Mind Your Manners
Jeff Wonoprabowo -- Always let the other person go first. That sounds like a very civil thing to do, doesn't it? It sounds like something that one might hear at, say, an etiquette dinner (a dinner organized for the sole purpose of teaching proper etiquette for formal/business situations). It sounds like something a father, hoping his son will grow up to be a fine gentleman, might say to his boy. But when I heard this advice during my first year of medical school, it was not meant to be a civil, polite gesture.
When the upperclassman told me to let the other person go first, he was giving me advice about blood lab. Now, when I wrote about drawing blood last time, I wrote that I had hoped blood lab would only involve finger pricking. I guess that was just wishful thinking. Or maybe selective memory blocking. Regardless, I should have known the blood lab would involve needles because I was told about it over a year before it happened.
The rationale for such advice? If your partner was horrible at drawing blood and treated you like a pin cushion, you could be sure to return the favor when it was your turn to draw blood. This was, of course, for the sake of education. After all, we should know something about what our patients (or in this case, blood lab partners) have to go through, right?
In my previous post I wrote about my one-try successful blood drawing. I wish it were due to my own skill. But I was lucky to have a partner who was nice and had large veins that were easily visible and fairly superficial. So I take no credit for my success.
When it was my turn, my partner tied the tourniquet around my arm. I told him to go ahead and make it a lot tighter. After tightening it, he proceeded to examine my arm closely around the cubital fossa.
My brown skin mischievously kept the location of my veins a secret, and my partner asked one of the nurses for help. She came over, palpated my arm, and located a suitable vein. After showing him where it was and allowing him to feel it, she left.
I sat there waiting for the sting. The pain came, and I waited. No blood. The needle pressed further. No blood. The needle pulled back without coming out of my arm, changed directions, and again pushed forward.
The needle's under-the-skin directional change was definitely a weird feeling.
Again, no blood appeared in the tube. At this point my partner mercifully pulled the needle out and called for help. The nurse came, relieved him, and drew my blood.
I suppose I got off easy, though. The next day I heard from and of classmates who had to suffer through three or more unsuccessful attempts. One classmate finally had his blood drawn from a vein in the radial side of the wrist because all the attempts in the arm were unsuccessful.
Looking back, I wish my partner could have had the chance to try again. It isn't the most comfortable thing, but we all need to learn how to draw blood. And I wouldn't have minded if he needed to try one or two more times under the guidance of the nurse. And in feeling this way, it seems that I totally ignored the advice I received. I guess I'm just a rebel that way.
The Single Greatest Advance in Human History
Colin Son -- I have really neat handwriting. In fact, if I dotted my ‘i’s with little hearts, you’d mistake me for a fourteen-year-old girl. Per the mythos of the profession, my handwriting should probably prohibit me from being a physician.
But not for much longer, hopefully. The days of pharmacists translating the hieroglyphics of some physician’s handwritten prescription or of illegible clinic notes should be over. Indeed, where I come from they already are, but unfortunately, not where I’ve been.
As I’ve written about in previous posts, I’m on back-to-back, month-long away rotations. Before these rotations I had never seen a paper chart in a hospital. And now I have a new found respect for the benefits of computer based medical records.
The time for full fledged electronic medical records has come. Hell, it has been here for a while. It’s just that many places haven’t gotten clued in yet apparently.
Let me be clear, I’m not arguing for some mandate for every private physician to stick an EMR system in their office. But, for large tertiary hospitals to still be using paper charts is absurd, what with the clear benefits of well designed EMR systems. It is shameful, and I don’t use that word lightly, for the health care systems I’ve rotated through recently to still be using paper charts.
I know that paper records have worked well for a long stretch of modern medicine. Ether had a nice run as well in the operating theatre. But the benefits of electronic medical records are undeniable, and I won’t even fancy a discussion with anyone who denies such.
Let me count the problems with paper records.
First, you can’t read them. I don’t know how many times I’ve had to call consulting services because you couldn’t read their notes. And who knows how many times others have had to make that call?
Second, the record is with the patient. For instance, you go to drop a note on a patient or check the patient’s recent vitals and discover that some other service has taken the patient to surgery early and the chart along with him.
Third, there is only one copy of the chart. A physical therapist can hold onto a chart for a long time, let me tell you. Health care has become so specialized, and every consulting provider needs their time with the patient’s chart. It can become a major hassle searching for the patient’s chart you need.
