neck to see how she's doing - and maybe answer the question how this unheard of complication could have happened.
Our Chief made it in late, but Jason didn't, so the two of us did rounds at a fairly lazy pace. The morning procedures had been canceled. And while in the ICU visiting my favorite patient at the moment (a repeat ventral hernia repair) we came across a pretty fascinating ID case.
A 41 year old woman came down with Strep throat along with two family members. However, her infection progressed to necrotizing fasciitis. I couldn't see much since her neck was completely covered with dressings and a trach tube, but the nurse said ENT has had to debride her neck twice. She's almost been decapitated by Strep throat!! Obviously she has to have some co-morbidity like Diabetes or an immune-compromised condition. The infection is still spreading down her trunk, so it doesn't look like any antibiotics can save her at this point.
Even if she did survive, they had to remove all her neck muscles, so her trachea and jugulars are exposed. She'd never be able to move head on her own again. The whole thing is morbidly fascinating.
I didn't feel well around lunch, so I let Jason, the third student and our Chief John head over to the hospital where one of our Attnedings did an inguinal hernia, a Lap Chole and a Lap Chole that had to be converted to an open surgery. Attendings have only so much patience for removing big gallstones stuck in ducts with laprascopic tools before cutting the patient open. I missed some good scrub time, but I feel better after a long nap. And Jason just got home so it was a long afternoon in scrubs.
Tomorrow is Thursday, we have our half day a week of didactics starting at 7am. That means fast rounds starting at 6am. Hopefully I can peak in on the woman with no neck to see how she's doing - and maybe answer the question how this unheard of complication could have happened.
Monday, February 12, 2007
Interesting day...
I started a little late, 6:30am for rounds instead of 6:00am. Got done by our 8:30am, but it ended up being a hernia repair instead of a planned colonoscopy. We repaired the guy's hernia last week. It was a huge one he had had for years with pretty much all of his bowels in front of the remains of his abdominal wall. He had lived a hard 61 years.
Well, we had hernia repair wound dehiscence. So our surgical Attending started the week in a foul mood. At least he doesn't take his anger out on personally. Still, everyone tends to tiptoe around the OR on days like this. The patient's tissue was so bad that he tore the sutures holding the mesh down. He had an elastic binder and staples holding his guts inside, so we had to rush him to surgery before they spilled onto his bed!
The surgery was very extensive. We put down two layers of mesh this time, and huge pieces sutured almost to his sides. If they tear out this time, he may have to live with the result because there won't be enough good fascia left to suture.
Then we had a radioactive labeled sentinel biopsy and mastectomy. It was another hard life case. She had a tumor as hard a rock encompassing most of her breast. It must have been palpable for years. The lymph nodes came back metastatic. So in addition to losing her breast, she's going to get at least radiation treatment. That's best case, if we don't find any metastasis.
Then Jason and I grabbed a quick dinner and saw a new consult in the ER (inguinal and scrotal abscesses) before rounding on our patients with our Attending. It was pretty quick, but we didn't get done until 7pm so it was a long day.
Now it's time to start studying!
Well, we had hernia repair wound dehiscence. So our surgical Attending started the week in a foul mood. At least he doesn't take his anger out on personally. Still, everyone tends to tiptoe around the OR on days like this. The patient's tissue was so bad that he tore the sutures holding the mesh down. He had an elastic binder and staples holding his guts inside, so we had to rush him to surgery before they spilled onto his bed!
The surgery was very extensive. We put down two layers of mesh this time, and huge pieces sutured almost to his sides. If they tear out this time, he may have to live with the result because there won't be enough good fascia left to suture.
Then we had a radioactive labeled sentinel biopsy and mastectomy. It was another hard life case. She had a tumor as hard a rock encompassing most of her breast. It must have been palpable for years. The lymph nodes came back metastatic. So in addition to losing her breast, she's going to get at least radiation treatment. That's best case, if we don't find any metastasis.
Then Jason and I grabbed a quick dinner and saw a new consult in the ER (inguinal and scrotal abscesses) before rounding on our patients with our Attending. It was pretty quick, but we didn't get done until 7pm so it was a long day.
Now it's time to start studying!
