Step 18 of becoming a doctor, wade through the bullshit

I'm interviewing for residency right now and it's a bizarre process.  I'm applying into neurosurgery and surprise! it is a 7 year, "88" hours a week, 5am to 8pm on an easy day, work your ass off residency.  Turns out people want neurosurgeons to train kinda hard like.

So going through this interview process is a strange trip.  On the one hand, most good applicants get a program in their top 3 choices.  That's pretty comforting.  In fact, by far the most common scenario is to get your number 1 choice.  And more than that, most people like their home institution and their home institution has interviewed them for the 4 years of med school (particularly in neurosurgery where people start from day 1 walking around introducing themselves as, "Hi, I'm JohnI'mgoingtobeaneurosurgeon, what's your name?"), so it's sort of clear that it's a mutually beneficial situation and a bit of a lock.

However, there are political games galore, lying, applied game theory, and tons of horror stories of the "locks" at Home Institution University ending up at Third Best State School in the Region University.  So everyone gets very nervous, no matter how good an applicant and develops a self destructive habit like alcohol abuse or watching Whitney.

A common question at this point is, "well what's wrong with Third Best State School in the Region University, won't you still be a neurosurgeon".  Yes, and likely a well trained one.  Still, 7 years, working that hard with 7 to 21 other people (most programs take 1-3 residents a year) is just not a flippant choice.  It's like trying to pick the best prison for you.  Which penitentiary has the coolest inmates?  Who's the best Warden? Where do they give you the most time for arts and crafts, but still enough time to read?  How much outdoors time do you really get?  You can't switch residencies (or rarely) and you can't speed it up.  At the end of the day, we will all be rehabilitated and ready to re-enter society, but you still want the best prison possible.

Let the games begin!

Let's smoke pot and play computer games

There are some words that are just about impossible to say cooley (like, "cooley").

Try to talk about marijuana and sound cool.

"We are going to go smoke some pot".  Thanks for the update, Baby-boomer.  Let me know how groovy it is and if you guys are going to the Simon and Garfunkel concert later.

"Those guys are going to eat weed brownies".  I hope they get a glass of milk with those and don't stay up too late watching Animaniacs, they have a big homework assignment due at the end of the week.

Using a desktop is another one.

"Let me just write this down on my PC".  Oh right, take whatever time you need to write on your "Personal Computer".  Do you think you can get me a copy with your Dot Matrix Printer, or better yet, Fax it to me.

"I have a desktop".  Cool dude, can't wait to come over and play computer games.  Should I bring a joystick so we can both play Civilization or SimCity 2000?

I've just started saying, "I don't have a mac".  That basically answers people's questions.

So you want to get into med school...

I often get asked how med school and residency works.  It's not really clear or intuitive and most people get their information from extremely accurate TV shows like Grey's Anatomy and Scrubs.  As someone who finally understands it, and I can assure you I did not until probably this year, let me do a bit of explaining.

For pre-med, I've given a decent explanation here, so I'll leave it alone.  I'll move on to first year.  This year is all about minutia.  It has been said that you spend the first year learning a language, and that is more or less accurate.  Particularly first year, your life is to learn basic science, basic science related to medicine.  This is like getting hired as a lawyer and then being asked to spend a year learning how books get made.  You learn new fancy words, with no idea how to use them or what they really mean.  You hear about things that sound important, but don't really exist.  The kind of thing where your attending* sees primary syphilis and is like, "It does exist!", and he's been doing it since the pre-antibiotic era. You definitely learn a lot, but it's mostly useless or won't stick. The major utility of this year is to drink and hook up with your classmates.

The summer between 1st and 2nd year is the only summer med students get.  This is a hard concept to understand for the rest of the working world, who assumes school is school and schooooooooool's out.for.summa! It's not.  And most people work this summer, doing research.  Lawyers get paid around 30,000 for the summer.  We get paid around 3,000.  If you have a good grant.  Again, a good time to drink and sit by a pool and regret hooking up with your classmates.

Year 2.  This is pretty much the same, but they get your ready for the wards**.  You do things like see standardized patients; paid actors who pretend to be sick and then give you feedback afterward that is always the same, one good thing, one bad thing, and "how do you think it went?"  "I think it went about as well as it could go considering you aren't sick and I've seen you tending bar at The Back Saloon.  We were both there last night.  Didn't have a bum knee then, did you?".  We learn physical exam, interviewing skills, basically all of the stuff that teaches you how to diagnose the fact that you need to order a cat scan.

At the end of this year, you take Step 1. This is the MCAT for residencies and is a super painful test.  More about it here.

More on year 3 and 4.

*Note: An attending is the head doctor (Dr. Cox, if you will) who runs the show, makes final decisions, and pimps the shit out of you.
**Note: The wards is the name for actually being in the hospital.  Clinics is a synonym.

I'm like a super hero but without being super or a hero

In response to my recent post, truthfully, I've had to pull back on everything.  I'm basically hiding from the internet right now.  I have to apply for residencies which is, for all its other bullshit, still a job.  So posting poop jokes on twitter and the pictures of me in cat-face for the month of July are not cool, bro, not cool.

Privatize this, anonymize that, stop making up words like anonymize; life in the real world blows.  I realize the problem, you can't have doctors going around writing shit like I write, saying the shit I say, using the word "shit" so often.  It's unprofessional and makes people lose faith in doctors.  So I keep it anonymous.

Although in reality, I'm a work hard, play hard kind of person and I never mean anything but a joke.

I can complain about med school and make jokes about rectal exams being uncomfortable, but I don't dislike my patients and I don't dislike my work.  I'm ecstatic to be doing what I'm doing and take it very seriously.  That's why I write this.  It's an outlet for me to get all of the jokes out of my system before I walk into a manic patient's room, because when they start telling my team a 25 minute rambling story about a cat, going into exquisite detail about the cat, never letting focus get off the cat for more than a sentence, when they finally finish talking about the cat, if I don't have an outlet, then I feel it necessary to blurt out, "Sorry, you said you had a cat? Can you tell me more about that?".  That tends to make me unpopular with my colleagues (although super popular with the manic patients).  So I get the jokes out now.