Fourth, you have to chart in geographic proximity to the patient. Imagine being on a floor housing many patients with polytrauma. Imagine all the services involved in those patients' care, with attendings and residents and students plus the hospital staff. Even in relatively modern facilities, there is often not enough physical room for everyone to flip open a big, bulky patient chart on a countertop or desk.
There are plenty more arguments but those outline my complaints against hard charts. And EMR solves them almost in full. In fact, this is more than a matter of convenience and efficiency, it is a matter of patient safety as well.
To be fair, EMR systems have a set of problems of their own. For instance, automation can breed complacency. In many computer based charting systems you can set up templates for notes. Then you have to wonder, is a note accurate or did the physician just forget to edit his standard template?
But EMRs bring so much to the table. Many of them warn physicians about conflicting orders (say, drug-drug interactions) or question unusual orders (say, accidentally prescribing too much of a medication). No longer is there a question about the plan of care for a particular patient. Every service can actually read every note from any computer in the hospital and often even from home.
I don’t buy the pragmatic arguments against EMRs. They tend to revolve around costs or physician opposition to change. I am hard pressed to imagine a lack of funds for an EMR system at any of the hospitals where I recently rotated, and they all are undervaluing the benefits… no matter the cost.
This is an important issue. So much so that it is very high on my checklist of things I’m looking for when I hit the residency interview trail. I’m not kidding. While it is one amongst many considerations, I feel strongly that I want to be at a program whose primary teaching sites have integrated electronic medical records.
Nowadays, it simply is an important part of patient care.
The Numbers Game
Ben Bryner -- In the days leading up to the election, we in the US are used to hearing a lot about traditional American concepts like apple pie and, of course, baseball (my apology up front if this post is irrelevant to you). So this op-ed by Oakland A's manager Billy Beane, former Speaker Newt Gingrich, and Sen. John Kerry that compares health care to major league baseball is in keeping with the theme. The main point of their article is that the health care system would benefit from a new statistics-heavy approach. Their analogy is "sabermetrics," which is the approach to baseball decision-making by relying on statistics, many of them complicated measures derived from several other data points. I don't understand all the statistics, but it's best known for enabling the managers of small-market teams to post wins out of proportion to their low payrolls. There's obviously a lot more to it (here or in the most famous book on the topic, Moneyball). It's an interesting idea, and I definitely think medicine needs more evidence-based care.
But one problem with this line of reasoning is that sabermetrics usually have something to do with runs or wins; when you get down to it, these are the only numbers that really matter in baseball. It seems like the same would be true in medicine, but you have to consider a lot of other things, too. When you're making a decision about a surgical procedure, you have to consider more than just survival, you have to consider recovery times, disability, etc. And while the costs in baseball are relatively simple to unravel, tracking down the true cost of a given procedure is incredibly difficult.
That's not to say this is impossible; plenty of people are working on these statistics (and I imagine the article annoyed some of them). It's not like we have these huge piles of statistics lying around and just need someone to devise new stats to interpret them; usually the problem is getting reliable health care data (or getting the money to collect that data). Collecting data about a baseball game is one thing; what they're suggesting is the equivalent of collecting data on everybody in the stands: How old is each spectator? How many nachos did each person eat? How many times did each person wave a big foam finger? It gets out of control fast.
Strike two is that the analogy breaks down when you consider the people involved. While the sabermetrics for a given player may be interesting to all sorts of people, managers would seem to be the only people who stand to gain any concrete benefit from calculating them. And as far as I can tell, there's no real equivalent to a manager in medicine. (The baseball itself that gets hit all around the park could be the med student, and the bases that get stomped on could be interns, but that's all I can see.) The doctor, who they argue would be the main beneficiary of these stats, often has plenty of useful statistics at his or her disposal. The problem is that they aren't making the decision; they're trying to help another person, the patient, make a decision, and that often is where problems occur. A patient doesn't necessarily understand the numbers and doesn't necessarily care, and the doctor can't explain them all in a fifteen-minute visit. Health care decisions aren't as simple as deciding when to steal a base or when to recruit a certain shortstop. A large portion of the decisions a doctor makes in a given day are affected by so many different factors that it seems impossible to ever design a study addressing that situation.
