With just three more clerkships left in my third year (psychiatry, pediatrics, and OB/GYN), the time is quickly approaching when I will have to start making some serious decisions about my future.
The fourth year schedule is by design flexible, allowing me the freedom to choose those courses that I'm interested in and are relevant to my future career. The problem I'm faced with is figuring out my fourth year schedule when I still have more than a few possible career paths before me. Although we sign up for fourth year classes in February (so soon!), a friend told me that it's usually pretty easy to change the schedule in the middle of fourth year. That's comforting.
But it's more complicated than that. By the end of August, I will want to have completed all fourth year coursework required for applying to whatever field I choose. The Dean's Letter is written in September; residency applications are submitted in October; and I'm interviewing November-January. That means I have a short four months to play around with in my fourth year before I start working on my residency applications. Yikes!
As it stands now, my top interests (in no particular order) include: adult neurology, pediatric neurology, and internal medicine. In order to prepare myself for all of these eventualities, I would need to do the following: 1) internal medicine sub-internship (sub-I), 2) adult neurology elective, 3) pediatrics sub-I, and 4) pediatric neurology elective. Four months right there. Plus, with psychiatry in the back of my mind, I could end up wanting to do a psychiatry elective, as well.
Regardless of what I end up deciding, there will be a period of dead time between my last interviews in January 2013 and Match Day on the third Friday of March 2013, when I find out where I will be doing my residency training. Then more dead time between Match Day and graduation in June 2013, eighteen months from now.
Friday, December 30, 2011
Monday, December 26, 2011
Operating on a friend
One morning during my surgery rotation, I looked at my list of patients and was shocked to see a friend's name scheduled for surgery later that morning. I went down to pre-op immediately after rounds, deciding that providing emotional support was more important than respecting her privacy. I'm glad I did because she really appreciated me being there for her. She expressly invited me to watch her surgery, even though I hadn't even planned to ask, so I accepted her invitation.
The moment my friend slipped into unconsciousness, I struggled against my habit, acquired out of necessity, of relating to the person on the operating table as just another body that needs to be fixed. The legs were spread open to insert a tube into the bladder; taking care to pad pressure points, the body was contorted into a position convenient for the surgeon; the surgical field was sterilized with a solution that turned the skin a robotic bronze hue; finally, everything was draped so all that remained of my friend was a rectangle of this bronze-colored skin neatly wrapped in thin plastic.
I cringed behind my surgical mask when the first incision was made. I cringed despite such measures that effectively obliterated any hint that the body on the operating table was a human being, let alone my friend. That initial discomfort passed quickly, though, as the laparoscopic camera entered the patient's body and I saw the familiar array of organs on the monitor. Looking up at that monitor further distanced me from my friend. Young or old, fat or skinny, we're all made of the same building building blocks and put together approximately the same way. Without consciousness, we're all just another body.
The surgery went well, no complications. It was over before I knew it. Perhaps the time flew by quicker than usual because I was so transfixed by this internal struggle of remembering who owned those organs displayed on the monitor. The surgeon, who I had worked with many times before, knew that the patient was a friend of mine. "Do you want to help close?" he asked me when the surgery was nearing the end. That was his way of acknowledging that I had broken my routine of always asking if I can help sew up. "No thanks," I replied, "I want her to have a perfect job." "We wouldn't let you close if we thought you'd be anything less than perfect," my resident said. Still, I passed.
With the procedure finished, the surgeon invited me to go with him to the waiting area. In a bland windowless room, I silently observed the conversation between the surgeon and my friend's loved-one, reassurances that the surgery went well. I was struck by the solemnity of the conversation. I was also impressed by the respect and appropriate emotion afforded by the surgeon throughout the conversation. This was the only time I had the privilege of being included in a post-operative conversation with loved-ones.
I spent more time than usual with my friend in post-op, holding her hand and telling her that everything went great. Later that day, after she had been moved to a room upstairs, I spent more time than usual checking up on her. The standard post-op questions about nausea and vomiting and urination and ambulation seemed less important; I stayed for more than an hour, visiting, quality time. Rounds the following morning were somewhat awkward as I had to balance my dual roles of friend and medical student, not being able to give as much time to my friend as I would have liked.
