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.