intern year: a nocturnal perspective

Wow it's been a long time since my post about coffee in Ethiopia. I have good excuses about the past three months but none for the end of medical school except to say it was a time of not knowing... very little to write about except fear of the unknown, worries about matching, then moving to a brand new place away from family and apprehension about what intern year would really be like. Natural fears, and probably well warranted... but also not productive fears in terms of making the transition any easier.

Thank goodness for the amazing support of my family and friends! So, a bulleted summary of the time since I last wrote, by month:

• I travelled all around Eastern Europe in February (you can see Valary's blog about those adventures). My favorite country was Montenegro, although I also really liked Bosnia as well as Istanbul and Cappadoccia in Turkey.

Kotor, Montenegro

• I matched at a great combined community/academic program on the East coast in March.
• In April I finished up my academic requirements for med school with a Capstone course (or "intern year crash course") and a business of medicine elective that was super interesting, as well as found a place to live in my new area for the next 4 years.
• In May I graduated from medical school and received that "MD" which felt both somehow well deserved and strangely foreign, with a vague combination of pride in the privileges that suffix affords me and fear about the extreme obligation/responsibility it demands.

From my white coat ceremony at the beginning of med school

Graduation... oh how things change in four years!

• Gracie the cat and I moved to a brand new place in June, where I knew no one except a co-intern from medical school who also matched at the same program. I also bought a new car, a blue Mazda 3 which I love - it makes me happy driving to and from work each day!

New car! Having a salary is awesome :)

• In July I began with working the first 33 calendar days of my intern year. I worked Monday through Thursdays during the day, then Friday and Saturday nights. In my "spare time" I fought with Ikea on the phone in multiple attempts to get my furniture delivered. By August my apartment was finally set up and I got a weekend off for the first time! It was glorious. 

Gracie thinks the new place is okay, as long as she gets food

I'm now 3 weeks in to my third rotation of intern year, "night float." What night float means is that you take care of laboring mothers, respond to any emergencies, especially stat Cesarean sections, as well as cover the pager for all post-partum (after delivery) and gynecologic surgery service patients. It has been both truly rewarding and one of the hardest experiences of my life. It's strange how those two things come together so often in medicine.

I've been able to deliver so many babies, both to happy and distraught new parents. I had to "ride the bed" when one of my patients had a cord prolapse, meaning that the umbilical cord falls below the head and the baby could die if you don't lift the head off the cord and do an emergency Cesarean section to deliver the baby. The physician (me!) doing the vaginal exam at the time has to stay on the bed lifting the head with a hand during the surgery until the baby is delivered. This week I did my first Cesarean section as "surgeon," meaning that I was the one performing the skin incision, the hysterotomy (incision into the uterus), and delivering the baby through the incision in the uterus. Getting to do that for the first time was amazing!

The hours are brutal. I work from 6pm to anywhere from 8am to 10am some days. Sleeping during the day is difficult, even with black out curtains and a face mask. Sometimes I have so many patients, so many tasks, and my pager just won't stop going off... About half the time I don't have time to eat, and when I do it is often around 3 or 4am. I was having a particularly hard week this week because it was just super busy and there were some sad patient outcomes, and then I found out I had misunderstood the vacation/call schedule over Christmas and I just about fell apart. Thank goodness for my mom, letting me call her on the drive to and from work and just cry because I'm tired and sad and don't know how it's possible to work this hard sometimes.

Then at night I had to go back in even though I barely slept and I was really upset because I miss my family so much. The night started off with a scheduled Cesarean section that had been delayed because the day team was dealing with other emergencies. It was a really beautiful C section (if I do say so myself) and I was able to deliver the head for the second time in a row (which is often the thing interns are unable to accomplish) and I was starting to feel a lot better, when the attending and the pediatrician realize that the baby has features consistent with a disorder associated with learning problems... which was completely unexpected for the family. (I'm trying to be super vague to protect patient privacy, which is also why I'm vague about the program where I'm at on this blog.) So as this is explained to the patient, she begins crying. I have to sew up her fascia while her abdomen is actively heaving with her sobs. I cannot imagine the sorrow of finding out that you and your new, beautiful baby girl are going to be living a much harder life than you imagined. It was just so sad. The medical student afterward said "I don't know how you and [the chief resident] did that... you kept operating in such a sad situation." But that's just what we had to do. You stand there and you operate and whisper "that sucks so much" to each other but you keep taking care of that mom no matter how terrible the situation is. That poor mom and family really put my situation in perspective at least. My life may be really hard sometimes but at least I had the privilege of taking care of that woman in that moment, of trying to make her incision look the best that I could even when that was the least of her worries. I may not get the vacation I want or as much time with my family as I want, but in the end the reason I'm even here, working as a doctor, is because my life has been extremely blessed.

Being an intern is really hard. Harder than I could have imagined even after watching others go through it as a medical student. You are expected to do a ton a bitch work even though of all the people available to do that work, you are currently the slowest and most clumsy about it (because the other people are dealing with much more complex situations). You want to be really good at everything you do but you just aren't. You literally can't be. There is no amount of trying hard that will magically make you into a good doctor, at least on a day to day level. And patients are most likely hurt from it sometimes... usually in minimal ways if you have enough supervision, or in ways that are debatably your fault, but it is very easy to internalize every bad patient outcome, no matter how minor, as somehow your fault. It is so difficult to figure out how to have confidence when the majority of the time people only find it worthwhile to give you feedback when you did something wrong (which is constantly) or missed something you should have done, such as write a note or put in a certain order. If you don't have confidence and try to be proactive and manage patients somewhat independently, then you will earn a reputation of being slow and you will struggle more later on in residency when this is expected that you act independently. But if you make decisions about patients without confirming them with a superior first, then you are more likely to make the wrong decision/will end up having to stand up for yourself in terms of why you made that decision. This leads to more negative feedback than otherwise, and you can earn a reputation of being over-confident, or worse, you can actually harm patients by making unwise decisions. The trick is finding a balance between actively managing patients yourself and knowing when to ask for help.

In summary, it is very difficult to have self esteem as an intern. Add in the emotional burdens of sleep deprivation, trying to make new friends/being alone in a new place, and feeling compassion for your patients who are dealing with tragedies and you maybe start to get a picture of what intern year is like. Oh, and then you have a medical student following you around watching your every move who you are expected to teach and have patience with at every moment, even when you yourself are learning and struggling.