A question that gets asked on interviews with a frequency high enough that I'm pretty sure it's  JCAHO* required interview question is, "how do you deal with stress? how do you relax?".  You have to say things like, "exercise" and "playing with underprivileged minority children", but even a legit real outlet, like writing a blog, is a huge no-no.  I took certain things off my application that were actually impressive and show me to be a well-rounded individual because you can google them.  Since this is just a job and they don't care how well-rounded I am, I'd rather them think I'm boring than think that I write the word "shit" so frequently.

I guess this is the duel-life I have signed up for, by day, mild mannered doctor, by night, slightly annoyed doctor, every month or so, when I have a free hour or so, dude who writes a shitty blog.

*note: JCAHO is the Joint Commission on Accreditation of Healthcare Organizations.  They are the standards committee that comes by once a year "without warning" and makes sure that people aren't like tossing needles into patients from a distance or letting patients just wee where they want.  They are sticklers for things like washing hands and not weeing wherever you want.  A real drag.  They would never sanction a question about the well-being of doctors because they would never care about the well-being of doctors.

5 years. Is anyone still reading this?

Holy shit, I've been doing this for 5 years.  Look at my first post, that was over 5 years ago and before I was even in med school.  I was applying to med school; a doe-eyed premed, full of hopes and dreams, and fresh out of college.  And look at me now, applying to residency, a weary-eyed soon-to-be doctor, filled with realities and not enough sleep for dreams, or fully coherent thoughts, still fresh out of college (right? right?!?! I can still party right? I'm cool, right? Say it!  Say it!!).  So let's highlight the differences between me now and me 5 years ago.

1) Let's start with the most pressing for any hopeful premeds.  Primary care blows.  I sort of figured I wanted to have a long-term relationship with my patients, doing primary care in an underserved area, stomping out diseases with a tongue depressor and deep thought.  I'm going to listen to my patient. Fucking listen to her. That's what I'm going to do, fuck yeah!

Primary care sucks.  I don't mean people who do primary care sucks, I mean the way primary care physicians are treated sucks.  Every specialty has it's own brand of suck, but something about primary care, particularly outpatient, feels like you are standing there in your white coat, trying to listen to your patient, acting dignified and thoughtful, like a good doctor should, while monkeys surround you and fling poop at your face and laugh at you.  Fifteen minute visits, gatekeeper status, hyper-specialized docs keeping you out of the loop are the poop on your face.  The insurance companies are doing the flinging.

All of the underserved, long-term relationship, sword of justice stuff is superfluous to my new found love of hyperspecialization.  Everyone with a brain tumor is under-served.  I still like all that stuff, it is just mostly irrelevant in my world, and takes a back seat until I can breathe on the other end of residency.

2) I have confidence.  As you can tell by my first post and the subsequent ones about interviews  that I wasn't really sure how this whole thing would go.  Med school has a 58% rejection rate the last time I checked.  Residency is virtually guaranteed.  I didn't know how I would do in med school, on my board exams, with extra-curriculars, etc.  I now trust in the system.  They let me in because they thought that I would be fine, and I was.  "Med school is the narrowest hoop, and once through that, you will do just fine and get a residency" that's the basic idea and it is pretty much true.

3) I have chest hair.

4) I am jaded. Not jaded, that's not quite right, hardened, calloused.  I try very hard not to be jaded, but hardened for sure.  I've watched people die, I've pumped on their chest while they die, I've had my patients die.  That's never great, but the weird thing is just how used to it you get.  Not to mention all of the gross shit I've done or seen or been asked to do and just been like, "yeah ok whatever".  As in "Stick my finger in that guy's butt? Yeah ok whatever."

Ways I am the same:
1) I still want to be a doctor.  I want to  be a totally different kind of doctor, but I love this profession so much.  We love to bitch about it and prove how much more hardcore we are than all the other professionals, but truthfully, we get paid a more than decent salary to go around thinking about how the body goes wrong and fixing people.  We can get jaded and bitch about the paperwork and the insurance companies (for good reason), but there are so many opportunities to more or less switch careers to teaching, or admin, or writing or even a different kind of doctor if it gets bad.  Worst comes to worst, it becomes like every other job, we do it for pay and can't wait to get home to our real passion.  Boo hoo for us.

2) I want a cat.  I wanted a cat then, I want a cat now, I still don't have a cat and probably will never get one.  Seems like a lot of work.  A tattoo is in the same boat.  The same boat as the cat.  Which makes it some sort of strange boat with a cat and a tattoo and wanted by me, but only, like, sorta.

I am NSFW

A bunch of my classmates were asked to write blogs about their experience at my med school.  I have no idea why I was not asked to do such a thing.  I mean, I already have a blog; I feel like I'm an obvious choice.  What could possibly make them not want me to do it?  Pricks.

I was once asked to start a twitter account for the school where they would live feed my tweets to the admissions page.  They pulled me down in a month.  Apparently, the word "fuck" is not exactly the message they wanted to send.  But that's a totally normal, med school reaction to finding out you have another write-up to do. "You have an incomplete write-up" "fuuuuuccckkk".  See?  Natural. "You are not allowed to write an official blog" "fuuuuuucccckkkk you".  Just trying to express thoughts in real time.

display('programming sucks')

I'm learning to program (again), which is a lot like trying to learn to live in a world with a different set of physical laws, holding nothing but wikipedia.  It's like appearing in a world, wearing normal clothes, and the sun is shining, and people are walking around looking normal, so you try to take a step. Error.  Area (muscle) non-real index.

So your leg doesn't move. So you look up muscle.  Then you realize you need to know more than muscle, so you go looking for other stuff that is often cool, but you have no idea if you need it or not.  So you look up cell, nerve, desire, will-power, gravity, lactic acid, exhaustion, coordination, balance, track and field, world records, and walk-a-thon.  You try again. Your leg picks up and you try to extend your leg to land the step. Error. Undefined function or method 'step' for input arguments of "walk".

I respect the shit out of people who spend they're lives recreating the world through a made up series of logical operators, while listening to techno and monstering red bull.

This is what I think about when I'm on a research month

You will be locked in the same place for the rest of your life.  If you leave, even for a short time, you will be accompanied by a guard and in shackles.  You will get around 15 minutes of outdoors time per day, most days, weather permitting.  Exactly twice per day, you will be fed the same food you are always fed with no variation.  You may have water when you need it.  You will receive special goods and services, but only upon witnessed and continued good behavior.  You will speak only when spoken to, and never too loudly.  You will be castrated.

