When to believe my patient: Cynicism versus gullibility

During one of my medicine rotations this past year, I picked up a patient who had been admitted the previous night for abdominal pain. This was a middle-aged guy who had been in and out of the Emergency Department more than 7 times over the past few months for the same problem. A thorough chart review showed that he had the million-dollar work-up several times over, including half a dozen abdominal CT scans, and absolutely no biological cause was found to explain his symptoms.

Importantly, he also had a distant history of IV heroin abuse. On admission the night before, he said that he slipped up once a few months prior but swore he hadn't used since then. The admitting intern handed him off to me as a "drug-seeker with functional abdominal pain."

Talking briefly with my patient before rounds, I just didn't get the sense that he was drug-seeking. My resident was more cynical; he called me naive, but he also gave me leeway to do with my patient as I saw fit.

After rounds that morning, I spent a little more time with my patient. "What exactly happened a few months ago that caused you to use heroin again?" I discovered that his wife had committed a violent suicide and that he had found her. He blamed himself for her death. This was a revelation to me. Incredibly, my patient felt that he had put this traumatic event behind him, despite never going through any grieving process. He didn't draw any connection between his wife's suicide and his current abdominal pain, even though his pain began at around the same time.

I gently suggested to him that perhaps his abdominal pain was a result of that psychological trauma. He resisted that idea because, to him, it implied that he was "crazy" or making it up, and the pain felt so real to him. I asked him to just consider it and told him that I would return later in the afternoon to talk more.

During our next conversation later that afternoon, he was surprisingly receptive to the possibility of a psychogenic cause of his abdominal pain. "In all of my hospital visits, not a single doctor has suggested that, but it makes sense." He was in unbearable pain even then, so I suggested that we try a simple breathing relaxation technique. After five minutes of this, we got his pain down to a manageable level, and he seemed bolstered by the improvement. At this point, I was practically convinced that his abdominal pain was psychogenic in nature.

We were treating his abdominal pain with narcotics, which is a poor choice of medication because it can actually cause constipation and exacerbate abdominal pain. I suggested that, overnight, he first try the relaxation technique that I had taught him and only ask for oxycodone if he really needed it. This was the real test: How much pain medication would he ask for? When I came back the next morning, I found that he decreased his oxycodone from 10 mg every two hours to 5 mg every eight hours. This was objective evidence that my patient was not drug-seeking and supported a diagnosis of pain disorder.

My resident and attending were both surprised, to say the least. The management of drug-seeking patients is truly difficult, especially at a safety net hospital that predominantly serves a socioeconomically disadvantaged population with a high proportion of drug addicts. I grant that I am naive and perhaps too trusting when it comes to handling these patients. But I also see that if I hadn't at least been open to believing my patient's story, that he was in fact not drug-seeking, I would have failed to properly identify the underlying cause of this man's abdominal pain. This hospital visit would have been just as unproductive and wasteful as the previous 7 admissions. Most importantly, his abdominal pain would have persisted, with inappropriate medical treatment, and his need for counseling would have continued to go unrecognized.

Before discharging my patient, we started him on an antidepressant and gave him a list of psychiatrists who he could see on an outpatient basis. He had already made an appointment with an outpatient psychiatrist before leaving the hospital.

He was tearful when we said goodbye, thanking me for genuinely helping him after many frustrating hospital visits. Then he handed me a folded piece of paper, a letter addressed to my attending, who later shared it with me and quoted it verbatim in my evaluation:

I have been in and out of the hospital the last few months. No reasons were found for my problem until I was assigned Mr. O. He was able to help me in such a way that I am able to function again. He spent a good deal of time talking to me about my medical and personal life. He personally has brought back faith and recovery for me. He spent his personal time explaining ways to help with pain. I wanted to tell you that I am grateful for all his council, medical advice and help.

Silence

A few months ago, near the beginning of the interview season, I started feeling self-conscious about what I was writing in my blog. Knowing that this is a public space, and that it is entirely possible that residency program directors may find this blog and associate it with me, I felt constrained in describing my thoughts, feelings, and opinions about the residency application process and specific programs. So I stopped writing entirely. This reaction may have been extreme, but it was also the safest and easiest. As a result, though, my family, friends, and other regular readers have missed out on a significant segment of my medical school experience. For this I apologize. I continue to write, without publishing to this blog. After Match Day on March 15th, I will start publishing back-dated posts about my residency application and interview experiences. Until then, I may write on topics that will not directly impact the Match process.

Med/psych externship at Tulane

I arranged a second med/psych externship at Tulane University and started this past Monday. My main goal for this externship is to experience med/psych in a completely new environment. I want a broader perspective of med/psych, something with which to compare my experiences at UC Davis. I also obviously want to learn as much as possible about Tulane in general and its med/psych program in particular.

I've never been to New Orleans (N'Awlins) before now, so this externship promised to be an adventure for me. Finding acceptable housing was an issue because Tulane didn't officially confirm my externship until a week and a half before my start date. Life moves at a different pace in this city. I got lucky, though, and found a great housing situation through craigslist. It is a historic landmark built in 1845, located in the Garden District, which is a fancy-schmancy part of town with beautiful mansions in ornate French New Orleans style. I am staying in a flat on the second floor of the house, rented out to me by a real estate professional in his 30's. He is a proper Southern gentleman who offers all the hospitality that comes along with that background. So far, the living situation has worked out very well.

The first two days of the externship, I worked directly with the med/psych program director at her psychiatry clinic. Then I started working at Tulane Hospital with the consult & liason (CL) team. This is basically an in-house psychiatry consult service. For example, doctors in the emergency department may consult the CL service to determine whether a patient meets criteria for placing a 72-hour mental health hold (here in Louisiana called a physician emergency certification, or PEC for short). The CL service is also commonly called in to evaluate delirium and psychosis.

I will likely be spending the majority of my remaining time at Tulane working with the CL team, along with several weekly afternoon med/psych clinics. I will also be attending "Friday School," which is basically required lectures for internal medicine interns. I'm glad to be getting a taste of the didactic training that I would be experiencing myself as a Tulane intern.

Priorities

The annual meeting of the Association of Medicine and Psychiatry (AMP) is being held in Chicago this weekend. This meeting is an excellent opportunity for medical students to network with dually-trained physicians and program directors, current med/psych residents, as well as the handful of other medical students applying to combined training programs. I had been looking forward to this meeting ever since I discovered med/psych earlier this year, but it unfortunately falls on the same weekend as my grandmother's 91st birthday.

The decision wasn't difficult, to skip the meeting and celebrate my grandmother's birthday. How many birthdays and other big family events have I already missed because of medical school, and how many more will I miss during residency? I am still disappointed to forgo all the networking opportunities, especially heading into interview season. But the program director at Davis offered me some reassurance when I told him why I couldn't attend: "There will be meetings every year. Go spend time with your family."

Well-deserved vacation

I finished the Davis externship, and now I'm on my first real vacation since Winter break in December 2011. The two weeks I spent at home last month don't count because I was studying for Step 2. So here I am back at home: nothing to study, no patients to care for, no responsibilities except to relax. It feels great.

Davis: End of the externship

My externship with the Davis combined medicine/psychiatry program ended today. I left the clinic this afternoon with a sense of satisfaction that the experience was all-around positive and that I received encouraging feedback from everyone. I'm sad to be leaving, and I'm eager to return to Davis for the interview; this speaks volumes about my gut-level feeling about the program.

I had two goals when I started this externship. First, I wanted to figure out whether combined medicine/psychiatry is right for me, or whether I might be better served by a pure medicine or pure psychiatry program. Second, I wanted to get a better feel for the UC Davis program, in particular: the leadership, the residents, the strength of the training, and the general environment of Sacramento.

On the first goal:

I am much more certain now than when I started this rotation that I want combined training. I could only feel comfortable coming to this conclusion after gaining first-hand experience in an environment that combines medicine and psychiatry to provide integrated patient care. This rotation leaned heavily toward the psychiatry end of the spectrum, much to my initial disappointment. But this limitation to my experience here at UC Davis provided a contrast that helped me appreciate the satisfaction I feel from treating patients' medical and psychiatric needs together.

Over these past four weeks, I learned why much of my clinic experience was straight psychiatry: MediCal reimbursement rules prevent billing for medical and psychiatric services in one visit. In fact, one of my last patients of this rotation lamented that she would soon have to find a new primary care provider for her medical needs because her insurance was switching over to MediCal. This is a woman with COPD, congestive heart failure, diabetes, and bipolar disorder, all of which my dually-trained attending has been managing well. She would be ill-served being forced to find a new primary care provider who just treats her medical needs. My attending says that changes to MediCal reimbursement rules are in the works to address this problem. This is a poignant lesson, though, of the types of struggles that I will likely face in choosing the combined medicine/psychiatry path.