And it's not as if a numbers-driven approach has never been tried. I think the closest medical equivalent of a sabermetric is the quality-adjusted life year (QALY), which tries to quantify disease burden by assigning a year lived with a certain disease a value between 0 and 1 that represents the relative quality of life with that condition. Calculating them requires several assumptions, which means it can never truly mean the same thing to two different people, and when the state of Oregon tried to use QALYs to ration out Medicaid dollars it didn't work out. Basically, Oregon gathered a bunch of people together and asked them to calculate QALYs and similar values for various medical services. They ranked each medical service based on those values, and then the plan was to pay for the interventions from the top of the list working down until there was no more money left. But the list of approved and denied services seemed arbitrary, and Oregon was forced to shy away from many of the uncomfortable implications of this kind of decision-making (more here).
I'm not saying evidence or statistical analysis isn't a good idea. I'm all for taking good ideas about health care from other disciplines. One of the reasons that health care problems are so intractable is the lack of applicability of solutions from these other arenas, and that's something we have to overcome. But all the same, medical sabermetrics aren't the home run that Beane, Gingrich and Kerry are hoping for. Fundamental systemic changes need to be made to make the system safer, cheaper, and more fair. Stats will be critical in guiding those changes, but the stats themselves aren't the solution. And I’m open to other baseball-related suggestions: roving beverage vendors in the clinics, a seventh-inning stretch during a long operation, nacho cheese dispensers in the nurses’ stations –- I’m all for them. Play ball!
Thomas Robey -- Lately, there has been a good deal of attention paid to the risks of participating in medical blogs. The warnings originating from deans about posting drunken pictures on Facebook or making outrageous claims on blogs have been on the upswing in my neck of the woods. Likewise, advice in the form of commentary or career counseling from professional societies and specialty publications still weighs heavily on the “Watch out! People can search the internet to learn what you really think!” To that I say, “Go ahead, Google me!”
I’ve noticed a tendency for advice meant for high school students and undergraduates to be redirected to medical students and residents. I don’t know about you, but these "helpful tips" come across as paternalistic to me. It’s too easy for commenters to caution against using Facebook accounts or blogging because of the negative connotations tied to those activities. Granted, lapses of professionalism should not receive amnesty on the internet, but articles like those I just read in the October 2008 edition of the emergency medicine newspaper published by ACEP (sorry – needs subscription) are too easily used by faculty and administration who argue that blogging and social networking should not be engaged in by any student for any reason. There are so many potential positives of Facebook, LinkedIn, and blogs (like this one) that I think there needs to be more emphasis on the potential of these media to balance out the cautionary tales.
Articles critical of blogging are most often written by non-bloggers. Arguments levied by hospital administrators tend to lean toward concerns of HIPAA compliance and risk reduction. Ethicists’ positions suggest that patients’ stories are fully owned by those individuals, even if details are changed. Skeptical readers and skittish posters are worried that their opinions can be counted against them thanks to the permanence of the internet. Many of these articles (typically by ethicists or administrators) end with a call for a code of ethics. Oft-cited internet magnate Tim O’Reilly has initiated a simple blog-wide code of ethics that has been adapted to science blogs among others. On top of this, a considerable number of medical bloggers have agreed to follow and support a Healthcare Blogger Code of Ethics. I’ve registered my personal blog and proudly display the code’s logo on my site.
I agree that medical blogging and Facebook shenanigans have the risk of damaging your personal reputation and one SHOULD be careful of posting stupid stuff. I also see the benefits of commentary like that on this site, the creative outlet, a new way to bridge science and medicine with the media and public, entertainment from reading humorous observations, and a general democratization of conversation. As some medical schools institute policies about blogging, it is important that we the bloggers, commenters and readers speak up to educate those making regulatory decisions about the benefits of blogging.
Articles referenced in the October 2008 ACEP News were written by Elliot Pennington, MS4, Jay M. Baruch, MD, and Jeanine Ward, MD, PhD
When Can a Doctor Refuse Care?
Kendra Campbell -- This morning, an article in the Baltimore Sun really caught my eye. The article described a new pharmacy opening up in Virginia that has decided not to offer any form of birth control for sale. I was shocked to find out that this pharmacy is actually located very close to a town that I lived in during my undergrad years, and hence the article really hit close to home for me (literally).