FREE DOGS!!!

You can take my freedom, but you can't take the word Dong.

I was taking this test where we see standardized patients*, take a history and physical on them, then write the whole thing up, come up with a differential diagnosis, and order some fake tests.  It's a timed test for both the interview and the write-up, so you tend to rush through and not care much about spelling and whatnot.  Still, I finished one patient and had a bit of time to review my write up, at which point I found this:

"64 year old female complaining of left sided chest pain following exertion.  Patient was taking her dong for a walk when she began feeling chest pain."

Hahahahahahahahaha, dong, hahahahahah, no but seriously, delete.

*note: Standardized patients are actors paid to pretend to have certain diseases and to give us information only when we ask the right questions.  It's a bit like a LARPing in terms of realness, skill at acting, and awkwardness.  

Pimp my expensive education

There is a thing in medicine called, "pimping". Basically, pimping is when a higher up doctor puts a lower down doctor or medical student on the spot in front of the group and makes them answer a question about medicine.  The idea is to see what a young doctor knows about a subject that comes up on patient rounds regarding their disease.  Although sometimes it's about history.  Or trivia. Sports sometimes.  I once saw an attending pimp a patient.  No joke, the patient was a PhD in physics and he started asking him who discovered some string theory equation.  The guy was like, uh I don't know, but my ankle reallyl hurts.  He was then told to read more. Pimping is as old as medicine* (there is a story in the bible where Jesus, right before healing a sick man, asks one of his disciples to name the 4 kinds of gastric ulcers, then smotes him and tells him to read more.  I think it's in John somewhere) and has a lot of surrounding controversy.

The controversy exists because it sort of sucks to be made to look like an idiot in front of a bunch of people.  Generally, the term "unnecessary humiliation" gets thrown around in sensitivity meetings.  On the other side of the coin is that fact that frankly, you learn a lot from being pimped.  Once you get over the shear terror that is being asked a factual question in front of a bunch of people you don't really know who will judge and grade you based on your answer, you swallow your fear, take a small poop in your pants, and give an answer.  You will either surprise yourself with what you know, or get the answer wrong and be told the correct answer.  I know some of the most obscure facts in medicine because the emotion associated with the question burned the answer into my brain parts (but let's be clear, that emotion is fear).

A good pimper, one who asks relevant and useful questions (see this post about the difference) without adding too much visible weight to the answer, will teach you more than you can imagine.  In fact, once med students get over the sharp pain of being pimped, many will agree that a rotation without pimping is a decidedly dull one.  A lot of being a med student is scut work; a term that means "shit" work.  "Call this nursing home", "make sure that CT got done", "walk this patient down the hall"; those are things I am asked to do on a daily basis.  Only paying 70 grand a year, NBD.  So getting a little extra teaching in the form of a jeopardy (because you are in actual danger) style learn-a-thon is not that unpleasant.

*Note: I once looked up the origin to the use of the word, "pimping" in medicine.  It doesn't seem novel now, since MTV pimps everything that can be bejeweled, but it is listed in books and articles in the 70's.

I've seen the trifecta

My school health insurance requires that if you aren't going to use the school health insurance, that your alternate insurance plan has this stipulation, "My plan does cover me for Sports injuries, alcohol-related injuries or conditions, eating disorders." ...I'm offended by your accuracy.

Downer alert. My B.

People dying is sad.  That prolific statement is brought to you by my current rotation, Neurosurgery: "Where people die a lot."  Not the slogan of the national society, but certainly a reasonable runner-up option.

What I've discovered during my recent acclamation with death is that I find certain deaths more emotional and tragic than others.  This is another obvious statement, but instead of listing some criteria like "people with families" or "contributing members of society", I am basing this off of my emotional experience. I just sometimes walk away from a patient who died or is about to die, and find myself more moved than with a different patient.

The only variable I can seem to cite with some consistency is age.  Social status, family status, mechanism of injury, events leading up to death; all seem to not make a difference, but age fucks me up.  In particular, it's the 18-35 crowd that jerks my soul around.  There is something about seeing someone with the prime of their life torn from them that really gets me.

I realize this is very egocentric, I myself being in this age range, but I think there is more to it than that.  Older individuals have gotten to live an impressive amount of life.  From your 85 year old former paper editor, to your 55 year old father of 3, their death is sad without a doubt, but their life is established and in status quo.  A great place to be, but a plateaued place, at least from a year-to-year view.  But 18-35, that's when you are really setting up the rest of your life.  You are making the moves to get to that plateau.  You are starting college as a theater major; getting promoted to manager; knocking up that waitress; heroine binging your way onto a reality show.  You are a real fucking winner, and no one can tell you different.

Kids are obviously sad; there is so much life lost.  But when I was a kid, I wanted to grow up to be a fire-truck (Ding-ding!), now I want to grow up to be a doctor and I'm like 90% there.  If you robbed me of life when I was 8, then we can just build a new fire-engine.  If you rob me of my life when I'm 28, then we have just lost my realistic future as a physician (and my loans, see you in hell Sallie-Mae). 

People are in the active process of realizing their future.  It's not a pipe-dream anymore.  It might not be glamerous, it might be laying actual pipe, but it's an active, conscious persuit.  It can be painful, and full of introspective self-doubt, but at least it's not boring status quo, like 20 years from now, and it's not dinasaur catchering and wand-makering like 20 years ago.  It's like running a marathon and getting pulled at mile 16.  You'll never know if you could have made it.  And you won't care, you're dead.  But I will.  I care if you could have made it.  I wanted to see how you finished college.  Or even my Caesar salad.  I hear they were going to promote you to manager...

Anyway, back to work.

Oh also the scrubs on Ob/Gyn were awesome and I stole like 10 pairs

I loved my Ob/Gyn rotation, unlike approximately 103% of other med students.  It was the weirdest, most fun experience, top to bottom (pun intended).  Oh sure, there were the bad residents.  Well just one really.  She was actually the worst human being I've ever met, but she was so bad it was comical.  Plus she hated me, and since I didn't use the adverb "fucking", that means she didn't make my life any particular hell.  My love of that rotation can also be qualified with, "it was your first," making it new and exciting and fun.

