Medicine From The Trenches

Experiences from medical school, residency and beyond.

Hospital Haiku

“hospital moonlight

cacophony of machines

teardrops cascading”

As we come to the end of National Physician’s Week and today, National Physician’s Day, I related this haiku from one of my most gifted and amazing friends. Some years back, he suffered a  critical and life-threatening illness that resulted in profound changes in his life with some time in the intensive care unit. This illness changed a man who is talented beyond belief, a brilliant creative genius and professor in ways that few of us can relate or even imagine. Still today, he’s affected by his illness and the events that surrounded it.

I share this haiku because it brings to mind, something that we as physicians must always remember about our patients. They place their health, their trust and many of the most intimate aspects of their lives in our hands. With our hands, we have to care for them; relate to them, in many ways hold them, and be mindful of the honor and privilege of having them place their lives in our care.

As such, we also have to be mindful that illness changes their reality and in many cases their lives profoundly especially when they are critically ill. We have to reach out and extend more comfort over the “cacophony of machines” that becomes the background of their intensive care and sometimes hospital care experience. We have to block that “cacophony” whenever and wherever we can.

I remember watching a tear roll down the side of the face of one of my ICU patients who appeared comatose. The nurses were bathing him and chatting with each other as they turned him. I saw the tear; asked them to speak with him over the ICU noise background. I asked them to play music in his room and I always held his hand when I entered the room to examine him. I am sure that my soul could feel his soul even though he didn’t ever speak to me. I never saw that tear again, after we began speaking and focusing on him, holding his hand, touching his face, and playing his favorite music even though he did not recover from his illness.

I seek to connect with my patients without exception as that is my honor as a physician/surgeon. I spent years learning the science and techniques of medicine and surgery but in these, the later years of my clinical practice, my focus is on the art of medical practice. Within that art is my chance to give some of my heart to those who have placed their trust in me (and my training). I strive to be more human and more comforting. To do less of the science and more of the art is great joy for me. My joy is in the connections; kind of strange for a surgeon.

On this National Doctor’s Day, I am honored to be a physician and grateful for all that this profession has given me. This profession has given me far more than I can give back but I will spend as much time as possible giving as much as I can to those who are in my care.

30 March, 2017 Posted by | medical school, medicine, practice of medicine | , , | 2 Comments

A touch of tenderness (Reblog)

Here’s is a great post to remind us that touch may be the best medicine out there for our patients. Don’t be afraid to touch your patients and connect with them. This is the true “magic” of medicine. Touch is needed more today than ever.

Sue Vincent's Daily Echo

The Cathedral by Rodin.

My son gleefully squeezed harder at the knotted muscle in my shoulder, with a ‘Now I’ve got you’ as I groaned in agony. We have established and agreed that he has a slightly sadistic tendency where I am concerned. It may have something to do with my knack of getting just the right spot on the painful muscles as we got his body working again. Day after painful day, for months on end. So now it is payback… and he appears to enjoy it. He still manages to lay the blame squarely on my aching shoulders, muttering something that sounds vaguely like ‘hereditary’.

He is a little more squeamish than I. His face screws up in horror as my wrist bones crunch back into place when he applies traction. It is, however, nice to regain freedom of movement occasionally. So I make him do it…

View original post 1,189 more words

25 March, 2017 Posted by | medical school | 3 Comments

Great Post from “Life of a Med Student”

“Beyond the H&P” A Guest post by Jessica Morgan It’s 4:00 pm on a Thursday: time to present at teaching attending rounds. I have prepared my presentation and know about the patient’s pathology, but I can never help myself from being incredibly anxious for these moments. I gather my papers and begin…

via Beyond the H&P — #Lifeofamedstudent

24 March, 2017 Posted by | medical school, residency | | Leave a comment

You Have Matched!

A hearty “Congratulations” to all who matched! This is the next step in your medical career no matter where you matched. On Friday, you will find out where you matched; some taking the news with tears and fears. Make no mistake, if you didn’t match, the future becomes more uncertain but certainly not bleak. As I have stated in other posts, those who didn’t match should be aware of the current S.O.A.P process and should be working on getting a training position for next year.

