January 26, 2009
The Differential Has Moved!
New location: https://blogs.medscape.com/thedifferential
Be sure to bookmark the new address!
January 21, 2009
Practice Makes Perfect
Jeff Wonoprabowo -- Earlier this quarter I had a pretty busy afternoon. And for a while it was stressful, too. It all started when a 51-year-old man came into the hospital complaining about shortness of breath. On the way in he began to feel some chest pain. I stood by his side as he struggled to breathe and complained about mid-sternal chest pain. Two of my classmates began to auscultate the patient. I looked back at the monitor and read his vitals. He was hypotensive and his pulse was approximately 180.
The interview was over quickly. The ER doc asked what we wanted to do and my classmate suggested a beta blocker. I picked up the book to look up dosing but couldn't find it. It was the first time I had ever opened this particular book and it was frustrating not being able to find a simple drug. And it wasn't in the index, either.
The patient showed no improvement. Another classmate suggested adenosine. I found that dosage: 6 mg, intravenously. No change. I suggested we try a second dose, this time 12 mg. The book was turning out to be of some use.
The man's blood pressure started to increase and his heart rate lowered slightly. Positive signs. But it didn't last very long. Soon his blood pressure dropped again. My classmates and I looked at each other. I opened the pharmacology book again and flipped through the pages. It said that we could give another dose of adenosine. We gave him .76L normal saline instead.
The patient started complaining about trouble breathing. The doctor suggested we give him oxygen. Why didn't we think of that? My classmate fitted a non-rebreather mask over the patient's mouth and nose. But his vitals still weren't looking very good. We tried another drug to no effect.
Finally the doctor suggested electric cardioversion. He adjusted the settings on the defibrillator and moved aside. I picked up the paddles, completely unsure of what to do with them. He told me where to place them and told me to press both buttons simultaneously after everyone was clear.
I called for everyone to be clear and pressed the buttons. The man's vitals began to stabilize and the tracings indicated a return to normal sinus rhythm. The doctor told us we did a good job. Relieved to be done, we walked out and walked to a different room where other classmates had been sitting and watching us on a large flat-screen monitor. We removed our lapel microphones and took a seat.
It was an interesting day in Pharmacology Lab. The patient was a robot, anatomically correct and featuring pulses, breath sounds, heart sounds, and pupillary reflexes. Everything was simulated. And as we discussed the case, I couldn't help but think about the poster up on the wall. It had a quote by Aristotle: "We are what we repeatedly do. Excellence, then, is not an act but a habit."
I thought it quite fitting to see that quote in the university's medical simulation lab -- where students and residents can practice, practice, and practice some more. At least we get to "repeatedly do" on simulated patients before trying our hand at real ones.
January 20, 2009
What Is the Best Age to Start Med School?
Anna Burkhead -- The average age of my first-year medical school class was 24.5. The oldest member of the class was 41, and the mythical youngster was but a raw 19 years old. The most common age was probably 22 or 23, a good three months wiser since college graduation earlier that May. But some of us had taken time off between college and medical school to pursue another calling, profession, or mission.
Starting with the young one: Obviously this kid had been advanced for his years throughout his entire schooling. Probably started college at 16. I never even met this person, so I can’t make any statements about his maturity level. Of course, if he made it through college at that young age, applied and was accepted to medical school, he must be something special. He’ll graduate and become a doctor at age 22, and finish residency around 26. There’s potentially a very long career ahead of him, with many accomplishments to be made!
The mode of the age graph for my class falls right at 22, ie, a very recent college graduate. There are many people out there who advocate heading straight from college to medical school. I can see some advantages: no loss of momentum, younger age upon entering practice, the “just get it over with” factor. But, no offense to my colleagues who followed this path, there’s a lot of life experiences to be had besides that of a student. And I imagine it can be pretty tough to identify with a patient who makes minimum wage working 16 hours a day if you’ve never had a full-time job.
My class includes people who had all kinds of professions before embarking on medical careers. I was a high school teacher. I have friends who were researchers, bankers, architects, professional soccer players. In my experience, having had another job before medical school has been nothing but a positive thing. I had things to talk about in med school interviews, and people still want to know all about it, even now in residency interviews. Countless other benefits in terms of my own maturity, compassion, and work ethic can be attributed to my experience as a teacher. Not to mention I made a little bit of money in the working world! (A very little bit of money).