The debate over pharmacists’ right to refuse to sell birth control pills based on religious views has been going on for years now. Some states have passed laws defending this right, while others require pharmacists to offer birth control, regardless of their religious beliefs. For years, the American Medical Association (AMA) has been battling the American Pharmacists Association's policy, which states that pharmacists should not have to “engage in activity to which they object.” The AMA has voted to support legislation requiring pharmacists to either fill prescriptions or refer the patient to a pharmacy that will.
I support the AMA’s actions to protect patients’ access to pharmaceuticals, but the issue is much broader than just drugs. What about a patient’s right to have access to medical treatments? What about a doctor’s responsibility to provide care to all patients? This is, of course, a very heated debate, and is a sensitive subject for many.
The Differential’s Thomas Robey wrote an article that touched on the subject of a physician’s responsibility to provide therapies to patients. The debate is very old, and I can only offer a small amount of insight in this short article. But, it’s something that I feel strongly about, and I wanted to give an opportunity to others to air their opinions on this important subject.
In the AMA’s Code of Ethics, it states that a physician must “refrain from denying treatment to your patient because of a judgement based on discrimination.” But, the Code of Ethics also states that, “when a personal moral judgement or religious belief alone prevents you from recommending some form of therapy, inform your patient so that they may seek care elsewhere.”
Here comes my very provocative question. Where is the line between denying a patient care, such as prescribing birth control or even offering an abortion, and denying a patient care because a personal moral judgement or religious belief prevents you from doing so? If I deny a patient care because they are black, is that discrimination? Most people would say yes. If I deny a patient an abortion because it violates my religious beliefs, is that within my right? Perhaps many people would say yes. But what about denying a homosexual couple access to in vitro fertilization therapy because your religion doesn’t condone homosexuality? Would this be considered denying care because of discrimination, or is the physician's right to deny treatment protected, because of their religious beliefs?
The waters are clearly murky. What do you think?
Jeff Wonoprabowo -- I'm not a big fan of needles. Never have been, either. So you can probably understand the anxiety I felt when I first heard we were going to have a blood lab for Pathology class. I had a blood lab in Anatomy & Physiology class when I was a senior in high school. In that blood lab we were supposed to prick our own fingers in order to figure out our own blood type. It took me multiple tries. The first few tries were unsuccessful because my right hand just couldn't prick my left hard enough. Maybe I just have a fear of pain. When I finally drew blood, I couldn't get enough. I only got one drop (the first drop was supposed to be thrown away). At the end of the lab I had two or three fingers pricked, each having donated a single drop of blood that could not be used.
Well my anxiety turned into trepidation when I found out that we weren't going to be finger-pricking. Instead, we would be pairing up and drawing blood from each other -- with a tourniquet, needle, vacuum tube, pumping fist, and all. To top it off, most of my classmates have never drawn blood before and my skin isn't light enough that my veins are easily visible.
Our class was split into two sections. One section would go in at 1:00 and the second would go at 2:30. I was in the second group. A few days prior to the lab, I started overhearing people talk about this lab and trying to partner up. I figured that I could easily find a partner once I got to lab, so I didn't bother asking classmates if I could stick them with a needle.
When it was time for my section to begin, I was ready on time and found a seat in the lab. I looked around, but it seemed that most people were already paired up. So I sat and waited a while. I noticed someone who had no partner, but she soon found someone. I stopped looking for a partner once our instructor began showing us how to draw blood using a volunteer. They had a camera so we could all watch what was happening on some large LCD TV screens.
Anyways, I finally found the one person in the lab who still didn't have a partner. He offered to let me draw blood first. I accepted and started laying out my supplies. After I laid out everything I needed, I tied the tourniquet on his arm and started looking for a nice vein. That was the easy part. This guy had white skin and large, superficial veins that were easily visible. I wiped the area with some alcohol wipes, uncapped the needle, pointed the bezel up and nervously looked at the arm.
I'm glad one of the nurses was standing right next to me as I pushed the needle in. "You're barely in," she said to me.
I pushed in deeper, and then popped the vacuum tube into place and -- nothing. "Now, pull out a little more," she told me.
I pulled back slowly and suddenly blood rushed into the tube. After I got what I needed, I took off the tube and turned it over a couple times. Mission
My first time drawing blood was pretty exciting (although I may be just easily amused). It is a little strange pushing a needle into someone. I know it gets old very fast. Nurses do it all the time and think nothing of it. And with time, I'm sure I'll think nothing of it either (and probably won't feel it's worth writing about either). But for now, it remains unnatural. And for now, it's still something interesting enough (for me, at least) to write about.