Still, it was a cool trip down memory lane (you know, because I was born there.  The vagina that is.  I came out of a vagina).  There is some surgery, some primary care (find that combo in another specialty) and an interesting patient population.  But what really made that rotation for me was one single person.

The head of the department was probably the best teacher I've ever had.  He was this hilarious guy who just knew exactly how to give you information so it was useful, relevant, and interesting.

Those are all code words.  Useful means it had the number one most important feature, it would appear on our test.  I know this sounds shallow.  I'm supposed to be a medical student learning for the sake of learning.  Learning so I can be a better doctor.  Learning so I can help people.  That's the kind of bullshit that I said to get into med school. The truth is that I will never remember even a 20th of what I learned over my clerkship year, so the fact that it got me through my test is the most important feature by far.

That being said, relevant refers to its usefulness in the actual clinic, helping actual people, when it actually matters.  The kind of stuff you need to know as an Ob/Gyn resident.  There is a large overlap between useful and relevant, but not nearly big enough. A good teacher can differentiate the two.  A bad one pimps you on both indiscriminately, then tells you to read more.

Interesting means what it sounds like, but it also means that it had a chance of sticking beyond my 6 week rotation.  It didn't, but it had a chance.  This is a rare skill indeed.  Let me provide an example.

"Fetal heart monitors are sensitive, but not specific (useful).  They help us decide whether or not to perform a C-section (relevant).  This is bullshit forced down our throats by lawyers.  They have never been proven to do anything, but increase the rate of C-section.  We use them because we can be sued if we don't (interesting)."

See how that is a unique skill?

Medicine often laments that the most influential aspects of choosing a specialty are the residents and attendings you worked with during your clerkship; the most dynamic and least legit reasons to choose a specialty, but true nonetheless.  I'm not going into Ob/Gyn, but if I did, it would definitely be because of him.  And vagina.  J/k, just him.

Please don't take all of my hatred the wrong way

I realize that my post about my sub I makes me sound very bitter and begs the question, "why are you doing this?"  And also, "please don't go anywhere near me if I'm in the hospital."  Those are legit concerns.  But let me reassure you, that was me bitching about the amount of work I'm doing and the basic quality, not me bitching about my future work.  Let me shed a different light on it.

I fucking love the OR.  I really do.  I once heard this melodramatic, masturbatory statement, "If you can think of yourself doing anything besides surgery, surgery isn't for you".  The same thing is told to ninjas before they start their training, imagines brain surgeon.  Get over yourself.

But, it is a really brutal life during residency and if you don't love the OR, it's just not worth the pain.  I don't get to do much in the OR.  I regularly stare down a tiny hole, in which at best, I can see some fat for 5 hours, just so at the end of the case I can tie a few knots.  Most of which will be cut out because they aren't tight enough and that layer of fat needs to be tightly tied to that other layer of fat.  But two things.  One, it is worth it.  I love tying those knots and suctioning that blood and irrigating that wound enough that I'm willing to wait until I climb the ladder.  And two, the shit I'm watching, if I can see, is awesome.  Being a surgeon and being a med student interested in surgery are two totally different things.

No one likes watching someone else do something, particularly not the A-type* personalities that go into the surgical specialties.  You have to imagine yourself on the other side of the body, the dude with his hands inside the human.  The lady under the microscope.  Those are the people you have to want to be.  If you want that, and can deal with mostly watching for a few years, surgery is for you.

And it is for me.  I love it and it's worth all of the pain.

People often comment that I'm a masochist for doing what I'm doing.  No, I just find the pain to be less painful than others, so the pain to pleasure ratio is in my favor (I guess the same can be said for masochists, but let's not get into a philosophical argument about the true nature of pain and pleasure). I'm allowed to bitch about paying 70 grand a year to work over 100 hours doing virtually nothing.  I earned that right, and in turn, earn that right to be the one elbow deep in a person**. Plus, I dropped out of ninja school and don't know what else to do.

*note: The A stands for asshole.  ADHD. Arrogant.  Get me a thesaurus and look up Douche-bag. 
**note: I'm going into neurosurgery, if I'm elbow deep inside someone, something has gone terribly wrong.

I see what you did there

Because I'm a bit slower about posting, and I'd like not to be, I'm going to post more rough-cuts. I'm also applying for residency, so I'm going to shift to a little more auto-biography. Please let me know if you see any glaring erros.

Sorry mom, you may have to find a new blog to click 1000's of times

I haven't posted anything in almost a month.  This does not bode well for my future in residency when I will similarly have no time.  See right now I'm doing a "Sub I" in my chosen specialty, which happens to be a pretty intense one.  Like the most intense one (arguably).  And they are taking no shortcuts on mercilessly beating the living shit out of me at every turn.

See I'm on call literally every other day.  That means every day of my life, I'm either on call (staying over night with a pager and a sticker on my forehead that says, "your bitch") or post-call (the day after call, when you haven't slept).  That is brutal.  Literally more brutal than anything else possible.  You can't be on call more than that.  And it's much worse than that.  Instead of going home post-call at 11 or 12, like a resident on call, I'm going to the OR and staying until at least 530.  Calculating it out, that's 36+ hours of straight work*.  I've worked 41 hours in 2 days. That's overtime in 2 days. 

Generally, this is because I'm there to love surgery, and since I don't have real clinical responsibility, they send me to the OR, so I can love more surgery.  In the OR my duties range from suctioning blood to standing in a corner trying to peer over someone's shoulder.  Well appearing to try to peer over someone's shoulder

When I get out of the OR, I do scut work.  A term that means, scientifically, "shit work".  Taking off bandages, drawing blood, telling residents how pretty they look, stuff like that.  I do get to see patients that need a consult from my service, which can range from fun to extremely painful (turns out there are a lot of odd ducks in the world), but is generally the highlight of my non-OR time.  We do this all through the night, then back to the OR, then home to sleep for 4 hours and back again the next day at 5am.  So sorry about not posting a lot, mom.

*note: "Work" is a loose term.  Generally work implies receiving monetary compensation for effort and results.  Instead, I pay to do this.