On the second goal:

Over and over again, I was struck by how friendly and happy people are here at UC Davis. I'm left with the feeling that I would enjoy working with these residents and attendings, an extremely important feeling considering that these would be my colleagues for the next five years. Both the medicine and psychiatry programs, as well as the combined training program, are very strong. And Sacramento itself was a pleasant surprise. It's a small city with not too much going on, which suits my purposes just fine for residency. The heat was not unbearable as I was expecting. And it's close by to many attractions (e.g. San Francisco, Lake Tahoe, the Redwoods). My attending says that Sacramento is a better place to live than visit. I agree.



So, with everything said and done, my mind wanders back to about four years ago when I was visiting different medical schools. I remember walking around Colorado's medical school campus, taking everything in, thinking, "I could see myself happy here." And it turns out that I was. I get that same feeling from Davis. This is a nice starting point to have heading into interview season.

First residency interview offer!

I got my first residency interview invitation this morning! So exciting! The whole thing feels a lot more real, now.

Late Update: My first interview offer was to Iowa's combined medicine/psychiatry program. Exciting!

Residency application: Submitted!

Today is a big day for fourth-year medical students all over the country, the day when we can finally apply for residency programs. This is done through ERAS, the Electronic Residency Application System that aggregates all application materials. The whole process is much simpler than applying for medical school. There are only three parts to ERAS that medical students have any control over: 1) the personal statement, 2) the curriculum vitae, and 3) letters of recommendation.

I did my fair share of freaking out about the personal statement. My perfectionist traits shine brightly when writing an essay that's meant to convey most of who I am and the kind of doctor I want to become, all in less than a page. But beyond that, I've had a surprisingly zen attitude about this new round of applications. It doesn't do to obsess about something that can't be changed. For all the nit-picking over my application this last week, the substance of my application has been settled for quite some time.

Perhaps that's why clicking the "Submit" button this afternoon felt anticlimactic. I celebrated, regardless. How exciting to think about all those program directors out there reading through my application! Nerve-wracking to wait for the interview offers? Yes. But I'm confident in my application and am looking forward to this next step in the long slog of becoming a doctor.

Be a sponge

I had lunch with the med/psych program director for my midpoint evaluation. His feedback was different than any of the feedback I have gotten during other midpoint evaluations, which more often than not are formalities and not all that helpful. "I want you to take a step back," he said. "I want you to absorb everything that's going on around you. Be a sponge."

This advice was especially interesting to me because it echoes something that a close friend told me as I headed off to medical school: "Be a medical anthropologist. Look at what works and what doesn't work in the medical system and think about how you would do it differently." So, throughout medical school, I have been purposefully doing just that. Here at UC Davis, taking a step back and observing as much as possible of my surroundings and the people around me, that is all the more important as I am trying to figure out whether this is the right residency program for me.

Face time with med/psych residents

Last week, the chief resident took me and a few other med/psych residents out for my first recruitment dinner of the interview season. It's a great opportunity to get to know the people who I may be working with closely over the next five years. Do I like them? Would they be easy to work with? No doubt they are asking those same questions about me. This dinner was all the more important, for all of us. Because I have mostly been working with dually-trained attendings and psychiatry interns, I haven't had the opportunity to get to know my potential future colleagues.

Recruitment dinners in general have an interesting dynamic. On the one hand, it's a social event, and everyone should be having fun. I don't want to come across as boring or rigid or anything else negative, but I also don't want to have too much fun. I've heard many stories from current interns about applicants who drink too much alcohol during these recruitment dinners and end up making asses of themselves. Why anyone would do such a thing with so much in the balance is beyond me. Regardless, I did genuinely enjoy dinner and chatting with the med/psych residents.

Then, this weekend, I took a day trip to San Francisco with one of the med/psych interns and a couple of her friends. The whole day was very relaxed and a ton of fun, a showcase of what my days off could be like if I end up at UC Davis.

Answering personal questions from patients

I was interviewing a depressed patient with my attending in the room, watching. I asked my patient if she had any thoughts of death or dying, and she said yes. "Well what of it? Haven't you had those thoughts?" This direct personal question took me aback. I faltered, then I answered her question. I knew right away that she was trying to rationalize her own morbid thoughts by normalizing them. See, you think about death, too, so my thoughts of death are normal.

Then she turned to my attending and asked him the same question, but he handled it completely differently. He sat back relaxed in his chair, looked down at the floor briefly then right back up at the patient meeting her eyes, he smirked slightly, then he said, "You know, I think it's really interesting you asked me that." His voice was saturated with sincere curiosity. "Why is it do you think you asked me that?"

I was in awe. How deftly he had flipped her question right back to her and incorporated the very fact that she had asked that question into an exploration of her depressive symptoms! The patient went right along with the flow of the conversation. My attending never did end up answering her question.

I talked with my attending about it afterward. "You're going to be asked a lot of personal questions throughout your career: Are you single? Do you have children? How much money do you make? There's always something behind the question, and it's your job to figure out what it is." He went on to say that a very real power differential exists in the clinical interview. It's not unfair; that's just the way it is. If I ever feel like a patient is interviewing me, that should give me reason to pause and wonder, Why? From there, I should let my own curiosity guide my response.

This lesson made quite an impression on me, and it gave me an important tool to use in future clinical interviews.

UC Davis: Summary of the first week

My first week on medicine/psychiatry was a good one.

I am spending most of my time at the Sacramento County Primary Care Center (PCC), which mostly caters to an indigent patient population. There is a separate Integrated Behavioral Health clinic with a set of three dually trained physicians who supervise me and another fourth year student. She attends UC Davis and is applying for internal medicine residency. I am also spending a few mornings per week at a pain clinic staffed by the Medicine/Psychiatry program director.

Everyone with whom I have interacted is very nice and welcoming... and just as important, they all seem happy.

But so far, I haven't met any Medicine/Psychiatry residents. The one resident at PCC is a psychiatry intern and so is not a good person to talk with about dual training. The Medicine/Psychiatry chief resident, though, has been in close contact with me to make sure that I am having a good experience. I am looking forward to interacting more with the Medicine/Psychiatry residents. Beyond just asking them questions, I want to get a better feel for how happy they are in the program, with their training experience.


Regarding what I have discovered about the actual practice of combined medicine and psychiatry, I was surprised that the vast majority of patients who I saw at PCC were there only for management of chronic psychiatric conditions without addressing any of their medical problems. My attending says that this is mostly due to insurance reasons, because neither Medi-Cal nor Medicaid reimburse fully for office visits that address both psychiatric and medical problems. That is concerning to me but not altogether unexpected given some of the criticisms I have heard from various people about combined training programs.

I have been exposed to a lot more of mixed medicine and psychiatry in the pain clinic, where patients' chronic pain issues often stem from both physical and mental causes.

There is still so much to experience during this externship. Next week I will also see patients on the psychosomatic medicine inpatient unit.

Studying for Step 2: A thank-you to my parents

I want to say a special thank you to Mom and Dad.

Before driving up to UC Davis for my externship, I spent a couple weeks studying for the USMLE Step 2 at their house. I'm pretty sure that I wasn't the most pleasant person to be around during those two weeks, but they put up with me anyways, and they did so much to help me get through all the studying.

They set aside a designated study area and respected my need for a quiet study environment. My dad found an empty room at his office that served as an alternate place to study when I got tired of studying at home. My mom was home most of the time, and we chatted or played a quick game of Parcheesi in between question sets or when I needed a short break. We went to the movies together and played pool together in the evenings when it was time to relax. Plus, my mom fed me! Except for all the studying, I had a wonderful time visiting with my parents.

They have already done so much to support me in medical school, and I want them (and everyone else, apparently) to know how much I appreciate everything they do to help me.

In short, my parents are wonderful. Thanks, Mom and Dad!

Externship at Davis

I have neglected to mention on this blog a major development in my medical education. During fourth year, it is common for students to do clinical rotations at different medical schools. These away rotations are called externships; they serve as a sort of month-long interview for residency, allowing both the student and the program to check each other out before or during the interview season.

I applied for an externship at the University of California Davis in their combined medicine/psychiatry department, and that's where I am right now. In fact, today was my first day! I am looking forward to this coming month to gain first-hand experience in this combined field.