I hope this wasn't too negative of a post. I just really needed to write out what I've been experiencing. I waited until after I'd slept about 17 hours over the past 24 so that I would hopefully sound less terribly emotional and dramatic. I will try my best to blog more often during intern year, but based on my blogging history during medical school I'm sure that promise falls flat...

In the end, I think intern year is just something to be survived, with the hope that I will come out of it with a thicker skin yet more compassionate heart and as a better, more knowledgeable and skilled physician. And hopefully make some friends at some point... oh, the little things :)

coffee

For a coffee lover like me, Ethiopia is a dream come true. It’s no wonder, though – legend has it that the coffee bean was discovered by Kaldi, a goat herder in Ethiopia. Kaldi noticed that when his goats ate this certain berry, they acted really wired. So he tried it himself and felt the same way. He shared his discovery with a local monk who brewed the beans in hot water to help him stay awake through prayers, and coffee as we know it was born! Frankly, it doesn’t matter to me whether or not this legend is true, because Ethiopian coffee is the best damn coffee I have ever tasted. 

All coffee is served in small, concentrated espresso glasses. Besides plain coffee, the main other drinks are tea and macchiatos (coffee served over milk). I have also seen an espresso shot served with tea instead of milk (which I haven’t tried yet because I’m not sure I would like it). All of these drinks are served with a ton of sugar, which is placed in the bottom of the glass before pouring the coffee. You are also often offered extra sugar to add if you like. This is the only sweet I have had in Ethiopia so far, so even though I prefer my coffee black, I’m getting more used to it being served with sugar.  I also still haven’t figured out how to say “no sugar!” yet so there’s that…

Ethiopia is also unique in that they are the only culture (that I know of) that has a traditional coffee ceremony. I have heard of traditional tea ceremonies is various cultures, but never a traditional coffee ceremony. So far, I have only experienced one traditional coffee ceremony, which was randomly served when I was “on call” with Dr. Ismael, by a couple nurses and “porters” (which we call transport staff). The ceremony starts with an offering of popcorn, then coffee (with sugar) is served in at least three successive rounds. From what I understand, it takes a long time to learn how to prepare the coffee properly. In the lower right side of the picture, you can see the coffee pot on top of a jebena (a small charcoal oven). Elsa is fanning the oven to heat the charcoal. The coffee grounds are in the bottom of the pot and then water is added and boiled in this fashion. When the water is the right temperature (I think judging this is one of the hardest parts, although Elsa made it look easy), the coffee pot is removed and tilted, allowing it to cool for a certain amount of time. Some of the smaller pieces of charcoal are placed in a small stand (near the popcorn platter in the picture) and sprinkled with incense. The coffee is then poured over sugar and served all around. There are blessings associated with each round of coffee. 

The main point of the coffee ceremony, as well as just asking others for coffee (or tea), is community. The people here never seem to rush. I like the cultural tradition of taking time to talk and socialize – making it a priority. Coffee and talking to people – what a wonderful fusion of two things I love!

transportation

Although this isn’t something the first thing that struck me when I first left the airport, I think the first thing to say is that there are no addresses in Mekelle. It is a relatively large city, the second largest city in Ethiopia after the capitol, Addis Ababa, and home to around 200,000 people. There are paved streets (which were apparently installed in the last 2 years by the Chinese government), but there are no street names and thus no way of directing people to a particular location. For example, we were near the downtown area with some OB/GYN residents getting coffee after lunch yesterday, and we walked by this restaurant called “Pizza Jerry.” The residents pointed it out and said “we have been wanting to go back there but we couldn’t find it!” It is hard for me to imagine directions without the premise of street names, but it seems like everyone gets around just fine.

The next thing I should explain is our main transportation, the bajaj. A bajaj is similar to the tuktuks found in Asia and India, I am told, but it is essentially the motor and wheels of a moped with a metal car built around the structure. Inside, the driver sits in the front and steers like you would with a motorcycle, and the passengers sit in the back row. You can fit 3 people in the back, maximum, but it is a tight fit! The bajajs basically function as an American taxi does, except there are no meters – you must ask for the price to your destination, negotiate, and determine the price before the driver takes you there. We are obviously foreign so we are often charged more, but we still pay somewhere between 25-35 birr for three of us to ride downtown, which is about $1.50. 

There is another form of public transportation which are called taxis here. It is a larger van that has 4 rows of seats. They pile about 13-15 people in the van and drop you off at predetermined destinations. It costs 1.5 birr per person, so 7 cents. We’ve only taken a taxi once, and it was an interesting experience because we were told to ask for “ketema” to get to downtown, but we ended up in a place that was more like the local market, with rows of shops selling spices and flour and necessities – we looked very out of place (although that’s really nothing new I guess). Also, we had variable opinions of the taxi depending on who we sat next to…

Wealthier people here own cars like you would see in Europe. One resident, Dr. Ismael, told me he is preparing to get his driver’s license in anticipation of being able to afford a car as an attending. The most desirable cars, according to him, are Toyotas. In order to obtain a license, you have to attend a month long course and then take a written and practical exam. There are also 5 levels of driver’s licenses depending on what type of vehicle you would like to drive. A “landrover,” which is basically defined as a truck or a Bronco type vehicle, is level 3 and requires a higher certification, level 3. I think tour buses, etc are part of levels 4-5. Ismael wants to get a level 1-3 license so that he can drive between cities. There are sedans here, but those are really only appropriate for driving within town, and would not be adequate for driving in between cities. Also, you can’t buy a personal car in blue because that is the color of the bajajs and taxis!! 

We walk back and forth from the hospital, but otherwise we take bajajs everywhere. We are weak (I’m blaming it all on the fact I’m still getting used to the altitude!) and also directionally challenged foreigners!

Oh and I completely forgot to mention that there are also many horse-drawn carts and goats being herded through the streets. Oh, and random donkeys wandering around!

hike up a hill in photos

A Ethiopian geologist, Philmon, who we met through a professor, offered to take us on a hike up a hill.

It was harder than we thought... again, blaming the altitude.

The breathtaking view of Mekelle. They light a huge bonfire from this spot on the holiday "Meskel." You can see the fire from the city, as well as people walking down the hill with torches.

We found goats!

I almost touched the sun!

No words.

We walked back down as we watched the most beautiful sunset I have ever seen.

selam!

As an addition to the travel blog linked with my previous post, I’ve decided to post my observations about Ethiopian culture and medical practice. We have only been here three days and already I have observed and experienced so much that I want to share! From transportation and introductions to surgery, food, and the very concept of time, I have learned so much about Ethiopian culture. My goal is to post short blurbs about individual topics. 