I would have called it "Statulence"

There is a scent by Justin Beiber called, "Someday".  The ad is a clearly much older woman whispering in his ear.

I believe she's saying, "it's only illegal if you prosecute".  And she should know, she'll be an attorney if she can finally pass the bar.

I guess the word HIPAA is kind of funny

I hate when a patient has a hilarious name.  I want to tell the world about Ying Ding Woody Wang (dangerously close to a real patient's name), but that would be a violation of HIPAA, a government agency that makes sure health care providers don't share hilarious names.

How to get out post call; or How to be professionally unprofessional

I haven't posted anything in almost a month. See right now I'm doing a "Sub I" in my chosen specialty and they are taking no shortcuts on mercilessly beating the shit out of me.

See I'm on call literally every other day.  That means every day of my life, I'm either on call (staying over night with a pager and a sticker on my forehead that says, "your bitch") or post-call (the day after call, when you haven't slept).  This means that I've taken more call than any other human on earth in a 2 month period. Like seriously.

So with that experience, I'm going to take on one of the top 5 med student challenges. How to get out post-call. 

Often, post-call, residents and attendings don't actually realize you are post-call (or there).  Since you aren't calling the attendings and chiefs relentlessly all night, they don't know you are on hour 30; and the girl who took call with you is a real resident and has work hour restrictions, so she went home hours ago and can't get your back.  This leaves you in the awkward position of trying to get people to notice you are post-call without mentioning that you want to go home.  If you mention it, they may think you are uninterested and give you a bad grade for not working hard for 30+ straight hours like some sort of mortal. You need a strategy:

1. Pick one case from overnight and talk about it relentlessly. It will seem like you are super interested and also super there.  Try to use it in every conversation.  "Yeah, let's get lunch.  You know who else had lunch? That guy who came in at 2am when I was here.  I know so, because I took such a good history that I found out he ate Thai food, which isn't usual for him.  Might have caused his stroke.  Who knows."

2. Never shower.  This is tempting.  You feel disgusting and want to shower.  Also, you are disgusting.  But resist the urge.  Instead, put on a nice potent deoderant or axe body spray or serious perfume.  The mix of 30 hour musk and Red Zone makes someone think twice when you walk past.  They will say, "Is that kid homeless? Wait, maybe he was on call."  Goes without saying, do not brush your hair.  Just look like you tried to brush your hair, but gave up when you fell asleep in the bathroom.  Which I recommend.

3. Pick a post call look and stick to it.  I only wear glasses post call.  I never shave post call.  I chew gum aggressively post call.  If I could walk around without pants post call, I would.   Motherfucker, these glasses mean I haven't slept; stop asking me to fill out discharge documents.

4.  Save one task for the morning.  That way, when a resident says, "hey are you doing anything?  It's kind of scut work, but I have something for you." You can respond, "Yeah definitely! Let me just finish this post-op check from last night, then I'll be happy to do your paper work for you, you prick".  Leave that last part out, but the first part is gold.

5. Run.

6.  Ask if the coolest resident needs anything.  There is one resident who all his friends from home always say, "how the hell is he a doctor?"; that's your guy.  That guy channels his desire to go home into getting you home.  Find him (he has long hair and Nike kicks) and see if he needs anything.  His first thought when he sees you will be, "are you post call?" and then he will cover your ass while you sneak out before noon conference.

That's it for now. Since I'm post call writing this, I think it's only appropriate to post this in its raw form, unedited.  Also, I really need to post something.

Why community will sadly fail

If you haven't watched Community, it is a fantastic show.  The writing and the characters are the best since [insert show with writing and characters that are really good.  Probably something from the 90's.  Saved by the Bell.], and the show does unbelievable themed episodes: crushing zombies, spot on post-apocalyptic action movies, and nails the "documentary" style show (i.e. The Office).  The jokes come fast and the delivery is perfect.  Abed and Troy are clearly actual friends and the most dynamic duo since Turk and JD (plus Donald Glover, "Troy" is right on the verge of becoming massive*).


But, the big problem with the show, is that the drama sucks. That isn't really a problem, because it's a comedy.  The problem is that shows like this, comedies, need relationship,     it's the thing that keeps it together.  The stickiness.

Look at the best comedies, they all have a bit of drama. The Simpsons definitely has it (or had it).  Homer got his job after almost committing suicide for failing his family; Marge and Homer have separated countless times; Bart sings to Lisa on her birthday; Homer saves Barney.  Seinfeld has Jerry and Elaine, plus all of the characters had good relationships with each other.  Family guy has it, The Office beats it to death (and notice now that the Pam and Jim thing is done, the show suffers), and Arrested Development rocked it with every character.


There is only one good show I can think of that doesn't really have any relationship, Southpark.  Maybe I'm wrong, I don't remember the show that well, but I can't pinpoint any real relationship in that show.  So how do they work as a show?  Zany.  Non-stop zany.  They can make episodes lightning fast and can just pick anything in the news and rip it to shreds.  Pick a subject, make non-stop jokes without limit, end episode. The show is pretty much a 22 minute long Conan opening with cartoon characters.


And that's what Community is doing.  Non-stop jokes for the episode, delivered perfectly, with awesome themes.  But no relationship. They tried the Britta/Jeff thing, they tried the love-triangle, they tried the sad Pierce, the sad Shirley etc.  They all failed. And they know it, it's why they dropped all of those story lines.  Their writers know this, so they keep trying different angles of drama (which is predicated on relationships) and they keep failing.    They have moved on to moves that are reserved for season 6 or 7.  Self-referencing, calling out characters on their classic moves, call-backs to past episodes. They succeed at the zany, but it's not sustainable. They can't do it like Southpark.  Southpark picks from whatever is hot and kills it.  Community can't do that.  They do genres and character jokes, and they will eventually run out.  Thus they will fail.  So soak it up while you can; there will not be another show like it.

*Note: Donal Glover wrote for 30 rock, does great stand up http://comedians.jokes.com/donald-glover, and is the oddly serious rapper Childish Gambino.  Give him 6 months.

NY: where stuff is.