Sunday, February 11, 2007
Second week on surgery
Another week of fun surgeries such as bowel resections, big hernia repairs and breast lumpectomies. It definitely felt more routine, even though the learning curve is still quite steep. I wasn't allowed to much more in the OR, but got scrubbed in on most of the good cases and did a decent job holding retractors, guiding cameras and closing up with sutures and staples. It's getting easier to anticipate the surgeons needs and they aren't jumping on us as much for not catching on to their intentions.
Rounding is getting easier. I'm getting more efficient at the brief physical exam and progress note. I still miss knowing the whole picture on patients, but I only have time to check on GI and surgery-related issues. Plus, there's usually other specialists or primary care docs on board to address everything else.
Our third student is a decent guy, but I sure started the week miffed about giving up a third of the cases. We'll see how this works out, but so far I only feel like he's taken some office visits - which is just fine.
Our intern and Chief resident (since he's the only resident in this new program) went away for the weekend so I house sat for him. It was a wonderful break from the "cell". I played with his boxer Griffin, got to use his Saab and slept on a real bed. Of course I stayed up too late on Friday enjoying cable TV again.
Rounding this weekend with our Surgeon on call as rewarding. Jason and I scrubbed in on a morning X lap (exploratory bowel surg) since the Chief was gone. We also had the opportunity to share everything we'd been assigned to read. Both of did very well according the surgeon and scrub tech. Jason didn't feel great, so he went home early. This gave me a lot of face time with my Attending. She spent a lot of time teaching and explaining things. It was SO much different than the classic arrogant surgeon-student relationship or the Medicine Attendings with God complexes I met at the VA. Now I have to read up on C. difficile and breast pathology.
One case is worth highlighting because it's so disturbing. We have a women who is an illegal alien getting an incredible amount of taxpayer funded care for no good reason other than her family isn't ready to let her go. The woman is a vegatable from a CVA, has a trach, and can't speak English anyway. Moreover, her kidneys, heart, liver and circulatory systems are collapsing. Finally she has ALL the superbugs: VRE, MRSA and the scary new Actinobacter buneii from the Iraq war. I saw here the first day in full chemical warfare gear, but have been told since that students aren't supposed to expose themselves and risk spreading it around.
It is a travesty that she's getting every antibiotic, imaging study and specialty consult available. The family, I assume for some cultural reason, won't unplug her and let her pass even though there's no where but down to go from here. And can you believe I was called in on this case to disimpact her!! At this hospital Medicine turfs those fun jobs over to surgery. I wonder if we're at this point because they are also avoiding the heart-to-heart conversation with the patient's family (through an interpreter).
From what I've been told, none of the family speaks English or is here legally either, so the whole thing certainly leaves an anti-immigration taste in my mouth. It also highlights some of the huge problems in our medical-legal system. As one of the Indian Attendings said, the only country in the world this could happen is the USA.
Rounding is getting easier. I'm getting more efficient at the brief physical exam and progress note. I still miss knowing the whole picture on patients, but I only have time to check on GI and surgery-related issues. Plus, there's usually other specialists or primary care docs on board to address everything else.
Our third student is a decent guy, but I sure started the week miffed about giving up a third of the cases. We'll see how this works out, but so far I only feel like he's taken some office visits - which is just fine.
Our intern and Chief resident (since he's the only resident in this new program) went away for the weekend so I house sat for him. It was a wonderful break from the "cell". I played with his boxer Griffin, got to use his Saab and slept on a real bed. Of course I stayed up too late on Friday enjoying cable TV again.
Rounding this weekend with our Surgeon on call as rewarding. Jason and I scrubbed in on a morning X lap (exploratory bowel surg) since the Chief was gone. We also had the opportunity to share everything we'd been assigned to read. Both of did very well according the surgeon and scrub tech. Jason didn't feel great, so he went home early. This gave me a lot of face time with my Attending. She spent a lot of time teaching and explaining things. It was SO much different than the classic arrogant surgeon-student relationship or the Medicine Attendings with God complexes I met at the VA. Now I have to read up on C. difficile and breast pathology.
One case is worth highlighting because it's so disturbing. We have a women who is an illegal alien getting an incredible amount of taxpayer funded care for no good reason other than her family isn't ready to let her go. The woman is a vegatable from a CVA, has a trach, and can't speak English anyway. Moreover, her kidneys, heart, liver and circulatory systems are collapsing. Finally she has ALL the superbugs: VRE, MRSA and the scary new Actinobacter buneii from the Iraq war. I saw here the first day in full chemical warfare gear, but have been told since that students aren't supposed to expose themselves and risk spreading it around.
