Residency. Already.

Fun fact about getting close to finishing med school: we're all realizing WE ARE ONLY HALF DONE with all this "temporary" suffering.  Residency is another 3+ years.

And I'm being told that residency is harder than med school!  A lot!  Really!  I still don't quite know if intern year will feel like all those years at Microsoft when we shipped 97 million products in time for the Christmas catalog.  Back when I could call almost anybody at 3 am and they were still at their desk.  Working.  At computers.  Arguing with other smartypantses about details that don't matter in the long term.  Like interns.

So: residency applications.  I'm going after obstetrics and gynecology.  This is not realistic.  I'm 49, my board scores are not impressive, I have no peer-reviewed publications, it's a surgical specialty, and it's tons more competitive now that scary malpractice and oppressive overnight deliveries have gone by the wayside in favor of conglomerate-managed group practices.  But I applied anyway.  The east coast is very crowded with community ob/gyn programs, and these are where I might have a chance.  I applied to 66 of 'em.

And I'm also going after family medicine.  In addition to everything else, FM docs deliver babies and do contraception and sterilization.  I'll be perfectly happy in family med.  I can most likely come back to the west coast to do residency in FM.  I'll also be more likely to get to do systems/process stuff if I stick with family med.  Such as figure out how to do a decent local managed primary care model on Medicaid's dime like IORA and Chen/JenMed did with Medicare.  Don't get me started.  I applied to 32 family med programs.

Here's my status map.

some observations on 2nd year

I knew the second year of med school would be difficult.  I'm sure I enjoyed being dramatic about predicting this.  I'm sure I've said "it's going to be harder than cancer" and that "second year is the thing I have to survive to get to the good stuff".  I'm sure I then looked off into the distance like Luke Skywalker in his pajamas on Tatooine, deciding to man up to the challenge.

I was right.  This year of endless studying and exams and thousands of bland words to memorize is the hardest thing I've ever had to do, and I'm surviving it.  I have to find a way to tell amlodipine from amiodarone.  Ondansetron I can remember, because it sounds like one of Santa's reindeer.  Maybe you remember the game "Dead or Canadian?" from MTV's early years?  Now I play "Foot Bone or Antibiotic?"  If I make the mistake of thinking I know enough about herpes or T cells for tomorrow's test, the test exposes my folly.  Study fast, study more, take a test, do it again, do it again.

At the end of classes in May, I'll take my first board exam, which I think is six hours long.  My better classmates do 200 prep questions PER DAY for this exam, starting a long time ago.  The rest of us talk about when we'll be able to start doing prep questions along with scrambling like rodents to pass the next school test.  I fear these prep questions, because they want me to remember things from last year, like...um...things about...metabolism?  Did we study metabolism?  This six hour board exam will result in a score that is the single most important factor in my competitiveness for residency.  And I'm blogging about it, instead of doing 200 prep questions, in the 90 minutes I have before the next thing I have to do.

This year has some neato stuff too.

I just finished my 12th session with a family medicine doctor out in Virginia Beach.  At my first session, I was worse than useless.  I'm sure I added an hour to his workday.  I did not know what any of the medications were, I did not know how to get anything accomplished with a patient.  My stethoscope didn't leave my too-white coat.  Worse, my classmates were all excited about getting things done in their first session, like finding a heart murmur.  I found the bathroom?

On Tuesday at my final session, I was somebody else.  I had the slightest inkling of credibility, sitting knee to knee with patient after patient, getting the story, getting the details straight.  Laughing, often.  Six months ago, I was unable to imagine that I'd ever be comfortable reaching for the throat of a stranger, that this would ever be comfortable for the stranger.  Now the reaching is just work, expected, performed.  It's a question needing an answer.  It's easy to explain what I'm doing and why.

I can't begin to describe how much I love knowing what's under the skin, and how fun it is to try to find out what's going on in there.  Heart sounds, bowel sounds.  My hands spread apart by a deep breath, the echo of a finger tap on a lung, the confident look on a woman's face when she denies pain with my fingers pressed eight inches into her stomach.  Pictures in books, images onscreen, cadavers in the lab, animations on youtube, all of these are detached, unreal.  But in a living person who is trusting me to answer questions with my hands and my senses, then a carotid artery sitting behind a thyroid, the motion of bones in a joint, the change in the sound of a heartbeat from the third rib space to the fifth, the shine on an eardrum, these are all like new friends, continuing a conversation that will never stop being interesting or having more to say.  We never need to talk about the weather.

