Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Heading into Residency!

It’s that time of the year when many recent medical school graduates are in the heat of getting things organized for the beginning of residency. Residency is the next phase of medical education in the United States and as such, is a period of rapid change and learning. You will be fairly independent in your care of patients; studying in a different manner from your medical school coursework but definitely getting your style of learning and practice honed.

This is a time to drop any pretenses of being the perfect “intern” and let yourself learn and absorb as much knowledge from those in your program who are more experienced. If you have traveled to a position that is different from your fourth-year medical school hospital, you have to learn how the place works as well as how you will work within your locale. When your ward work starts formally, you want to have your organizational system in place, know your way around and have your most important home location settled and ready.

For example, you should have made sure that all of your training licensure materials have been taken care of. You need to make sure you have your paperwork completed long before your program starts “New Resident Orientation”. There will be many details that need to be presented thus you don’t want to add to things by not having your paperwork completed.

For many, USMLE Step 3 will come into play rapidly. For this exam which becomes something of a nuisance for many, myself included, you have to have a date in mind to complete this test. For my residency, which was in General Surgery, I knew that my in-training exam was in January, thus I set a goal of taking Step 3 within the next two months after my in-training exam. I knew that I wanted to place most of my emphasis on my surgery exam, thus I dedicated about 30 minutes per day on reviewing my medicine for Step 3. I set this schedule into my schedule of reading so that it became a habit.

In terms of reading, I asked my second-year residents which books and papers would be best to start my reading for both my in-training exam and Step 3. Again, I wanted to rely on the experience of those who were immediately above me in my program. I also sought the wisdom of my faculty adviser in my baseline reading too. If there was anything that I didn’t count on, it was that I wasn’t able to set up a regular physical conditioning program, something that would have made my PYG-1 year more efficient.

In other posts, I have emphasized the importance of taking care of your physical conditioning. Not only is being in good shape helpful for stress-reduction, good conditioning is most helpful on those very long nights when call seems to go on forever. If you are in good aerobic condition, you perform better even when you are exhausted. Figure out a way to eat well, low fat and low sugar foods along with doing at least 30 minutes of aerobic exercise five to six days per week. Your rest and your brain with be grateful.

If you haven’t figured out how you will keep track of your patients, look into any system that might work for you. At this time, you can do a little experimentation and make adjustments when you begin seeing patients. I had to alter my patient tracking system from the one I used as a fourth-year medical student because my residency hospital patient tracking/health record system was different. It’s easier to make adjustments than find yourself overwhelmed because you didn’t have a system to begin with.

Make your home your sanctuary of solitude in any way you can. For me, my solitude involved investing in dark curtains in my bedroom that I could close on a bright sunny day post call. I found that I needed the darkness and cool for rest and relaxation. I also found that I functioned best post call when I didn’t encounter another human being for a few hours. Figure what works best for you and stick to it.

I made a schedule for my post call days so that I could do routine chores such as laundry and grocery shopping as part of my relaxation. Grocery stores that were open all night became wonderful for me. I planned my menus for the week, cooked on weekends that I wasn’t on call and kept my freezer stocked with meals that I could pop into the microwave rather than hitting the fast-food establishments. I have continued this practice even today because as I have aged, good nutrition is very important.

I used one of my spare bedrooms as an office. In my home office, I kept my textbooks, computers and study materials, much as I had done in medical school. Since I kept a regular reading schedule, I checked off book chapters and topics as I completed them. Even with a regular reading schedule, I always felt that my fellow residents were better read than I was, even though it probably wasn’t the case.

Finally, I had to schedule in time for my friends and family. Residency is a very hectic time but family/friend time is as important as reading and study time. Most Sundays, if I was able, I attended church if for no other reason, to thank my Higher Power for giving me the strength to stay on top of my work. Find a religious institution in your location and attend once in awhile if you don’t belong to any particular religion. It’s just another outlook and fellowship with people who are likely not hospital folk-good for your brain.

My favorite hobby, outside of sleeping on my rare days off, was going to the movies. My restless brain needed to enjoy some pure entertainment. While television can be tempting at home, especially since you can be in your “jammies”, it was better for me to get out of the house for a couple of hours and watch a movie or attend a concert. Football, lacrosse and soccer were also great getaways for me too.