I am going to write these posts offline and then upload them at times when my iPad will connect with the internet, which is unfortunately only occasionally… but I at least have a SIM card! It was a very lucky find in Addis Ababa because it allows me to communicate with people here and connect with the internet. I wish I were dextrous enough to compose an entire blog post on my phone, but a mini keyboard is so much easier. So I hope to post frequently, but this is my forewarning that it may not happen or I may potentially post multiple sections at once. 

I was told before I left that the pace of life was just different here. I thought I understood what that meant, but I think you can’t really understand until you experience it. I am definitely learning what patience truly is, and what life is like when you have very few distractions (although I have actually felt very busy these past few days). I feel so blessed to have the opportunity to be here for a month in a town that is not used to tourists. Walking to and from the hospital every day I am greeted by children who wave and giggle whenever you wave back like it is the funniest thing in the world. They also love giving high fives. I think I might show them how to fist pump next time! I am also overwhelmed by the generosity of the Ethiopian people I have met. Whenever I eat with an Ethiopian person, they refuse to let me pay for anything! I have also met many random people who, although we literally only have the word “selam” (hello) in common, laugh and smile easily. 

I know I will learn so much here, and I just hope I can give a little back!

interviews, rank lists, and ethiopia... almost

So I return to the blogging world after a long hiatus to explain what I was doing during November and December and to introduce my next big adventure!

Mostly, I haven’t blogged in a few months because I was busy flying all over the country to interview at a bunch of different OB/GYN programs. The way doctors get their first jobs (called residency training programs) is through a process called the “Match.” The basic gist is medical students apply to a bunch of programs in their chosen specialty, receive invitations to interview, and then are expected to pay to fly and stay in hotel rooms for at least 10 programs in order to have the best probability of matching. The applicants and residency programs then create "rank lists" of each other which are put into an algorithm and then you are magically matched! It is nerve racking to fly all over and navigate new places, but I also loved staying with friends I hadn't seen in a while and getting to see cities in the US that I'd never been to before. It's funny that the most anxiety-provoking aspect of interview season was not the actual interviews - it was making sure I got to the random meeting rooms in hospitals I'd never been to before, parking in the correct garage, etc, and making sure that I was always 15 minutes early!

I am excited about the next four years and I can't wait to find out where I will be spending them on March 20th! I definitely have some favorite programs but those will remain secret. :)

And now for the pressing news that is even more exciting than decisions about my future - I'm going to Ethiopia! I will be doing a rotation in obstetrics and obstetrical fistula repair at Mekelle University in northern Ethiopia. There are two hospitals in Mekelle, Ayder Hospital and Mekelle University Hospital, and I will also be spending time at the Mekelle University Fistula Clinic, which is associated with the famous Hamlin Fistula Hospital (http://hamlinfistula.org/) in Addis Ababa (the capitol city of Ethiopia). I am so excited for this experience - I know I can't fully anticipate its significance in my life, but I know I will learn so much and be stretched in so many ways. Then, after a month in Ethiopia, my friend and I will be traveling around southeastern Europe for a few weeks!

This adventure has turned out to be overwhelming in so many ways: first with doing the last minute prep like applying for a visa and getting my brother to give me a yellow fever vaccine in between interviews, then with attempting to pack for hospital dress clothes in warm Ethiopia and warm layers for winter in Romania all in a tiny carry-on size backpack. But little could I have imagined how a relatively small snow storm in Chicago could lead to a whirlwind of standing in customer service lines in the middle of the night (I may or may not have burst into tears in front of a United customer service rep at 3am today), countless phone calls, frantic flight searches on phones, and sleeping in an airport. You can read more about that adventure on the blog I'm sharing with Valary at  http://www.travelpod.com/travel-blog-entries/valaryr/3/1420828752/tpod.html. 

We are currently in a hotel in Toronto (hey! we made it out of the country!) and hopefully leaving on a direct flight for Addis Ababa in the monring. I am planning on updating this blog occasionally but will mainly be focusing on that travel blog during these two months. 

four things about fourth year

After a few requests, I return to blogging again with apologies for my recent absence! I really wanted to write a recap of third year - this transformational year in the life of a doctor - but I kept putting it off while studying for Step 2 and thus missed my window... but now I bring to you my thoughts about fourth year of medical school after approximately 2.5 "sub-internships."

1. Fourth year is great! As I've been told all along, fourth year is the light at the end of med school tunnel vision.

One thing that makes fourth year great is the vacation time. I actually took my first month off to take the USMLE Step 2, which is the second round of sitting in front of a computer for 8 hours straight. This time, I did not even come close to having a panic attack (which is probably my biggest accomplishment so far this year) and happily, I did way better this time around. I think that is a combination of the test being more focused on clinical knowledge than basic science, which is much easier for me to study, and simply having a calmer attitude about the whole thing. Despite the fact that my Step 2 score actually matters as much if not more than my Step 1 score, there was so much pressure surrounding Step 1 that I think my score primarily reflected that stress. Anyway, moving on - vacation! After taking Step 2, I had the amazing opportunity to go to London, Cinque Terre (in Italy), Nice and Paris with my family. When lying on the beach in Nice speaking French with my former host mom, I truly wondered why in the world I had chosen to go to medical school! But in the end, it was a great time to spend with my family and a refreshing reminder that the world is much bigger than the 10 minute walk between my apartment and the hospital! I am going to have a lot more time off this year to spend with my family and friends, and I will also be going to Ethiopia and traveling around Eastern Europe in January and February! This year is going to be great.

Another - much more medically relevant - aspect of fourth year that is awesome is my role in the hospital. I have truly loved my sub-internships (or "sub-Is" as we call them) this year. A sub-I is a month long rotation in the specialty you are going into where you are supposed to act as the intern, aka the first year resident. They serve two main purposes - to prepare you for intern year and to impress the people in your specialty in order to get letters of recommendation. I have loved my sub-Is because I'm finally getting to do what I love - OB/GYN - and I'm actually decently good at it. Gone are the days of feeling completely lost and worrying more about where the stapler is than how your patient is doing. Now I can actually give confident advice to patients about their problems and even give preliminary diagnoses without running it by the attending first. I'm trusted to do more procedures and have more responsibility. I also have more time to connect with patients. Although there is still so much more for me to learn and so many skills for me to perfect, I feel like I actually know how to be someone's doctor. :) It's an amazing feeling. It confirms my hope that I will truly love my job and look forward to going in to work every day for the rest of my life.