It is a travesty that she's getting every antibiotic, imaging study and specialty consult available. The family, I assume for some cultural reason, won't unplug her and let her pass even though there's no where but down to go from here. And can you believe I was called in on this case to disimpact her!! At this hospital Medicine turfs those fun jobs over to surgery. I wonder if we're at this point because they are also avoiding the heart-to-heart conversation with the patient's family (through an interpreter).
From what I've been told, none of the family speaks English or is here legally either, so the whole thing certainly leaves an anti-immigration taste in my mouth. It also highlights some of the huge problems in our medical-legal system. As one of the Indian Attendings said, the only country in the world this could happen is the USA.
Sunday, February 04, 2007
First week of surgery
The week has gotten better. Still feels like we've had no orientation and we're flying by the seat of our pants. But the very helpful and somewhat obnoxious MSIII student shared his wisdom with Jason and I and left for his next rotation. Even better, our new resident is an English speaking intern that likes to teach.
We may learn something yet. If nothing else, I think I'll be able to perform a cholecystectomy myself after this rotation. I scrubbed in for about my fourth gallbladder removal on Friday and am getting pretty good on the camera and closing up. Suturing with gloves is still tricky, so I spent some time practicing last night while watching a movie in the room. Our intern (we call him Chief since he's the first DO surgical resident in the new program here) wants us to study fluid management and nutrition for Monday. So tomorrow is going to very busy preparing for my Peds rotation exam on Monday, studying fluids/nutrition and watching the Super Bowl. Oh, I also have to do laundry.
Yeah, I didn't get a lot done today unfortunately. I was exhausted from the first week. It's a lot more hours and more intense than Peds ER. So I slept in, did a couple errands and borrowed Jason's car. He was kind enough to loan it to me while he takes call this weekend. So I got in some grocery shopping and caught a movie, the very weird Pan's Labyrinth.
We have three surgeries scheduled for Monday, so the week looks pretty good so far. Then I'm going to do call next weekend. All these hours are certainly convincing me that surgery isn't my top choice. Even our attendings work like 90 hours a week. It's crazy.
At the same time I've exchanged a few e-mails with recent FP residency graduates that state my goal of a procedural, rural FP practice is very doable. I even got tips on how to get hospitals to bid against eachother tin order to get the most financial help with student loans and start-up costs. It still feels like a good fit, even though I might get a bit jealous of ER and Anesthesia when they make more on less hours.
One thing is for certain. Toledo isn't where we're going to end up. With the wind chill it's like 10 degrees below zero! The snow is blowing off the drifts into little clouds. Exposed hands get painfully numb just walking across the parking lot. The wind burns your ears and cheeks.
Time to get some sleep for a big day tomorrow.
We may learn something yet. If nothing else, I think I'll be able to perform a cholecystectomy myself after this rotation. I scrubbed in for about my fourth gallbladder removal on Friday and am getting pretty good on the camera and closing up. Suturing with gloves is still tricky, so I spent some time practicing last night while watching a movie in the room. Our intern (we call him Chief since he's the first DO surgical resident in the new program here) wants us to study fluid management and nutrition for Monday. So tomorrow is going to very busy preparing for my Peds rotation exam on Monday, studying fluids/nutrition and watching the Super Bowl. Oh, I also have to do laundry.
Yeah, I didn't get a lot done today unfortunately. I was exhausted from the first week. It's a lot more hours and more intense than Peds ER. So I slept in, did a couple errands and borrowed Jason's car. He was kind enough to loan it to me while he takes call this weekend. So I got in some grocery shopping and caught a movie, the very weird Pan's Labyrinth.
We have three surgeries scheduled for Monday, so the week looks pretty good so far. Then I'm going to do call next weekend. All these hours are certainly convincing me that surgery isn't my top choice. Even our attendings work like 90 hours a week. It's crazy.
At the same time I've exchanged a few e-mails with recent FP residency graduates that state my goal of a procedural, rural FP practice is very doable. I even got tips on how to get hospitals to bid against eachother tin order to get the most financial help with student loans and start-up costs. It still feels like a good fit, even though I might get a bit jealous of ER and Anesthesia when they make more on less hours.