How are medicine and psychiatry combined in practice? What do my attendings' careers look like? What sorts of careers do the medicine/psychiatry residents hope to forge for themselves? Do I want to spend the extra time and money for this dual training, or can I achieve my career goals through another training route?

This coming month promises to be very informative.

Escape

After taking the MCAT, I escaped to China. After taking the USMLE Step 1, I escaped to the Utah National Parks. Now that I just finished taking the USMLE Step 2, both Clinical Knowledge and Clinical Skills, I am escaping up the California coast. I love California!

Half-mast

I'm on campus today studying for Step 2, the first time I've been on campus since the Aurora shooting 10 days ago. It was a bit of a shock to me seeing the heightened security and having to show my ID badge to get into the building in which I took all my classes during the first two years of medical school.

I set up shop in a corner room on the second floor, quiet with lots of natural light. It also has a view of the main flagpole standing over the main entrance to campus. The flag was still at half-mast when I arrived this morning, but sometime during my first or second problem sets, the flag was raised back to the top. A sign of this community trying to move on.

Oral presentation without notes

Today I had to present a new patient from memory. The team split up in the morning, half going to clinic and the other half rounding quickly on patients. I only had two patients to present, one of which was a new patient I had seen yesterday with an intern and still needed to be staffed with the attending. I realized after it was too late that my intern had taken the History & Physical with her to clinic.

Given my previous struggles with oral presentations, I was a little worried about how this presenting-without-notes thing would play out. To my surprise, though, I not only pulled it off but gave a thorough, concise, and conversational presentation (in my humble opinion). What's more is that the senior attending from another team happened to be at the patient's room and stayed specifically to listen to my presentation, so I had an audience.

It felt good to get it right.

Numerous attendings have told me that the best way to improve my oral presentation is to present without notes. That seemed like an impossible task a few years ago but within reach now that I have some more clinical experience under my belt. I'm going to take their advice now and try to present patients with as little help from notes as possible.

Zebra hunter

Working on a consult service is very different than taking care of my own patients. The primary care team calls up neurology when they think that a patient of theirs has neurological problems. The neurology team evaluates the patient, gives the primary team a set of recommendations, and follows the patient until the neurological issues are resolved.

Over the past two weeks, I have seen what a "good" consult looks like and what a "bad" consult looks like. A "good" consult has a true neurological problem with a clear question for the neurology team.

We had a "bad" consult the other day that was essentially, "I think my patient has corticobasilar degeneration," a neurodegenerative disorder similar to Parkinson's disease but much more rare. The resident who ordered the neurology consult anchored onto a very rare neurologic diagnosis and basically wanted the neurology team to confirm his diagnosis.

On exam the patient did indeed have some parkinsonian signs and symptoms, but he was also taking some medications that could potentially cause those symptoms.

My neurology resident got frustrated when he was pressed on corticobasilar degeneration. He finally told the primary care resident (in a very professional manner) that the neurology recommendations would be the same regardless of whether the true diagnosis ends up being corticobasilar degeneration, Parkinson's disease, or drug-induced parkinsonism: Discontinue all medications that could cause parkinsonian symptoms and re-evaluate the patient in two days.

This could have been a "good" consult if it was worded differently: "I have a patient with intention tremor, small handwriting, and cogwheel rigidity who is also taking psychotropic medications. Our team wants you to evaluate the patient to rule out Parkinson's disease or parkinsonian variants."

Aside from learning what good and bad consults sound like, I also learned that one quickly develops a reputation based on behavior like this. When my resident staffed this patient with the neurology attending, the attending interrupted to ask, "Is this the zebra hunter resident who ordered this consult?" His reputation had preceded him.

Immature

My neurology attending is a big kid dressed up in a suit and tie and a white coat. Don't let the gray hair fool you.

There's a line of tape on the ground in clinic, to help evaluate gait in patients. Today he jumped on the line, arms spread wide, walking it like a tightrope with an exaggerated wobble. Then he banked hard to the left around a corner, made an engine revving sound, and yelled "Airplane turn!"

He turned around and flashed a grin. "You're never too old to be immature!"

I can't wait until I'm established enough to get away with letting out my inner kid like that.

First day of neurology elective

Change of plans:

Originally, I scheduled child psychiatry for July. Over the past few months, though, as I've been talking with some of my classmates who are going into neurology, I began regretting the fact that I never got a taste of adult neurology. What if it's substantially different from child neurology, and what if I really like it? Like it enough to perhaps make a career out of it?

Regardless of the low likelihood that I will actually go into neurology, I decided last-minute to switch my child psychiatry elective for neurology. At the very least, neurology is very relevant to the combined practice of medicine and psychiatry.

My day started at 7am, as will all weekdays this month. I had only one patient to round on in the morning, then I had only one consult patient in the afternoon. My resident told me to go home at 3:30. I don't expect every day this month to be this slow, but it's definitely a change of pace from last month.

Happy ERAS day!

Today the Electronic Residency Application Service (ERAS) opened for the Class of 2013. Thus begins yet another epic application process, this time for residency.

ERAS has five main components:

• Curriculum vitae: General information, education and training, publications, awards and honors, extracurricular and volunteer activities.
• USMLE transcripts: Step 1 and Step 2.
• Personal statements: There aren't any limits to how many personal statements can be written and uploaded, but only one personal statement can be assigned to each program.
• Letters of recommendation: There aren't any limits to how many letters of recommendation can be uploaded, but a maximum of four letters of recommendation can be assigned to each program.
• Program selection: There aren't any limits to how many programs can be selected. Also, multiple specialties can be selected. Then, for each program, the specific personal statement and letters of recommendation are assigned.

I spent an hour or so this morning transferring the information from my CV into the ERAS system. Having maintained my CV on a regular basis over the last few years made this a very simple process.

ERAS is open only to medical students until September 15th, at which point applicants are allowed to submit their application. The few residency program directors I talked with strongly encouraged me to submit my ERAS application on September 15th, rather than waiting, because they like to start sifting through the applicants and offering interview immediately.

Smart choice

Earlier this week, I forgot my bike helmet when I left the hospital. There I stood outside the hospital, looking at my bike, trying to decide whether I should go back upstairs to get my helmet or just bike home without it. I was tired and really, really wanted to just go home. But I turned around and went upstairs to get my helmet.

On the elevator ride back down, the elevator stopped at the surgery floor. A man about my age limped inside the elevator. He had a black eye, his mouth was swollen on one side, and he was leaning on a single crutch. He looked down at my helmet and said, "Smart choice. A car hit me a month ago. They had to take out two feet of my small intestine, and I banged my head pretty good."

"Were you wearing a helmet?" I asked, a stupid question because I already knew the answer.

"No."

The elevator doors opened to the ground floor. I thanked the man for sharing with me and wished him a speedy recovery. Then I walked away on two good legs, carrying an atraumatic head on my shoulders, thankful that I decided to go back upstairs for my helmet.

Recognition

I went out to a wine bar this evening to celebrate the end of my Internal Medicine sub-internship. As I was looking around for a table, a woman sitting at a table behind me said, "Excuse me, are you a doctor?" She was holding a baby.

My first thought: "Oh no, is she going to ask me for medical advice?" My second thought: "Hmm, she looks familiar." I said no, I'm not a doctor.

"Are you a doctor in training?"

"Yes..."

"You delivered my baby. In fact you caught him."

I took a closer look at the woman, then at her husband sitting across the table from her, and I suddenly remembered them. I did indeed care for her when I worked on Labor and Delivery, and I did indeed catch her baby. I even cut his umbilical cord. And there he was, sitting in his mother's lap peacefully sucking away at a bottle, a healthy two-month-old boy.

"Can I see him?" I ooohed and ahhhed and ogled over this little boy who I helped bring into this world. I said my congratulations to the lucky parents, thanked them for recognizing me and saying hi, then I sat down at my table, glowing.

Finishing my Medicine sub-internship today felt pretty awesome, but this moment by far made my day.

Later in the evening, the waitress came over to say, "Your glass of chardonnay is on the little baby boy at that table." I smiled and raised my glass to them from across the room to say thank you. And I almost cried.

Medicine sub-internship at Denver Health

I start my Internal Medicine sub-internship tomorrow morning. I decided to do my medicine sub-internship at Denver Health for two main reasons:

First, as a county hospital, Denver Health is the safety net for disadvantaged people who have slipped through the cracks of our broken healthcare system. Such a patient population almost by definition includes a high proportion of people with drug addictions, cognitive impairment, psychotic illnesses, and many other psychiatric comorbidities.