The 41-year-old woman in my first-year class had a long, successful career as a Physician's Assistant before applying to medical school. On the first day of class, one of our peers gauchely remarked that her daughter was older than some of us. (Note: there is no age requirement for medical school, and there is obviously no requirement for social appropriateness, either!) Although she has a good amount of experience, wisdom, and maturity over the rest of us, does being 15-19 years older than most of her class mean that her career will be 15-19 years shorter, after the same amount of resources spent training? I don’t know, and I don’t know if it matters.
Med school can be experienced in a completely different way as a youngster, recent graduate, worker with a few years under a belt, and veteran in another career. Of course I’m biased, and I prefer my path, but I can see pros and cons to each career trajectory.
January 19, 2009
Illegal or Inappropriate?
“Are you married?”
“Do you have kids?”
Have you ever been asked any of these questions? Have you ever been asked by a potential employer? Would your response depend on the inquisitor? If you have been asked by a person more senior than you, have you ever been uncomfortable? You should be. There are a number of questions about certain topics that are inappropriate for residency directors to ask. And sometimes the inappropriate can bleed into illegal.
I've just gotten home from my twelfth and final interview. In the past two months, I've been asked all of the above questions several times. I do have the occasional grey hair on my temples, I wear a wedding band, and I did indicate on my application that I'm couples matching. And I approached my interviews as though the program was the candidate. So in many cases, the question enforced a feeling of comfort with the interviewer (and the program), and I was happy to answer. On other occasions, I felt off-kilter; my tack was to change the subject quickly. I do regret that once I shot back “that's an illegal question.” (By the way, that answer is inappropriate!) On the other hand, if the candidate initiates conversation about a potentially off-limits question, it becomes fair game for conversation.
So what is the law?
Although they're often called "illegal interview questions" in discussions and on the internet, most questions may not actually be illegal. It's illegal when an interviewer asks a question that has discriminatory implications (most commonly about race, age, family, religion, or politics) and then intentionally denies you employment based on your answer. For example, according to the US Equal Employment Opportunity Commission, it's not against the law for an interviewer to ask your age or birth date; it is against the law for an interviewer to deny you employment because you are age 40 or older. Even if the interviewer does not go against the law, there is still the sentiment of the law and social grace that should be considered. I certainly felt backed into a corner when I responded to the question of whether I planned to have children.
The difference between uncomfortable and illegal is even harder to define in the context of the residency match. Most programs interview 10-15 times as many applicants as they have positions. The interview is an exercise in speed-dating where a 3-6 year relationship is on the line. Residencies are looking for applicants who are the "best fit." How can you tell when "personality" overlaps with "youth?" Or (more sinisterly) if a preference for Ivy League trained medical students implies a program's class preference? I'm optimistic that most residency programs intentionally avoid these mistakes in their selection process, but the applicant has to take a leap of faith on this issue. We applicants never know how we were ranked at any of the programs we applied to except for one -– and even then we can not be certain.
In the end, my strategy was to bring up these issues in a way I was comfortable. After all, I'm interviewing them!
January 15, 2009
Starting All Over Again
Ben Bryner -- I'm finally on the home stretch for interviews. Only a few more left. As I've mentioned, the thing I like most about interviews is the chance to talk to the leaders in surgery, meet residents, and imagine what my future would be like in that program. Also, sometimes the food is pretty good.
My least favorite part of interviews is waiting for hours in airports or buses to get somewhere. I try to leave plenty of time for each trip. I tell myself that it’s OK to have some extra time at the airport, that I can get some work done at the gate or stretch my legs by doing laps along the moving walkways. But as soon as I get there I’m totally nonproductive, and it’s not relaxing either, waiting in a weird bench/seat and waiting impatiently for them to announce my “boarding zone.” Obviously anyone who’s traveled knows it’s like this, but what’s interesting is that I keep believing myself when I plan these trips. One of my dad’s friends has a personal motto: “If you’re not occasionally missing a flight, you’re spending too much time at the airport.” Maybe that’s the philosophy I need to adopt.
Once you get to the interview there’s still a fair amount of waiting. Like I say, I enjoy the actual interviews, but there are only so many people conducting interviews and a lot of applicants, so there is some downtime between interviews. A lot of my fellow applicants are the same from interview to interview, so it’s fun to catch up with them and see what programs they’ve liked, too. And often there are residents hanging around and answering questions. This is a good chance to get questions answered and hear opinions from residents at varying points in their training.