One thing is for certain. Toledo isn't where we're going to end up. With the wind chill it's like 10 degrees below zero! The snow is blowing off the drifts into little clouds. Exposed hands get painfully numb just walking across the parking lot. The wind burns your ears and cheeks.
Time to get some sleep for a big day tomorrow.
Tuesday, January 30, 2007
Starting Surgery
Well the first two days have been pretty anti-climatic. The rotation isn't really ward-based as I had hoped. It's more like a preceptor-based rotation that happens to have Residents as First Assist or Surgeon at one of the four hospitals we work at. Yes, that's four hospitals to go to for surgeries and to call on patients every morning. Kind of difficult when I have no car and it's fourteen degrees outside. My fellow MSIII student has been kind enough to give me rides so far. And there's absolutely no orientation or Resident teaching, so it feels like flying by the seat of your pants. We do get some didactics, but they seem vastly inferior to the ER lectures from last month.
All the surgeries so far have been gallbladder related. I stayed up late last night studying surgery on the biliary tract for a long open cholecystectomy this morning. Usually gallbladder removal is done with scopes through small incisions, but this patient had enormous stones that had to be manually removed in the bile ducts and all the way up into the liver. It took hours using tiny balloons and mesh cages to fish them out. My job thusfar has been holding retractors, suctioning and a little stapling. I've only rounded on one patient so far. The good thing is that we only have to write short SOAP (progress) notes instead of H&Ps. If we have 8am surgeries, that means days start around 6:30am in order to have enough time to see patients and write notes.
One of the reasons I'm not doing more in the OR is that we have an extra student in our normally two student service. He's off schedule so he's got one more week with us. That means he's been able to help us figure where we're supposed to be and what we're supposed to be doing. But it also means that we have three students trying to scrub in on a limited number of surgeries.
The surgeons themselves seem ok. A little ornery, but certainly not arrogant. So far the teaching has been mediocre, but I hope that it improves as we get up to speed and the third student heads out. I'm holding onto my hope that things will improve after the first week like they did with Peds last month.
Tonight I hope to study some Peds for my test on Monday. At least I have a full weekend to prepare. That also means there won't be too much time to miss the family. Who knows, maybe I'll even get motivated to work out a bit.
All the surgeries so far have been gallbladder related. I stayed up late last night studying surgery on the biliary tract for a long open cholecystectomy this morning. Usually gallbladder removal is done with scopes through small incisions, but this patient had enormous stones that had to be manually removed in the bile ducts and all the way up into the liver. It took hours using tiny balloons and mesh cages to fish them out. My job thusfar has been holding retractors, suctioning and a little stapling. I've only rounded on one patient so far. The good thing is that we only have to write short SOAP (progress) notes instead of H&Ps. If we have 8am surgeries, that means days start around 6:30am in order to have enough time to see patients and write notes.
One of the reasons I'm not doing more in the OR is that we have an extra student in our normally two student service. He's off schedule so he's got one more week with us. That means he's been able to help us figure where we're supposed to be and what we're supposed to be doing. But it also means that we have three students trying to scrub in on a limited number of surgeries.
The surgeons themselves seem ok. A little ornery, but certainly not arrogant. So far the teaching has been mediocre, but I hope that it improves as we get up to speed and the third student heads out. I'm holding onto my hope that things will improve after the first week like they did with Peds last month.
Tonight I hope to study some Peds for my test on Monday. At least I have a full weekend to prepare. That also means there won't be too much time to miss the family. Who knows, maybe I'll even get motivated to work out a bit.
Saturday, January 27, 2007
Peds down, halfway thru Toledo confinement
I finished the Pediatric ER rotation on Wednesday. Tuesday was my last shift in the ER. It was busy and the time passed quickly. Nothing too unusual, but good learning cases. At the end, my Attending gave me a glowing evaluation. I'm not sure how the Doc that actually pens my evaluation for the entire rotation will use it, but it sure felt good. I had had this Attending for most of my shifts, but he had always just checked off "performing as expected" on my daily log sheets. The paragraph or so he wrote was my first real feedback on my performance.
Wednesday I was coming down with a cold so I didn't do a procedural shift in the ER like I had intended. My only required duty was some mock codes with three other students on a $40k doll. A second year ER Resident instructed us while a tech handled the computer operation for the doll. This doll could be male or female. It breathed, cried, opened its eyes, bled, had heart and lung sounds, fractures and much more. We did scenarios like head injuries where the doll had one blown pupil and chest injuries with a tension pneumothorax and cardiac tamponade. Of course, we also had the AMI with ECG readout where we had to intubate (RSI) and run an ACLS code.