If you have matched, some things to work on as soon as you can:

  • As soon as you know where you will be training, get in contact with one or two of the senior residents to find out which textbook(s) is (are) the major reading material for your program. Purchase the book(s)(electronic or paper) and start reading.
  • Make a list of the sentinel journals for your specialty and start reviewing articles. You need to practice evidence-based medicine. Getting a head start on your journal reading helps to make journal reading a habit.
  • Start a physical conditioning program if you have been relatively sedentary during medical school. Aerobic exercise (30 minutes per day) can help reduce stress, help with stress and keep you healthy. Make physical exercise a habit along with journal reading. Even on your on-call days, you can walk/run the steps for a quick work out which will keep you more efficient in the long run. You will also sleep better if you are in good condition. Add some strength training too.
  • Find a place to live if you are moving. Don’t put this off because you need to be comfortably in your residence before orientation week in your new hospital. Your home should be simple, convenient for commuting to the hospital, restful and useful for your lifestyle. Though you won’t be spending tons of time at home, you need for your home to be your haven in your off hours. Make sure you have a washer and drying in your residence. You don’t want to be heading to a laundry room when you need to be sleeping.
  • Get your paperwork done for your training license as soon as you get information from your program. Some states have many tasks for you to complete before you can be licensed for training purposes. The sooner you get this done, the better.
  • Take a week or so off but do this long before you start your program. You need to have a bit of fun but using too much time in vacation before you start your PGY-1 year can be a problem too. Complete off time is great but not an escape.
  • When you get your residence, scout out several routes to the hospital so that you know how to get in even if there is a problem with weather, roads and other mishaps. Make sure your car or bicycle is in good repair with a good back-up plan.
  • Learn how to cook and take your meals into the hospital. Trust me, hospital food in most cases, is not great for keeping you healthy. I cooked on my days off, put a week’s worth of meals in the freezer and carried them in for my call days and nights. Good nutrition is key to good learning and training.
  • Learn a good organizational system for your ward work. I used an Excel program complete with dropdown menus for my sign-outs; still use this system. Learn to make check-off sheets to stay on top of your patients and their needs (lab tests, radiographic studies).
  • If you can, arrive a couple of days early to get familiar with your hospital’s physical layout, systems for dictation and record-keeping. Do a recon mission that will save you time in the long run.

Finally, this is a great time of learning and professional development. Having some organization is key to keeping your head in the right place. Enjoy the experience so that you can take advantage of every minute of residency with a positive attitude. Don’t underestimate the value of a smile on your face because you are learning the tools that will make you a good physician.

14 March, 2017 Posted by | medical school, organization, residency | | 5 Comments

(Re-post) The Supplemental Offer and Acceptance Program (SOAP) Process

I am re-posting a previous post because Monday of Match Week is coming up. People may need to learn about the Supplemental Offer and Acceptance Program (SOAP) process very quickly. It is not anticipated that there will be huge numbers of positions available in this program but one does need to know how the program works and how to make it work for you. Good luck to all of those who match and those who are going through the SOAP process this year. It’s stressful but it’s exciting to move forward with the next career steps in medicine.

Introduction

In previous years, a process known as “The Scramble” existed for:

  • People who were unmatched on the Monday of Match Week
  • Unfilled residency programs
  • People who matched to an advanced position but not a first-year residency position.

The Scramble was also utilized as a primary residency application process for people who didn’t want to go though the Electronic Residency Application Service (ERAS) who often submitted their application materials via fax to programs who didn’t fill (from the list provided on the Monday of Match Week) or even contacted those programs via phone or e-mail. The Scramble does not exist any longer and programs who participate in the Match cannot accept applications outside ERAS. In short, the SOAP process is a different entity with hazards and plenty of opportunities for mistakes on the part of applicants.

SOAP is NOT “The Scramble”

Programs that participated in the Match are no longer allowed to interact with applicants outside of ERAS as this would be a violation of the Match participation agreement. This means that all applications to unfilled programs (those programs that are on the unfilled list) have to be submitted via ERAS. For programs, this means that e-mails, fax machines and phone lines are not jammed with people attempting to submit application materials. Frequently in previous years, many applicants (IMGs, FMGs in particular) could pay for a mass fax service to fax applications to every program on the unfilled list as soon as the Scramble opened which often jammed machines. Most residency programs were only interested in filling with desirable applicants who may not have matched (by mistake usually) and were not able to screen for those applicants because their fax machines, e-mails and phone lines were jammed.