Second, since I also completed my psychiatry sub-internship at Denver Health, this will allow me to more directly compare my psychiatry and medicine sub-internship experiences. Will I enjoy this medicine sub-internship as much as I enjoyed psychiatry? How will this medicine sub-internship influence my feelings about applying to combined medicine/psychiatry residency programs?

While I expect that my plans won't change much as a result of my medicine sub-internship, the possibility remains that two months of back-to-back psychiatry and medicine may clarify which field I'm more passionate about.

Ethical ambiguity: When to certify a psychiatric patient

The greatest difficulty I've had during my psychiatry sub-internship is deciding when to take away someone's personal freedom by placing them on a mental health hold (MHH) or a short-term certification (STC). My attending told me at the beginning of the rotation, "I want you to make decisions about your patients. We'll do what you want, so long as you can explain why you're doing it and you have your head screwed on straight."

This responsibility hit home a few weeks ago when I knocked on my attending's office door to talk with him about a patient. I was uncertain about whether to place this patient on a STC. My attending sat back in his chair and listened while I explored both sides of the argument.

On the one hand...

This is a middle-aged guy with an unclear history of psychosis who's experiencing paranoid delusions to the extent that he has isolated himself from the entire world, including his family. He has a history of attempting suicide, and there is evidence of increasingly bizarre and disorganized thoughts. According to the police who originally placed him on a MHH, the patient's apartment was a disaster. Charcoal briquettes were placed around the periphery of each room, bed and couch and lamps were turned upside down, curtains were turned inside out, and two pennies were placed in strange places like in the refrigerator and in the shower. This is a man who could certainly benefit from continued hospitalization and treatment.

On the other hand...

The patient does not want to stay in the hospital, does not want treatment, and does not believe he has a mental illness. He shows no depressive symptoms and denies wanting to hurt himself or other people. He sure has some bizarre and paranoid thoughts, and doesn't have a job, but he pulls in a Social Security disability check each month and is able to clothe and feed himself. He may or may not meet legal criteria for being "gravely disabled," which would justify holding him on a STC.

When I finished, my attending leaned forward, looked at me intently, and asked, "So, what are you going to do?" I understood what he was doing: pushing me to make a tough decision and stick by it. This is part of my education, the process of becoming a doctor.

"I don't know, that's why I came to you for advice."

"Do you think this patient is mentally ill and needs treatment?"

"Yes."

"Do you believe that he is a danger to himself or others?"

"No."

"Do you believe that he is gravely disabled?"

"Possibly."

My attending then advised me to remember that my primary responsibility is to my patients. As long as I believe that I am following the law, I should do what I think is necessary to take proper care of my patients and let the judge decide if our actions should be upheld.

"So, what are you going to do?" my attending asked again, this time with an amused smirk.

"I'm going to cert him."

Although he never explicitly said so, it was clear to me that my attending thought that we should keep this patient on a STC.  I made the decision, though, based on my gut feeling that my patient was indeed gravely disabled and would benefit from treatment.

The patient stayed for another week with nominal improvement of his paranoia and disorganization. He agreed to keep taking medications after he left the hospital. That was something.

Everything about this patient's case was ambiguous to me. Did I really help him by keeping him in the hospital against his will? Was I justified in holding him on a STC? Was he really gravely disabled? Sometimes there are no clear answers, and I just have to make a decision that seems best at the time. I feel better knowing that I would make the same decision again if I had to do it over.

The legal side of psychiatry

Most of the inpatient psychiatry patients I have seen were admitted voluntarily. But some patients can be held involuntarily if they meet certain criteria: 1) They pose a threat to themselves, 2) They pose a threat to others, and 3) They have grave disability. Those first two are self-explanatory; "grave disability" just means that a patient's psychiatric illness impairs his or her ability to properly care for themselves. Think food, clothes, and shelter.

A mental health hold (MHH) is the shortest involuntary hold at 72 hours. Its purpose is to further evaluate a patient's mental state according to the above three criteria. There are important legal implications of the MHH. Most importantly, since the purpose of the MHH is fact-finding, the psychiatrist is allowed to obtain medical records from other institutions, and talk with the patient's friends and family, without the patient's consent. This means that if a patient is initially admitted on a MHH then switches to voluntary status, the psychiatrist is no longer able to get that information if the patient doesn't agree to it. I saw this happen a few times.

Short-term certification, which lasts for 3 months, is the next step of involuntary hospitalization. By the end of a 72 hour of a MHH, the psychiatrist must convince a judge that short-term certification is necessary, again demonstrating that the patient poses a threat to himself or others or has grave disability. Long-term certification lasts an additional 6 months and also has to be argued before a judge to be granted.

Lastly, there are involuntary medications (i-meds), which are exactly what they sound like. Typically, a patient flies out of control after refusing voluntary medications, emergency medications (e-meds) are given to control the patient in the short-term, then the case is brought before a judge to grant power to administer i-meds. Concern for the physical safety of fellow patients and staff is often cited as justification for requesting i-meds.

The gravity of depriving a person of freedom is not lost on me.

Going to court

One particularly memorable patient took his case to court. Among other problems, this patient had delusions of grandeur that led to increasingly serious run-ins with the law.

The patient was shackled and escorted to the courthouse by a sheriff, while the rest of us piled into a government-issued van for a field trip. The intern would be testifying, a first for him. He practiced his testimony on the ride over, and the attending prepared him for what to expect. "The public defender is going to try to discredit you as an expert witness. Don't worry: It's not personal, and the judge will likely rule in your favor."

That's exactly what happened. My intern became a newly-minted "expert" with the privilege of providing testimony related to the matter of placing our patient on a short-term certification. He stood at the podium with his hands clasped tightly behind him, so tightly in fact that his fingertips were white. His back was straight, his shoulders squared, his head held high, and in that pose he answered questions thoroughly but succinctly in a clear and certain voice. I was very impressed.

After some back-and-forth questioning from the public defender and city attorney, the patient/defendant had the opportunity to address the court. It turned out that our patient sealed his own fate with a diatribe that clearly demonstrated to the judge that he poses a threat to himself and suffers grave disability. We won short-term certification and the ability to administer involuntary medications.

Observing the legal process in action was fascinating, a valuable component of my psychiatry education.


Update: This patient is now doing fairly well. My intern writes:

The patient became less and less resistant to medications as he become more linear and logical. He never quite thanked us for forcing medication on him, but he did start saying positive things about the way he was thinking. Before he left, he actually became quite socially appropriate, responding to social cues, which previously he had not been able to do. He started telling jokes, some pretty funny and some bizarre. But he would occasionally follow a bizarre comment with reality testing saying, "Does that sound crazy?" and then laugh it off. At discharge, he was nervous to go home and thought it was happening too fast. Last I checked, he was making his outpatient appointments. His home visits have found him pleasant; he has been very welcoming to his case worker and showing off how clean and organized his apartment is, as well as new writings he has been working on.

Acting intern

Two weeks into my psychiatry sub-internship at Denver Health, and I'm having a blast. I was right in guessing that Denver Health would be a great place for a psychiatry sub-internship, given that it is a county hospital and a safety net for indigent and socioeconomically disadvantaged people.

The psychiatry inpatient service is capped at 12 patients, 6 patients for each of the two interns covering the service. On the first day, my attending told me that he wants me to build up to seeing 6 patients by the end of the month. This is consistent with the purpose of a sub-internship to prepare medical students for being an intern.

I'll get a chance to do exactly that this coming week. For the first part of next week, my attending will be away at a conference, and one of my interns will be out taking Step 3. The doctor who is covering for my attending spent some time with the team on Friday to help smooth the transition on Monday.

"You take three patients, and I'll take three patients," he said.

"What?" I said it without thinking, and it may have come out somewhat indignantly.

The new attending looked a bit surprised. He sat back in his chair, smirked, and asked me, "How many patients have you been carrying?"

I told him that I had been carrying 5-6 patients this past week. "Good! Then you can take your own team." He went over to the white board at the nurse's station, where all the patients are listed according to which resident is taking care of them. He erased my intern's name and wrote in my name. "Make sure to bring your pager on Monday. The nurses are going to be paging you when they have questions about your patients."

This promises to be an interesting week.