I wish that I was able to give all of my patients this VIP treatment. Even if I can't always carve out time to connect with my patients on a more personal level, I think it's worth remembering to go back to the bedside when I do have a few minutes to spare. Observing my friend's operation and caring for her afterward also highlighted how easy it can be to accept the sufferings of my patients as routine and how I must guard myself against that attitude.
The moment my friend slipped into unconsciousness, I struggled against my habit, acquired out of necessity, of relating to the person on the operating table as just another body that needs to be fixed. The legs were spread open to insert a tube into the bladder; taking care to pad pressure points, the body was contorted into a position convenient for the surgeon; the surgical field was sterilized with a solution that turned the skin a robotic bronze hue; finally, everything was draped so all that remained of my friend was a rectangle of this bronze-colored skin neatly wrapped in thin plastic.
I cringed behind my surgical mask when the first incision was made. I cringed despite such measures that effectively obliterated any hint that the body on the operating table was a human being, let alone my friend. That initial discomfort passed quickly, though, as the laparoscopic camera entered the patient's body and I saw the familiar array of organs on the monitor. Looking up at that monitor further distanced me from my friend. Young or old, fat or skinny, we're all made of the same building building blocks and put together approximately the same way. Without consciousness, we're all just another body.
The surgery went well, no complications. It was over before I knew it. Perhaps the time flew by quicker than usual because I was so transfixed by this internal struggle of remembering who owned those organs displayed on the monitor. The surgeon, who I had worked with many times before, knew that the patient was a friend of mine. "Do you want to help close?" he asked me when the surgery was nearing the end. That was his way of acknowledging that I had broken my routine of always asking if I can help sew up. "No thanks," I replied, "I want her to have a perfect job." "We wouldn't let you close if we thought you'd be anything less than perfect," my resident said. Still, I passed.
With the procedure finished, the surgeon invited me to go with him to the waiting area. In a bland windowless room, I silently observed the conversation between the surgeon and my friend's loved-one, reassurances that the surgery went well. I was struck by the solemnity of the conversation. I was also impressed by the respect and appropriate emotion afforded by the surgeon throughout the conversation. This was the only time I had the privilege of being included in a post-operative conversation with loved-ones.
I spent more time than usual with my friend in post-op, holding her hand and telling her that everything went great. Later that day, after she had been moved to a room upstairs, I spent more time than usual checking up on her. The standard post-op questions about nausea and vomiting and urination and ambulation seemed less important; I stayed for more than an hour, visiting, quality time. Rounds the following morning were somewhat awkward as I had to balance my dual roles of friend and medical student, not being able to give as much time to my friend as I would have liked.
I wish that I was able to give all of my patients this VIP treatment. Even if I can't always carve out time to connect with my patients on a more personal level, I think it's worth remembering to go back to the bedside when I do have a few minutes to spare. Observing my friend's operation and caring for her afterward also highlighted how easy it can be to accept the sufferings of my patients as routine and how I must guard myself against that attitude.
Tuesday, December 20, 2011
Why I decided against anesthesiology
Over the past few weeks, I have been "trying on" anesthesiology as a career. I started collating a list of anesthesiology programs I would be interested in, I attended an anesthesiology information session during the clinical interlude week, and I networked with some anesthesiologists.
Specifically, I talked with a neuroanesthesiologist, since concentrating in neuroanesthesiology is the direction in which I would want to take my new career. He was very encouraging, in fact excited, about my neuroanesthesiology interest and strong research background. We talked about a scholarship program designed for anesthesiology residents interested in research, and he helped me sketch out a plan for applying and getting accepted to the Colorado program. Wow, things couldn't be better!
I left that meeting with the neuroanesthesiologist, my spirits high, to complete a standardized patient encounter. The purpose of this exercise was to hold a family meeting about a patient at the end of her life. Although these conversations can be especially difficult and emotionally taxing, the patient-actor gave me remarkably positive feedback: "I am glad that you're going to be a doctor. No matter what field you go into, you're going to need to use these skills to talk with patients, and you're a natural at it." These words meant all the more to me because patient-actors are known to be very liberal in their criticisms.