Somebody else's breasts

I did my first breast exam on somebody else today.

One thing:  I felt euphoria, from not finding anything.

Another thing: it's terrifying to reach for a breast not knowing if there's something in there.

Another thing: I was sure there would be something in there.

For almost five years I've been 90% med student and 10% survivor.  Today that flipped.

It was so hard.  I don't want to ever find another lump.  Sad and anxious.  Bigger than me.

This exam was with a "standardized patient", a patient, soulful teacher of the pelvic exam and the breast exam.  A lovely body that made four babies.  Her mother died of ovarian cancer.

Like a sailor no more

I was 16.
Christie was a pottymouth.
Of all the girls my age
she was the first I met
who had confidence,
grit and fire.

Just that one time
a bunch of us girls
crammed in a pickup cab
in Ventura.

I loved every word
out of her foul mouth.
Elvis would have been
a less interesting person to meet.

I was raised on vanilla
and angel food cake.
I went to church
three times a week.
I thought I was pro life.

But it ended right there
when some girl named Christie
said shit and fuck
and Christ All Fucking Mighty.
That was more who I was
than who I was.

My own pottymouth got me in trouble last week.  It's over.  The above is a eulogy.

Professionalism, with and without the house in Baja

This is a story about personal standards.

About a week after I finished six months of chemotherapy for breast cancer, I popped a 103.5 fever that put me in the hospital for a few days.  I'll just spoil the medical case right off: it was probably a mild pneumocystosis, which is a lung fungus that only infects people with crapped-out immune systems, like AIDS and cancer patients.  (I lived.)

I'd been awake and feverish for maybe 20 hours when I was wheeled up to the oncology floor, lying on my side to help my breathing.  My brain function was that of a gerbil or so.  As my stretcher came to a halt, in front of my face was a leather toolbelt.  And some corduroys.  Which are both relatively normal for Seattle in April, but not so much in a hospital.

The toolbelt and corduroys were on a nurse, an older guy named Tim.  Tim also had on an ironed long sleeve shirt and a decent pair of shoes.  He stood there, in Hannibal-Lecter-meets-Clarice fashion, minus the creepiness, and welcomed me to the oncology floor.

Tim's business casual dress was an oddity on a hospital floor where every other nurse wore scrub bottoms, a tshirt and birkenstocks.  His toolbelt-of-plenty was an oddity among staff that could never find a pen or their walkie talkies.  Tim got me set up in my room as if he'd been trained by a good British butler.  In the evening, he came by after his shift to play guitar and sing a bit.  He was outstanding.

It seemed I was his only patient, given how present and attentive he was in taking care of me.  But I found out that he was running four patients, as well as teaching the tshirt nurses.  By day two I was feeling fairly normal and started interrogating him.  He and his wife, also a nurse, worked in Seattle six months of the year.  The other six months they spent in Baja, in a house they built, writing cookbooks, composing and recording music.  He was so damn good at nursing that the University of Washington repeatedly hired him, on a locum basis, to work and teach on any terms they could get.

So, you know, holy crap, that's an enviable life.  Tim seemed entirely happy.

This professionalism was something I'd never seen before, certainly not in the software industry, nor in shadowing a large and varied collection of doctors, and Tim defines How It Should Be when I'm thinking about how I want to practice medicine.  What this looks like to me:

• Choose good priorities.
• Figure out the best way to do a thing and constantly improve.
• Do things the best way.
• Don't be affected by people doing things less well.

Which I suck at, mostly.  For example: on a test this morning that is 6% of my grade for a class that is just starting, I got a 72, ostensibly because I have final exams for other classes next week, but really because I've been playing Starcraft.  And blogging.  And doing free clinic stuff.  And coming out of retirement on SDN.  My future patients were not well served this week.  I was not Tim-like.

Now, what got me finally writing about Tim, after all this time, is my previous post about my passionate professor.  Because my passionate professor is about the same age as Tim, is as impressively professional, but is otherwise totally different.  I don't think my passionate professor would be interested in not working six months of the year, and I can't picture him taking a long leisurely vacation.  I think he'd rather go talk to high schoolers, with his bike helmet painted to look like a brain and his rolling ice chest presumably loaded with brains.  I expect that on average he briefly indulges in loveliness, and then gets right back to work.  He tends to look harried, and serious, and to apologize for not doing even more.  I should ask him if he's happy.  I honestly can't tell.