Pig lab a week or so prior was similar, but a first year Resident and I performed several procedures on a live (anesthetized) pig before it was put to sleep. It was a little weird (and smelly) but a great experience. I put in an IO line, did an LDP, pleuracentesis, cardiocentesis, chest tube and cricothyroidotomy. One procedure shift wouldn't have come close to that experience.
Interesting cases in the last two weeks included sickle cell crisis, respiratory distress, croup, an ovarian cyst that turned out to be GC, Candida and UTI, sunflower shell impaction, lots of fractures and lacerations. I sutured a bunch, did a digital block, stapled a scalp lac and helped set a couple fractures. And I had all the AOM, RSV, rotovirus, etc. that I would have been inundated with at a Pediatric office.
So was it worth leaving Phoenix, my family and all the comforts of home for this learning opportunity? Wow, that is still a tough question. I like to think so. It certainly gave me more exposure to Emergency Medicine than most MSIII students get. For a single student interested in ER, you could do a lot worse that St. Vincent's. The Attendings, Residents and fellow students were great: nice, interested in teaching and without any arrogance.
Now that I'm home though, I'm not looking forward to flying back to Toledo tomorrow for surgery. It's been a great couple of days with the boys and Becky - and the dogs. I didn't think I would appreciate the sunshine this much. Seventy degrees and sunny in the middle of January is pretty darn nice! I drank too much red wine last night ending my month of celibacy and sobriety. Tonight is Gray's Anatomy catch-up. Tomorrow I have just enough time for a lazy morning, packing some khakis, dress shirts and ties so I can look like a proper surgeon, and then it's off to the airport.
I hope I can get through the remainder of my Pediatrics book on the flights back. I have to take my rotation test in the next week or so. And at this point, I feel more prepared for an ER test. Time to hit the books.
Wednesday I was coming down with a cold so I didn't do a procedural shift in the ER like I had intended. My only required duty was some mock codes with three other students on a $40k doll. A second year ER Resident instructed us while a tech handled the computer operation for the doll. This doll could be male or female. It breathed, cried, opened its eyes, bled, had heart and lung sounds, fractures and much more. We did scenarios like head injuries where the doll had one blown pupil and chest injuries with a tension pneumothorax and cardiac tamponade. Of course, we also had the AMI with ECG readout where we had to intubate (RSI) and run an ACLS code.
Pig lab a week or so prior was similar, but a first year Resident and I performed several procedures on a live (anesthetized) pig before it was put to sleep. It was a little weird (and smelly) but a great experience. I put in an IO line, did an LDP, pleuracentesis, cardiocentesis, chest tube and cricothyroidotomy. One procedure shift wouldn't have come close to that experience.
Interesting cases in the last two weeks included sickle cell crisis, respiratory distress, croup, an ovarian cyst that turned out to be GC, Candida and UTI, sunflower shell impaction, lots of fractures and lacerations. I sutured a bunch, did a digital block, stapled a scalp lac and helped set a couple fractures. And I had all the AOM, RSV, rotovirus, etc. that I would have been inundated with at a Pediatric office.
So was it worth leaving Phoenix, my family and all the comforts of home for this learning opportunity? Wow, that is still a tough question. I like to think so. It certainly gave me more exposure to Emergency Medicine than most MSIII students get. For a single student interested in ER, you could do a lot worse that St. Vincent's. The Attendings, Residents and fellow students were great: nice, interested in teaching and without any arrogance.
Now that I'm home though, I'm not looking forward to flying back to Toledo tomorrow for surgery. It's been a great couple of days with the boys and Becky - and the dogs. I didn't think I would appreciate the sunshine this much. Seventy degrees and sunny in the middle of January is pretty darn nice! I drank too much red wine last night ending my month of celibacy and sobriety. Tonight is Gray's Anatomy catch-up. Tomorrow I have just enough time for a lazy morning, packing some khakis, dress shirts and ties so I can look like a proper surgeon, and then it's off to the airport.
I hope I can get through the remainder of my Pediatrics book on the flights back. I have to take my rotation test in the next week or so. And at this point, I feel more prepared for an ER test. Time to hit the books.
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