Fourth year scheduling

As rigid and uncompromising as third year was, that's the degree of flexibility that I have in determining my fourth year schedule. Senior year of medical school is all about further exploring specific career interests, taking courses that will help for getting into residency, and filling gaps in education. The requirements: take at least 32 weeks of coursework (out of 52 total weeks), take at least one sub-internship, and take enough research to finish the mentored scholarly activity requirement.

Also, fourth year is all about add/drop. A web-based program is used for scheduling. At any time, I can log in and sign up for a new class or drop a class that I signed up for earlier. The only restriction is that any dropped courses must be dropped at least 30 days prior to the start of that course.

As of now, my fourth year schedule is as follows:

May: Adult psychiatry sub-internship (at Denver Health)
June: Medicine sub-internship (at Denver Health)
July: Child psychiatry elective (at The Children's Hospital)
August: Time off to study for USMLE Step 2 CK and CS, and to work on residency applications
September - November: Set aside for externships
December - January: Set aside for interviews
February: International Spanish immersion elective (I'll write more about this once it's finalized)
March: ICC, and a fun "Film in Mental Illness" 2-week elective
April - May: More ICC, plus a 2-week "Cardiac Diagnostic Skills" elective

Then graduation at the end of May!

It's shaping up to be a good year.

Taking stock of year three: Advice for rising third-years

"The transition from classroom learning to the the clinical years will be the most difficult transition of your careers."

So said one lecturer preparing my class for clinical rotations, one year ago. This sentiment has been echoed by numerous other doctors over the past year. The transition from classroom to clinic represents a fundamental shift in the way that learning takes place, not to mention the additional considerations of teamwork and professionalism. Other major transitions in the medical career (e.g. graduating medical school and becoming an intern, or finishing residency and becoming an attending physician) represent increased responsibility, which is arguably more easy to deal with than a fundamental shift in the way one thinks.

Because of this, I decided that now would be an ideal time to step back, think about all that I have learned over the past year, and pass some of those lessons on to those who will follow me. Keep in mind that that what follows are my own opinions drawn from my own experiences. Other people will have different opinions, and I don't pretend to have all the answers.

1. Attitude. This can be said about anything in life, but I think it's especially true during third-year: A good attitude goes a long way. You are transitioning from learning in a classroom setting to learning in a clinical setting. You will have to figure out how to function well as part of the healthcare team. The reality is that there are many factors outside of your control that will cause you to be a burden on the team. This is more true at the beginning of third year than at the end. Try to minimize your burden on the team, and the best way to do that is to have a good attitude.

• Be happy; if you're not happy, don't show it.
• Be easy and fun to work with, even if you don't like your resident or attending.
• Be excited to learn, even when you're exhausted.
• Take the initiative when caring for patients.
• Take as much responsibility as your resident is willing to give you, even if you feel it's a stretch. If a question starts out with "Do you want to..." then the answer is always "Yes."

2. Perspective. Approach every clerkship as if that will be your specialty for the rest of your career. This may sound silly, or impossible, if you know 100% that you do not want to go into that specialty. But I found that this helped me to maintain a good attitude when I very well could have done otherwise. It's a lot easier to work hard if you feel that what you're doing is important. For that matter, if you absolutely hate a clerkship, remember that it will be over in just a few weeks; just push through it.

3. Study. Treat all of third-year as one long study period for Step 2 Clinical Knowledge. In my opinion, every shelf exam that I took was harder than Step 1. For each shelf exam, start studying early and study frequently, a little bit every day. My general approach to studying:

• Learn from patients. Your patients are your best teachers. Read about your patient's disease on UpToDate: review its pathophysiology, learn different ways that it presents clinically, know its diagnostic criteria and how to treat it. Do a pubmed literature search, if there are any questions related to your patient that can be answered by evidence-based medicine. Then bring back to the team what you find. Information sticks way better when you associate it with one of your patients.
• Pre-Test. This is a specialty-specific series that offers about 500 questions meant to prepare for shelf exams. I only used the surgery, psychiatry, pediatrics, and Ob/Gyn versions. They are all available as real books or as apps on iTunes. I borrowed the book versions of pre-test for psychiatry and pediatrics but decided to splurge for the $30 iTunes apps for surgery and Ob/Gyn. I'm glad I did, too, because there is a lot of waiting around during those two clerkships, so I would just crank out 5-10 questions whenever I had some time to burn. I finished all 500 questions before each respective test. It's important to note that these questions aren't nearly at the level of difficulty as questions on the real exam. In retrospect, I think pre-test would have been helpful for my family medicine departmental exam. I would stay away from pre-test for Internal Medicine, though, because there's MKSAP, a question bank published by the American College of Physicians. 
• Step 2 CK question bank. I bought a year-long subscription to Kaplan's Step 2 CK question bank at the beginning of my surgery clerkship and immediately wished that I had gotten it earlier in third year. I'm told that, like Step 1, Kaplan's Step 2 questions are a little harder than what is on the real test. They worked well for me as a shelf exam study aide. Throughout the clerkship, up until the last week, I did just 5-10 questions every other day or so. Then during the last week I did timed full blocks of 44 questions until I ran out of questions, of course reviewing explanations for every question. If I had extra time, I re-answered questions that I got wrong.
• Specialty-specific textbook. Most clerkships recommended specific text books. The family medicine departmental exam was drawn heavily from Essentials of Family Medicine, which unfortunately is an awful textbook (poorly written, poorly edited, too much emphasis on arcane statistics rather than big picture). The Internal medicine text is Internal Medicine Essentials for Clerkship Students 2 versus Step-Up to Medicine. I chose the first option because it is published by the ACP and is linked to the MKSAP question bank, which I also bought. The surgery departmental exam was drawn heavily from Essentials of General Surgery, which is actually a very well-written book, albeit heavy on text. Ob/Gyn recommended Beckman's Obstetrics and Gynecology, which provided a decent start to studying for the shelf exam. The rest of my clerkships did not recommend any specific textbook.
• Case Files. This is a specialty-specific series that offers case studies as a means of learning the materials. A patient's case is presented, then questions such as the most likely diagnosis or the diagnostic tests to establish the diagnosis or the means of treatment are asked. A short discussion then expands on those learning points. Each chapter is accompanied by a few softball questions that I found relatively useless. The major utility of Case Files, in my opinion, was talking over the cases with classmates. I only used Case Files for neurology and psychiatry, clerkships without a recommended textbook.

4. Practice. Your jobs as a third-year medical student are to learn how to take a good history, do a good physical exam, and present your findings both in notes and oral presentations. This is all easier said than done. If you're on your first clerkship and you think you're good, you're most likely overestimating yourself. Remember that there is always room for improvement. Don't worry if you're slow and clumsy at first; your residents and attendings expect that at the beginning of your third year, but they also expect steady improvement as you move through the year.

• Be methodical about how you collect your patient's history. The conventional order is 1) chief complaint, 2) past medical history, 3) past surgical history, 4) medications, 5) allergies, 6) family history, 7) social history. This will quickly be burned into your mind so deeply that it becomes the way you talk about patients in normal conversation. If it helps, create a template for you to fill in as you're interviewing your patient.
• Sit down when you're talking with patients, even if it means excusing yourself to get a chair or stool. It sets the patient at ease and gives them the impression that you're spending way more time with them than you actually do.
• Figure out how to end patient interviews without being rude or awkward. This is especially important because you'll often be pressed for time.
• Try to do a full physical examination, even if it means coming back to see the patient later when you have more time. Obviously this is not always practical, especially in the clinic where an entire patient visit is only 15-20 minutes. But the more normal exam findings you see, the easier it becomes to recognize an abnormal finding.
• Be proactive about seeing abnormal exam findings, even if it's not on one of your patients.
• Look to the fourth-year medical student notes as good examples to follow. The attendings and residents typically write more abbreviated and utilitarian notes that are not as useful for learning how to write a good note.
• Run your assessment and plan by the intern or resident before presenting a patient on rounds, if possible. This is an opportunity to see if he/she agrees with your plan or wants to change anything, and it helps make you look better in front of your attending.
• Find someone who you can present to as practice, if oral presentations make you nervous. This can be a friend or family member or a significant other. I was fortunate enough to have a resident who taught me how to present, but given how busy residents are, I think this is more the exception than the rule.
• When presenting, fall back on the methodical approach in which you took the patient's history. This will also save you if you're having a nervous brain-freeze. As you progress, you'll figure out how to pick out pertinent positives and negatives that tell the patient's story and guide the listener to your assessment.
• Don't forget to present the patient's vital signs!!! Some attendings want to hear each individual vital sign, but most of the time you can summarize it conversationally: "Patient is afebrile, normotensive, normal heart and respiratory rate, and satting well on room air." Or, more succinctly, "Vital signs stable and within normal limits."