Time for a tirade on New York.  I was born in Chicago and I think the first thing the doctor said to me was, “heard of New York?  You will”.  Someone posted this: “Philadelphia is like the Toon version of New York.”  NYC must be the single most egocentric place on earth and it has no right to be.  Philly is not a mini-version of New York, it’s the oldest city in the fucking US.  I’ve been in Philly for 3 years now, and although I have no loyalty to it and want to punch a Phillies fan just as hard as you do, it is a city that is probably 10 times as great as NYC.  In fact, every city I’ve ever been to is better than New York.  I’m a city snob, and I only count about 10 US cities as real cities, Boston, Philly, Miami, Chicago, San Francisco, LA, Atlanta, a few others; so my list is considerably shorter, but they are literally all better than New York. 

If you chose a color for every city, Green for Boston, Red for Philly, some color you’ve probably never heard of for San Francisco, you know what color New York would get?  Brown.  New York is what happens when you start a coloring book and then monster a few pixie sticks and go ape shit with the box.  It looks like shit, it feels like shit, but yes, you did it, all the colors are there.  How novel.

Now, I’m the first to admit the relevance and necessity of NYC.  I get it, it’s fun as hell to go out in, it’s got everything you could want, it’s the functional epicenter of the US, arguably the Western World.  I would live there in a heartbeat.  But that’s because I have a short list of cities.  Cleveland is not on my list of cities.  If I had a choice of living in Cleveland or New York, I’m not suicidal; all of my mental faculties are in place.  I would be in New York.  But if it’s New York or Miami, someone order me something bright and frooty.  I would live there because it’s a real city and I need to be in a real city, not because it’s the tits. It is not even one tit. It’s a shit hole.  It’s greatness is only because everyone is there.  It has no intrinsic value.  It’s bland and messy.  It has no character.  If we could just get everyone to get up and go somewhere else, then we could finally stop talking about it.  But we can’t.  So fuck it.  Someone get me a slice of mediocre pizza and an overpriced beer, I’ll be in Brooklyn if you need me.

NaK Attack.

I have a thing of Trader Joe's delicious Tomato Bisque soup that was accidentally purchased as the low sodium version.  More or less, they try to replace sodium with potassium.  Now I don't know much about gustation (the sense of taste), but I do know that if my body were easily confused about the difference between sodium and potassium, I would be fucking dead.

Everything, from the function of my nerves, to my cells, to my freaking heart are completely dependent on my body's exquisite ability to tell the difference between those two ions.  It is the crux of all of life.  This isn't shitty sorbitol, Soup, this is ionic gradients, the foundation of cellular survival.

There is even a sodium/potassium pump in every single biologic cell.  This thing takes sodium, and pumps it out of the cell, and at the same time, brings in potassium.  It knows the difference so well, that it can let 2 of one in, while pushing 3 of the other out.  It's the racist bouncer of the body.  And to say you might slip one K+ by, disguised as a Na+, would be like saying, oh yeah, Oxygen and Carbon Monoxide are pretty similar, my body won't know the difference.
And yet this low sodium variant is so bold as to think that it can trick my tongue, and a few billion years of evolution, into believing I'm having awesome soup and not mediocre soup.

But I trust you Trader Joe's, so let's do this.

Phoenix University, ur dewng it rong.

I had a girl come in recently to get her her meningococcal vaccine because she was starting college.

"Oh great, no problem.  What school are you going to?"
"Phoenix, it's an online school"

I'm not sure you need this.  Maybe try McAfee or Norton. And if you find that one day your laptop can't touch its screen to its keyboard, take it in immediately.  Macingitis is nothing to joke about.

In my cult, we drink the milk

If I offered you a snack with the following nutritional information:
110 calories
1g of fat
135mg of sodium
25g of carbs with 3g of fiber and 12g of sugar
10-25% of your daily value of all vitamins

Would you say that was a healthy snack?  Would you consider that pretty good stats for a meal addition?  I mean, it has infinity the fiber of juice, 12g of sugar is less than would be found in 110 calories worth of carrots, and it has more iron than lean beef (and apparently "Pilchards" according to this website questionablytrustworthywebsite.com).  So is that a decent choice as part of a meal? Yeah?

Great, now lay off my fucking Froot Loops.

Yes, that's the only thing I would do with a time machine.

If I had a time machine I'd go to DC comics and be like, listen, Batman is going to be huge. Are you sure you want to call him fucking "Robin"?

SOAP notables

This is a new segment I'm starting called The POETRY of SOAP notes*.  Like all of my new segments, this will be the first and likely the last of its kind.

There was an old woman who lived in a shoe. She had so many children, she didn't know what to do. Old woman doing well, going home. 

Signed: Ob/Gyn

Roses are red, violets are blue, but up to 20% can appear inhomogeneously blue-black.  Cannot exclude mets.

Signed: Radiology

There once was a man from Nantucket, which is a major breeding ground for the Ixodes tick species that carries Lyme disease.  Consider starting Doxycycline after ID approval. Consider running serology for Nantucket Nectar intoxication after ID approval.  Consider starting ID approval after ID approval.

Signed:  ID

Humpty Dumpty 36, male, s/p great fall.  Assessment and Plan: External fixation. Going to OR now. Get platelets high before OR.
Signed: Orthoepoediaec surgery

Ring around the rosie, pocket full of posey, ashes, ashes, then see how they all fall down?  That's pathognomonic for cancer. It's the pseudo-rosette, signet ring, atypia sign.  As you can see, this is a perfect case of cancer.  We recommend starting a drug that treats cancer.  Also, from a humanistic perspective, we recommend informing the patient it has the cancer.
Signed: Pathology

I know an old woman who swallowed a fly, why oh why did she swallow a fly?
Assessment:  Hypothyroidism vs. Hyperthyroidism.
Problem list: 1) Discharge: patient ready for discharge.  Social work consulted.
2) Patient swallowed fly: Follow up on TSH.  GI consulted. Psych consulted.  Social work consulted.
3) Discharge: Nursing facility placement pending.  Patient ready to leave when social work issue resolved.
4) Hypotension: Fly anaphylaxis vs. sepsis.  Pressors started.  Patient intubated. Anesthesia consulted.  Social work consulted.
5) Discharge:  Patient refusing to leave or follow commands.  Social work consulted.  ER blamed.
Signed: Internal medicine

*Note: These are very esoteric and I apologize.  I hate both making esoteric medicine references and making fun of specialties.  This is both together.  Let's just bury this one and pretend I didn't do it.  SOAP notes are what every specialty in the hospital writes so that other doctors can see how shitty their notes are.  Mets are metastatic cancer (i.e. traveling, bad cancer) , they can never be excluded.  S/p means "status post", which is a fancy, confusing way of saying "here after". Pathognomonic means "synonymous".  Psuedo-rosettes, signet rings, and atypia are things that are specific to certain types of cancer in the same way that shirts are specific to certain types of people.  A TSH is a thyroid test and can be blamed for just about anything.  So it is.  Hypotension, pressors, and intubation are bad; very busy scene with dramatic music on Grey's Anatomy kind of bad.