Through the flush of receiving such high praise, I noted with a pang in my stomach that I wouldn't need to use these skills often, if ever, as an anesthesiologist.
More confusion, bred from conflict of what I wanted anesthesiology to be versus its reality. When thinking about the prospect of following through with applying to anesthesiology residency programs, which all of a sudden seemed much more real, I felt a heaviness in my shoulders, a shortness of breath, a quickened heart rate. All of these symptoms were so slight, subliminal, easy to dismiss as a normal reaction to thinking about an uncertain future.
A good friend and classmate, sensing this inner conflict, asked me a simple question: "Why wouldn't you want to be an anesthesiologist?" He kept quiet and listened, allowing me to verbalize thoughts that until then I wasn't ready to consciously recognize.
Relief. Having finally verbalized my concerns about anesthesiology, it was impossible to ignore the fact that lack of meaningful long-term doctor-patient relationships is a deal-breaker for me.
Specifically, I talked with a neuroanesthesiologist, since concentrating in neuroanesthesiology is the direction in which I would want to take my new career. He was very encouraging, in fact excited, about my neuroanesthesiology interest and strong research background. We talked about a scholarship program designed for anesthesiology residents interested in research, and he helped me sketch out a plan for applying and getting accepted to the Colorado program. Wow, things couldn't be better!
I left that meeting with the neuroanesthesiologist, my spirits high, to complete a standardized patient encounter. The purpose of this exercise was to hold a family meeting about a patient at the end of her life. Although these conversations can be especially difficult and emotionally taxing, the patient-actor gave me remarkably positive feedback: "I am glad that you're going to be a doctor. No matter what field you go into, you're going to need to use these skills to talk with patients, and you're a natural at it." These words meant all the more to me because patient-actors are known to be very liberal in their criticisms.
Through the flush of receiving such high praise, I noted with a pang in my stomach that I wouldn't need to use these skills often, if ever, as an anesthesiologist.
More confusion, bred from conflict of what I wanted anesthesiology to be versus its reality. When thinking about the prospect of following through with applying to anesthesiology residency programs, which all of a sudden seemed much more real, I felt a heaviness in my shoulders, a shortness of breath, a quickened heart rate. All of these symptoms were so slight, subliminal, easy to dismiss as a normal reaction to thinking about an uncertain future.
A good friend and classmate, sensing this inner conflict, asked me a simple question: "Why wouldn't you want to be an anesthesiologist?" He kept quiet and listened, allowing me to verbalize thoughts that until then I wasn't ready to consciously recognize.
When you get down to it, anesthesiologists have a different kind of relationship with their patients. It's condensed down to 5-10 minutes during which the anesthesiologist obtains informed consent and reassures the patient about the upcoming procedure. Sure, there's a little room there to insert your personality, but that's about the extent of the relationship. Talking to patients is something that I both enjoy and am actually good at; plus, it is something that can make a lasting difference in people's lives. It would be a shame to waste that talent in a field with minimal patient interaction.
Relief. Having finally verbalized my concerns about anesthesiology, it was impossible to ignore the fact that lack of meaningful long-term doctor-patient relationships is a deal-breaker for me.
Sunday, December 18, 2011
Home sweet home
Ahhh, it feels wonderful to be home and on vacation.
If I wasn't burnt out already, I was getting dangerously close to it: unhappy, irritable, lacking enthusiasm, increased cynicism. Separating myself from school physically, mentally, and emotionally, and spending quality time with my family and friends, will do me a world of good, so I can return in 2012 refreshed and ready to continue learning.
Inpatient psychiatry at the VA is next.
If I wasn't burnt out already, I was getting dangerously close to it: unhappy, irritable, lacking enthusiasm, increased cynicism. Separating myself from school physically, mentally, and emotionally, and spending quality time with my family and friends, will do me a world of good, so I can return in 2012 refreshed and ready to continue learning.
Inpatient psychiatry at the VA is next.
