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. :)