How I Got Into Medicine
Ben Bryner -- I’m still interviewing for residency, just trying to take it one trip at a time. Traveling and finding my way around new cities and unfamiliar hospital buildings is always a little stressful, and I won’t miss that come February. But the interviews themselves are usually a lot of fun; none of mine have been remotely stressful, and they've been great chances to talk to some very interesting people who also happen to be leaders in academic surgery.
Some of the more inane questions I’ve been asked are:
* what my SAT score was (which seems irrelevant since I took that test over a decade ago)
* why I took a year off from medical school to write this blog (I didn’t, my interviewer misunderstood my application) and
* which state contains the most ski resorts (I guessed Utah, my interviewer said it was Michigan, and when I researched it afterward I found the correct answer is New York).
But those are the exceptions, and almost always I’ve been asked some very good questions. At first I thought that shorter interviews would be better, but now that I’ve been through several, I really like the chance to discuss issues that a longer interview allows. It usually allows for a longer discussion of the program and of why I want to go into surgery, but I also think it allows for more time to discuss the city and other important factors that a short interview is a little to tight to accommodate.
The questions themselves aren’t usually a surprise; you can find lists of sample questions, and the ones you get that aren’t on that list usually make sense and are fairly easy to answer after a moment’s thought.
One of the questions I’ve only been asked recently is how I got interested in medicine in the first place. I actually haven't thought about it much for a long time, since most of my questions are about how I got interested in surgery, what kind of surgery I want to practice, what my ideal surgical job would involve (Surgeon/Pirate during the week, Rock Star on the weekends), that sort of thing.
But the experience that pushed me toward medicine was a trip with my dad (who takes his students to northern Mexico to participate in a service project at the end of a course in international development) when I was fifteen. There I met a doctor who runs a small clinic high in the mountains. He provides free health care to the impoverished Tarahumara indigenous people, some of whom walk for several hours from their isolated villages to see him.
We stocked the medical supplies we had brought in the closets and got a tour of the spare but clean facility. We had also brought some toys for kids to play with while at the clinic, and as I sat on the patio blowing soap bubbles and tossing Nerf balls with some of them, I realized I wanted to have some kind of involvement in improving global health. My plans and goals have evolved somewhat since then (this was a long time ago, before I took the SAT in fact), and I’ve gotten excited about surgery’s role in global health issues, but I guess that’s where it started.
It’s hard to fit that whole story into any interview (I left out the part about the bubbles), but I was glad for the chance to talk about it again.
"Top 10" Lists
Some of my favorite year-end lists are here:
The Boston Globe's Big Picture Blog’s 3-part 2008 In Photographs series
List-making seems to satisfy a deep-seated need to categorize things, but also the need to show off one's encyclopedic knowledge of some category and taste in judging them (this aspect has been recently parodied by the brilliant David Rees).
It's hard to come up with a meaningful "best-of" list like, say, the ten best moments of medical school. (A list of the ten worst experiences of medical school would be easier, since #10 through #2 would all involve studying for USMLE Step 1, and #1 would be taking it.) It's an interesting exercise, but when I look back on medical school up to this point, lots of moments blur together. The things I remember as the best parts are more vague, like a month where I really liked my team, or a couple of weeks where I really had a good routine going.
But the end of the year demands a list, and who am I to defy tradition? So here are the top ten things I learned this year:
9. The most stressful part of an interview for residency is finding the right conference room within a gargantuan maze-like hospital.
7. Text messages are ridiculously expensive, despite being basically pure profit for carriers, and can inflate your phone bill even if you only receive them.
6. You can see the actual tools used in the Watergate break-in at the Gerald Ford Presidential Museum in Grand Rapids, Michigan.
5. For some reason, NBC has posted dozens (maybe hundreds) of clips from their 1980s game show of preposterous physical competitions, American Gladiators.
4. In Alaska, the practice of flushing wolves out of the bushes with bombs and gunning them down, known as Aerial Wolf Hunting, is considered by some to be a sport. If I were to travel there, I don't think I'd feel OK about participating in this activity. It seems a little unsporting. But you know what they say...WHEN IN NOME...
3. One of the most difficult things about growing up is realizing that Halloween is sometimes just another day; even though it's October 31st, people will schedule things like academic conferences on that day, and you can't wear a costume.
2. When you live in Michigan, Easter can be snowier than Christmas.
1. The fourth year of medical school is terrific, because you have freedom to decide what you're going to learn and opportunities to work closely with residents and attendings, but, since you're a student, you also have some extra time to get to know patients and think about what you want to do with the rest of your life. Or to just watch American Gladiators.