2. Fourth year can be kind of frustrating. It is mainly the sort of legal/logistical aspect of it, but essentially, I am no different than I will be at the time (almost exactly 8 months from now) when I will graduate and have an MD behind my name. Unfortunately, I will not be any smarter or much more knowledgeable than I am now. Especially during my inpatient rotation on Labor and Delivery, it was frustrating how I couldn't help more simply because I'm not legally allowed - for instance, I can't sign prescriptions, put in official orders, or write certain notes. In some ways, I'm happy I don't have those responsibilities. I'm glad I did have this time to learn more because that will help me be a better intern eventually. And it's nice to avoid any flack when something goes wrong... :) But it also kind of feels like I can't really learn until I'm fully responsible for something. Which leads me into my next point...

3. Fourth year makes me afraid for intern year.

I think I've gotten a pretty good picture of what it will be like to be an intern, both from doing my labor sub-I and from hanging out with the interns, and it scares the heck out of me. Intern year is this perfect storm of an enormous increase in responsibility, consistent sleep depravation for month after month, and having to adjust to a new city and make new friends. All while working 80+ hours/week. And wanting to be perfect at everything I do right away. And at work I will suddenly be responsible for everything that I was just whining I can't do now - without any more know-how than I currently have. It's truly birth by fire. In many ways I think intern year will be amazing. I'll go from having delivered 8 babies to delivering hundreds. I will finally have the privilege of being the primary surgeon on a case. I will learn an amazing amount about patient management. But these past few months are the first time I really contemplated what interns lives are like and it is truly a fearsome thought.

4. Fourth year is full of fear of the unknown. In addition to fear of the known (I know I will be doing intern year somewhere next year and it will be difficult) fourth year is also a year of unknowns and possibilities.

Tomorrow is the first day I can turn in my residency application. While I am looking forward to flying all over the country and experiencing what different programs are like, this senior year is just like the other two in that I have no idea where this year will take me. Either it hasn't really hit me yet or I have been talking about the Match for so long that the idea doesn't seem crazy to me anymore, but on May 20th I will open a letter in front of an auditorium full of my classmates and find out where I will spend the next four years of my life. At this point, I feel very peaceful about all this and believe that I will end up where God wants me. I think I will be happy with whatever program I match at. I have a feeling, though, that the anxiety and fear will increase as I go along this process, so that's why I included this last point. Also because I like the symmetry of having four points for fourth year.

Sorry again for my relative absence (especially following such a morbid post last time) but hopefully I will be able to keep up a lot better now!

death and dying

I have debated writing about this subject. The first death I mention actually took place a while ago, and it took me a long time to be able to talk about it at all. I feel like we talk about death in many ways - we talk about people who have passed and what death means to us in our lives. We talk about how it has touched us and how it affects our decision-making. So I guess when I came to medical school, I was expecting to deal with death. I expected to talk to people about it, to express sympathy for people who had experienced it in their family, to learn how to tell people they are going to die or that their loved one is dead.

But what I didn't really think about was what it would be like to experience the act of dying.

The first person I saw die was an eleven year old boy. He was shot in the heart by his mom.

He came to the emergency room and they did what's called a thoracotomy. This is an emergency surgery where you cut open the ribs in order to be able to massage the heart directly. You already know death is coming when you do this - survival from a thoracotomy is about 10%. They opened this little boy up and his heart was shredded. They pronounced him dead.

No one really talked to me about it afterward, besides my preceptor saying "that's fucked up" - which is about the best summary I can think of. It was numbing. The ugliness and brokenness of the world we live in was so vivid to me that day. I turned on the news when I got home that night and heard some personal details about him, but I had to turn it off because I couldn't bear it. I couldn't bear to personalize it. Kids aren't supposed to die. They are resilient. They recover.

They definitely aren't supposed to be shot by someone who loves them.

A few weeks ago I watched an old man be coded and die. They did CPR and pushed epinephrine and intubated him. About half way through the code his wife came back to the room, realized what was happening, and began wailing and saying "it's over" and calling all their children. The team continued to "work on him," but after 20 minutes he still had no pulse. They pronounced him dead.

I didn't know him well. He was one of the patients on my team but not one I was following. I had met him once about a week before. At the time he just kept saying he was thirsty.

While he died, I was just overwhelmed by the ugliness. Death, especially death in a hospital with people fighting to keep you alive, is terrifying to watch. There is no dignity. It is not peaceful or romantic or even sensational like it seems in tv shows. But after he died, all I could think was: at least it could be worse. Nothing seems quite as bad after seeing a little boy die from being shot by his mom.

Death and dying are hard to talk about because we're afraid to be "morbid" or "depressing." I hope, in reading this, that you aren't too depressed or fearful. Because the opposite of death is life. You are living! All we can do is live each day God gives us. I wish I could end with more wisdom, but at this point all I can say is that experiencing dying changes you. I hope it changes me for the better.

concept: "on call"

This is a concept I had completely wrong before I came to medical school. Considering I'm about to do four weeks of q4 (I'll explain later) call, I thought it would be a good time to explain what being "on call" actually means.

So when I was a young fresh-faced college student applying to medical school, I imagined being "on call" actually had to do with receiving calls - silly me! I imagined being "on call" meant your lightest day - either you stay at home all day and just answer calls about patients, or that you are at home but have to be ready to go in if needed. The strangest thing about this idea was when I heard that medical students did it - considering we know practically nothing compared to the residents and attendings and because our opinions very rarely (read: never) matter.

Turns out this wasn't completely wrong, but what I was imagining is actually specifically called "home call." It's also true that only the senior residents and attendings have home call where during certain periods they are responsible for answering calls and making decisions - but here's the wrench - another, younger resident actually has to be there at the hospital to call and to do the bidding of the more senior resident. And the medical student gets to be there right along with the resident! So my idea of call days being the lightest days was actually the complete opposite of reality - similar to many of the other things I imagined about medical school.

So what being "on call" really means is that you are the person on a particular service responsible for accepting patients. When someone comes to the ER and it's decided that they need to be admitted into the hospital, they are assigned to a medical service related to their problem. Heart attack goes to cardiology, stroke goes to neurology, etc. There has to be someone there from your "team" to accept the patient, take their history, do a physical exam, and start any work-ups and necessary treatments overnight. So the way "call" has classically worked is that you come in the morning for rounds, stay all day and overnight in the hospital, then stay through rounds the next morning to present the new patients to the team. So after approximately 30 hours you go home, hopefully sleep a lot, then come in the next morning.