In conclusion, residency is going to be a time of learning, reading and stress. Most of the stress will be self-imposed because any new situations are stressful for most humans. You will be learning about your patients in depth, trying to anticipate their needs and keeping your senior residents/attendings up to date on how you are caring for the patients on the services.

Again, try not to take yourself too seriously in terms of forgiving yourself for making mistakes but learn from those mistakes. The people who are more experienced on your team only expect that you do your share of the work and that you learn from your mistakes. It turns out that this is a great way to learn what you need and sets you up for getting the best experience for your program.

17 June, 2017 Posted by | intern, life in medicine, relaxation, residency | | Leave a comment

One Week to Go to My First Marathon

What have I learned about myself? With every mile that I have run in my training runs, I have learned that I have a mental toughness that I found quite elusive a couple of weeks ago. Now, I have learned to face my mental “demons” with calm reserve, much the same as I approach a difficult case or patient.

I had found myself sinking, for lack of a better word, into a spiral of self-doubt and mental vulnerability. My mental shenanigans cost me a wonderful friend but I now move forward with every step and pick up the pace without fear. I can’t reason why I spiraled a bit over my academic work but I did and it’s done. From here on out, I deal from a position of strength rather than questioning myself and my motives.

This past week, I have had the pleasure of thinking long and hard about my medical and academic career. After many years of practice, I believe that self-examination is not an entirely bad exercise but I have also learned that I cannot ask anyone else to “walk in my shoes” or “understand” the things that can send me into self-doubt. My questions were not about my training or my ability but about how I handle adversity in matters that I didn’t fully understand.

Yes, I have plenty of regrets that I lost the friendship of a gifted colleague but I discovered new insight into myself and new support from unexpected colleagues and friends. I took the time today on my last long run, to think of each of my friends and thank them as I ran. I am very grateful for their friendship and I know that I will continue to move forward professionally and personally.

I thought about setting goals and achieving those goals. Certainly, there is no guarantee that I will finish my first (and only) marathon race next week but I feel calm and physically prepared. Mentally, I am in a state of surprise in that I have been able to train for this race and that I will have the toughness to make the needed adjustments to my pace and form that will allow me to complete the distance.

This training has make me something of a philosopher in terms of what I see and hear around me. I have taken great pleasure in simple things like a wonderful warm shower or that drink of water when I have pushed myself to the brink of dehydration. I have tended to avoid the “sports” drinks because I haven’t felt the need for sugar/salt loading. Plain water, not too hot or too cold, has been my best friend.

My training has increased my need for rest and sleep. For most of my career, I have had a love/hate relationship with the number of hours of sleep that I require. Most days, I cannot sleep more than 5 hours but with my increased running mileage, I have moved into the six to seven hour range. More sleep has allowed my body to rest and heal for the pounding that the increased mileage required.

With the end of the school year, I am looking forward to taking a week or so off and heading to California for some much-needed relaxation. I love being near the Pacific Ocean, smelling the salt in the air and just watching the fog cover the Golden Gate Bridge from the deck of where I stay in the Bay area. I have also completed my longest and best runs up and down the hills of San Francisco, a place of unrivaled beauty and wonder.

Finally, I know that I cannot be “all things to all people” and I just need to let things fall as they will. For a surgeon who is quite used to affecting something definitive in most cases, letting go is a new feeling for me. Most of the time, things just work themselves out and I am the instrument. This has been the best part of my marathon training; seeing how I am an instrument of my training and experience.

This training for a marathon has been something of a metaphor for life for me. I set this goal and I have made some progress toward it in some manner over the past year. Though I didn’t reach the distances that one typically associates with distance running, I am very grateful for every step as I have moved along. Yes, I know I am a very secure middle-distance runner but stretching the distance has been good experience for me. With the stretch has come great self-knowledge.

 

8 May, 2016 Posted by | medical school, medicine, practice of medicine, relaxation, stress reduction | , | Leave a comment

“It’s not a sprint, it’s a marathon.”