5. Relax. No, seriously, relax. This isn't necessarily the most easy thing for me to do, but over the past year I learned how important it is for me to take full advantage of time off, even if that time is just a post-call day. Spend time with family and friends outside of the medical field, or at the very least try not to talk about medicine-related topics when you're hanging out with medical school friends. Think about what hobbies or activities recharge your batteries, and be proactive about scheduling time to do those. Be aggressive about protecting your relaxation time. Otherwise, you will burn out.

Code C: Emergent Cesarean Section

"Code C, room 8 to OR 3! Code C, room 8 to OR 3!"

The Labor & Deliver control room burst into activity with the overhead announcement. A quick glance at my resident, whose head nod told me to go for it, and I rushed back to OR 3 just in time to catch the patient being transported down the hall.

She smiled at me as she wheeled by. In the middle of a labor gone awry, surrounded by nurses and doctors moving and talking much faster than usual, lying in her inclined hospital bed, breaking speed limits as she flew down the hallway on her way to the operating room where she was about to undergo an emergent Cesarean section - this woman met my eyes and smiled at me. It wasn't a frightened smile or a nervous smile; she actually appeared serene, an emotion that didn't belong in this moment.

The patient was already on the operating table by the time I entered OR 3, nurses buzzing about the room as if their hive were being attacked. I stood near the patient's head, mesmerized by the serenity of her smile that was now hidden behind a face mask and then a few moments later faded with her consciousness. I moved down to the foot of the bed, out of the way but with a good view of the operating field, then stood frozen lest I get stung.

The anesthesiologist was preparing for a rapid-sequence intubation. The scrub nurse was already dressed in her sterile gown, governing her table of sterile instruments. Two Ob/Gyn doctors were already dressed in their sterile gowns and posted on either side of the operating table, one looking at the anesthesiologist expectantly and the other posed like a runner in the starting blocks, her scalpel blade millimeters from the patient's pregnant belly.

"Tell us when you have her airway!" said the first Ob/Gyn in a commanding voice that couldn't be ignored.

"Do you have her airway?" ...

"Do you have her airway?" ...

"Got it!"

Cut, a curved incision. "Cut again!" Yellow fat and gushes of blood. Scalpel down. The two doctors took a firm grip at either side of the incision and pulled with all the weight of their bodies to open the incision. Sound of ripping flesh. Underlying muscle. More blood. "Cut again!" More ripping flesh. More blood. Then the uterus appeared, large, holding a baby whose life was in danger. "Cut again!" Amniotic fluid washed away the blood. Hand inside the uterus. Some pushing, some pulling, then Baby. "Knot in the cord!" Clamp it, cut it, then Baby was whisked away to the care of NICU nurses.

No more than 30 seconds passed from first incision until Baby's birth.

With Baby out, the doctors turned their attention to controlling Mom's bleeding. I stood there planted in my out-of-the-way spot at the foot of the operating table, even as the flurry of activity around me dissipated, dumbstruck by the sheer speed and exquisite coordination of the emergent C-section I had just witnessed.

Mom recovered beautifully, and Baby was entirely healthy.

USMLE Step 2: Clinical Knowledge and Clinical Skills

Step 2 has two components to it: Clinical Knowledge (CK) and Clinical Skills (CS). Both CK and CS must be taken during the fourth year of medical school. Some residency programs want to see that one or both have been taken before offering an interview, but all residency programs require that CK and CS are completed before ranking students for the Match in February.

The CK portion of the test is a multiple choice exam very similar to Step 1 in both format and grading. However, rather than testing basic science knowledge, Step 2 CK questions are more designed to test the ability to evaluate symptoms, establish a diagnosis, and manage disease. Regardless of the question stem, the variety of questions is rather limited:

• Which of the following diagnostic tests can most likely establish this patient's diagnosis?
• Which of the following is the most likely cause of these findings?
• Which of the following is the most likely finding on physical exam?
• Which of the following is the most likely diagnosis?
• Which of the following is the most appropriate next step in management?
• Which of the following is the most appropriate intervention?
• Which of the following would be the best initial treatment in this patient?
• Which of the following is the most appropriate pharmacotherapy for this patient?

The CS portion of Step 2 is quite different. It is an 8-hour pass/fail exam that makes use of standardized patient-actors to evaluate clinical skills in a simulated clinical setting. There are 12 patient encounters, each one lasting 15 minutes with an additional 10 minutes afterward to write a note summarizing the encounter. In the 15 minute encounter, we're expected to obtain a full history from the patient and perform a focused physical exam that addresses the patient's presentation. The patient note written in the 10-minute post-encounter is meant to be just like any note I would write on a real patient, though parts of the note are standardized for the purposes of grading.

The CS exam is only administered in five locations nationwide: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. Because of the nature of the CS exam, the grading is necessarily complicated. Scoring is separated into three "subcomponents": 1) Integrated Clinical Encounter, 2) Communication and Interpersonal Skills, and 3) Spoken English Proficiency.

The ICE subcomponent is graded by checklists. Observers behind a one-way mirror check off physical exam maneuvers and such, and the patient note is reviewed to see if it incorporates certain information that the creators of the test deem important. The CIS subcomponent is necessarily based on subjective feedback from the standardized patient, though I have no idea what criteria or grading rubric they use. The SEP subcomponent is obviously not an issue for people who speak English fluently.

As part of the end-of-third-year ICC, everyone in my class took a five-hour CAPE exam to prepare for the USMLE Step 2 CS. A lot of effort was put into making this practice exam as close to the real thing as possible. Except for the CAPE exam being 5 hours instead of 8, and 10 patient encounters instead of 12, I think that this experience did a great job of preparing me for what the CS test experience will be like.

Information about combined medicine/psychiatry residency programs

What is combined medicine/psychiatry?

A lot of people, even medical students and doctors, have never heard of combined medicine/psychiatry residency programs. So, what exactly is med/psych? A regular internal medicine residency program is three years; a regular psychiatry residency is 4 years. Combined medicine/psychiatry residency programs shorten this training period to a total of 5 years.

How are the two programs combined?

The two residencies can be combined without compromising the integrity of the training because much of the training overlaps between the two programs. For example, the psychiatry program at Duke University requires 4 months of internal medicine and 1 month of neurology during the first year of residency, while the entire fourth year is comprised of electives and research. Likewise, Duke's internal medicine program includes a 5.5 months of electives. Adding up all that time gives you about 2 years that are saved by combining medicine and psychiatry into an integrated training program.

How many med/psych programs are there?

The National Residency Match Program (NMRP) reports that 11 combined medicine/psychiatry programs participated in The Match in 2011:

• Charleston Area Medical Center; Charleston, WV
• Duke University; Durham, NC
• East Carolina University; Greenville, NC
• East Tennessee State University; Johnson City, TN
• Emory University; Atlanta, GA
• Medical University of South Carolina; Charleston, SC
• Southern Illinois University; Springfield, IL
• Tulane University; New Orleans, LA
• University of California, Davis; Sacramento, CA
• University of Iowa; Iowa City, IA (This program's website is especially informative and well-presented.)
• University of Kansas; Lawrence, KS

How competitive are combined med/psych programs?

I tried to get a better idea of how competitive combined medicine/psychiatry programs by looking at "Results and Data" documents published by the NRMP for the last five years, 2007 through 2011. I compiled all the Match data for med/psych programs and used those data to put together this table:


There are a lot of very interesting observations in these data:

• The average number of positions offered per year is 22 (Range 19-26) with the greatest volatility over the past two years.
• There are consistently two med/psych positions per year that are left unfilled, and those tend to be at the same institutions year after year (Kansas, East Carolina).
• The number of med/psych applicants in 2011, both US seniors and total applicants, seemed to decrease significantly from previous years.
• Med/psych applicants, both US seniors and everyone else, apply on average to about 3 programs.
• Over the past 5 years, the percentage of total med/psych applicants who were US seniors ranged from 35% (2011) to 50% (2010). Likewise, the percentage of matched med/psych applicants who were US seniors ranged from 47% (2009) to 75% (2010). There are two major points here. First, most applicants are either international students or people who took some time off after medical school. Second, US seniors have a better chance of matching to med/psych than non-US seniors.

Altogether, this is a pretty thorough presentation of what a combined medicine/psychiatry residency program actually is, what programs there are, and the Match statistics. I will likely update this with a follow-up post when I have more information, which will be sometime after I have finished interviews.