Don't worry, I'm not looking...or listening...or smelling.

Let me tell you, there are some uncomfortable situations that they put you in during medical school.  Some real awkward turtles.  Having to do your first pelvic exam, being sent back in to ask a 70 year old their sexual history, putting your hand wrist deep inside of someone, you know, awkward shit.  But nothing so far has beaten having to stand there in the room and make small talk with a girl about your age while she is bent over the exam table with her butt cheeks taped open while the attending goes to find a nurse to do a proctoscopic exam.  


"So... I guess while the doctor is going to find something to shove inside of your butt, I thought we could take this time to talk about coronary artery disease.  You see your vessels are like pipes..."

Step 1: It's not just rote memorization, it's also useless!

The National Board exam, Step 1 is a test all medical students have to take in which we are expected to solidify and deepen our knowledge of the basic sciences so we can appreciate just how much worthless and bullshit they are.

Part of the worthlessness is that even when something is clinical for this asinine exam, it is not particularly helpful.  For example, I may learn about acanthosis nigricans, a velvety skin lesion* that signifies either insulin resistance (diabetes) or an underlying malignancy (cancer).  Whenever we learn about it, they show us a picture of someone's underarm with this dark, velvety (whatever the fuck that means) discoloration and we immediately know what it is and pick the right answer.  In the explanation, they will say things like, "the most common location is the underarm or the crotch (I'm using the laymens terms here, we say things like "axilla" and "crotch"), but the palms and soles are also common".  It's that last part that is the problem.  If you showed me the darkest, velvetiest lesion in the world on someone's palms and told me this person resisted enough insulin to murder a cow, and has a cancer the size of an Oldsmobile on their face, I would have no idea what it is.  Acanthosis nigricans is a lesion of the underarm.  I've seen that question and picture 1000 times.  It's in the underarm.  You, Patient, may only present with a velvety underarm, as I've been taught, or you can leave and come back when you've figured out how to present like the textbook.

Even the National Board people know these are pointless questions with no clinical basis.  On Step 2, the next exam we have to take, all of the questions start, "A 53 year old male with a history of hypertension presents because of abdominal pain...".  The question stem implies a clinical situation.  The questions for Step 1 start, "Medical students wanted to quiz each other so they created the following diagram..." Another actual gem I came across, "A doctor was cleaning out their old files and found a case report of a rare disease..."  Even they know this stuff isn't real.  Why not just ask, "Do you know the following piece of useless information?"

*Note: A lesion is a term we use for a variety of  problems when we don't want to be so specific as to reveal ourself as a clueless jackass.  It's as generic as saying someone is from "Asia".

Thank goodness it's not the 90's anymore*

There is a guy who legitimately sat down at the book store to look at Magic Eye. I wonder if he wants to devil stick later, then watch TGIF?


*Note: I really wish it were the 90's again.

Long time, no poop joke

"My pooping schedule is way off." -Every med student that just started clinics.

Starting over, again.

I just finished studying for the national board exam (way more to come on this, but first I have to drive all that bullshit knowledge out of my head. And get over my post-traumatic stress disorder) and went back to the clinics.  This was a bit of a shocker.  I left clinics 2.5 months ago feeling as confident as a med student can be.  I could walk blindly into a patient's room and come out 15 minutes later with the most complete history and physical this patient has ever received.  I'm talking full review of systems.  I'm talking recent pet exposures. I'm talking auscultation and palpation*.  My fellow students and I were armed with a complete set of medical knowledge (as defined by our ability to bullshit our way through pimping questions).  We could stand for 18 hours without even so much as an awkward shift.  We gave up the instinctual need to urinate.  Those things are for the weak.  We were medical students done with our clerkship year.  We were the strong.

Then we went on winter break.  Then we went on extended winter break.  Then we sat down and studied 12 hours a day for the board exam learning the most clinically useless information ever to be associated with medicine.  Then we went on another winter break.

Then we went back to clinics.

And guess what? We didn't know shit. Again.  As my one friend put it, "I forgot to do an assessment and plan.  I finished my presentation, presented the lab values and radiology studies and just stopped.  Everyone was just staring at me. I was like, 'That's it'.  Then a resident politely said, 'We were kind of waiting for your assessment and plan.  You know, what we should do with this patient now that we know about him'.  I just completely forgot we did that."  We are back to being worthless, awkward, stupid med students. Two months and we are already back to borderline lay people.

I think if you could find the end of a rainbow, you wouldn't find gold, you'd find all that shit you used to know.

*These are med school jokes. A review of systems is a review of asinine things completely unrelated to the patient's symptoms.  Pet exposures are very important if your patient is a walking board exam question.  Inspection and palpation are parts of a physical exam to be done on all general parts of the body and are therefore never done.  Ever.

My defense of Twitter or, how I've lost all self respect and started defending Twitter (and capitalizing Twitter)

I used to think Twitter was the stupidest fad since friendship bracelets*.  Only 140 characters, a bunch of shit-heads saying whatever comes to their mind, more screennames, profile picks and customized backgrounds.  It's Myspace for away messages.  Or as one friend described it, "Twitter, were we come to talk to ourselves, together".

But that's like saying 1970's Harlem street ball sucks, look at it, just an asphault black top, two poles and a basketball on a broken playground.

You're missing the point, which is, look who came to play.  Fucking everyone.

It's just the new playground for awesomeness.