Med Student Gift Guide
Ben Bryner -- It can be difficult to find a good holiday present for someone when you're a medical student. Money is very tight, and so is free time to do shopping. But the pressure is on, since the holidays represent a key opportunity to rebuild the personal relationships that you've let crumble because you've been so busy studying or interviewing.
Medical students can be especially tricky to buy for. Before you object, I agree with you that the winter holidays have become way too commercialized and we should just scale it all back a little bit. I'm not trying to encourage shopping at all, but if you're already going to shop, some of these suggestions might make it a little easier.
So, here are some gifts for the med student in your life:
* U.S. Senate seat (OK, you probably guessed this was coming. Seriously, though, I've been fascinated by the recent news about the attempt by the governor of Illinois to sell a Senate seat. There are so many amazing aspects of this story, but most of all are the various harebrained schemes that he [allegedly] thought of to sell the seat. Incredible.)
* "Avocado's Number" guacamole from Trader Joe's. Again, huge nerd points for naming a line of premixed guacamole after a pun on the constant named for Italian chemist Amedeo Avogadro. Well done, Trader Joe.
* Board review books (from multiple publishers). This gift says, "Study more, I want to see you less often."
* A sticky hook and some sheet protectors (from any office store). For someone with boards coming up, give them some plastic hooks they can stick to their shower wall. Then give them a bunch of sheet protectors, so they can stick pages of notes in the sheet protectors and hang them on the hook so it’s easy to study in the shower. No more wasting valuable study time by only getting clean!
* Arrested Development DVDs (from any entertainment store). Every medical student needs a study break every so often, and an episode of this series, twenty minutes of sheer comedic gold, is perfect. (Or you can just send them this link and say, “click, watch, thank me later.”)
* Homemade gifts (from you). The best gifts are always ones that show you were thinking about the recipient, and often a handmade gift is the easiest way to convey that. Obviously, whatever you give depends on your talents and your time. If all you can do is write a nice letter or email to someone you don't talk to enough, that's better than almost anything that people are out there fighting over in store aisles.
Good luck and happy holidays.
What I Was Thankful For This Thanksgiving
Ben Bryner -- I had some time off last week to celebrate American Thanksgiving. I love Thanksgiving because it is one of those common-denominator holidays that includes everyone. (Well, it's easy to feel a little left out as a vegetarian, but it’s still not bad.) This time of year is obviously a good time to reflect on the blessings of family and friends, home and food, and the other important things. And if you're interviewing for med school or residency, it's also a stressful time where you might be thankful for a few different things than most other years. Here is a partial list of things I'm particularly thankful for on the interview trail:
1. Interviews. Although they're expensive and the arrangements are stressful, it's nice to have them. And as far as the actual interviews go, the ones I've had so far have been surprisingly low-key and enjoyable.
2. Stain removing solution. There are plenty of lunches and receptions with awkward eating arrangements on the interview trail that make this a must-have.
3. Stock questions. Sometimes the only thing that gets you through a late-afternoon Q&A with residents is a good stock question. Just as a good pile of snowballs is essential to a post-Thanksgiving snowball fight, developing a list of questions you want to have answered about every program is a wise move.
4. The patients I've learned from. Most of the questions in these interviews are about me as an applicant. These get pretty repetitive and aren't that interesting from my perspective. But sometimes an interviewer will ask about a memorable patient, or a more specific situation where it also makes sense to bring up an experience with a patient. And to me, this is a more interesting avenue for discussion than my research or volunteer experience or my year in Cirque du Soleil (okay, that last one would be interesting if it were true). Discussing memorable patients in an interview has basically the same rationale as Grand Rounds or other conferences that center around individual patients: that disease processes and therapies are only so interesting in isolation, but become much more comprehensible and captivating in the context of an individual person.
Not just while interviewing, but as a medical student in general, patients are the thing I am most thankful for. When you get down to it, access to patients is the whole rationale for building teaching hospitals and affiliating them with medical schools; patients are one of only a few elements of medical education you absolutely couldn't get by without. Last year at this time I reflected on how patients reminded me of Squanto, and I stand by that analogy even if nobody else thinks it makes any sense.
So these are a few of the things that I appreciate at this time of year. While you’re eating that turkey sandwich I’m going to go refill my supply of stain remover and stock questions before I hit the trail again.
Surgery, Interviews, and Rock 'n Roll
Ben Bryner -- Like Colin, I'm on the interview trail, trying to line up a residency (although I'm applying into general surgery). I'm hearing some of the same questions as he is. Actually, nobody's really asked me what I would to if I couldn't be a surgeon. But my predetermined answer is: A sushi chef (like surgery, but more delicious) or a reporter.