It's an Oprah-ism that on our deathbeds, we won't wish we'd worked more.  I suggest that this could be true for Tim, with his beautifully lived life, divided between Baja and the art of nursing.  But I think my passionate professor will wish he'd worked more, will wish he'd done better, will wish he'd had just a few more years to advocate for brain injury causes.

I want to be more like both of these guys.  I don't know what that would look like.

You can't win on virtue

This is a story about pragmatism.

My med school has a professor, a neuroscientist, who for decades has worn himself down to the bone advocating for humanitarianism.  He walks the talk, as the leader of a number of community outreach efforts.  He's done a TED talk and testified before Congress.  His standard of professional excellence is impeccable.  Every time he lectures, he highlights the diseases, the injustices, the impacts that result from damage to the nerves we're studying. About one third of his lecture slides are marked "FYI" to indicate that we will not be tested on the material, and these slides list stat after stat on whom we are helping, whom we are hurting.  Traumatic brain injury: who is going to take care of all these mangled soldiers and former teenage DUI quads when their parents are too old for the job?  Geriatrics.  Primary care.  Nutrition.  Palliative medicine.  He rails against policies and against lack of policy.  He rails against us for being willing participants in a profit driven medical system.

I love this man, truly, and I believe him, believe in him.  But I get worn out.  I don't have the goodness to take a moral working over like a vitamin with every meal.  Mea culpa.  My community work, excessive for a med student, is in organizations with which my most passionate professor is not involved.  Mea maxima culpa.

Meanwhile, recently, a community physician from a major city visited EVMS and spoke about her work.  She has an effective outreach model that trains low income HIV patients to visit other low income HIV patients, and support them in navigating their medical care and solving their ridiculously complex life problems.  If ever there was an initiative with measurably positive outcomes that costs little and impacts the neediest, this is it.

I asked her to describe the effort to fund her organization.  What happens when she goes after donors and grants?  She described a heartbreaking, unending effort.  Of course.  But what she said that knocked the wind out of me is this:  you can't win on virtue.

She can get a grant or a fellowship by showing effectiveness statistics.  By filling out forms.  By courting organizations that target populations segmented on zip code, religion, refugee status.  By applying for funds that the ACA (that's Obamacare) allocated for ACOs (accountable care organizations).  But if she tries to get funding by saying "this is the right thing to do" she gets nowhere.  She can't win by saying "look at the humanity here."  The Sally Struthers starving African child guilt-mercial model never broke even.

Clever gamesmanship.  Marketing.  Business savvy.  Networking.  Entrepreneurship.  These don't naturally come to mind when I think about an operation that helps mentally ill homeless HIV patients get to their doctor appointments.  It would be more comfortable to believe that those who have the backbone and dedication to serve the least of us don't have to have MBAs to get to do their work.

The genius of the visiting community physician, I think, is in her clever flexibility, her recognition of the need to fit her mission in a package of comfort for those who might provide funding.  Hmm.  Maybe the genius of my passionate professor is in his disregard for the comfort of med students.  He makes it maximally difficult to confuse our ambition "to help people" with virtue.

Judge Judy McJudgey O'Knowitall

First, I am Dr. McJudgey all day long, with classmates and teachers and administrators.  People are just not any good.

Second, I get judged all day long.  Turns out I am just not any good.

Third, I have an extra helping of opinions about everything lately.  That heap was really high before.  Higher now.

Fourth, nobody wants to know what I think, which I keep forgetting until I already started saying what I think.

Fifth, many of my classmates are at the same level of bossy know-it-all as I am.

Thus, I spend all day hearing what I think get overruled with what they think, and what they think clearly proves they weren't listening to what I think, to the extent that I listened at all.

Repeat from step 1.  Dumb.  Assholes.

I figured out why this is happening, maybe, this morning, in a required Saturday morning class.  Which I spent judging, feeling judged, offering my opinions, having my opinions overruled, repeat.

See, the thing is, everybody here in med school is a pretty good person who wants to help.  Not out of selfless goodness, like a nurse.  No, we want to be in charge of dealing out the goodness.  We want to BE THE ONE who has the calm assured control over a dire situation where we apply our knowledge and judgment to quickly make mature and correct decisions and take correct and responsible actions.  Reasoned and seasoned.

This is not mental health.  It's grandiosity and ego and insecurity and fantasy.  And for a bunch of us at my med school, it's every day, all day.  All the live long day.

I'm pretty much the worst offender.

I am embarrassed to admit that I didn't expect this dynamic.  It's not that different from software, where you can't really go wrong by assuming people are smartypants with Asberger's.  I think the difference is that software people are more likely to keep their mouths shut.