A visual illustration. (Not my actual schedule for next week, just in case anyone wanted to stalk me.)

I would argue that this is a ridiculously stupid system. As scientists who study things like sleep cycles, circadian rhythms, cortisol peaks, and the mental consequences of sleep deprivation, it astounds me how we continue to expect physicians to be these magical people who can go without sleep every fourth night and still function at an exceptional level. Simple shift work at night has been shown to be detrimental to health as compared to day shift work, but at least your body has a chance to adjust. Having an irregular sleep schedule in addition to sleep deprivation seems like a terrible idea to maximize mental acuity of residents, not to mention maximizing their health. So far I have only done two weeks of q4 call when I was on the neurology inpatient service - and I was a complete mess. I actually began this blog post at that time (about 3 months ago)...

At least there is some hope. There are two things that are changing/have changed about this system now.

One is that we are doing call less frequently. When I say "q4" call I mean that I do this overnight, 30 hour work day every fourth night. Older attendings will tell you how residents nowadays "have it easy" because they used to have to work q3 call, but this has essentially gone away with increasing work hour restrictions for residents. While I would agree that their lives clearly sucked and that q3 call sounds terrible, I don't think that means q4 call is a joyful schedule full of free time.

The newest solution to this problem that many residencies are now implementing - the one I personally like the best - is a "night float" person instead (also known as the "mouse" on ob/gyn). Thus instead of working q4 call during your entire residency, you work a couple months out of the year where you are consistently on nights for a whole month. Granted I haven't worked nights yet, this sounds so much better than working q4 call. At least you are able to establish a steady sleep schedule (in addition to purchasing dark blinds).

Obviously someone has to be there at night. Obviously no one wants to be that person. Obviously, as a resident you will be that person. But I still think it would be nice if we used a little scientific reasoning when we come up with the best way to schedule shift work.

advice for the OB/GYN shelf exam

This is an atypical post for me because I usually tend toward the narrative - and write for a non-medical audience. However, the only medical blogs I look at myself are ones that give advice on how to study for the NBME shelf exams or USMLE step exams. Until this point, I really didn't feel like I did well enough on anything to be worthy of giving advice, but considering on how often I look at this blog post about third year shelf exams, I wanted to put in my two cents about how to do well on the ob/gyn shelf exam - because for once this year, I did do well on a shelf exam!

Here are the resources I used: 

1. Blueprints Obstetrics and Gynecology - This book is great for the people who prefer to read text, and I believe this edition is considered to be the best in this series. I think the obstetrics chapters are more helpful/detailed than the gynecology ones. What I found really useful about reading this book is that I read the chapters in coordination with the 10 APGO questions on that topic. This is my favorite learning format (think back to ExamKrackers for the MCAT) so I liked doing it this way, although I think it might have been more time-consuming than necessary.

2. Case Files: Obstetrics and Gynecology - I was really glad I forced myself to finish this book during the last week of my rotation. It was more updated than Blueprints and I thought it explained certain differentials with more clarity. I wondered whether I should have read through Case Files during the first two weeks of my rotation (but I was on Gyn Onc, so this is really useless wondering). It did seem nice to have fresh in my brain right before the shelf, but I really think reading this first, then reading Blueprints (if you have time), is probably the better way to go.

3. APGO U Wise Question Bank - This is the indispensable resource in my mind. Unfortunately, I've read that not all schools pay for this question bank, but it was definitely the best resource I used. It contains ~580 questions grouped into 10 question quizzes by topic, as well as 50-question and 100-question comprehensive tests. A nice piece of trivia to know is that the 50 question tests are actually just randomly generated from the question bank. This means that you will recognize questions if you were able to go through the whole bank, but it also means that if you are studying at the last minute, just doing the 50 question test over a few times would expose you to a smattering of topics. I'm unsure whether or not the 100 question comprehensive test contains questions from the bank. Some of them seemed familiar to me, but by the time I was taking this my brain started to feel a little numb, so I'm not sure. Still worth taking to see how ready you are for the shelf.

4. UWorld Question Bank - I made the plunge and paid for this question bank for the whole year, and I always do the topical questions before each shelf. There are about 200 questions for ob/gyn. I did them all on tutor mode over the last couple days before my shelf. I would recommend going through them, although I did find that some were more nit-picky than I found the shelf and APGO questions to be. A usual recommendation is to then go through your incorrects, but I didn't have time to do this.

Summary: 

I was definitely glad I was thorough with my studying because the exam was harder than I expected. I had heard it was one of the easier exams to prepare for because it actually stays on-topic (unlike surgery, psych, neuro, oh yeah... all shelf exams), which was true, but I thought the questions were more complex than the questions in APGO and UWorld. So although the question banks were great prep, I was glad I read something in addition. Also, just a reminder that I really want to go into OB/GYN, so I was highly motivated to do well, and otherwise I definitely wouldn't have come home and studied two hours every night while working 80-hour weeks on L&D. I think you could still do pretty well with simply doing the APGO questions.

Hope this helps and good luck!

a day in the life...

No essay today. A picture is worth 1,000 words.

a surprise maybe-not-so-surprising announcement

There are some people who come into medical school set on an idea (most typically it's a jock-looking guy interested in orthopedic surgery) and are shocked when they love pediatrics and completely change their career path. There's actually a statistic that 75% of medical students end up going into a different specialty than what they planned when starting medical school.

Then there are others, like me, who insist they are open minded. I insisted on my awareness of this statistic and how I would change my mind anyway, so I didn't even want to tell people my favorite specialty. But while I remained purposefully vague, the people around me seemed all too certain. When I look back, I think about my weird obsession as a preteen with watching "The Baby Story" on TLC (which literally just consists of interviewing couples and then watching the birth in a 30 minute episode). I think about how of all my high school science classes, AP Biology and Anatomy were my favorites. I think about how I took Women and Gender studies classes in college just because I was interested - when they didn't count towards either of my two majors. I think about how my college roommates and I would have too many discussions about how "it's your uterus and not your vagina shedding during a period" or how does surrogacy really work? I think about how first year of med school I got really mad when a professor said that sperm penetrate the egg - which, by the way, is a lie which you can read about in this fascinating article - and then a med school friend said "if you don't become an OB/GYN I will eat my shoe."

Then came third year when everything I loved pointed to the same thing. On surgery, I liked the breast cancer patients the best. I loved being in the OR and doing surgery much more than I expected, and one of the things people forget about OB/GYNs is that they don't just look at vaginas and deliver babies, they also perform various surgeries.  On radiology, I liked ultrasound the best.

