Medicine From The Trenches

Experiences from medical school, residency and beyond.

Christmas 2014

This Year and This Time

As I sit here in my office, I want to share that I have experienced a profound loss in my life. I now, fully understand, how profound loss can be for my patients at this time of the year. When everyone else seems to be so joyful, a painful loss can zap every bit of the joy of the season and fellowship from the person who is suffering the loss. I am fully human and I fully understand life’s challenges but I am not immune from mourning.

I am meditating on Walter Anderson’s quote: “Bad things happen: how I respond to them defines my character and the quality of my life. I can choose to sit in perpetual sadness, immobilized by the gravity of my loss or I can choose to rise from the pain and treasure the most precious gift  have — life itself”.  I keep repeating this quote over and over so that I have some sense that I will be able to move past the holidays and celebrate the joy of others in this time of the season. I can say that right now, this is one of the hardest experiences that I have faced in my life.

My Shared Humanity

I know that many people are anticipating major changes in their lives at this time. Some people are nearing the end of the residency selection process (rank lists go in soon) and some people are eagerly awaiting that first interview invitation or medical school acceptance letter. If those things don’t come, there will be a period of mourning the loss of what you expected life would hold for you in the future that you envisioned in your mind. As Mr. Anderson so elegantly states, you can “choose to rise from the pain”, because loss of anything is so gut-wrenchingly painful.  I share these words with you because I am trying so hard to live them with my loss (and it’s so hard).
We are human beings and we will go through experiences in life. I have always been an advocate for learning as much as possible from those experiences, good or bad, as one is able to learn. We always hear, “how can you appreciate the good things in life if you don’t experience some bad things in life”? Well, those “bad things” hurt very deeply and I am going to say that I understand and share that hurt with so many people right now.

My Patients and My Medicine

I have always said that one of the greater aspects of medicine and its practice is that one can look around the hospital and see people who are dealing with issues that are far greater than any issues that you, as a practitioner, will have to deal with in your medical practice.  I want to also add that dealing with a personal loss can connect you with your patients in ways that are deep and profound. Medicine allows one to see patients in times of great sorrow, at the beginning of life and at the end of life. When things are catastrophic for our patients, we have to find ways of letting them know that we are connected to them; not suppressing our feelings and using outside means (chemicals, self-destructive behaviors) to numb ourselves of those connections. Yes, it sounds a bit “corny” but we, as good physicians, have to allow our patients to see that we are connected even in these times of less time spent with the patient and more revenue generated.

Trying to deal with Loss

To live life is to have experiences of loss. It’s the nature of life to have changes and those changes will deal with frustration, loss, joy and hope. Anytime one anticipates the future, there can be some change from that anticipated future that will involve a loss. With that loss can come mourning of what might have been but in essence, one only has the present. The past does not predict the future though when dealing with medical school acceptance (past grades) and residency selection (past board scores and medical school grades), it would seem that the past in inescapable.

If one does not find a residency or if one does not get into medical school, there will be a loss of the future plans that one has been anticipating. It is very understandable to mourn the loss of that anticipated future. It is very human to mourn the loss of that anticipated future and that humanity/humility is just the thing that will connect you with your fellow humans.

I applaud anyone who has never known loss as they are indeed fortunate but I would also say that never to know loss is never to be completely human.  I want my patients to see my human side and appreciate that I experience loss and hurt as deeply as they would. I want to be as human as possible and feel the joy with my colleagues and patients when experiences are going well.

Right now

Right now, I am meditating and writing because I feel that my experiences are worth sharing with my blog readers. I am secure in my role as surgeon and teacher but I have been shaken in my role as human being. I also know that it is up to me to find what will make me stronger so that I can get past this painful loss. I also know that this painful loss has made me a better physician/surgeon and my hope for the future is that my patients will see this in me. In this sense, I have been given a gift.

25 December, 2014 Posted by | medical school | , | Leave a comment

Residency Interviews and Choosing a Residency Program

Introduction

At this point, most people have completed most of their residency interviews. Many programs tend to go on “interview hiatus” until after the holiday season. At that time, there isn’t much time left to interview because rank lists will be submitted. Here are some things to consider if you have an interview coming up or you are trying to make a decision as to how to rank programs.

Interviews (What’s important and what is not important)

Once you have interviewed, you should make a point of sending out thank-you notes to the program director and the administrative staff that made your interview day a success. It takes a bit of planning and work to make sure that everyone gets interviewed and everyone gets a good experience. Be sure to let the staff and program director know that you appreciated their efforts on that day.

The next thing that you need to consider is if you want to go back for a “second look”. This may be most important because one has to remember that on interview day, your schedule is largely governed by the person(s) who organized the day. Sometimes it is good to have a look on a day that isn’t so organized. It’s also good to try to see what the department is like on a “regular” day especially conferences and educational items. These become vitally important as in-service exams are going to be coming up rapidly once you get settled into your program. All good programs will extend an invitation for a “second look” where you can get a chance to spend some long hours with the residents because they will be your colleagues.

