The Differential: Medscape Med Students Blogs

Will Resident Work Hours Be Reduced?

Thomas Robey -- One of the (many) things I pay more attention to now that I'm interviewing for residency is work hours restrictions. Granted, residents in emergency medicine (EM) typically fall well under the current limits of 80 hours a week (averaged over a month), maximum 30-hour shifts, and a minimum 12 hours between shifts. (EM residents have their own numbers: 12-hour shift limit, at least an equivalent period of time off between shifts, and a 60-hour work week with an additional 12 hours for education.) But when it comes to off-service rotations –- when I work in the ICU, for instance, or on the medical floors -- I'll log my hours along with everyone else.

Some of my stock questions when I interview include direct inquiries about work hours. Thanks to an Institute of Medicine (IOM) report issued on December 2, I have a new way of asking. You can try it too: “How do you expect your institution will respond to the new IOM recommendations that resident shifts be shortened to 16 hours?”

At my medical school, most rotation sites provide sleep rooms for students so that they may take overnight call with the team. This means that I've had a taste of 30-hour call and 80-hour clinical work weeks. (Keep in mind that these restrictions do not apply to medical students -– there are no restrictions for us!) My experiences on call helped me learn how to work up a patient from start to finish, introduced me to multitasking between several clinical tasks, and provided several others on my team with interesting diversions (in the form of delirious post-call musings). Low on the list of why I chose emergency medicine is that I will not have very many 30-hour call nights. But it is on the list.

So when the IOM report came out last week, I took notice. Keep in mind that these are recommendations, and are not policy (yet!). Here are the details:

Shift length now: 30 hours (admitting patients up to 24 hours, then 6 additional hours for transitional and educational activities)

Proposed shift length: 30 hours (admitting patients for up to 16 hours, plus 5-hour protected sleep period between 10 p.m. and 8 a.m., with the remaining hours for transition and educational activities); 16 hours if no protected sleep period

Time off between shifts now: 10 hours

Proposed time off: 10 hours after day shift; 12 hours after night shift; 14 hours after any extended duty period of 30 hours, with no return until 6 a.m. of next day

Days off now: 4 days per month; 1 day (24 hours) per week, averaged over 4 weeks

Proposed days off: 5 days per month; 1 day (24 hours) per week with no averaging; at least 1 48-hour period off per month

There would be no change to the 80-hour weekly limit or to emergency room shifts. A one-page digest comparing the current policy with the IOM's recommendations is available here.

Remember, these are just recommendations. It is hard to say whether the Accreditation Council for Graduate Medical Education (ACGME) will act on these recommendations. My biased hope is that they do, even if it doesn't change my off-service rotation work hours. The ACGME indicated in a news release that work groups within the council will convene in April to consider the IOM recommendations.

Among the issues to be discussed will be the cost of these proposed changes. Perhaps there is something to the oft applied phrase “cheap labor” when discussing residents: The IOM estimated the annual cost for additional personnel to handle reduced resident work could be $1.7 billion. That's less than 0.5% (yes, one half of one percent!) of what Medicare spends on Americans annually. But something tells me the current economic situation may be a detracting factor in progress on this issue...

So, what can we medical students do? I think a good first step is to talk about it -– with peers, residents, and the residency directors we interview with this year.

The Inner View

Thomas Robey -- “That's it?”

I walked out of the emergency department where I just finished interviewing, wondering where the time had gone. Granted, this was my first residency interview. Many of my peers are in the midst of a grueling travel schedule. How many more will there be? I have no idea. Will they all fly by as this one did? Will I find myself out on the street wondering, “what next?” The likely answer is no. A lttle bit of preparation could go a long way. My goal is to be able to think by the end of the mind numbing exercise in self reflection known as the match.

What are your strategies to deal with the same questions and the endless slide presentations that you encounter on the interview trail?

Here are my once-tested tips on interviewing:

1. Physician, be thyself. It's probably less tiring if you do not need to put up a front of who you are all of the time. It's not in your best interest to pretend to be different than you really are. Plus, that's a lot of work!