In the meantime, more information can be found on The Association of Medicine and Psychiatry website.

I'm a fourth-year medical student!

As of yesterday at 4pm, when I finished my Ob/Gyn shelf exam, I can officially call myself a fourth-year medical student. Holy cow! Time has passed so quickly with practically every minute of my life accounted for by clinical duties, studying, or scheduled relaxation so I can work and study some more. Also contributing to this feeling of time dilation, the past year has been divided into discrete 2-8 week blocks of intense focus on one subject matter.

This next year promises to fly by even quicker. Sub-internships, externships, USMLE Step 2, residency applications, interviews... and so much more!

Oral presentations: The urge to keep talking

I have made amazing progress in terms of my oral presentations since the beginning of third year. I started out having literally no idea how to properly present a patient. A stellar resident taught me the basics during my Hospitalized Adult Care clerkship, and along the way other residents and attendings interested in teaching have helped to fine-tune my presentation.

Today, I was presenting to my attending an obstetric patient who was in for a regular check-up. The attending remained quiet as I went through all the pertinent subjective information about my patient's pregnancy, described the fetal heart rate and height, and gave her my assessment and plan for this patient.

I was about to talk about the patient's breastfeeding and post-partum birth control plans when my attending said, "Stop!" It's not uncommon for attendings to interrupt oral presentations of medical students. So I stopped, wondering what she was going to say. "Your presentation was perfect. You covered everything I wanted to hear, and you said it succinctly. I know your assessment and plan. You don't need to say anything else. Stop talking!"

The lesson: Part of a good oral presentation is knowing when I've said enough. I should be confident that I have covered all the pertinent details and act on that confidence by ending my presentation. For a third-year medical student who is just now starting to feel comfortable giving oral presentations, this is a valuable lesson to learn.

Nights on Labor & Delivery

This past week I worked the night shift on Labor & Delivery, from 6pm to 8am. Flip-flopping my schedule like that was disorienting to say the least. While I didn't break down and start a coffee habit, I did eat a fair amount of dark chocolate to keep me alert. In fact, I noticed that eating any food throughout the night helped me stay awake.

When there were things to do, when babies were being born, staying awake was not an issue. Rather, I had difficulty with those long stretches of early-morning quiet. I tried to use the time to study, at first, but my brain wouldn't cooperate. Preparing my progress notes during those quiet hours saved some time in the morning and didn't require too much brain power. If nothing really was happening, and my resident was feeling nice, she would send me to the call room so I could take a 1-2 hour "nap" before rounding on patients at 5am.

Generally, after a night shift, I'd get home at 9am, eat a bowl of cereal, and manage to sleep 3-4 hours in the late-morning and early afternoon. Except one day last week, I had to schedule a bunch of meetings on campus, which meant that I didn't get home until 2pm and was essentially running on no sleep for 2 days straight. I felt miserable.

Looking back, it's a wonder how I functioned at all. A week of nights on Labor & Delivery is as much a medical school hazing ritual as anything. It was definitely the most physically demanding week of medical school I have experienced yet.

I caught my first baby!

Early this morning while I was rounding on my patients, a nurse sitting behind me answered the phone. "Yeah, he's right here." I turned around, expecting the call was to tell me that one of my patients was about to deliver. "You're wanted in room 9, stat!" The nurse smirked as if she knew she were reading lines straight from a medical drama TV show. I dropped what I was doing and flew down the deserted corridor, overloaded white coat pockets flap-flap-flapping against my body.

The room was already prepared for delivery when I arrived. The bed was raised, the patient's legs up in footrests, my resident in sterile gown and gloves standing between the patient's legs, and the table of instruments and a nurse behind her. Standing room only crowd of family. A quick glance showed me that the baby's head hadn't yet crowned. "Gown and gloves!" my resident shouted at me. I gowned up quickly and stood beside my resident between the patient's legs.

"That's it, give me a good push, you're doing great!" I took cues from my resident. She was standing beside me the whole time, coaching me through each step with hand signals and a quiet but firm voice, ready to take over if necessary. After having watched so many deliveries over the past several days, the motions came surprisingly naturally.

The head crowned just a few minutes later. I held the baby's head in my left hand and followed him as he turned his head to the left. Unwrap a loop of umbilical cord from around his neck. Gentle downward pressure to deliver his top shoulder. Then with a gush of amniotic fluid and blood, he entered this world. With my right hand I supported his back and swung his body over so that I was cradling him in my left arm. Suction, suction, first breath, then a loud cry.

Remarkable. Miraculous. The whole process would seem magical if I weren't so familiar with the biology.

I clamped the umbilical cord and gave Dad scissors for the honor of cutting the cord. Then I presented Baby to Mom. She held him close on her chest, smiling down on him with tears in her eyes and that singular glowing expression of a new mother.

I could have lost myself in the emotions of that moment, but my job wasn't done yet. I collected cord blood, delivered the placenta, massaged the uterus, and inspected the vagina for tears. Under my resident's supervision, I repaired a mild tear with a single stitch. Then we cleaned up.

Dad asked my resident and me to pose for a picture with Mom and Baby. We gave our congratulations all around, I thanked Mom for inviting me to be a part of her delivery, then we left the family to celebrate.

How I decided on a combined medicine/psychiatry residency

The third-year medical student has three jobs: 1) To learn how to take a good history and do a good physical exam; 2) To learn how to present patients, both written and orally; and 3) To figure out what field of medicine to specialize in. I found this last job to be the most difficult.

Pre-med and the pre-clinical years

To provide some context, I came into medical school having worked for four years researching the neurobiology of eating disorders. I very much enjoyed and valued my pre-med experience in psychiatry, but I also wanted to keep an open mind when it came to other possible specialties and career paths. This translated into me looking practically everywhere except at psychiatry.

During the first two years, when I was just in the classroom and didn't yet have any practical clinical experience, I investigated various specialties: emergency medicine, neurology, neuroradiology, interventional radiology, surgery.

The third year

Over this past year, as I've gained clinical experience in various fields, I have tried to be purposeful and methodical about how I evaluate each specialty as a possible career. This process of elimination is pretty typical for third-year medical students. I had all but ruled out many possible specialties before third year, but I also tried to keep an open mind. I liked most of my clinical rotations and seriously thought about careers in those specialties.

• I was very interested in emergency medicine, ever since my first year, but eventually nixed it because I want to have continuity of care and to treat the whole patient rather than one acute problem at a time.
• I seriously considered surgery but reluctantly decided against it because of lifestyle issues.
• I got excited about anesthesiology but vetoed it because I want more significant patient interaction.
• I loved pediatric neurology and only recently crossed it off the list because I decided that I don't like general pediatrics enough to do the training. Also, even though I figured out that I could probably handle the sad stories and poor outcomes, I decided that it's just not what I want.

Then there were my internal medicine and psychiatry clerkships. I loved them both.

Internal Medicine

Last Summer, on a warm evening after a long day at the hospital, I was lying underneath a tree in the park talking on the phone with my sister. She asked me how I was liking internal medicine, and my immediate response was that I love the puzzle. I have a patient with a given set of symptoms and a unique history, and based on both of those, I have to decide on what labs and studies to order to figure out what is causing that particular constellation of symptoms and how to treat it. I told my sister that the inpatient setting gives me more time to sit down and really talk with my patients, as well as to thoroughly think through the differential diagnosis. I like internal medicine because it involves both thinking and doing.

Looking back, my most memorable and favorite medicine patients all had psychiatric comorbidities. After awhile, my medicine residents were giving me the "difficult" psychiatric patients because they knew that I was drawn to those patients.

Psychiatry

Then there was my psychiatry clerkship. I looked forward to it with excitement but also some trepidation. What if I liked it? Could I really become a psychiatrist? I worried about that because there truly is a distinction between the practice of medicine and the practice of psychiatry.

It turned out that I did very much like psychiatry. I found that reading for psychiatry was easy because I was so interested in the subject matter... I spent much longer talking with my patients than I needed to... I wrote much longer notes than I should have because I had so much to say and was so fascinated by my patients... I jumped into psychotherapy with some of my patients even though that's way beyond the scope of a third-year medical student....

Discovering med/psych

Liking psychiatry so much posed a problem because I held a mental block against it. Much of that mental block likely came from my desire to practice medicine, not solely treat mental illness. About midway through my psychiatry clerkship, responding to what I recognized as ambiguous reservations against psychiatry, I started researching various psychiatry fellowships. That's when I "discovered" combined medicine and psychiatry residency training programs.