Tuesday, December 13, 2011
Why I decided against surgery
Over the past 8 weeks, I have been giving serious consideration to surgery as a career. I love it. I love the OR environment, the immediate gratification of doing something tangible to fix a physical problem, and I think that I would be good at it. I've watched my surgery residents, imagining myself in their shoes a few years from now, jealous that they actually get to do the surgeries rather than watch from the sidelines. They work hard, really hard. All that hard work would be worth it, though, to do something that I truly love.
But I have other considerations in deciding on a career. A lot of introspection has led me to understand that I need to find a balance between my career as a physician and the rest of my life. I'm speaking mostly about a hypothetical family. This may be just an abstract concept right now, but I know that the importance I place on family now will only magnify when there's an actual flesh-and-blood family to care for.
It's an unfortunate reality that surgeons must sacrifice more in terms of family life than do most other medical specialties. However, most of the surgeons at my community hospital seemed to be able to find a balance between their professional and personal lives. My surgery mentor, for example, has six children! Even the surgery residents at this community program seemed relatively sane and well-adjusted. But the bottom line is that, even if I chose a community versus academic program (usually a more stressful and toxic environment), going into surgery would still require too much sacrifice from other areas of my life that I value.
This reasoning felt like a cop-out when I was first coming to terms with the realization that surgery is not the career for me. My wise older sister picked up on this sentiment, which I hadn't quite consciously expressed, offering me this advice: "Don't feel apologetic for choosing a career that allows you to find balance in your life. There's a difference between wanting to find a career that makes you happy in all areas of your life and being lazy."
At the beginning of this rotation, I laid out three questions to ask myself to help me decide if surgery is right for me:
But I have other considerations in deciding on a career. A lot of introspection has led me to understand that I need to find a balance between my career as a physician and the rest of my life. I'm speaking mostly about a hypothetical family. This may be just an abstract concept right now, but I know that the importance I place on family now will only magnify when there's an actual flesh-and-blood family to care for.
It's an unfortunate reality that surgeons must sacrifice more in terms of family life than do most other medical specialties. However, most of the surgeons at my community hospital seemed to be able to find a balance between their professional and personal lives. My surgery mentor, for example, has six children! Even the surgery residents at this community program seemed relatively sane and well-adjusted. But the bottom line is that, even if I chose a community versus academic program (usually a more stressful and toxic environment), going into surgery would still require too much sacrifice from other areas of my life that I value.
This reasoning felt like a cop-out when I was first coming to terms with the realization that surgery is not the career for me. My wise older sister picked up on this sentiment, which I hadn't quite consciously expressed, offering me this advice: "Don't feel apologetic for choosing a career that allows you to find balance in your life. There's a difference between wanting to find a career that makes you happy in all areas of your life and being lazy."
At the beginning of this rotation, I laid out three questions to ask myself to help me decide if surgery is right for me:
- Do I absolutely love being in the OR? Yes.
- Can I see myself happy doing surgery when I'm 60 years old? Possibly, but the chances are slim.
- Can I see myself happy in any specialty other than surgery? Yes, I think so. Before this rotation, I felt pretty optimistic that that specialty could be pediatric neurology. It's still high on my list, but this rotation has made me a little less certain. I learned that I like doing things, that I do well with a mix of action and cogitation. I hadn't seriously considered anesthesia as a career until this rotation, but from my one-week exposure to anesthesia, it provides both action and cogitation.
Monday, December 12, 2011
Backup plans
A patient was brought back to the OR for an emergency exploratory laparotomy one night while I was on call. I didn't scrub in on the case but instead hung out at the head of the bed with the anesthesiologist. Soon after he intbuated this patient, it became apparent that everything was not going according to plan. Oxygen saturation was dropping to the mid-80's indicating that the patient was not being ventilated properly.
The anesthesiologist quickly confirmed correct placement of the endotracheal tube then determined that the problem was with the ventilation machine itself. There was a leak. "Let's bag him," the anesthesiologist called out (referring to bag-valve mask ventilation). Ordinarily, the Ambu bag is kept in the back of the mechanical ventilator cart, but no Ambu bag could be found.