Things to consider from your Interview Day

It’s wonderful for folks to rave about where they “scored” an interview and most of us are no exception to wanting to let everyone know that a high-powered residency program is interested in us. The first thing to think of is not so much the reputation of the program but your feelings about the program as you went through your interview day. How does the faculty and residency staff get along with each other? Do the residents look overwhelmed, especially the PYG-1 folks? Remember, you will be in their shoes in a few short months and looking weary at this point in the year is not great. People may be tired especially post call but they should not be exhausted and frustrated. That is a harbinger of a non-supportive environment.

Make sure that you look at some of the places that residents from your program of interest live. The program may be great but you have to have a safe and secure place to live and sleep. There are fabulous programs in older and larger cities but if you are in constant fear of your car being vandalized/broken into or your possessions being stolen, you are not going to perform your best in your residency program. Make sure you have a good idea of housing and its costs because your life is going to be the hospital and your home for the most part during residency. You won’t have much money for much entertainment other than sleeping in your own bed which needs to be secure and comfortable.

How did you fit in with the rest of the residents especially the folks who will be the chiefs next year? This is vitally important because you will be learning so much from your more senior residents. If you are not a good fit (you should have met some of them during your interview), then you won’t be a good match. Besides providing much of your day-to-day education, your more senior residents will become your colleagues and your friends. You want to make sure that you are a good fit with the rest of the crew so you can pull together for each other and help each other. Residency is hard enough without having to deal with personality disorders and problems getting along with your chiefs.

Your vital education

Yes, you made it through medical school but as most of us know, it will be your residency that determines your style of practice. You want to make sure that your environment is educationally supportive and conducive to learning as much as possible. Is there protected time during conferences? Are the conferences well organized and informative? (It would be good if you had a chance to attend some of the conferences during your interview).

If you observed that the residents spend too much time taking care of patients and “extending” the attending physicians, at the expense of their education, then you may want to consider ranking another program. The best programs make sure that residents have ample opportunities and support for educational activities (good library and protected time during conferences) as well as good resources for research (vitally important if you are interested in fellowship).

Your professional development

A good residency program will have faculty that is interested in your professional development. It’s great to have an assigned mentor and supportive faculty. I can say that my assigned mentor had very little in common with me during residency but I found plenty of “unofficial” mentors in the faculty that were priceless. A mentor does not have to be in the same area of your main interest but it helps to find at least one faculty member that can guide you along with your chief residents. Usually the best faculty members for mentors are the new faculty who are close to their training. They have the latest information and educational strategies, thus it is good to seek them out for guidance.

You want to look at where graduates of a specific program wind up. There should be a good mix of general practice folks and fellowship folks from your program. Not everyone wants to enter a sub-specialty but the option should be there should you find that this is your aim. You should have spoken with the folks who are the present chiefs so that you can get an idea of where they will be headed next year.

Consider how you were received by the faculty that interviewed you. I can tell you that one person who interviewed me, spent most of my interview time on the phone dealing with a personal matter. This is not a good situation and I requested to be interviewed by someone who wasn’t so distracted. I thanked him for his time but I also felt that if he couldn’t give me his attention for a majority of my interview time, then I needed to be interviewed by another person. Fortunately for me, that program was not high on my list of places that I wanted to match.

Some final words…

If you are at this point and you don’t have at least 10 places to rank, you will likely have a difficult time matching. Remember that many people will go unmatched because the number of medical school graduates has increased but the number of programs has stayed static. If you find that you don’t have enough places to rank at least 10, then you need to have a solid plan for getting a job if you don’t match. Now is a good time to work on that plan because there just isn’t much interview time left before the rank lists go in.

You also need to look at the Supplemental Application Process (SOAP) which is not a “scramble”. You should not rely on this process for finding a job as the number of places that you can apply to is limited. Have a back-up plan should you not find a position in the SOAP or match outright.

Be sure to consider your competitiveness within the context of the people that interviewed with you. It’s great to shoot for a “dream” program but make sure you realistically rank programs where you would be a great fit.

10 December, 2014 Posted by | academics, applying for Residency | | Leave a comment

The Advent Season, a time to prepare for that which is “coming”.

Advent 0r a time of that which is to come

As I write this, the Advent Season begins in many of the western churches such as the Roman Catholic Church. The word “advent” mean “coming” as many who celebrate the season prepare spiritually for the coming of Jesus Christ. This does not mean that one has to be a christian or spiritually prepare for the birth of Christ but one can use the season to spiritually prepare for the new year and all of the possibilities that it will hold. For most of us, the Fall semester has (or is close) to coming to a close. This means that the Spring semester will be coming after the Christmas/ New Year holidays/recess and there is a chance to begin again. Anytime one is given another chance to begin (in my case to reinvent myself), I always think about taking advantage of that chance.