SOAP should not be your primary residency application

If you are seeking a residency position in the United States, you need to meet the deadlines for ERAS with your application materials. In short, you need to submit your application materials (to your medical school if you are an American grad or to ERAS if your are an FMG/IMG) and participate in the regular Match.  If you are an applicant with problems such as failures on any of the USMLE Steps or failures in medical school coursework, do not make the mistake of believing that unfilled programs are desperate and will take a chance on you rather than remain unfilled. First, there are far more applicants in the regular match than ever before. Many people who will find themselves unmatched either overestimated their competitiveness for a program or were just below the cutoff for a program to rank. If a program interviewed you but you didn’t make the cutoff for them or you didn’t rank them at all, you have a better shot at securing a position in that program through SOAP than an applicant who didn’t interview at all. Programs would rather take an applicant that they have seen and interviewed rather than just a person on paper (which is why trying to use the SOAP rather than the Match is a poor strategy).

You are limited to an absolute maximum of 45 programs in the SOAP

In the SOAP, your maximum is 45 programs. You can apply to 30 programs during the first cycle (Monday) and 10 programs during the second cycle (Wednesday) and 5 programs on the third cycle (Thursday).  Applications do not roll over so that if you don’t get a match by the third day the start of the second cycle, you are likely not going to find much out there. There are more applicants who will be unmatched (because there are more people participating) thus the positions will go quickly because programs can review applications to chose the most desirable candidates with the SOAP system.

If you have problems that prevented you from getting any interviews in the regular Match season or you didn’t get enough interviews to find a Match, then you are going to be less likely to find a position in the SOAP. This means that you won’t have a position for residency. If this happens (you know if you have academic or USMLE/COMLEX problems), have a contingency plan in place. This means that rather than sitting around wishing, hoping and praying while your classmates and colleagues are going on interviews, you need to be looking at alternatives to residency that will enable you to earn a living and alternatives that will enhance your chances of getting a position in the next Match.

Strategies to enhance your chances of getting a PGY-1 position

If you know that you are a weaker candidate (failure on USMLE/COMLEX Step I, failure in medical school coursework, dismissal from medical school and readmission), then don’t apply to the more competitive specialties. Don’t apply to university-based specialties in the lesser competitive specialties and apply to more rather than less programs. If you have academic problems, you are likely not going to match in Radiology, Opthalmology, Dermatology, Emergency Medicine, Radiation Oncology or Anesthesiology. You are likely not going to match in university-based programs in Surgery or any of the surgical specialties, Psychiatry, Pathology, OB-GYN,Neurology, Physical Medicine and Rehabilitation, Family Medicine or Internal Medicine. In short, community-based programs in Family Medicine and Internal Medicine may be your best options.Do not believe that if there are unfilled positions in programs that are university-based or competitive, that you are going to snag one of those positions in the SOAP. A majority of those programs would rather go unfilled than fill with a less desirable applicant (in spite of what you hear, those programs are not desperate enough to take any applicant just to fill).

If you are an IMG/FMG, you have to meet the requirements for application which means that your USMLE Scores likely will have to be higher than those for American grads and you can’t have any USMLE failures. There are also cutoffs in terms of year of graduation from medical school for many programs. In short, you need to look at the application requirements for any residency program that you apply to and make sure that you are eligible (better yet, that you exceed) those application requirements.

The best resource for estimating your competitiveness for a particular specialty is to look at the previous years  National Residency Matching Program ( NRMP) reports for those specialties. You can look at the characteristics for matched and unmatched individuals to see where you fit. With a greater number of medical school graduates (most American medical schools increased their class sizes) and the number of residency positions staying static, there are fewer positions out there to be filled. There will be fewer position in the SOAP and the competition for those positions will be greater. Since the competition in the SOAP is greater, it is best to avoid having to use that system all together if possible.