2. When you answer a question, use specific vignettes. Think of this as "evidence-based interviewing." Your evidence is examples from the past. Plus, people remember stories better than abstract ideas.

3. Prepare for common questions. Each field will have a couple of common questions that are asked in the interview. Stock questions include, “Where will you be in 5 or 10 years?” or “What is the air-speed velocity of an unladen swallow?” Colin provided some of his stock answers in a previous post. Be sure you are ready to talk about your hobbies. I spoke today about Wunderkammern.

4. Have two or three questions about the program that you are ready to ask when the, “Do you have any questions about the program?” question comes along. I'm interested in knowing what kind of social and professional support I'll get as an intern and how the program can nurture some of my specific interests, so you can bet I'll be asking that of my interviewers.

Hopefully by the end of the day, the folks on the admissions committee will have better insight into your motivation and personality. My goal is to provide them with an “inner view” of my credentials. By now, we've undergone so much self-examination that a conversational interview should come naturally. My challenge is to get comfortable enough to let the good stuff show.

What are your interview pearls?

Vote for Health

Thomas Robey -- Did your man win? No matter your answer, there are more Americans this year than ever who can answer that question. There have been a few nods to this year’s election here at The Differential. If you’re from the US and reading this, you are probably in the voting demographic cited as having the most impact on this outcome. So if this was the first time you voted (no matter who you voted for), congratulations.

But waiting in line for three hours or slogging through pages of propositions doesn’t entitle you to complacency for the next four years. Whether in New York or New Guinea, the UK or the UAE, we medical students have our hands full with future careers in health care. If the stresses of caring for patients -– limited supplies, long hours, unintelligible reimbursement procedures, and the complexity of disease -– aren’t enough, take a moment to consider your patients. Issues such as limited housing, decisions between food and medicine, neglected diseases, and access to care transcend what we learn in medical school. These are in the academic domain of social and political scientists. They are also problems that outlast any elected official.

The transient nature of representative government makes health care issues difficult to address. The kind of quick fixes officials make to get re-elected may conflict with a cogent long-term approach. For a few moments –- in between debates about the war and the global financial crisis -– I heard talk about a plan to expand the American health care system to improve access for more than 40 million in the US who cannot pay for health care. I think I remember talk like that 15 years ago.

Politicians come and go, but medicine is a career for life. Many of us would rather name it a calling. Why not pick up the phone and call your representative to say, “I’m in the business of caring for the sick, and my company needs a bailout?” And after you get a canned response that health care is important to so-and-so, thank you for your vote, find an evening clinic that needs a volunteer provider. Maybe someday you’ll open your own clinic. Or consider malaria or dengue fever as a research topic. Or take a few more classes to get an MPH or other degree that will help you understand the health system so that you can take the next step of fixing it.

After November 4, 2008, there’s a lot of excitement around the United States, and the world. I’m afraid that response will fall into the category of patients we worry about the most: lost to follow-up.

Medical Blogging

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

The Waiting Game

Thomas Robey -- Like many fourth year students, I'm anxiously awaiting notice from residency programs about interview invitations. Some specialties have been sending invites for a few weeks, while others wait to make an offer until after they receive your medical student performance evaluation (MSPE, formerly called the Dean's letter). My chosen field, emergency medicine, is in the latter category. So when my colleagues who've applied to surgery, family medicine and pathology tell me about the 10-15 interviews they have, I have the opportunity to practice some of the calming techniques we teach patients with panic disorder.

It's also nice to rehearse the clinical interviewing technique of reflective conversation. With it, I'm getting to know my friends and colleagues better. Reflective conversation is when the interviewer summarizes what the patient says. This helps the care provider both understand the patient's position and reinforce the therapeutic alliance. By focusing on the other person's challenges of navigating cheap airfare sites, organizing program information, and their worries about how to offset their expanding carbon footprints, I'm learning what could be in store for me over the next month when emergency medicine programs start contacting me.

Even with these constructive approaches to dealing with my own anxiety, there are still the sheepish check-ins with my colleagues applying to EM residencies. I see one classmate rather regularly on my commute to the hospital. We're at the point where he greets me with, “Still only three.” And I reply: “Two here.” (We each applied to about 30 programs.)