I am in the process of training for my first marathon. As a middle-distance runner at university, I always toyed with the idea of running 26.2 miles but after running a race of 10 miles about 20 years ago, I discovered that I didn’t enjoy running after the 8-mile mark. This put running the marathon distance on my “back-burner”, so to speak. There the marathon goal stayed until the idea surfaced about 4 months ago when I began running again for physical conditioning.

After graduate school, I attended medical school and found that I didn’t have much time for running as study was my constant companion.  If I had been wiser, I would have carved out time to keep up with my running, even 30 minutes three to five times per week, thus I would not have gained weight in medical school. My medical school weight followed me through surgery residency and fellowship. I kept promising that I would “get in shape” but never quite put a sound schedule together.

Well, after many years of practice and my sister’s wedding-photos of me were terrible, I decided to revisit getting in good physical condition. Since my weight slowly crept up to the heaviest that I had weighed in my life, I made the decision to lose a few stones so that my knees would hold up in my recreational rugby play. I kept up with my weight-lifting but my cardiovascular work was lacking in a major manner.

In the back of my mind, I knew that my knees would not want me to start out running, thus I began walking at least 30 minutes per session. I used my walking time to meditate (and pray) largely for stress relief. I had found that while lifting weights did relieve some of the stress, I missed running. I decided that I would attempt to get back to the point of being able to run a 10K if the opportunity presented.

Along with my dedicated walking, I changed my diet to no fried food, no candy, no processed food and certainly no “junk food”. My dietary habits were probably the easiest part of my journey because my wise sister had always been a great example for me. She simply doesn’t eat food that her precious body doesn’t deserve. She always said that it was better for her not that eat food that was processed. As I visit her often, I found that her consumption of fresh fruits and vegetables along with lean meats was a good strategy. She is lean, strong and wonderfully alive.

Soon, I found that by eating three nutritious meals with proper portion control, my weight was dropping. As I lost weight, I became faster finally able to jog and then run. Three weeks ago, when I was in beautiful San Francisco, I broke the 20-mile mark running those delightful hills as my training. It also helped that I have a wonderful colleague who was a world-class marathoner, until a devastating knee injury, but still maintains that wonderful thin body build of a marathoner. I envy his metabolism but he’s a great resource.

Today, I am many pounds lighter and running daily runs of 10 miles with great joy. My stress level is zero; my mind calm and at rest, my body continuing to thin out as my distances increase. While I am a bit worried that I won’t be able to finish the 26.2 miles, I keep running and keep running. I set the goal of completing a marathon and I work toward it daily by running, stretching and weight training also with keeping my diet sound. In short, I understand the concept of a “bucket-list” and I hope to mark “completed a marathon” off my bucket-list.

Another benefit of my running and weight loss is that people who haven’t seen me even as short as one month ago, barely recognize me. I have to say that losing enough weight to become unrecognizable is a wonderful benefit of this training. The only downside for me is that since I suffer from a hemolytic anemia (same as my father), I have to keep an eye on my blood counts. So far, even though I can chew red cells on my long slow distances (LSD), I remain asymptomatic. I can also indulge myself with an occasional beer or glass of wine without thinking about calorie counting. I have learned to savor those little treats of Sam Adams or Cakebread Chardonnay, my rewards for training hard.

Setting a long-term goal, working/training for that goal and getting that goal accomplished are items that are very nice for spiritual growth. Stress-reduction is great for intellectual and physical growth. In short, training for this marathon has been a great learning experience for me physically and intellectually. I can’t say  with certainty that I will finish those 26.2 miles but I can say that the journey so far, has been very positive. I am stronger and more resilient in all aspects of my life as my marathon training has spilled over into my academic and clinical practice making me calm, positive and accepting of things as they come, one step at a time. All in all, not bad and quite joyful at times. Bring on those 26.2 miles!