So I went into my OB/GYN rotation hopeful that I would just have this feeling. That everything about it would be perfect. Truthfully, not everything about it is perfect. I am not ignorant of the negatives. I'm not terribly thrilled about going into a specialty that has 90% female residents. I have already experienced how terrible it is when a baby is born and can't breathe on its own. But there is a lot of happy to counter the sad. And dealing with the tragic parts of life is a burden anyone going into medicine is choosing to carry.

But there were two things about OB/GYN that made me sure it was the right fit - 1) I just liked the people better. When I look back at my blog post about surgery, that was a major thing that made me feel unsure about choosing it as a career - I just didn't like the people. I didn't think "I want to be the kind of doctor you are" - but on OB/GYN, I thought this so many times. Not only did I want the attendings to be my friends, I also wanted to be as good with patients and as interested in what I do as they are. 2) I loved delivering babies. I know this is cheesy, and there are certain things that all medical students love to do - and delivering babies is definitely one of them. But delivering babies made me emotional in this deep and wonderful sense. And even though I said there were only two reasons, if you reference above, clearly 3) is destiny. Ha I love how freaking cheesy that is.

I am going into Obstetrics and Gynecology! (surprise!)

Chosen for its complete creepiness

I am so excited. Not just because I love the relief of finally having decided and getting to focus on the next steps, but because I feel like I've found something that really fits me. The first time I delivered a baby, afterwards the attending said "I've never had to help a medical student so little! You just knew what to do!"

I am also so happy to be choosing a specialty that is so varied in what I can do with my life - I can be a generalist and do surgery, see people in the office, and deliver babies; I can be a cancer surgeon and operate and follow women during chemotherapy; I can specialize in endocrine and infertility and work on medical problems as well as do procedures to help people get pregnant; or I could specialize in high risk OB and deal with sick pregnant women and the interesting and intense complications surrounding high risk pregnancy. So many choices! I can't imagine I will ever be bored for too long. I get to combine surgery and procedures with primary care and advocacy.

I am really excited and I just want to thank my family and friends for supporting me along the way! Can't wait to see what adventures the future holds.

snow day: a contemplation of expectations and evaluations

What does a medical student need to arrange in order to get the day off work? Just a foot of snow and a wind chill of -30 degrees. No big deal.

This is actually from the snow Sunday before my snow day, when I should have been doing work, but instead I was doing arabesques in the snow!

I would apologize for my lack of posting, but when I realized my last post was about burnout, so I thought - how appropriate for me to illustrate my own point!

As I sit curled up on my couch with snow drifts on my windowsills and an espresso in my hand, I'm thinking, what do I have to say about being a medical student lately? I want to talk about expectations and evaluations. Because I am sick of both of those things.

Expectations. Here are some things I am expected to know how to do, magically without ever learning. Granted, some resident will show me how to do these things, however they will make it clear how very nice and patient they are being because the idiot med student can't figure it out:

1. How to use a fax machine. This, ladies and gentlemen, is a complicated task. I thought the pathophysiology of glycolysis and gluconeogenesis was complicated, but figuring out how to send a fax to a long distance number is more complicated. Speaking of long distance numbers...

2. The long distance code. Sounds simple, right? A long distance code. I didn't even know these existed. That's what cell phones are for, right? Ok, so the hospital has a system, right? Every single rotation I have been told a different story about this magical code. On the psych floor, the social worker has it. On the neuro floor, every resident has their own code. On ob/gyn, it's on the board (duh! how could I not know that). I've been told on medicine everyone uses the same code, so you just have to memorize it. I've also been told by every secretary I've ever asked that I should have my own code. I don't. On surgery, I never called a long distance number. Ha.

3. Where the stapler is. Probably a common office problem, just never thought it would be a problem I'm often working on solving. Where is the stapler???

4. How to write notes in the fashion of each specialty:
a. Copy it out on this lined paper.
b. Print out this form and "skeletonize" it for us.
c. Print out this form, fill it out, sign it, then copy it with four pages per sheet and put the real one in the chart.
d. Don't write a note, just have it memorized.
e. None of the above, SNOW DAY!

The point is, no matter the environment, and perhaps especially in the uptight medical environment, it is difficult to figure out how the seemingly simple things work. It takes time. I don't magically know how to be the best secretary ever and a brilliant budding doctor. And that leads us to...

Evaluations. Here is the range:

5 = Honors (greatly exceeds expectations)
3 = the average 3rd year medical student (is this strange to you too? shouldn't we all be 3s?)
1 = probably never selected because they would have already pulled you aside and failed you

You are judged weekly, if not daily, on your performance. And whatever small amount of time you spend with a physician, halfway through you should ask for "mid-rotation" feedback. This week I'm going to ask a doctor for mid-rotation feedback after spending two afternoons with her. It's really insane. I think the point of it is supposed to be that we receive feedback "in time" for us to use that feedback to improve our performance and hopefully get the grade we want, but the feedback is usually either "you're doing fine" or "I haven't spent very much time with you." Very formative.

I guess I'm just getting tired of being evaluated constantly. Imagine for this whole year if every day were an interview and you received feedback at the end of each week on your performance. That's kind of what being a third year medical student feels like.

But here's the thing. If you're not somehow already magically performing like a fourth year or intern after one week, you're probably not going to get higher than a High Pass (the equivalent of a B). Now I say this with the caveat that everyone has a different view of how many students deserve Honors (the equivalent of an A) and what constitutes honors-level work. So naturally your grade not only depends on your performance, but on your grader's opinion of what grades mean and how they should work.

So basically Honors is the enigma of the third year medical student. What does it mean, really? What is the formula to achieve it? It seems that the usual medical student recipe - hard work, studying all the time, knowing everything - doesn't really work. It also seems that my method - hard work, being really helpful, people skills :), and trying to convince myself to study sometimes - also doesn't really work. It's not that I really need Honors in everything. It's just kind of hard to work 60 hours a week, to try your hardest at something that kind of scares you, and then to be told that you "seemed like a genuinely nice person" (literal direct quote) but you get HIGH PASS. Buzz. Next.

Needless to say the excitement of third year has worn off a little bit, in addition to the fact that I'm still tested around once a month (the results of which are always discouraging), thus I am already close to ready for third year to be over with.