Sometimes I see the glint in residents' eyes when they overhear our conversation. They're thinking, “those medical students... what a big deal they're making of this!” I know because it's the same thing I think when a contingent of first year students board the Metro bus after being released from afternoon class. We talk about trans-continental airfare and living expenses; they compare study strategies and small group assignments. Soon, we will be focused on work hours and continuing education.

But now, we fourth year students have sent in our applications, confirmed a number of interviews and are antsy about learning about what's next. In a few weeks, the emails will be flying about interview date preferences, the cash will be flowing to online flight booking agencies, and the dark suits will be dusted off for more adventures in interviewing. By comparison, now is the calm before the storm. It's funny though -– I don't feel very calm.

Physician, Heal Thyself

Thomas Robey -- How many colds have you had this season? I'm working on number two. This is from a man who can count on one hand the number of times he missed school in grades K-12 because of illness. Okay, maybe two hands, or a polydactalied hand. Whatever. I've been sick in the third and fourth years of medical school more than any other time in my life. For example, the only time I remember vomiting (ever!) was on my medicine clerkship in Spokane. And I even drink from mountain streams. So what gives?

1. Stress. Lots of it. Long hours. Wanting to learn EVERYTHING, like memorizing the eMedicine article about hepatic encephalopathy.

2. Not eating well. Granted, hospital food is great, especially when it's free. Wait a minute... “Hospital food is great?” I am sick.

3. Not exercising as much. Taking the stairs helps, and that 20 pounds I lost on my emergency medicine rotation wasn't only because I forgot to eat twice during the 12 hour shifts, but being on your feet doesn't cut it for getting the heart rate above 120.

4. Vectors, fomites, sick contacts... we get them all.

5. Sympathy for your patients.

6. Sleep? We don't need no stinkin' sleep.

7. “But I got the influenza vaccine...”

You get a medal if you get through these two years without a viral URI, the flu (stomach or real), strep throat, sinus infection or scabies. For those of you without a medal around your neck, the next test is what you did after you got sick.

The sick doctor has an obligation not to infect her patients. “First, do no harm.” How do you draw the line about deciding to come to work? Stay home with active vomiting? Sure. Is it okay to have a runny nose on pediatrics because everyone else does? In the OR, you'll get you no sympathy from the scrub techs. “Aw, the medical student is spotting his mask...” is as uncomfortable as if I were spotting somewhere else. Lower GI problems? No one wants you around. Don't even think about it! But I'm sure some of us do. After all, not only are we students part of the provider team, we are learning and being evaluated. Missed work equals missed opportunity, right? I don't think so. If you are sick, you're not going to learn. Instead, stay home. Yes, students help the team. But remember your first month on the wards? The team got on without you. They can get by one more day, but be sure to call in. They'll probably thank you for staying home, too.

So what can you do to get back ASAP? There's a lot of stuff that people say works. Many swear by that effervescent pill Gas-Birth. (Names were changed to protect the clinically disproven.) There's something special about chicken soup -– especially if someone else makes it. Drink fluids when you're down. Stay healthy with fruit, exercise, sleep. You know the drill: you've told patients hundreds of times. The CDC promises us the flu vaccine is going to work this year -– get that not for yourself, but for your immunocompromised patients. And you probably know you should be washing your hands AND using hand gel more than you think you need to. Cover your nose. Wipe down your workstation. In the end, the best advice I've received is simply to stay home. You'll be back to your eager medical student self faster that way.

Train of Thought

Thomas Robey -- The following entry was inspired by a patient encounter. But first, a preamble:

There's enough in medical school that's hard to deal with that it's worth trying to make the most out of enjoyable assignments. Two of my favorite clinical rotations in medical school thus far have been emergency medicine and psychiatry. This month, I'm combining the two by working in our county hospital's psych ER. Inpatient psychiatry exposes students to really sick patients, but these folks are typically stable via detox, medicine, a roof or what have you. This is not the case in the psychiatry emergency service (PES) section of the emergency department. Life in the PES goes a little more like this:

So what brought you to the hospital today?