10 April, 2016 Posted by | life in medicine, medical school, practice of medicine, relaxation, stress reduction | , , | 2 Comments

Achieving a balance

Introduction

As I write this, my career has been shifted into a higher level of comfort. I have spent the years since graduation from medical school and residency honing my surgical skills and the craft of taking care of patients. If anything has suffered in the task to become the best physician that I can possibly be, it has been my personal life. In short, it became easy to head off to the hospital or university rather than deal with things in my life that just were not working. Well, working in medicine has a way of making one reflect on what is truly important and making one move past things that are not a good fit for life.  I had decided after ending a relationship that had somewhat sustained me through medical school and residency, that I would throw myself into my work with vigor and a quest for self-discovery.

Make a definition of your “complete” life

I always knew that I was a person who saw the miraculous in all of medicine and humankind. I am just an instrument for our creator does the actual healing. You can call the creator anything that you like, God, Mohammed, the Great Spirit but positivity and balance have a way of forcing one to move along on a plane that is stable. One gets used to “death” as part of “life” and one can sometimes feel how to be aligned with the universe in one aspect of life but “going through the motions” in another aspect of life. So it was with me and I attempted to fill in my “gaps” and “blanks” with interests, flying, sailing and so forth. Being above the earth or on the ocean/lake can allow one to exhale and just marvel at how wonderful the world is at times. I also knew that I wanted to share the miracles of my life with another soul; as a human we all reach out for intimacy in some form. We can have a close friend or we can have a significant relationship (marriage) that allows us to find that person who can help us complete our mission in life. At times, I believed that I needed to work on myself and put all parts of my life in compartments so that I could achieve a close bond with another human that doesn’t mind that I sleep on my abdomen hugging a pillow and look like a “street urchin” in the morning after my nightly pillow fight; that my phone frequently rings all night if I am on home call; or that I might be away for 30 hours straight taking in house call. These are the realities of being in a relationship with most physicians and certainly with a surgeon. I can also add the time that I must spend in reading and study to keep up with my craft. In short, any person who is involved with a physician needs to see that they won’t have 100% of our attention all the time but when we are “with” you, we are 100% committed and need you like we need oxygen, food and water to live. My definition of my complete life was to meet and find a person who could be my friend first and perhaps more later. The inhumanity that is sometimes represented in my trauma bay can color how I look at relationships between humans. Domestic violence is very difficult to deal with but deal with it, I must and I must have a place in my mind that allows me to give my best treatment to the victims and sometimes to the perpetrator too. I am not the judge but only an instrument to an end point – getting that person back to health and solving health problems. My complete life has to allow me to find that person who can allow me to complete my “mission” on Earth and I complete them.

What I tell myself…

I had told myself that my life could be complete and satisfying with a job well-done. I would enjoy “discovering new truths” in my research and writings. I would enjoy hearing the successes of my students and colleagues. I would have a rich and satisfying career giving back with my skills and teaching. Yes, my life was indeed full but not complete. I didn’t have that intimate relationship that adds the depth and richness that just needs to be there. And so I was going through my career, happily enjoying my friends, colleagues and adventures in surgery, medicine, flying and sailing.

No, one can’t plan everything…

I was happily moving along with the things that occupy my time. I decided to do some exploration in trying to reach out and expand my circle of friends. It’s good to be a trailblazer in some aspects of one’s life. I have always challenged myself to take some risk with something at various times. I took a risk and was happily enjoying the experience when a man reached out to me in a most unexpected manner. There was something in the things that he shared so readily with me. He knew that I was a physician/surgeon yet he said that he saw something that drew him to me. At first, my scientific training kicked in and I attempted to define what was going on here; I ran in the opposite direction. Well, there is no definition but only that one has to have the courage and sometimes the faith to know that your instincts are correct (much the same as how I treat a critical patient). In short, life does not always come with clear directions. I have been in uncharted “exploration” the past few weeks and it’s been both exhilarating and unnerving at the same time.  Here I am in a relationship that I can’t plan or define and suddenly my life that I thought was so full, seems empty before I was able to get to this point.