One of the other questions that I've been told to prepare for is "What kind of people do you have the hardest time working with?" Obviously, this is a trap. (The old tried-and-true trap question, "What are your weaknesses?" is now such a cliché that I haven't heard anyone ask it.) So when someone asks you what kind of people are difficult to work with, you can't give the correct answer ("People that are both mean and stupid"). But this is fine, because the interviewer's point in asking the question is not to obtain information (everybody knows the right answer) but to see how you think.
So one way I've answered the question is to say that as a medical student, people who don't give you a chance to get involved are the toughest ones to work with. If a resident assumes I don't know how to take a history by myself and makes me just watch them talk to a patient, it's frustrating and I tend not to learn much from them. Or, one time when I asked a nurse how to log into a program for tracking patients, instead of doing so she said "I don't think you have access to that program" even though I did. That specific situation wasn't a real problem, but when enough people share that attitude, it makes it a frustrating place to work. Conversely, when an attending assumes I am interested in a procedure and lets me help at an appropriate level, I learn a lot more and enjoy it.
By answering this way I hope to show the interviewer that I like getting involved, am a team player, and will be interested in teaching students when I'm a resident. I have no idea if this comes across the way I mean it, but it's obviously better than some other potential answers.
Maybe I can explain my answer another way. If you've played the game Guitar Hero, you'll remember that there's a little meter on the side of the screen that shows you how well you're doing. The needle starts out in the middle as the song starts, and with each note you play correctly, the meter inches toward the green zone at the right of the meter. When you miss a note, the meter dips down toward the red zone on the left. For a lot of songs, if you're bad at the game like I am, before you can get past the tricky intro to the song, the meter hits the far left, the virtual crowd starts booing and the song stops abruptly. It's very sad, because if I can just get the song started I can move the needle to the green, build up some momentum and even if I fumble through the solo, can finish the song.
Sometimes it seems like every new resident or attending I meet has a little meter in his or her mind that tracks my performance -- how well I answer questions, how well I present patients, how efficiently I work, etc. If the meter stays in the green, I'm doing well and I get a good evaluation. If it hits the red I get ignored. Which all makes sense. The good ones start the meter out in the middle, giving me a chance to show what I know and show my interest. But some people start that meter out in the red, and before I get a chance to get involved, they've already decided not to bother teaching me, a mere student. Thankfully those people are a lot less common than the good ones in my experience. I haven't yet busted out the Guitar Hero analogy in an interview (it's time-consuming, for one), but I'm ready to do so if necessary.
It Has to Be Something Collective
Ben Bryner -- I've been reading Newsweek's gargantuan seven-part report of the 2008 presidential election campaign, written by five reporters who got unparalleled access to the campaigns in return for embargoing their reports until after November 4th. It's a terrific read, whether last Tuesday went your way or not, and it gives plenty of detailed description and analysis of the McCain, Obama, and Clinton campaigns. I hadn't been following the inside-baseball aspect of the campaigns, so the amount of discord within some of the campaigns was surprising to me.
But the most alarming aspect of the article was this quote from part two:
McCain loved the comparison. He began making guttural pirate noises, punctuating his jokes and one-liners with "Aaarrgh" and occasionally greeting reporters with this oddly cheerful growl.
I know, you’re thinking “I had no idea that McCain was a pirate!” Me neither. I thought I was paying attention during the race, but apparently not. Your reaction is probably one of the following: “I wish I’d voted for him instead of Obama!” or “I’m glad I voted for him, I only wish I’d sent him some more dubloons!” Or maybe you voted for Nader or you don’t care.
I am saddened that America missed a critical opportunity to elect a pirate, as swashbuckling transcends party lines. Who better to deal with the problems we face than a pirate?
OK, maybe there are some more qualified than a pirate to address economic problems. But pirates did develop a primitive form of catastrophic health insurance, so maybe we can learn a few things from them.
Actually, the part of the report I found most interesting was a transcript of a conversation between Obama and one of his advisers. Dismissing the idea that his individual actions would make a difference, he said about any effort that would seriously affect climate change that "It has to be something collective."
Although he was speaking about the environment, certainly the same is true about health care. As plenty of people have noted, our health care system is in trouble and is in need of radical solutions. I think there are some good suggestions out there. What seems most important to me, as Obama said, is that it must involve multiple parties -– in this case patients, providers, insurers are all going to have to work together.
Importantly, too, I think students must be involved in the decision-making process. After all, we’ll certainly feel the effects of these changes. For example, we need to push for debt relief to make it easier for more students to choose primary care or research-based careers. I think most of us in medical school understand that we will need to continue to be involved in the politics of health care issues throughout our careers. If we fail to work collectively (either because some of us don’t do our part and assume someone else will get involved for us, or because we students as a group don’t cooperate with other groups in joint efforts), it’s not going to work. As much as it pains me to admit it, the pirate’s hostile approach to solving problems (pillage, drink some grog, pillage some more, make those who don’t like it walk the plank) is not really what we need.