On the Bus
Anna Burkhead -- For several reasons, not the least of which being ridiculous gas prices and Chapel Hill’s amazing public transit system, I take the bus to the hospital every morning. It is clean, timely, and free. It runs early enough that if I get a head-start skeletonizing my notes in the morning, I can still get to the hospital early enough to pre-round in time for 7 am rounds.
The population of riders on the early morning bus to the hospital is a particularly strong reminder of the variety and diversity of healthcare workers. At 5 am, pretty much the only people riding public transit are headed to the university and to the hospital. I use the 15 minute ride to sit quietly and mentally prepare for the day. I also think about what the other riders are about to get into as their day at the hospital begins.
There are many nurses, nursing assistants, and nursing students who ride the early bus. I think of their upcoming hours closely monitoring patients, administering medications, and generally taking care of patients' each and every need.
There are a few residents who board the bus with me. I think of them rounding, frantically entering orders and writing notes, possibly catching a bite to eat at some point, going to the OR, going to the call room, going to clinic, going to the code, going to grand rounds, going crazy?
Cafeteria workers dressed in their white buttoned shirts and black pants take the early bus. I think of them in the hot cafeteria kitchen, dealing with stressed and hungry hospital patrons all day.
There is the occasional environmental services worker riding public transit at the dawn hour. I think of them working long hours trying to make the hospital a clean and safe place for patients, visitors, and employees.
Too often in the hospital we are surrounded by our own. Yes, I’m surrounded by nurses, assistants, technicians, cleaning crews, and food service workers all day, but my primary interactions are with other medical students, residents, and attendings. I am grateful for these early morning moments on the bus when I have a moment to reflect on and be thankful for all the work that goes on behind the scenes and all around us. Each of these dawn bus riders is vital to the daily operations of hospital life, and I love that moment of shared purpose as we travel to do our very different jobs in the very same place.
The typical conversation about my future goes a little like this:
“Do you know what you want to do yet when you qualify?”
“Oh. Well, do you at least know whether you want to do medicine or surgery?”
Hurrumph! Why is there this divide in medical practice? And why should students know this distinction before they decide their area of interest, when this distinction is about the practice of medicine rather than its actual division –- into subject areas such as "cardiology", "gastro", etc.?
Thinking in particular about the rotation I’ve just done, neurology, the distinction seems much more a consequence of organisation rather than knowledge. To quote one of the neurology consultants, neurology is “diagnose and adios”. Much of the challenge of neurology comes in the diagnosis, the fine discrimination of possible options. In neurosurgery, the challenges seem to arise more in the management of their patients who are referred, often with diagnosis, from other areas. But they’re both dealing with problems of the nervous system. So, I kind of see medicine in general, and neurology in particular, as a coin, with one side as diagnosis and the other as management. Whereas physicians seem primarily concerned with the former, surgeons deal more with the latter.
But this sometimes seems like an arbitrary distinction. The vast majority of those in my year haven’t yet decided between surgery or medicine. And despite the pervading stereotypes of the specialties, most people would do well in either because your specialty shapes you as much as you shape it. When it comes down to it, it seems that most people will choose based more on lifestyle and work-style than on interest or competence. That really disappoints me because I didn’t go into medicine thinking “I want to be a surgeon” or “I want to be a physician” but because it’s fascinating.
Unfortunately, medicine isn’t there for my personal amusement; it’s there because the general population needs a health service. And because the practice of medicine sprang up distinct from surgery, which has its origins in a separate (more hirsute!) source, this divide has since remained both in practice and in training. Yet the body and its ills are not divided into management strategies; when will the time come for that to be recognised?
Hot on the Interview Trail
The program where I’m doing an away rotation is going to interview me while I’m here. There are reasons to not want to do an interview while you’re actually on a rotation. For instance, when I make an ass of myself, I won’t be able to hop on a plane and never see those attendings again. Instead I have to stick around and take call with them.
In seriousness though, interviewing while on a sub-I sets you apart from the other interviewees. That has some potential benefits and some potential pitfalls.