Why this is so vitally important…

In order to give our best to our patients and colleagues, we have to give our best to ourselves. My best now includes a very brilliant environmental engineer (he can’t stand the sight of blood) who inspires me to reach higher and further in all aspects of life. Suddenly the things that gave me immense satisfaction go beyond that and give me immense joy at the same time. I smile and laugh with my patients, my students and my colleagues. In short, he has made me a better and more fulfilled person. The only downside has been that my favorite OR music has moved from my signature “thrash metal” to a bit more “smooth jazz”. For those who work with me, that’s a huge change but they secretly like the music change. I am not playing as much Pantera or Goatwhore in the background. As you move through your university work and your preparation for medical practice, one has to have the best of humanity brought out from within themselves. To be able to give my heart, a myocyte at a time to this environmental engineer who can’t even see my lectures without getting sick, has made me a better surgeon, physician and human being. One simply has to find balance in all things in life and not shut off any part of life to focus on other parts of life.

10 October, 2014 Posted by | organization, relaxation, stress reduction | , , | 5 Comments

” Not because they are easy, but because they are hard..”

“We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.”  John F. Kennedy at Rice University on Sept 12, 1962.

Introduction

Why choose medicine (or any profession in health care) if the work and preparation for that work is so hard? I asked myself why I spent hours in chemistry, physics and biology lab when my friends who were business and marketing majors were spending their weekends enjoying the club scene and knew the latest shows on the telly? Why was I putting in the hours making sure that my organic chemistry lab reports were accurate and complete? Why did I choose to study advanced applied differential equations, multivariate calculus and higher algebra (math minor) when I could have stopped with integral calculus? In short, why did I deliberately choose a rigorous college education in math and science where I demanded only the highest performance from myself when I could have taken a far easier route? The answer for me was pretty simple, “I had to know how things worked” and setting a hard goal energizes me and my skills.

Yes, my majors in undergraduate were considered difficult by some people but they were sheer heaven for me. Every minute that I spent in lab and applying math theories was not a chore but a pleasure. I had always loved to “figure things out” and I had parents who challenged me (and my siblings) to always do our best work no matter how many hours the job would take. From undergraduate to graduate school (I was a research scientist before medical school), I could focus in on a problem and see many alternative methods to solve that problem. I wanted to explain mathematically, how energy from a laser was transmitted via a heavy mineral acid matrix to a delicate protein in order for that protein to become ionized. I wanted to understand the mathematical model for that phenomenon and others. Fortunately for me, science allowed me to go where my mind could take me and then some.

So what does that mean in terms of medicine? This means that all of my previous studies from primary school to secondary school to undergraduate university to graduate university and medical school are all aimed at understanding why and figuring out how things work especially the human disease phenomenon. One simply has to have a grasp of the whole picture and the whole person in order to have a strong perspective as to how to best help that patient. Medicine is not like business in that one can take a “shortcut” and still get to goal. Medicine is like preparing for a marathon or to lose 100 pounds in that one has to see the long-term goal, work constantly and consistently at a high level and one has to remain vigilant or the goal slips away. This doesn’t mean that the path toward the goal isn’t pleasant because the journey is great fun but the most enjoyment comes when one sees how building upon a knowledge base and application of that knowledge base actually solves a problem for a patient.

I remember spending hours as a third-year medical student in the anatomy lab as I was perfecting my suture techniques. I sutured the skin of cadavers much to the chagrin of the first-year medical students who had spent hours removing or dissecting that skin. I would come into the lab before my surgical rotation started (I was there at 3AM); practiced my suturing and tying techniques and was off (smelling of formaldehyde) to write my morning notes before rounds. Yes, it was “hard” to get up on a cold and snowy morning when it was dark outside and head to a cold anatomy lab with cold steel tanks all around. No, I didn’t “have to” get up early and practice my suturing and tying but after I knew that I wanted to be a surgeon, I knew that I had to put in the time and hone my skills.

When I was in the hospital on overnight call, I went to the library and read about my patients’ problems. I refreshed my knowledge of pathology, I reviewed every medication that they were on and I made notes of how the disease process should progress. Was this easy? No, it was far easier to grab a nap because the Trauma pager would be going off practically continuously after 9 PM and I would be in the emergency department almost constantly until 5AM when it was time for pre-rounding. I learned to cat nap on call (sleep no more than 20 minutes), read when I was exhausted (putting my feet up was better than sleeping for hours and hone in on a surgical procedure while the rest of the world slept. Was it easy? No but I had set a long-term goal for myself and I was determined to get the job done with the same work ethic that my parents instilled from day one.