Comedians are there.  You can see the new, up and coming, talented but currently without a network deal, comic just plop down and start firing new material.  You can see the old, established, veteran come hang out and show off their patented hook shot.  You can see STEVE FUCKING MARTIN come in and 360 dunk from the foul line.  It's the perfect place for comedians to give something a try.

Politicians are there.  They are tight, they are polished, they are informative, they are boring.  But they are there.  And if you are into that sort of thing, it goes all the way to the top.  Ghost-written, but it's the official word and it's coming out regularly.

Celebrities are there.  You cannot miss these.  They are tight, they are polished, they are drunk.  They are the fight that breaks out after a bad foul call (I'm really trying to push this streetball metaphor).  They are a train wreck and it's awesome.  Kanye West is notorious for letting his mouth rip on Twitter and man, that shit is raw.  If someone is ghost-writing his stuff, then that person lets his mouth rip and man, that shit is raw.

And like anything that seems to be popular, you can see the official sponsorship show up.  What better way to promote your product to the people who want it than to have them "follow" you.  Tweet and ye' shall receive.  I don't mean that Twitter is swarming with ads, I mean that CNN tweets their headlines with a link and if I'm interested, I direct myself straight to it.  But the best part is, that right underneath that is Fox News with their headlines.  I can pick and choose exactly what I want, when I want**.  It's kind of like saying, "I like vietnamese food, italian dishes and burgers most" and then every time you say, "I'm hungry" the whole menu from  Pho Cali, La Viola, and Brent's Burgers shows up in front of you, fully cooked and ready to go at the speed of a 4G network.  Anything you are into is there and updating constantly.

And Twitter is fast.  Twitter is the fastest thing out there.  You don't have to write a story.  You don't have to send a reporter or set up a news van.  You don't have to make a list-serv and craft and email.  You just have to write 140 characters and post.  If it's important, it will be seen.  And re-seen and re-seen until everyone relevant has seen it.  If you follow the right people, you won't miss anything relevant in your world.

Twitter is the only place where you can follow the news, the fake news, your favorite celebrities, your least favorite celebrities, your friends, Sesame Street, STEVE FUCKING MARTIN, and the game in under 3 minutes from your phone.

Oh, it also seems to be playing a role in some sort of revolution in another country.  I don't really know because The Onion hasn't produced any hilarious headlines about it yet.

*Note: I love friendship bracelets.
**Note: These are obviously fake examples. I wouldn't read either of those if you paid me. Probably replace "CNN" with "The Onion" and "Fox News" also with "The Onion". 

The map feature alone deserves a Nobel Peace Prize

Say what you will about smart phones, but where would we be without them?  Besides still wandering around looking for that bar that is, "I think just 2 blocks this way".

Is that the sound of the Waaaambulance?

Love may know no bounds and be limitless, but nothing in this world could ever touch the relationship I have with my bed in between waking up on my first alarm and actually getting out of bed.

You know that scene in X-Men when they drag a young Magneto away from his parents and he rips the gate off its hinges trying to get back to them?  If I could, I would do that.  I think thoughts in that time period that are shameful.  Shameful and wrong.  Unicorns and puppies would gnash their teeth if they knew my thoughts in those moments.  Nuns would blush if they came within a 100 mile radius of the vile that spills forth from my mind.  I.don't.want.to.get.up.

I would give up anything and everything I've ever worked for, just to stay in bed for 10 more minutes.  If it were the day before graduation and a small man, voiced by Robin Williams, appeared after my first alarm went off with the choice of getting up and becoming a doctor or staying in bed for 20 more minutes with guaranteed warmth and a return to that dream with the cakes, shaped like fun animals, I might just take those cakes. The fact that I ever get up should be rewarded with some sort of medal and a key to a city.  Not Cleveland.

Whenever this comes up, someone will invariably say, "You use 3 snoozes? Why don't you just get up?".  That's like saying, "You would do anything for her? She's just another human on this planet."  If you have to ask, you just aren't there yet.  You haven't been sleep deprived enough to really, well, understand.  I feel sorry for you.

Er, wait, me; I'm feeling sorry for me.

Please tell me we aren't broadcasting this crap to impressionable aliens.

You might think the world is going to shit because of comments on YouTube, but have you ever listened to talk-morning radio?  It's like tearing my nails out one cuticle on the hour, WKYshootmeinthefacepart.

Useless seems to imply there is less use, I will use a new word, "Usenone"

One of the skills that they don't mention that is crucial in medicine is being able to blindly, but fully throw yourself into a completely useless task without asking questions. I'm not accusing actual medicine of this, but the MCAT, Step 1 exam, Step 2, the clinical skills, pretty much every round of testing we have at a national level is utterly useless.  Like completely useless.  But nonetheless, you have no choice but to go full steam ahead and study like you've never studied before so that you can be an absolute master of useless information.  You have to just get right in there and learn every enzyme involved in a pathway that is almost completely clinically insignificant.  In the rare (like 1:100,000 live births rare) instance that it is important, the importance of knowing the specific enzyme that went wrong is about like knowing which province in China made your faulty car part.  Not only that, but you have to know the provinces around that province, even if they don't make car parts.  Then, for fun, they will ask you what year that neighboring province was founded and under what regime.  But don't worry, they've provided a picture of the leader of that regime.  Pricks.

If I wrote textbooks

"Enhancers increase transcription rates of specific genetic loci and also increase the zoom on a freeze frame image in action/thrillers when they catch an important clue on tape"  Enhance.  Enhance....ENHANCE.  There! What's that?  A transcription factor dropping off a brief case for that promoter gene.  You're mine Tyrosine Kinase, you're mine.

Shit, you're right. And I'm kinda ugly.

You know how people will come up to you and say something to the effect of, "OMG! You look just like my friend! Do you have a brother named Dave"?  Technology is now such that you better show me the goods.  I want to see this Dave on facebook and I'll be the judge of how much I look like this d-bag.  If you are wrong, I get your smartphone. 

I'm going to bbm the shit out of your friends.

Breaking news: this guy looks like an idiot.

If I were a celebrity, I would always walk outside with a huge smile on my face.  That way, when that story finally broke about that thing I do with mascot costumes, they couldn't use one of those stock graphics of me looking disappointed or embarrassed.  They would have to use that one of me in the Hawaiian shirt with a huge grin giving the "A-ok" sign.