In this moment, I saw an "oh sh*t" look of panic in the anesthesiologist's eyes. Pointing to a nurse: "Go get me an Ambu bag from another room." Meanwhile, he started troubleshooting the leak in the ventilator machine. He found the faulty valve and fixed it in about 30 second to a minute, before the nurse came back with the Ambu bag, and stabilized the patient who by that time had oxygen saturation in the high 60's.
The surgeon quietly watched this all unfold, letting the anesthesiologist do his job without interfering. "I thought I was going to have to do mouth-to-tube ventilation," the surgeon joked after the patient was stabilized. I chuckled. After the excitement passed, though, I realized that the surgeon had probably actually considered the possibility of ventilating his patient by breathing into the endotracheal tube.
This gave me a lot to think about.
Narrowly, this experience has taught me that I should always have an Ambu bag at my fingertips before intubating a patient. More broadly, every anesthesiologist who I worked with has emphasized the necessity of having backup plans. Know what you're going to do to stabilize a patient if something goes wrong. Have a backup-backup plan if your first backup plan fails. It's one thing to hear it, but that lesson takes on a much greater significance seeing it unfold before my eyes.
The anesthesiologist quickly confirmed correct placement of the endotracheal tube then determined that the problem was with the ventilation machine itself. There was a leak. "Let's bag him," the anesthesiologist called out (referring to bag-valve mask ventilation). Ordinarily, the Ambu bag is kept in the back of the mechanical ventilator cart, but no Ambu bag could be found.
In this moment, I saw an "oh sh*t" look of panic in the anesthesiologist's eyes. Pointing to a nurse: "Go get me an Ambu bag from another room." Meanwhile, he started troubleshooting the leak in the ventilator machine. He found the faulty valve and fixed it in about 30 second to a minute, before the nurse came back with the Ambu bag, and stabilized the patient who by that time had oxygen saturation in the high 60's.
The surgeon quietly watched this all unfold, letting the anesthesiologist do his job without interfering. "I thought I was going to have to do mouth-to-tube ventilation," the surgeon joked after the patient was stabilized. I chuckled. After the excitement passed, though, I realized that the surgeon had probably actually considered the possibility of ventilating his patient by breathing into the endotracheal tube.
This gave me a lot to think about.
Narrowly, this experience has taught me that I should always have an Ambu bag at my fingertips before intubating a patient. More broadly, every anesthesiologist who I worked with has emphasized the necessity of having backup plans. Know what you're going to do to stabilize a patient if something goes wrong. Have a backup-backup plan if your first backup plan fails. It's one thing to hear it, but that lesson takes on a much greater significance seeing it unfold before my eyes.
Sunday, December 11, 2011
Early mornings on surgery
As much as I enjoyed my surgery clerkship, I was just plain exhausted by the end. It turns out that the extra hour between 4am and 5am makes a huge difference in terms of being happy and well-adjusted. The early-early mornings and long hours in the hospital, without natural sunlight and little interaction with people other than patients or healthcare providers, had a dissociating effect that made me feel as if I was living apart from the rest of the world. In many respects I was, though in all fairness that is hardly unique to surgery.
I won't miss those 4am mornings. There's something about driving empty streets that made me feel like I was in a zombie movie, eerie and slightly unsettling. Maybe I had turned into a zombie myself but just didn't know it. Still, I appreciated those early-early mornings for being peaceful and silent, for having the city to myself.
I've already had a few days of "sleeping in" to a normal hour, and I feel like a new person again.
I won't miss those 4am mornings. There's something about driving empty streets that made me feel like I was in a zombie movie, eerie and slightly unsettling. Maybe I had turned into a zombie myself but just didn't know it. Still, I appreciated those early-early mornings for being peaceful and silent, for having the city to myself.
I've already had a few days of "sleeping in" to a normal hour, and I feel like a new person again.
Saturday, December 10, 2011
I'm done with surgery!
I'm done with surgery! I'm done with surgery! I'm done with surgery! Very excited. It feels good to have that rotation under my belt.
More thoughts to come about my surgery rotation as a whole.
More thoughts to come about my surgery rotation as a whole.
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