During one of these casual question-and-answer sessions recently, one of the residents pointed at my nametag and said, “Sorry about that.” I didn’t know what he was talking about, so I looked down at it:
Maybe a Bob Marley fan had been in charge of making the nametags. I didn’t care – it was still obvious what my name was, it wasn’t like they changed my name from “Dennis” to “Denise,” or changed my name to an obscenity or something. They probably just have a motto similar to my dad’s friend: “If you’re not occasionally leaving letters out of names, you’re spending too much time making nametags.” Which is reasonable enough – I’d rather the department plan a good interview day than worry about name-spelling. But some of the residents thought it was funny.
“That’s not bad. Maybe you should go by ‘Bejamin.’ It’s kind of cool, and nobody here would know.” They had a point. Unless you stay at the hospital where you did your medical school rotations (or you did an away rotation), everyone kind of gets to start over during residency. People there only know you by your application and your interview, so you could change a lot of your personality traits. Probably most people maintain the spelling of their first name, but you could decide to go out more (or less) often, reinvent yourself as an expert on some obscure topic, or affect a Cockney accent.
"Ello, guv’nor! I’ve jus’ seen a lovely documen’ary on centipedes, I ‘ave!"
So maybe you shouldn’t do it, but it’s kind of amazing to have this chance to reinvent yourself in a way that most people do only a few times in life, or, in Madonna’s case, every six months. It’s something of a leap of faith on the part of the residency. They’re agreeing to train you in a subtle, complicated art (or in orthopedics) without knowing you very well or demanding that you prove your skills to them directly. Obviously, it’s built on trust between established schools and departments, and by doing an away or “audition” rotation you are trying to prove yourself. It’s a pretty exciting time, in part because of the uncertainty and the possibility of starting over someplace new, which makes the waiting in the airport worth it.
Catching Winter Bugs
Winter brings many things. Like Christmas, frost, and an excuse for hot chocolate. Mostly, though, it brings norovirus. In as little as one day, the hospital changes into something resembling a besieged city; the initial vanguard of security personnel and nursing assistants greets you at the threshold of the hospital asking whether you’ve had any V or D over the weekend. At key points, little stations have been set up, complete with alcohol gel, leaflets about keeping the hospital virus-free, and yet more alcohol gel. And should the enemy dare infiltrate past these checkpoints, the closure of key wards tries to stop the invasion. A propaganda war is also being waged, with PA announcements and radio adverts beseeching people to stay away from the hospital if they’ve been ill in the last 48 hours.
The public are not the only targets of these rallying cries. Medical students have been banned from engaging in any types of clinical activities, including all theatre attendance, ward rounds, clinics, and teaching sessions, until further notice. Luckily, our year isn’t affected very much since we’re on community week anyway. But the poor first years have had 2 weeks of moping around with nothing to do. This sort of thing happens every year (hence why it’s known as "the winter vomiting virus"), but this year is the first time that students have been ordered away from the wards, and there’s a general air of disgruntledness.
You can’t really blame the hospital for trying; in fact, it’s rather commendable that they’ve realised students are one of the few sets of people who frequent a wide area of the hospital and are thus more likely to spread bugs from ward to ward. Certainly, even though we’re being allowed back on the wards, we still have to observe "clean-dirty" ward and not go into one if we’ve been in the other. But it does beg the question of how effective these measures are in the face of so many other routes of transmission… Do we try to avoid requesting consults from other teams in case they bring/ take bugs? What about stethoscopes? Most of us, even though we dutifully wash our hands between patients, don’t clean our stethoscopes. Not to mention the services workers, e.g. the lady who looks after the TV/ internet consoles on the patients’ beds -– should they be banned from frequenting different wards?
Infection control is a tricky business, and to try to keep the hospital running during the busiest season, in the face of this highly contagious bug, seems insurmountable. As always, we can only do our best… Now, where’s that Spirigel?
January 11, 2009
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.
January 09, 2009
To Be, Or Not To Be (In Class)
Jeff Wonoprabowo -- As a first year student I attended the majority of lectures. There were, after a while, a few professors whose lecture style I preferred not to listen to. And there were a couple of days when I woke up and just had to sleep in another hour and would skip the first class. But all in all, I think it's safe to say that I attended over 80% of lectures.
It wasn't because I had figured out that I learn better through lecture. It was because of fear. I had this paranoia that I would miss something important. Maybe the professor would say something like "Know this for the test," or "This part isn't important." I was always amazed at classmates who never came to class. On exam days I would occasionally see someone who I didn't recognize at all.
Since we returned from Christmas break, I attended the first lecture to pick up the class notes, I attended a Pharmacology Lab which was not optional, and I attended a Religion class that requires attendance. Aside from those three, I have not attended any other lectures in three days. I am trying out this self-study thing.