If you had some difficulties in your previous semester (academically or clinically), take advantage of the decorations and the festive atmosphere around the school (or hospital) to think of things that you can change in your approach to your work. If you want to change anything in your life, you have to change yourself because you have control of you and your thoughts. As I have stated in many previous posts, it is always easy to focus on the negative but you can change your focus to the positive and build upon the positive. If you struggled, you probably did far more things and tasks correctly than incorrectly. Think of your incorrect tasks as opportunities to learn and put them in the most positive light. If you compared yourself to others, then change your thoughts to comparing yourself today to yourself even yesterday rather than to another person. You can’t know the thoughts and feelings of another but you do know your thoughts and feelings thus put your focus there instead of wasting precious time and energy trying to deal with something you can’t influence.

As the season unfolds

Make a list of things that you feel you would like to change and put them in an order that will allow you to take them one at a time. Again, don’t just throw up your hands and say that “nothing worked well” but take an honest appraisal/ inventory of what worked and didn’t work as you make your list. For example, as I study and prepared for lectures, I ended up with a pile of books and papers stacked on and around my desk. My first task is to put order in my work space starting with the top of my desk and then filing all of those papers that I won’t be using the next semester. If you can get one area ordered and uncluttered, that usually means that you can focus on another small area and soon you will have an orderly and efficient space to begin the next semester’s work.

I have also made a small list of  things that I want to accomplish in the upcoming year. Under each of those things, I have put the smaller steps that will lead to the accomplishment of my larger goals. One of my goals is to eat more fresh and unprocessed foods. While this means that I will have to make some preparations each week so that I have fresh fruits and vegetables available for my meals, then I have made a system to make sure that I purchase what I need on a weekly basis rather than just dashing out of the door in the morning and relying on the hospital cafeteria for food (processed, high-fat).  I know that I have far more energy with a diet that is higher in vegetables and fruits (raw mostly) with less meat and nothing processed.

Another goal is to begin something called centering prayer. I have been practicing daily mindfulness but I wanted to incorporate my western faith into my eastern practices. In short, I have found that when I am still and quiet, I have gotten to know myself and to change myself from with. Advent represents a positive beginning for me thus I want to incorporate change in my spiritual as well as my physical self. I have recently been reflecting on doing things that can allow me to be more open to listening and contemplation. For me, listening and contemplation are the most important elements that I incorporate into my practice of medicine; integral to my practice of medicine. These are elements that I find that I must constantly work on and refine. These elements lead me to the observations that lead to my best decisions.

Taking a Step Forward by Standing Still

It often seems that there are a thousand tasks demanding your attention in your processes of daily living. Often many of these tasks are done with multitasking which means that you are not giving your total attention to one thing at a time. I would invite you to be still and live in each present moment rather than trying to analyze the past or the future. If one takes each task for what it is, the future has a way of working itself out in surprising ways. For example, I had been listening to my favorite band (Pantera, specifically Vulgar Display of Power) with a focus on each instrumental element of each song on the album. Every time I listen for an specific element, I find something new in the music which is why I enjoy metal for the most part. No, metal rock isn’t for many people but it adds much to my contemplative life these days. By standing still and appreciating every element of this complex musical genre, I have great admiration for this talent.

In this holiday season, the opportunities are often there to take the time to appreciate those that you have worked with or not seen if you have been away at school. This is one of the best parts of the holidays because you can express your appreciation for those many little tasks done by family, friends and coworkers that have added to the richness of your life over the past year. For me, the ladies in environmental services always leave an extra comforter in my call room which is the most welcome item when I am cold and tired during a busy weekend of call. I make sure that I leave something for all of them to share (this year it’s fudge) because that comforter makes me feel appreciated in a very tangible way. It’s such a little element but it means so much to me. Be sure to take time to thank everyone from your loved ones who miss you because you are away long hours to those folks who keep the call rooms comfy to the Pharm D’s who happily answer my questions and offer excellent suggestions. Take the time to stand still and think of all the folks who keep things going for you.

Medicine gives you more than you can ever give back

This season is a great time to think of why you seek to enter or stay with this profession. Just this past week, I found myself attempting to explain the special, almost sacred, relationship that I have with the patients that are under my care. One task that has fallen to me from time to time has been attending to people who are at the end of their life. I have always been able to never allow any of my patients to die alone even if I am the one that sits at their bedside. From the first death that I pronounced to the last that I attended just a few days ago, I have always made sure that someone was present with a person making the transition into death. I can say that bearing witness to a person dying allows me to see the dignity and wonder in being simply human.

The contemplation of Advent, that is the arrival of the season, the end of the year and the beginning of a new year is a great time to think of ways to get back to that which is so special about this profession. This profession is far from perfect but it allows a window into some of the most basic and intimate moments of our patient’s lives both sorrowful and joyful. It should never be “lost” in the performance of those thousands of tasks of the day in and day out practice that it is because of the role that we play in our patient’s lives that our life can become enriched.

6 December, 2014 Posted by | medical school | Leave a comment