Well, I was riding the bus thinking about what I needed to read next because the Step 2 had just completed and remembered that there were 783 (or was it 873?) steps in the Cathedral of Learning where the nations gather in their own rooms to talk about the current financial crisis, but that doesn't matter because liquidity is the best approach right now and this orange juice is delicious like an Orange Julius from Czechoslovakia and we used to send his family packages with American money hidden in green objects so that the mail inspectors wouldn't find it like the way Watson actually did all of Holmes' dirty work, but stole the data from Rosalind because she wouldn't sit in the back of the bus which is where I happened to be when the voice announced “Harborview, next stop.”

Are you hearing any other voices?

Coffee. They say, “coffee.” Sometimes, “Coffeemate.”

Are you thinking of hurting yourself?

With coffee, actually.

Do you feel like hurting anyone else?

Cigarettes.

I didn't know you smoked.

No. I want to hurt them. With fire.

Is there anything the doctors can do for you?

Coffee. <devious giggle> Coffee. <looking over your shoulder toward a non-existent cup of coffee> Yes, the coffee will do just fine.

Are there any medicines that have worked in the past?

Other than coffee? No, not really. Just coffee, cigarettes and olanzapine.

Maybe it's the fatigue secondary to endless education, but for me, the line between train of thought and flight of ideas is increasingly blurry these days. And who of us doesn't fixate on caffeine sometimes? To you, my response above is nonsense, or a puzzle at best. But to my wife or family, it all makes sense. It's a little circumferential yes, but is based in reality. Logical from one perspective. Seeing how my thought jumble is not unlike my patient's idea of a coherent response makes it easier for me to handle psychiatric illness, and dare I say, empathize with him. And if I cross the blurry line of sanity, at least this month, I'll be in a place where I can get the help I need.

Eloped!

Thomas Robey -- Medicine introduces a whole new language to medical students' vocabularies. Many of you would agree with me that learning a dictionary's worth of words is one of the hardest parts of medical education. Now in the midst of my language immersion experience, I've discovered a bonus of learning a new lexicon. Medicine not only invents new words -– it borrows them for its own use. My favorite of these new uses is the verb "elope."

To be fair, elope has two meanings in most online dictionaries. The first is the standard use regarding marriage. "Elopement to Las Vegas" puts one image in your head; "They eloped to save money," another; elopement in the context of parental disapproval yet another. There's a generic meaning of the word separate from matrimony, which is "to leave without permission or notification; escape."

Those of us who have worked on psychiatry wards or in emergency departments have learned this alternate definition. Let's say your floridly psychotic patient has responded well to the risperidone you've initially compelled her to take, then convinced her to take. Now she's asking you for the meds. (This is the story of my current psychiatry clerkship, by the way.) At our hospital, as patients progress to discharge, they can ask for increasing freedom. In my state, over the course of their stay, patients may transition from involuntary hold to a consented involuntary admission to a voluntary treatment. In parallel with this fluid legal status, patients may leave the locked floor escorted by staff (level 2), family (level 3), or other patients (level 4). This usually works out fine. On very rare occasions, however, patients are advanced a little too quickly. Someone on level 4 could encounter triggers on the outside. If, for example, your patient passes the corner across from the county hospital where crack is bought and sold, he may hatch a plan on his next level 4 release to leave the hospital and score a hit. Indeed this happened with one of my patients last week. I returned to work Monday to discover that the patient had actually only been admitted for 1.5 days, when I had been caring for him for about 10 days! It turns out he spent Friday night on a crack vacation, and checked back in on Saturday... What's the medical term for that? Elopement. Part of me thinks that the first physician to use the term had in mind some titillating scenario. I'll leave that question to the medical etymologists.