The good thing is that I'm trying this out at the very beginning of the quarter. I've decided that the experiment will not last longer than a week. Hopefully that will be enough time to figure things out.
Maybe it isn't a good idea to mix things up right now. I really hope I'm not trying this because I'm lazy. I am hoping that once and for all I will be able to know whether I study better with lectures or on my own. Although, in reality, the best will probably be somewhere in between the two.
I'm curious how others here study. Do you attend lectures? Do you skip all? some? none? Anyone else feel paranoid about missing "important info" by missing lectures?
January 07, 2009
What Do I Want To Be When I Grow Up?
Kendra Campbell -- I’ve recently been thinking a lot about what I would have done with my life had I not gone to medical school. So, I was inspired by Colin's post to make a short list of what I “could” have become:
1. An Artist: I’m not sure exactly what type of art I would pursue. However, given my inclination for incorporating the viewer into the art itself, I think I’d probably lean towards some type of performance/street art.
2. A Veterinarian: If you’ve read many of my posts here on The Differential, you probably saw this one coming. I’m an animal maniac. I can easily see myself in 20 years living on a ranch somewhere with hundreds of animals running around inside and outside my house. It seems that it would have made good sense for me to choose animals over humans!
3. A Musician: Unfortunately, this one exists as a possibility only in my mind. Although I am incredibly passionate about music, and think I have the heart and performance abilities to put on a good show, I am completely and utterly lacking in talent. I can’t sing or play a single instrument with any level of skill.
I could continue the list for pages, but I shall not. Since I am in my third year of med school, and I have a monumental level of debt hovering over me, my dreams of pursuing other fields have been all but extinguished. Now, I have a new decision in front of me. Which specialty should I pursue?
Some students know from the time they are 5 years old that they want to be a pediatrician or a surgeon. But there are many of us who really don’t have a clue. The third- and fourth-year clinical rotations are intended to expose us to the various specialties, and they do, in fact, help most students narrow down their choice.
There are also numerous quizzes, tests, and scales that students can use to help them decide which specialty fits them best. Here are just a few:
1. The AAMC’s Careers in Medicine website
2. The University of Virginia’s Medical Specialty Aptitude Test (MSAT)
3. Test of Attractiveness of Medical Specialty by Temperament via Myers Longitudinal Study
Of course, if all else fails, you can use this very technical flow chart to figure out which specialty fits you best.
I am currently leaning strongly towards either emergency medicine or psychiatry. My MSAT results revealed emergency medicine as my best match, and psychiatry as my worst. The highly technical flow chart was actually great for narrowing my choices down as well. I am definitely crazy, so it confirms my hunch that emergency medicine and psychiatry are best for me!
I think what it really comes down to is letting your gut decide. Of course, that’s way easier said than done. Perhaps some of us never really decide what we want to be when we grow up!
January 06, 2009
Resolutions of a Fourth-Year Med Student
Anna Burkhead -- It’s finally 2009! This is the year that fourth-year medical students across the USA (and final year students all over the world) have been anticipating and dreading for untold amounts of time. It’s the year we get a diploma, the year we stop paying tuition and start paying income tax, the year we become doctors.
But before we get there, we have to survive the hardships and obstacles presented by the final year of medical school: the long hours… the never-ending exams… the…
Who am I kidding? The fourth year of med school rocks.
With the new year and the approaching graduation date in mind, here are my 2009 New Year’s Resolutions.
1. I will take the time to really look at the cities in which I’m interviewing for residency, as the schedule allows. Yes, I’ll be a resident at that program. But I’ll also be living in that city!
2. I will thoroughly enjoy my last “official” Spring Break.
3. I will not fall so in love with my iPhone that I forget how to use a computer. Admittedly, I did attempt for all of 30 seconds to write this entry on the iPhone, to avoid getting off the couch (again, fourth year rocks) but even with mini, stubby fingers, it was a bit daunting.
4. I will use my Step 2 CS trip to visit friends, with a minor interruption for that pesky test.
5. I will conquer my fear of airplanes -- an apparent necessity when flying somewhere practically every three days. I am tired of looking like a crazy person during the take-off!
6. I will try to attend every medical school class function between now and graduation. We’ll be scattered all over soon enough!
7. I will learn how to pack all of my interview necessities in one small (-ish) suitcase… Why is this one so hard for me?
8. I will enjoy my LAST MEDICAL STUDENT ROTATION EVER (February -- Outpatient Medicine)
Match day in 2.5 months! Graduation in T minus four months!
Now back to my very, very stressful fourth year. :)