The benefits include the fact that this is good place to be starting my interview trail. Pending a few beers, interviews can stir a few nerves for most, including myself. The good thing is I’ll probably be more comfortable starting on interviews here than anywhere else. I have enjoyed myself on this rotation and I am interested in this program, so there is something at stake. I’m also, however, comfortable with the attendings I’ll be interviewing with. It certainly is more than a "practice" interview, but it is nice to have some familiarity and camaraderie with those who will be pitching questions to me.
I might need that for my first residency interview. On my first interview for medical school, I got the following question:
“What is your biggest strength?”
“Well, I think I’m pretty decisive. I’m pretty quick on my feet.”
The next question was obvious:
“What is your biggest weakness?”
An awkward ten second silence followed which prompted the interviewer to comment:
“Let’s just move on.”
Quick on my feet like a fox. I had composed and practiced an answer to that obvious question but in that moment of stress I could not, for the life of me, remember it.
It’s hard to defend myself as a skilled conversationalist and interviewee after revealing that gaffe, but I’ll try. It just takes me some warm-up laps. I promise that I did get better (much better) on the interview trail as my medical school interviews went on.
One thing I always have to work on before I head into the interview are what questions I’m going to ask the interviewer when I get my chance. Often, especially in a situation like this where I’ve gotten to know the program for the past three weeks, I feel like asking nothing. But that is obviously poor form.
If I draw an interview with a female attending, I’m thinking:
“What are you doing this Saturday night?”
I’m also thinking about some questions I may get. Such as,
“Who are your role models?”
The answer is obvious,
Personally I can’t wait until I’m actually "pimped" during an interview. Maybe they’ll show me some MRIs and I can pretend I’m taking a Rorschach test.
“I see a monkey drinking a beer,” I’ll say. “Or maybe a sagittal MRI of the brain showing a small posterior fossa and tonsilar herniation below the foramen, indicative of a Chiari malformation. We also see associated agenesis of the corpus callosum.”
Or maybe I’ll be asked to actually tie a suture while answering questions. The end result:
A beautiful bow tie, which I’m pretty sure is how you throw a surgeon’s knot.
When they ask me what my talents are, I’ll tell them MS Paint and offer to email them a portfolio of my work. That should move me up the program's rank list.
Taking a step back and a deep breath, I attribute my goofiness to nerves (and caffeine), and I’m really just using this post to get it out now before I actually hit the interview trail. Wish me luck and that I avoid all of the above as I head off for interviews.
Ben Bryner -- One of the common problems I run into while trying to write medicine-related blog posts is that for so many topics, Atul Gawande has already written about them so much better. One of these topics is the annual meeting of the American College of Surgeons, which he describes in the chapter of Complications entitled "Nine Thousand Surgeons" (you can read it, at least for now, at Google Books).
The meeting, properly known as the Clinical Congress, draws a huge number from all over the world. There are hundreds of hours of presentations and courses on all kinds of topics. The difference between this meeting and the basic-science conference some of us are more familiar with was the sheer number of panel discussions on the best ways to treat surgical problems. One of the most interesting lectures I attended was on different advances in treating the adult respiratory distress syndrome, where I was impressed by the....oh, forget it, just read Gawande to get an idea of what the panels are like, I can't compete.
There were also several hours of presentations aimed specifically at medical students. Most of them focused on advice to students at various stages of med school, the interview process, etc. Some were helpful, although the problem with any conference talk, on any subject, is that you usually don't get much time to do more than skim the surface. One exception was when the new president of the ACS gave the students a lecture on Dr. William Halsted, the founder of modern surgical training. Usually I don't get as excited as some people do about the history of medicine, but this was actually pretty interesting. He talked about Halsted's achievements and how they were even more remarkable in light of Halsted's addictions (first to cocaine, then to morphine) stemming from his early research into local anesthesia. And I'm not sure this was the point of his lecture, but it did make me realize I haven't had it so bad in medical school. Lectures and rotations are tough, but at least I haven't had to deal with the headaches of a narcotic addiction.
At the ACS, Gawande described feeling like a part of a "nation of doctors," which it certainly does when the convention dominates so much activity. It doesn't just fill up hotel rooms, it seems to take over the city to the point that city buses carry advertisements for company booths inside the convention. Normally, being in a crowd of nine thousand or so would make me feel anonymous and detached from others in the group. But I didn't, partly because I kept running into attendings from my school (usually right as I was taking a bite of food or blowing my nose or something), and partly because there was really a feeling of camaraderie despite the widely varying levels of training of everyone there. I'm very glad I had the experience.