The psych ward isn't the only place I've heard the diagnosis of elopement. In the ED where I worked, next to the bins that say, "medicine," "surgery," and "peds" where you pick up new patients' charts, there's a bin labeled "LWBS." I didn't use this bin until I had a patient come in who had smoked a sherm. Unless you live in California, where PCP is accessible, most sherms are cigarettes dipped in embalming fluid (formaldehyde, etc.), and unlike the usually credible resource linked above, smoking (non-PCP) sherm is not usually "a lot like being totally drunk on acid and meth at once." In my experience (as an observer, of course!), smoking embalming fluid leads to verbal latency, paranoia and aphasia at best, and unresponsiveness, paralysis, and arrested breathing at worst. Perhaps the folks who get the "good" high stay away from the hospital. But I digress. Per the patient's history, he smoked a joint passed to him while watching a football game. He didn't know what was in this cigarette. He did remember waking up in an ambulance on the way to my favorite ED. I got his story, but he refused to let me put in an IV, draw labs or rehydrate him. He certainly did not permit a urine sample. He believed I was in cahoots with the cops, and when I returned with my attending, he was nowhere to be found. Hospital security pointed him out across the street (on the aforementioned crack corner, actually). I asked if he wanted care; he advised me to shred the documents associated with his stay. Instead, I dropped my note in the LWBS bin. My attending explained that he had eloped; medico-legally, this amounts to his having Left Without Being Seen (LWBS).

Whenever I learn a new meaning of an old word, I like to test out its use. Sometimes this verbal experimentation crashes and burns. Like how I got AMA and elopement confused for about two weeks. (In the ED, to leave AMA, the patient must sign a form indicating she understands her condition and the risks of leaving.) Other times, I'm quite happy with the outcome. As part of my psych clerkship, I take evening call in the psychiatry emergency services (PES) section of the ED. Nights in the PES are usually a trip, and it's a great place to see acute psychiatric problems. Last week it was slow. We had one patient who was clearly sick but was worked up in the first hour of my shift. All that was left to do for him by 8:00 was to write an affidavit for an involuntary hold, and wait for the county designated medical health professional to see him. With my final in a few weeks, I was anxious to use the downtime efficiently. Without a patient to see (and learn from) and without a quiet place to study, I was out of luck. Like the patient scheming his escape from the psych floor to score some crack, I was looking for any open door to bolt from the PES. Talk about empathizing with patients. As soon as the attending noticed I was not in a position to help the residents, she said, "you know, you don't have to stay until the..." Sometimes it's best to not let your supervisor finish that sentence. When I called my wife to see if she could pick me up, I excitedly told her I had eloped from the PES and needed a quick getaway.

Firing Patients

Thomas Robey -- Fourth year students must fixate on personal statements and residency applications this time of year -– that’s why you’ve seen a few articles in that vein, and why I've been away from my desk. Not to fear, I'm back with something a bit more juicy on my plate today.

Recently, I was enjoying a pleasant Pacific Northwest evening at a lawn party celebrating a friend’s dissertation defense. The discussion moved from salmon burgers to medical education, and settled on topics related to the obstetrics and gynecology clerkship. It wasn’t long ago that I was in Fairbanks, Alaska delivering babies, so I thought I could add to the banter. Little could prepare me for an assertion that one of my more outspoken friends made. He said, “All medical students should be required to learn how to do abortions.”

That deserves a paragraph break. He went on to propose that all physicians be required to perform abortions if requested. This is related to the current debate in many states among doctors, pharmacists and lawmakers about whether a pharmacist is entitled to refuse a prescription of the high dose progestin “morning after pill.” You can imagine my friend's perspective that pharmacists must be willing to provide patients with their prescribed medicine –- especially if they are the only shop in town. Must also physicians provide every therapy at the request of a patient? For anything other than abortion, most people agree the answer is yes. For obvious reasons, dilation and curettage or mifepristone treatment for abortion are in their own category. It's funny that every medical student already has the skills to perform these procedures.

What many people don't know is that dilation and curettage is a very common procedure used for a number of uterine problems. And who hasn't prescribed medicines? So in that way, I could tell my friend that his first proposal is already being done. But what about requiring docs to do abortions? The majority of American physicians -- no matter their political views -- hold that if a woman asks for a doctor to terminate a pregnancy and that doctor's personal beliefs do not tolerate the procedure, the physician should refer her to a colleague who is able to provide that care.