If you know that you are a weaker candidate, apply for preliminary (not transitional) positions in either Internal Medicine or Surgery. You will stand a better chance of getting a preliminary position (more available) and you will have a job where you can demonstrate your clinical abilities for one year before you re-enter the Match for the next year. If you do a good job in your preliminary year, score high on the in-training exams and perform at a high level clinically, you may be able to secure a categorical second-year position in the same program where you do your preliminary position or you may position yourself to become more competitive for another specialty at another institution. The upside to this strategy is that you will not be relying on the SOAP as a primary means of residency application but the downside is that you have to be ready to perform extremely well in your preliminary position without exception. In short, getting into a preliminary position can be a huge asset if you are ready to work hard and prove yourself but can be a huge liability if you are not ready for clinical residency and perform poorly.

Things that generally DO NOT enhance your chances of matching

Doing graduate degree work if you do not match will generally not help your chances of matching. If you can complete a graduate degree (such as an MPH), you may enhance your chances but most graduate degree programs close their application submission dates before you know whether or not you have matched. If you anticipate that you are not going to match, then apply for graduate school long before Match Week or you will find that you can’t get into graduate school. Additionally, you need to complete your degree before the clinical year starts after the next Match. This means that you have to be able to ensure on your next ERAS application, that you will complete all of your degree requirements by the start of your PGY-1 year. Again, if you know that you have a high change of not matching, get your graduate school application done ahead of time or better year, delay entering the match and just apply for graduate school outright (can’t do a Ph.D) but plan on spending no more than one year away from clinical medicine.

Hanging out and “schmoozing” with residency attendings if you are not in their residency program is generally a waste of time. Doing additional observerships (IMG/FMG) generally will not help you if you have done enough before you applied. Working in “research” will generally not help you unless you already have an advanced degree (MS or Ph.D)  or you are able to produce a major paper or article for a national or international peer-reviewed journal. When I say produce, I mean first author not just run a few experiments  or enter data. If you can get yourself on a major clinical research project where you are actually gathering some clinical experience, you can use this to enhance yourself for residency but you face stiff competition for these types of projects and you need an unrestricted license to practice medicine (difficult to obtain without a passing score on USMLE Step 3 + 1-2 years of residency training).

Summary

Making sure that you match requires a bit of strategy and planning for everyone but for some applicants it will be a difficult process.

  • People who have academic and USMLE/COMLEX problems will have even more problems getting into a residency
  • It is important NOT to rely on the SOAP as a primary means to apply to residency programs because you put yourself at a distinct disadvantage in terms of the number of programs that you can apply
  • You need to make sure that you are even eligible for the SOAP in that you have to have applied to the Main Residency Match (at least one program) and are fully or partially unmatched.

Learn as much about the process as possible as soon as possible. The decisions that you make in the residency application process can profoundly affect your career in medicine. Educate yourself about all aspects of the process as there is little room for error.

11 March, 2017 Posted by | difficulty in medical school, Match Day, residency, scramble | , | 1 Comment

The Rosary

I stood there at her bedside seeing the white rosary clasped in her small thin hands. In my church, we don’t have objects such as a rosary as symbols of our faith. Perhaps the Book of Common Prayer comes closest to a rosary as it’s ever present. In the cathedral where I serve, we seldom use the actual books as our services are printed each week for worship along with our hymns. Everything one would need for service is in one’s hand along with instructions as to standing and sitting ease for the many visitors each week. Still, having a rosary in my hand would be wonderful.

As I stood next to her bed, I watched her breathing slow down and become shallow; tangible evidence that her body was dying. On my late evening run, my thoughts were of where one “goes” at death. Perhaps one stays around those loved in life or perhaps one goes. My childhood visions of death, rising souls that are ghostlike but where does that essence of humanness go? As I settled into a chair, I touched her cool hand and touched the white rosary. I always sit with patients who have no family as they become my family. It is my honor as a physician to do so.

She wasn’t even my patient though I did serve in a consulting role in her care. I looked in on her only to be told by the nurse that “they” decided to do nothing. Well, I never decide to “do nothing” because there is always “something” to be done in patient care. I guess, I needed to care for this patient thus there I sat in a familiar role, caring for one who is dying and would die.