I am currently in the middle of my Obstetrics and Gynecology rotation, which I really am enjoying (despite the difficulties inherent in third year mentioned above). My goal is mainly to study really hard so I hopefully get a better grade on this test than any of the others, then I basically feel like I can stop worrying and just settle on getting High Passes for my remaining rotations. Hopefully then I will have Honors in the two things I am thinking of going into, and that seems good enough to me! I am hopeful that I'll write another post summarizing OB/GYN in the next three weeks.

debt and burnout

These are two subjects that (almost) every medical student struggles with, but is afraid to talk about, even (or perhaps especially) with her med school classmates. I bring them up because I feel like both are topics that need to be addressed, and I would really like to get to the bottom of how we got here and what can we do about it now? I've chosen to link to two articles that specifically address these problems well, because I think they have a broader perspective than I could share.

Debt. Ugh. It's kind of the huge (more like gigantic) elephant in the closet, isn't it? I mean, I try to ignore it, I try to live my life in a conscientious way without stressing about money, but whenever I make a purchase over $5 - or even an unnecessary $3 purchase, like coffee - I think about how I am actually paying a significant amount of interest on that coffee or that toy for my cat. It is a constant burden that I would love to ignore but I would also be stupid to ignore - kind of a catch 22. I wanted to share this article about medical school debt and the path to becoming a doctor because 1) I don't have time to write something like this right now and 2) I think it's important to see the perspective of someone who has completed his training.

Note: I actually have no idea what this says... 

Burnout/mental health. Because I'm a person who has to talk about my feelings, profusely, to my friends, I feel lucky that sharing my struggles with depression and insecurity with my medical school friends has helped me to know I am not alone. I would be very surprised if I had a single friend who hasn't already dreamed about, let alone seriously considered, dropping out of medical school. This article  refers to a study that found that over half of medical students (I emphasize med students because this is really only the first half of our medical training) meet the criteria for burn out, and if anything, I would say this is an underestimation.

So how did we get here? What can we do about it now?

I think first we need to have physician voices willing to say that the burdens are too big and the stakes are too high. We need to have people willing to advocate for us and say that we need better loan options and better ways to fund medical education. I think it's mentally and financially healthier to have no debt and a smaller salary down the road, as is the case in many other nations.

I think it's important for medical schools not only to provide passive mental health care (ie where counseling is made somewhat available), but for medical schools and medical students to take an active role in prompting discussions about stress and burnout, and providing easily accessible options that aren't financially burdensome.

I don't have a perfect picture of what the solutions to these problems looks like, or how to get there. But the first step is just to bring them up.

change

Since I last posted, I finished my 4 week radiology clerkship and just finished the first two weeks of my neurology clerkship doing pediatric neurology, and let's just say my lack of posting can somewhat be blamed on the old adage, "When you don't have anything nice to say, don't say anything at all."

I think radiology is a fine specialty, but a really miserable rotation as a medical student. I had a radiology fellow say this to me, so I know I'm not alone in the feeling. Radiology as a medical student has been likened to be as interesting "as watching someone read." I honestly wished I liked it more - I actually really like the concept of radiology and anatomy, but we can just leave it at radiology is not the career for me.

So far, pediatric neurology was fairly depressing - dealing with death in children is not easy. Some day I will try to tell the story of the first (and so far, only) death I observed last summer, but I'm not quite ready to describe it yet. In addition, neurology just has many attributes that don't mesh well with me - I will attempt to write about this more later, but feel free to read my post from first year, cross one specialty off, in the meantime.

Anyway, what I really wanted to talk about is the third year of medical school in a more overall sense. Bear with me for another analogy:

Imagine you want to become a restaurant manager. You've already been to culinary school and know a ton about food. But in order to become a restauranteur, what you have to do is pay to rotate through different restaurants every two weeks. Every two weeks you are a waiter at a completely different restaurant - Mexican, Italian, American, French, etc, etc. And every week you are rated on your ability to be able to answer questions about the entire menu whenever the manager asks you, you are expected to work well with the other waiters and bus boys, you're expected to be friendly and accommodating to all the customers, work whatever hours you are assigned, and it's generally perceived that unless you use your own spare time to come up with unique additions to the menu, then you probably aren't very dedicated. There are some skills that you can carry from one week to the next - but in general, every two weeks you encounter a steep learning curve.

This sounds utterly ridiculous, right? A crazy, but maybe efficient way for you to become a good restaurant manager. But this truly is a comparable analogy to how we are trained during this year, substituting medical and procedural and physical exam knowledge and skills for the skills it takes to be an excellent waiter. On top of this, add a bunch of Type A personalities and feelings of guilt and failure about any imperfection and it's not surprising that articles like this are so unfortunately real.

With expectations and stakes so high, it is easy to forget that it is natural to struggle to excel at something when your work is constantly shifting. I find myself in the hospital sometimes longing for a "work home." Just a desk. A desk that is my place to sit, with people around it who will also be there tomorrow. I find myself jealous of the nurses who are just free to be good at their job and have plenty of time to do it. I find both of those emotions pretty strange, because a huge part of what appealed to me about becoming a doctor was avoiding a cubicle and being in a job where I could continue to grow and change. But it makes sense that in my constantly shifting world I would long for some continuity.

But where I find myself is when I embrace the change. Man, that sounds so freaking cheesy, and I'm sorry about that, but really... While part of me longs for the day when I can just be settled, I am forced to remind myself how exciting and dynamic my life is now. I am young and single and at the beginning of a career that could take me in a million directions - from operating on people to working abroad to starting a foundation to teaching students to researching cancer. I don't need to know the answers now. I don't need to be the expert now. This year, I have to cope with change. But I also get the opportunity to grow by being flexible and adaptable. I get to be open to being influenced by people. I get to just take it all in and work as hard as I can, and hope that along the way I grow closer to the person and doctor that I want to be.

concept: white coats

The idea for this new series has been brewing in my head for a while. Here's the crazy thing about medical school: not only are we expected to learn physiology, pathophysiology, common and uncommon presentations, diagnosis, and treatment of diseases, but we are also expected to learn an entire new culture. It continues to astound me how many there are, and in general how peculiar they are. I'll try to explain some of these cultural oddities in addition to continuing my normal posts.

So, white coats. If you haven't spent any time in a hospital, or maybe even if you have, you might not know that white coats are actually hierarchical symbols.

You see, medical students wear short white coats. Doctors wear long white coats. This distinction is probably hardly noticeable to patients, because who's really looking to see if the coat is to the doctor's hips or knees? But this whole message has gotten more confusing with the advent of other advanced practitioners. Nurse practitioners and physician assistants also have the distinct privilege of wearing white coats.