I hadn't even known that such programs existed. Thinking back to my internal medicine clerkship and how much I enjoyed it, I immediately started daydreaming about what I could do with training in both internal medicine and psychiatry. I stayed up way too late that night researching med/psych programs.


The more I thought about med/psych as a training path, the more excited I got. I could continue my work in anorexia and bulimia or focus on binge eating and obesity. I could do geriatrics. I could do palliative care. I could do international and refugee medicine. So many possibilities! I'm the type of person who likes to keep my options open. Med/psych training could give me the best of both worlds; I could have my cake and eat it too!

I realized, though, that I was getting all excited about med/psych with a very limited amount of information, only what was available on the various program websites and the Association of Medicine and Psychiatry website. I needed more information, better information.

Talking with med/psych program directors

A few of the med/psych programs stood out to me, both because of the quality of the integrated curriculum and the general feel of the institutional culture. The directors of these programs wrote open letters describing med/psych, promoting their respective program, and inviting those interested in med/psych to contact them with any questions. Recognizing that contacting these program directors could potentially be self-defeating, I decided that it was worth the risk because I needed to talk with someone - multiple people - in the med/psych world.

I e-mailed three program directors and actually talked on the phone with two of them. I was blown away by how open and friendly and helpful they were, that they would set aside time from their lives to talk with me about med/psych. They answered my myriad questions, settling two major concerns about pursuing both medicine and psychiatry.

• Concern #1: You'd just end up choosing one or the other eventually, so why waste time training for both? Response: We actively encourage our graduates to establish a practice that incorporates both medicine and psychiatry, and most of them do find a niche for themselves. Even if your practice ends up being predominantly medicine or predominantly psychiatry, you will draw upon your training in the other and be a better doctor for it. I doubt that you'll ever regret your training. Both program directors said essentially the same thing in different ways, and I agree with them.
• Concern #2: A combined program would leave you less well trained in both medicine and psychiatry than if you completed a pure residency in one or the other. Response: Our pass rate is 100% for both the medicine and psychiatry boards. Our graduates report feeling very well prepared for both boards and for the responsibilities of being an attending physician. That speaks for itself.

Talking with current med/psych residents

I asked those program directors to put me in touch with current med/psych residents. Being in the middle of this stressful decision-making process, I wanted to talk with someone whose memories of that process are more fresh in the mind. How did you discover med/psych? Did you seriously consider other specialties, or medicine alone, or psychiatry alone? Why did you end up deciding on med/psych? Did you know what you wanted to do with med/psych before residency? I felt that these questions needed to be addressed now as opposed to during an externship or on the interview trail.

One resident answered that he decided on med/psych simply because he wanted to treat the whole patient, not just a set of symptoms. This struck a chord with me. I thought back to my medicine rotation and remembered how frustrated I felt when the psychiatry consult service swooped in to evaluate patients with psychiatric concerns: I wanted to be a part of that aspect of my patient's care. I also thought back to my psychiatry rotation and my frustrations when the smallest medical issue was outsourced to internal medicine. I want to treat the whole patient, too.

Enthusiasm flowed freely from every resident I talked with. Everyone was happy. Everyone was 100% satisfied with their career choice. Everyone would do it over again the same way in a heartbeat. And talking with each successive resident, that enthusiasm rubbed off on me. The vague intuitive sense of rightness I originally felt when I discovered med/psych crystallized into certainty that a combined medicine and psychiatry training is perfect for me.

Trying on med/psych for size

I can't count how many times I've been asked, "What are you going into?" or "Do you know yet what you're specializing in?" It's especially bad toward the end of third-year and even worse when I start a new rotation. So pediatrics and OB/Gyn have offered me numerous opportunities to see how med/psych fits. Rather than hedging, I started answering decisively, "I am going to do a combined medicine and psychiatry residency program."

Reactions have been interesting, ranging from "Oh, what a waste of talent," to probing my reasons for choosing a less traditional training path, to "Wow, that's awesome!" The negative reactions didn't get me down, and the positive ones only stoked my excitement for med/psych further. These self-observations are incredibly helpful in making the final leap to a decision that without overstatement will profoundly shape the rest of my life.

So I've taken that leap. I will apply to combined medicine/psychiatry residency programs.

From clinic to the operating room

A new patient was referred to the gynecology clinic from an outside community clinic that serves a low-income population. She was at the end of her rope dealing with symptoms from a condition that she allowed to progress for so long because she couldn't afford to fix it.

I was working with the chief resident, who is essentially almost a "real" doctor; even she was taken aback. "I'm going to go talk with the supervising doctor, and we'll see what we can do for you." The attending was equally impressed with the patient's history and physical exam and scheduled her for surgery the very next day.

My resident invited me to watch the surgery. "It'll give you a chance to follow a patient from start to finish." Thank you so much! This kind of continuity, as a medical student, is not the norm. I had to play hookie from afternoon clinic (with the chief's permission) in order to see my patient's surgery.

During the first two weeks of this clerkship, I saw many surgeries on women whom I had never met and never examined. The only history I knew of them is what I read in their chart and what the resident told me beforehand. Occasionally, I'd have a few minutes to chat with these patients immediately before surgery. But the whole experience felt disjointed.

That's why I'm incredibly grateful to have experienced the kind of continuity of care, from clinic to surgery, that the residents and attendings enjoy. The attending even stepped back allowing my resident to operate and leaving me to first-assist! And she invited me to accompany her to talk with the patient's family afterward! The experience felt complete.

I think more effort should be made to give medical students this kind of patient continuity. In terms of teaching and learning, I personally find that such continuity is especially effective: I will never forget this patient.

Urogynecology and gynecologic oncology

I finished my week of urogynecology and gynecologic oncology (UroGyn/GynOnc) having seen a lot of pelvic organ prolapse and transvaginal taping for stress incontinence. But I didn't see much pathology. In fact I didn't see any. No ovarian cancer, no uterine or endometrial cancer, no cervical cancer, no endometriosis. I'm disappointed, but that's the luck of the draw.

Up next: A week of gynecology clinic, then on to obstetrics (a.k.a. "baby-catching").

Anesthesiology reunion

Returning to St. Joe's for OB/Gyn has been fun because I'm seeing a bunch of people who I worked with several months ago during my surgery clerkship. One of those people is an anesthesiologist who got me so excited about anesthesiology that I seriously considered it as a possible career.

He happened to be the anesthesiologist working one of my gynecology cases, recently. We exchanged pleasantries, caught up a bit, then he asked, "So, are you going to intubate this patient for me?" This caught the attention of my resident who practically shouted, "What? You never let me intubate anyone!" My anesthesiologist friend replied, "Yeah, but I've worked with him before, and I trust him."

This was all just playful banter. My resident wasn't really upset, but the pressure was on: I hadn't intubated anyone for more than 3 months! I had a little bit of difficulty visualizing the cords, but I got them finally and successfully intubated the patient on the first try.

OB/Gyn site and schedule

I had such a good time on my surgery rotation at Exempla St. Joe's that I decided to do my OB/Gyn rotation here, too. Since the site assignments for the OB/Gyn rotation are given on a first-come-first-serve basis, I got lucky with getting my first choice. ESJ is a very popular site among medical students because it has a reputation of very nice attendings and residents. So far, its reputation has borne out to be true.

The six-week OB/Gyn block is divided into weeks on different services. My schedule:

• Week 1: Benign gynecology. Lots of surgeries. Get in early enough to pre-round on 1-3 patients and have my notes written and shared with the resident by 6:45 am. Usually leave by 5:00-6:00 pm.
• Week 2: Gynecologic oncology and urogynecology. Similar to benign gynecology but with sicker patients.
• Week 3: Gynecology clinic. Show up for educational rounds at 7:00 am and leave after the last patient, around 4:30-5:00 pm. Have to wear professional clothes, not scrubs.
• Week 4: Labor and delivery nights. Shift work from 5:00 pm to 8:30 am, starting Sunday night.
• Week 5: Obstetrics clinic. Essentially the same schedule as gynecology clinic.
• Week 6: Labor and delivery days. Not sure about this schedule, yet.

I definitely wasn't expecting that I would have most of my weekends free. I'll have to come in on the Sunday evening of my L&D nights week, and the residents may ask me to round on patients over the weekend if my patients happen to provide a particularly good learning opportunity.

Overall, I think OB/Gyn will be a good experience.