When I saw the rosary, I questioned how many times she had said the rosary. I wondered if the rosary brought comfort to this elegant woman. I wondered what the moment of my death would be like? Where would I go? Would I even go? Would I stay? My heart in tears but not sad. My tears are for the people who loved this woman; not here with her in her last hours and minutes of life as we know it. Still, her long fingers, draped by the rosary and her beautiful white hair brushed neatly from her thin face; still the rosary. I made sure that it stayed with her, in her hands as the nurses prepared her body for the morgue.

14 February, 2017 Posted by | life in medicine, practice of medicine | | Leave a comment

If I could change one thing in the lives of those around me…

I would ask them to stop comparing themselves to others. Don’t compare your grades, your scores, your running times or anything else to anyone except you. Strive to be the best you that you can be looking at the past for experience and to the future for achieving goals. In these days of social media, when everyone is busy scanning what others are doing on sites such as Instagram, Snapchat and Facebook, look only into the mirror and be content with the miraculous person that you see staring back at you.

Your wiles and abilities have enabled you to navigate your life so far. Your experiences can allow you to toss what doesn’t work and hold onto what does work. Your goals can give you a reason not to hit the “Snooze” button in the morning but they also give you a heading for progress. If you express gratitude for what you have learned/mastered and keep you eyes on your goals, there is little time for envy, jealousy and other negatives that can hinder your progress.

I always know that there will be others who are faster, richer, thinner, smarter and more beautiful that me. I applaud them, celebrate them but I am so grateful for being able to breathe air, run my race and figure out my “stuff” these days. I am healthy, happy and blissfully loving life as I touch my students and patients lives. In short, I connect with humanity and love every second of those connections as they come.

A great and free gift to all of us is the ability to look around and lend a helping hand to anyone in need. The greatest joys come from helping others without the expectation of receiving something in return. On any day and at any time, one can choose to change one’s thinking about any situation; reach out and just connect with those in need. In today’s world, the needs are great and dire.

So in the early days of this new year, look at yourself and be thankful/grateful while looking around to see who you might help at any moment. Wear a smile (cheap accessory) and savor every moment of life as they move by. These are free gifts!

3 January, 2017 Posted by | medical school, medicine | | 1 Comment

Time keeps moving and it’s is a blessing that it does keep moving.

In most places, we await the end of 2016 and the beginning of 2017. The passing of one year and the advent of another full of hope and promise for most of us. Still, nothing is new because time always keeps moving and everything changes often from one instant to the next. I have allowed this movement, this continuum to spur me to renew and reinvent myself without question.

This past year to my surprise, I embraced long distance running. My stress level dropped to nothing; my self-empowerment went to high levels. As I race along streets at 3AM, the only time I can get 1.5 hours of pure running into my crammed schedule, I do this movement for me and my sanity. I work on problems, I accept my world with joy and gratitude. This turns out to be a great way to get every day started and every challenge faced head on.

I will often mull some paper or new information as I tread along my winding path in my neighborhood near one the the Great Lakes in midwest United States. I can always hear the ebb and flow of the waves of the lake as I run along the beach; even if it’s too dark for me to see them. On a bright moonlit early morning, now long before sunrise on these shorter winter days, I love seeing my breath just in front of me.

Since I live in a suburban area, I seldom meet any automobiles in the early morning. If I meet anything, it’s a heard of deer grazing or a racoon crossing the empty street heading for the deep woods next to the lake. The deer ignore me but after spotting a coyote or two, I run with mace but still I run with emphasis and determination.

The thing about running, or even a brisk walk to begin your day, is that you can’t do these tasks for others. As a physician, my life and my practice has centered around being present to help my patients and students with solving their problems even if I ignore my concerns. With running, I do this for me and me alone; heady for non-self sacrifice. I think about me and how my middle-aged body runs faster and faster in the cold early morning darkness.

Daily running has a way of adding discipline into every aspect of one’s life. I eat healthy and clean because I know that high fat, high simple sugar foods will zap this burst of energy that running gives. I also forgive my occasional indulgence of beer on a non-practice evening because I have already run and exercised for the day. I also know that I am at my thinnest and lightest weight in my adult life; enjoying how well my clothes fit and how comfortable I am parking far from my destinations and hiking the extra distance.

