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.