Conquering Hard Goals

Excellence becomes a habit if it is practiced on a hourly basis. This was the first thing that my parents instilled in me. When self-doubt creeps in and procrastination begins, remember that you can turn around your thinking in the next instant. Why is it so easy to NOT do something well when it is just as easy to DO that something well? There is always more than one way to do anything and any method that one chooses that brings about excellent results that are safe and ethical  is the method to accomplish something. In one’s academics, there is little time to spend on “thinking” about how inferior/superior you are in relation to one’s peers if one is constantly striving toward a long term goal of consistent excellent performance. This doesn’t mean that one wastes time on being “anal” or a “perfectionist” because these two traits carried to an extreme waste too much energy. Consistent excellence means building upon a foundation and linking prior knowledge to present knowledge to setting the foundation for future knowledge.

Sometimes one needs to get a different perspective. If you are finding that you are “spinning your wheels” on a task that seems insurmountable, break that task into more manageable pieces and tackle each one in turn until the whole task is done. Again, if you have 100 pounds to lose, you have to lose that weight one pound at a time. You can’t spend time hating the process (takes away from time that could be better spent working toward the goal) and you can’t afford to indulge in self-pity “Why is it so hard for me and so easy for everyone else?”. In short, your goals and challenges are unique to you and trust me on this one, everyone has goals and challeges that you may or may not be able to see or appreciate. You are no lesser or no greater than any person around you but you can make better or worse decisions as to how you will handle your challenges and goals.

Look from a different perspective

I have been fortunate enough to have spent some quality time looking at the world from the cockpit of my small plane. When I need to put a problem or goal into perspective, I head “up top” and look at the wonders of the world below. When I fly in a commercial airliner, the world below is much smaller at 37,000 feet (on a clear day), than at 3,000 to 6,000  feet where I can mentally interact with things below. The people below are not insignificant at that altitude and the world below becomes more than just the day in and day out tasks of getting things done. In short, find something (for me, it’s flying) that can take you out of your world for a short period of time and help you refocus. For me, flying takes focus and concentration but the pay off is worth the effort. It’s a challenge for a person who thrives on challenge.

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You can see the goal (the runway) down there and you can take the steps to line up and get down there to that runway. Flying for me, is a metaphor for meeting the challenges that I encounter on a daily basis. Again, I learned to fly not because it was easy but because it was a hard challenge” that it “serves to organize and measure the best of (my )energies and skills ” and it allows me to accept, willingly, other challenges (not postpone them) that I meet in life.

14 December, 2013 Posted by | organization, relaxation | 8 Comments

I just gotta have it!!!

I have been reading Brian Ambrozy’s review on Short Media about the Sumo-Omni http://www.short-media.com/articles/sumo_omni chair/lounge/i-don’t-know-what-to-call-it/thing and I must have one. As one of his children describes it, this is a “nest” that can be tossed from place to place with impunity. I just have to get one of these to fall into after a long day in the hospital. Take a minute and read Mr. Ambrozy’s review and savor the possibilities???

As I see it, I can survey the X-Box 360 from my Sumo-Omni or just park it in front of my patio door (removing a couple of beagles) and enjoy the afternoon sun on a lazy Saturday. I am also expecting that I will spend a fair amount of time removing the beagles from the Sumo-Omni so that I can hang out in this thing. Likely, I will end up buying one for them and one for me. In short, I am about to spend $260 on a couple of beanbags but as I see it, a great investment in getting myself “back to the womb”.

Why am I mentioning this? Because one of the greatest lessons that I have learned is that after spending days in the hospital, coming home and tossing myself into a Sumo-Omni with abandon is just my idea of heaven. Keeping some sanity in this profession is all about doing little “nice things” for yourself regularly. This is a $130 daily vacation complete with sunlight on the weekend. Who know? I might have to import this thing into the Chiefs Den for catching a nap between cases.

24 February, 2007 Posted by | on-call, relaxation, Sumo-Omni | 2 Comments