So now you can't just look at the length, you have to look at the badge. You should also take note of the badge for other purposes, like differentiating the *even more special* doctors. The division isn't just medical student vs. doctor - it's also residents (also called "house staff" because they literally used to live in the hospital) vs. fellows vs. attendings, who are all already doctors.

All this talk about white coats makes me want to rant about how medicine, an occupation where blood splatter is a relatively common occurrence, ended up with the white coat as its uniform. It's just so illogical. And also necessitates more laundry, which I hate, so yeah. This is probably where I should divulge some historical research about why there are white coats in medicine, but I usually get really bored when some old white dude tries to tell me why we do things a certain way because another old white dude thought of it, so you can google white coats if you're interested.

One really wonderful thing about white coats is that they can hold everything. At one point I've fit a small book, my stethoscope, 5 printed articles, a schedule, my cell phone, a pocket guide, three pens, a highlighter, a penlight, a small notebook, a roll of tape, a packet of tissues, my pager, and mints all in my white coat. It's like wearing a backpack! Except it does kind of start to pull on your neck after a while... but that's totally normal, right?

surgery: a summary

What did I love about surgery?

Cutting people open. Yeah, I definitely said that to freak you out. But, you know, if I'm super honest it's probably true in some weird way... and now I feel the need to say:

please-I'm-not-like-Dexter-I'm-really-a-normal-well-pretty-normal-person-who-just-thinks-surgery-is-cool-and-someone's-got-to-like-it-if-you-ever-need-surgery-right??? 

But really, whenever they let me do anything it is such a rush. There was this one attending on my last rotation that apparently has a reputation for not liking medical students very much. Let's call him Dr. Gruff. On my first day, he "pimped" me for about twenty minutes, quizzing me about anatomy and the treatment of ulcerative colitis and what I knew about the patient (which wasn't much because it was my first day and I didn't know what surgery I was going to until about 10 minutes before it happened). But apparently I did a good job, because the scrub nurse told me the next day that I actually answered his questions and sounded confident... which apparently not everyone does, I guess. I wouldn't have known I did well because basically the only sign was that Dr. Gruff stopped asking me questions. And sometimes this can be a sign that you're completely hopeless. Anyway, the point of this story is that this attending actually started to like me. Probably because we talked about playing Candy Crush one day when one of the nurses brought it up. :) (Thanks Mom for introducing me to that one...)

So anyway, the real point of the story is that one day I was in the pre-op area for one patient when this doctor taps me on the shoulder and asks me to help roll another patient back to the OR. I get there and help set the patient up, but I'm expecting the resident to show up at any time, and they always take precedence over us to scrub in on cases. Suddenly the attending is there scrubbing in and the resident is nowhere to be found so I think: well, I get to be first scrub! I grab gloves and scrub in on the pilonidal cyst excision.

It was so exciting. I got to make the incision and do a lot of bovie-ing (reference my initial post about surgery). Now let me explain a pilonidal cyst to you, so you can be shocked at my excitement: a pilodnidal cyst is a big mass that fat guys sometimes get right above their butt cracks. Yep. I got to help operate on someone's butt crack.

(I thought about putting a picture here - but then I googled it. For those of you brave enough to click on the link, it's actually a good representation. For those of you who are not brave, this is when you thank me.)

But then, but THEN, the most amazing thing happened. In the next surgery, we were almost done and getting ready to remove part of the bowel. There's a part where they clamp off the mesentery (the tissue layer with blood vessels that supply the bowel) and then tie it off. The fellow takes a tie, and Dr. Gruff says to me, "let Chelsea have a tie." It was THE MOST flattering thing that I'm pretty sure anyone said to me the whole rotation. I guess it's hard to explain, but that's the way surgeons think. The opportunity to DO something is the biggest reward someone could give you.

Anyway, that was a big tangent. And I hope if Dr. Gruff ever finds this he knows that the nickname is all in the name of fun and I really did enjoy working with him. Except for when he passed my level on Candy Crush.

What else do I like?

The pace. There's always something to do and you're always on your feet doing something. Maybe I won't like this when I'm 60 years old, but I really love it now.

Being able to concentrate on just one problem. This is an oversimplification, because surgeons do manage their patients and all their medical problems when they stay in the hospital after the surgery, but in reality surgeons get to focus on the problem they are trying to fix with surgery and leave most of the rest for the patient's primary care physician. I like this. I think this means I have more of a specialist mindset, but we shall see.

photo credit

Anatomy. It's just cool.

What don't I like?

The lifestyle. Aka the lack of lifestyle. I honestly didn't mind the hours as much as I was expecting to, but by the end of just eight weeks I felt pretty worn out. I didn't have time to do a ton of things outside of work, although I did continue going to my dance class and hanging out with friends and things. But the residents worked probably at least 2 hours longer than I did some days, plus all day on the weekends. It's just hard to imagine anything being worth working that many hours for 7ish years. And it's not like attending hours are that much better. I heard over and over, "only do surgery if it's the only thing you can love" (this was all from non-surgeons, though, so take that for what it's worth.

Sometimes, the people. I liked a lot of people I met, but I didn't meet very many people who I really, really admired. Who I just thought their personality was really similar to mine, or someone who I would aspire to be. I don't know if the mentality in surgery is changing, if it truly is becoming less hierarchical and paternal and God-complex-y, but I don't want to lose my compassion. I don't want to lose my desire to be a servant to others. I've been told don't fall into the trap of choosing a specialty based on a mentor you really admire, but I wonder if the converse is also true - maybe I shouldn't choose a specialty where I had trouble finding people who I greatly admired?

To end, an analogy:

Something I found really energizing about surgery was that it reminded me of dance. Surgery requires so much work and time and dedication that you have to be passionate about it. In surgery, you are expected to learn quickly and to take all corrections immediately and to remember them the next day (this, at least, was a philosophy I learned from my dance training that I applied to surgery and it served me well). Surgery is physical and requires muscle memory and a striving for perfection. It requires you to think on your feet. Even though you may be performing the exact same procedure, the patient's anatomy may be slightly different or you might accidentally nick a blood vessel and you have to adjust immediately. And there is definitely an art to surgery. I heard more than one surgeon say that you could have done the most beautiful surgery on the inside, but if the incision looks terrible the patient will think you are a bad surgeon. To be a great surgeon, you need to be a perfectionist who does amazing work in every single operation. It also helps when people like you. Malcolm Gladwell taught me that.

So this was quite a hodgepodge summary, and I refuse to jump to conclusions, but - surgery isn't crossed off the list quite yet. :)