This reminded me of an excellent teaching point my psychiatry attending made a few weeks ago. His patients are exclusively from our county hospital's population, which means he works with difficult patients who have been refused care (“fired”) by other psychiatrists. If you've done a psychiatry rotation, you know who I'm talking about. Some people with borderline personality disorder are impossible to work with; when everything is in black and white, it's hard to make stepwise progress. (By the way, on your board exams, these are the folks who say, “You're the only doctor who really understands me.”) These patients routinely get fired from practices. You're just another name on the list of many who've wronged the patient.

That is, unless you connect in a meaningful way. It may not work with everyone, but offering to fire a patient could be one step on her way to recovery. You've made a rudimentary connection with the patient, but for one reason or another, some cracks have appeared in the therapeutic alliance. When you say, “I don't think I can provide the best care for you. I can help you find another doctor,” some patients hear, “I care enough about you that I'm willing to send your business elsewhere so that you can get better.” In the three instances my attending offered to fire a patient, each decided to stick with him on new shared terms.

The same respect for the patient's priorities of care that the beleaguered psychiatrist has for his patient should be offered by the pro-life gynecologist. As entitled to her personal beliefs as she is, that doctor cannot provide the best care for her patient until she refers her to a clinic that will perform the requested procedure. Those who value the principle of autonomy in medical care will demand this be done. Of course, it's not so clear as this! The alternate view is that non-maleficence toward the conceptus demands the provider's refusal of the procedure. Currently, American law supports the former perspective over the latter, but that hardly solves the matter. In reality, many women first seek abortions from clinics known to conduct them. And for some individuals, there isn't a provider for hundreds of miles of where they live who will do the procedure. Maybe my friend had a good point, after all...

As a student, you may find yourself in the midst of conversations about the limits of patient care. When is it okay to fire a patient? Is it when there is no more need for treatment? Is it when patients go on Medicaid? When he misses three appointments? When she wants an abortion?

What happens when your idea of going into medicine to help people contrasts with those peoples' ideas about getting help?

Disclosure: Because this is a topic that many feel passionately about, readers may benefit from knowing that I support the perspective that abortion should be “safe, legal and rare.” I support sex education, contraception and waiting longer to have sex, am uneasy about practicing or procuring an abortion, and fully support a woman's right to seek that therapy.

The Importance of Being Earnest

Thomas Robey -- There’s been a little talk around this blog about applications to residency. It seems as though there are a few of us in the process of making that next step in medical education. I imagine there are more than a few readers who are applying to medical school, as well. Are you in the same boat as me?

If so, you’ll recognize some of our fellow passengers. They go by common names.  There’s Ambition in the lookout post trying to figure out what the best course is. Her foil, Trepidation, refers to the navigational charts too often. Fortunately, Patience is on the rudder and keeps the boat on track even though he can’t exactly share with the others where the crew is headed. But Heartburn and Heartbreak are restless in their bunks waiting to make their appearance later in the voyage. Two crewmen are recklessly practicing their swordsmanship on the bow; Humility and Showman are tearing apart your personal statement with alternating sabre slashes. As captain of this ship, you’re having a tough go of keeping the crew in line. Mutiny is an ever-present possibility, as folks are feeling more and more lost at sea.

If you’re smart, you’ll hire on as your first mate a chap who goes by the name of Earnest. Let me introduce him to you:

ear•nest: [ûr'n?st] <ur-nist> – adjective

1.    serious in intention, purpose, or effort; sincerely zealous: an earnest worker.

2.    showing depth and sincerity of feeling: earnest words; an earnest entreaty.

3.    seriously important; demanding or receiving serious attention.

– noun

4.    full seriousness, as of intention or purpose: to speak in earnest.

It seems to me that this profession we are about to enter into, whether as students, residents, or (gasp) physicians is one not to be taken lightly. Along the same lines, the grueling application and interview process must not interfere with our dreams. All of the hoops along the way get us all down; the sincere zealousness of the undaunted applicant is what will get her through in the end.

At least, that’s what I keep telling myself.