Ben Bryner -- If you're in med school or applying now, someone has probably emailed you this article by Dr. Pauline Chen in The New York Times about medical student burnout. (Or, if you're me, four people have done so -- are they trying to tell me something?) In the article, Dr Chen refers to a survey of medical students that showed widespread signs of burnout and a high incidence of suicidal ideation, as well as relating her own feelings of despair during medical school. It’s certainly an interesting topic and I'd like to hear some of my fellow bloggers' thoughts on it, too.
Burnout, as defined by Dr. Christina Maslach (who designed the Maslach Burnout Inventory to formally assess it) includes three elements: exhaustion, cynicism and feelings of inefficacy. It seems to me that med students are already at a disadvantage because of the third one; med school is a means to an end, a gateway to another training program where one will acquire the specific skills necessary to achieve the end goal (helping people). One of the hardest things about medical school is not being able to really help. By far the most satisfying experiences in medical school have been when for some reason I've actually been able to help someone, and the most disillusioning experiences have been when not just me but my whole team hasn't been able to help a patient. Most of the former experiences have been when I've sat down with a patient for a half hour or so and listened to their story, as time is mostly what I have to offer as a med student, and occasionally that does some good. Not much, but I've noticed I'm usually happier going home on those days.
As far as the latter goes, one experience I remember was during my cardiology rotation. One of my patients (meaning I'd taken his history, examined him and written his admission note; "presented" him to the team the next day; called and kept track of his consults; and discussed all of the above with the intern assigned to him) was about ready to go home. Mr. E had a previous diagnosis of aortic valve stenosis that was causing worsening heart failure. After much discussion and consultation, it was agreed that the risks of a procedure on the valve outweighed the benefit. The increasing workload facing his left ventricle as it tried to generate enough force to push the blood through a narrowing valve would eventually cause his death. He understood the situation and the bleak prognosis.
I brought my draft of the discharge paperwork to my resident so he could look it over. One of the sections in our discharge summary is the clinical course, or a summary of all the progress notes that covers everything that happened from the point of admission to the time of discharge. With patients who've been in the hospital for weeks, the clinical course can get out of control. Our EMR imposes a character limit on the note, which can mean going back over the note several times trying to tighten it up -- maybe the only time that editing skills come in handy as a medical student. But this time it was fairly brief; Mr. E had only been there a few days. As my resident read that section, he remarked, "Wow, we really didn't do anything for this guy." He didn't say it angrily or sadly or cynically, it was just a neutral declaration of fact.
It was difficult to realize that he was correct. It's always tough to give people bad news, but that's part of medicine; what made this worse than usual was the fact that he didn't get a new diagnosis or a new definitive treatment, just confirmation that he was going to die. If I had taken the Maslach Burnout Inventory that morning, I'm sure the answer choices to the questions that assess inefficacy wouldn't have been strong enough.
Since it was the weekend, I had time to sit down with Mr. E and his wife and talk as they waited for their ride. He was upset about having to take his last potassium tablet. He wanted to wait and take it at home. (I told him I certainly wasn't going to stop him.) Eventually we started talking about something else, about the things he was going to do that week and for the next few months. It wasn't enough to completely ward off feelings of burnout that day, but it was something.
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!
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.
Ben Bryner -- I think one of the weirder phrases in medical slang is the term "Golden Weekend." This refers to a weekend in which an intern doesn't have to work at all, which usually only happens once a month. I don’t know how widespread this term is, but whenever I hear someone use it, it reminds me of the Mitch Hedberg joke about corn on the cob:
"You know how they call corn on the cob 'corn on the cob,' right? But that's how it comes out of the ground, man. They should call that 'corn.' They should call every other version 'corn off the cob.' It's not like if you cut off my arm, you would call my arm 'Mitch;' but then reattach it and call it 'Mitch all together.'"
Same issue here. The "Golden Weekend" is a plain weekend in its natural form; you should call it a "weekend," and call a weekend where you have to work a "working weekend" or possibly something more derogatory. One time I even heard a resident call a weekend where he got one day off a "Bronze Weekend." This is getting ridiculous, because winning a bronze medal in something is still a big deal. If you win a bronze in the Olympics, that means there's only two people or teams better in the world at that particular thing than you. Two people -- that's pretty cool. I certainly can't think of anything where I would say, "I bet there are only two people in the world who are better than me at this." But awarding a weekend a bronze medal just because you don't have to be at work for the entire thing? That's serious grade inflation for weekends.
Of course, looking closely at these phrases is interesting only because of what it tells us about the social structure where they're spoken. I think the phrase "golden weekend" tells me that I should appreciate each day off that I have during my fourth year, because once I start residency I'll start thinking of them as some rare shiny object to be treasured and guarded.