The discipline that I have achieved with running, eating healthy and lifting a few weights has allowed me to keep a ready smile on my face and a song in my heart. I find that I simply enjoy interacting with my patients; joyful that I can help them feel better and meet the challenges of their worlds. This is some of the true magic of medicine that we keep learning, practicing and enjoying our art no matter where one is in the process. For many, just navigating the health care process is a source of added frustration and fear. Let your patients know that you are always the final common path for them as they place their health and trust in you; have their best interests in mind always.

As this year draws to a close, remind yourself of why you entered this profession and how fortunate you are to be able to help your fellow humans in any way small or large. Remind yourself that while this is a job for you, it’s often a change of life for your patients. Remind yourself that there is magic in empowering your patients; appreciating their fellowship and challenging yourself to be the best that you can be especially being authentic.

31 December, 2016 Posted by | life in medicine, medical school | | 1 Comment

We Do This

Last evening I was visiting with my classmates in one of the ministry classes that I am taking. As we moved through our discussion of our readings, my classmates nibbled on German Chocolate brownies that I had baked the morning before. I love to bake, therapy for this surgeon, as it is very nice to create something and watch other enjoy it. One of my mates produced a bottle of Benedictine with a supply of glassware; brownies and Benedictine!

One of our discussions in class centered around meeting Jesus. Quite an interesting discussion for a couple of physicians; two of us in the class. I related a story about one of my first patients that I treated as a medical student. This wonderful little patient was affectionately named “Ratso” by my supervising resident at the time. He was a patient in our Veterans Hospital coming in when his lung disease would get out of control.

“Doc, I was holding hands with Jesus”, he exclaimed to me as he began to respond to our treatments. He had been quite disoriented when his blood carbon dioxide level had achieved values that would be incompatible with life for most people. This patient not only had high levels, he turned the corner pretty quickly. “Yes, I will believe you saw Jesus”, I said to him as he clearly recognized me at last. I was seeing Jesus too.

So this is why I do this. For Ratso and the hundreds of others that I treat with care and love. Remember that what we do is like no other profession out there.

9 December, 2016 Posted by | medical school | , | Leave a comment

Some Thoughts for Those Starting Medical School this Month

As you get settled into your first-year coursework, I want to share some thoughts that come to mind:

  • Remember that you are fortunate to be on the doorstep of pursuing a magical profession. For everyone who achieves a seat in medical school, there are many who wish to be in your place. Honor them and remember them as you gather the knowledge that will make you a good physician.
  • Medicine is not easy, especially the study of the art of practice. There are many “all-or-none” tests along the way. There is a large volume of material to learn, master and apply to the practice of medicine and as such, you must make peace with that volume of material.
  • There are no “short-cuts”. This means that you have to make a concerted effort to be willing to take the long road. If you are looking for a short way around your work, medicine likely isn’t the profession for you. Get out early rather than later because medical school is expensive and quite unforgiving.
  • You are going to be working on people and not pathology. While pathology is interesting, always remember that the person with that pathology is loved by someone. Be willing to put yourself in the place of the patient or their loved one and treat them as you would wish to be treated.
  • Don’t believe what you hear but trust what you experience. Don’t go into any class or any rotation with preconceived notions of how it will be. Medicine is interesting and absorbing. Allow yourself to learn with a fresh approach and with fresh energy. While people who go before you will tell you horror stories about certain professors and certain subjects, it’s up to you to figure out and navigate them. You may be pleasantly surprised at how much you will enjoy this process.
  • Take some time to do something outside medicine at least once per week. Go to a movie, visit a museum or attend worship services. These outside activities keep your studies in perspective and keep your brain alive.
  • Keep yourself physically fit. Walk the stairs, take a 30-minute run daily and eat/sleep well. These physical activities will decrease stress and keep you healthy in the long run. Junk food, while quick, can make you overweight, sluggish and prone to picking up infections. Take time on weekends to prepare healthy (minimally processed) food and freeze it for ease during the week. You will save money, something that is always good.

Don’t forget to enjoy the process. Remember that you WANT to be here. Before you complain/gripe about something, try to figure out a couple of solutions or if the complaint/gripe is worth your time. If not, then focus on your studies and keep moving forward.

15 August, 2016 Posted by | first-year, medical school | , , | 1 Comment