Final Day

Today's my last day in clinic or hospital. At least of medical school. How will my wife and I celebrate? By packing, of course. But school is not quite over. After two days off next week, we teach second years procedures for a few days and then have a week of a summary course called "Capstone." I think that consists of advanced procedure training and learning the basic stuff that may have slipped through the cracks the first time.

Anyway, I am so happy to be finished with one more task that I could yip with joy. Fortunately, I can save myself the embarrassment because the neighborhood coyotes are at this moment doing just that. Well, at least they are yipping for some reason.

If you would like to read more of my reflections, consider following this link to my column at The Differential.

Goodbyes

ED Shoes, click on the image for a Flickr interactive view.

There comes a time when all that's left to be said is, "Goodbye old friend." This week I used that phrase twice. Once to the Harborview emergency department and later in the same day to my clinic shoes. Over the past 2 years I've used a dedicated pair of shoes during ED shifts and overnight call. The day I stepped out of the Harborview ED was the same day I said goodbye to these old friends. The left toe bears the badge of ortho (plaster). The right foot has a spatter from irrigating my last wound in Seattle. Both bear marks from my away rotation at San Francisco General, as the heels and laces retained a tinge of the scrubs' cranberry pink dye. The real reason for discarding this pair was the torn apart left heel and loss of sole traction. Otherwise, with a splash of bleach they'd be ready for another shift!

An expanded version of this article was published at Medscape's student blog, The Differential.

What to do Post-Call...

Earlier this week, I was feeling a bit wiped out from my overnight call on the orthopedics trauma team. I made the mistake of rambling a bit about my thoughts over at the Differential. Today I'm post-call and haven't been able to sleep yet. What a difference two hours in a call room makes!!!


Yes, this is the obligate link to another page post. Sorry about that.

Senioritis

This week at The Differential, I took a stab at suggesting an entry for the new Diagnostic and Statistical Manual of Mental Disorders. (The DSM V will be coming out in May 2012.) Nothing serious, though. My disease has been informally diagnosed for decades: senioritis. Head over there to check if you feel any of the symptoms or demonstrate any of the major or minor signs...


I'd say I had some senioritis before I started my current orthopedics trauma rotation. The schedule alone cured it for me...

Thinking About Next Year?

We're off to New Haven this weekend search for a domicile, which right now is one of the most pressing thoughts for soon-to-graduate medical students. But if you're a third year medical student, you're thinking about plans for next year. There's a lot that you can control about your life, and it starts with arranging a good curriculum. Check out my tips for doing it just the way you want at The Differential.

And don't tell me you can't read it because you've no password. Log-ins are free!!!

Imperial Battle Cruiser

On and off for the past 7 weeks, I've been working at the Seattle Veterans Affairs hospital. Many medical students spend part of their time at VA hospitals, but I was not assigned to one until last month. (I completed my geriatrics rotation and part of my radiology clerkship there.) But as with a lot of things these days, the day has come that I will not return to this place for a while.

The reason I am sharing this is to share a funny (if strange) phenomenon I experienced every day on my morning walk from the bus stop or the parking lot. By the time I approached the entry, I had started humming The Imperial March. It didn't matter if I was reading a book on my way in, listening to music or news radio. In the meters approaching the door, I had moved from the well recognized drumbeat to that catchy progression.

I cannot explain this. I mean, it's not like the hospital looks like an Imperial battle cruiser or anything.Or does it...

If your bandwidth is low, you may experience jumpiness in the music.

Is Match Day Overrated?

I think it is. We're waiting the extra hour to check my results from the comfort of home. So be patient, family! Since I believe in both free speech and the possibility of reform, I went ahead and listed a few reasons why the emphasis on the Match (even I use a capital letter) could be misplaced. You'll have to go over to The Differential to read it. And yes, you will still need your free login.

One of my blog friends recently asked me if the same computer that compares my rank list with 30,000 other lists and the lists from thousands of programs was the same that made Bowl Championship Series calculations. I am inclined to think that this present figuring very well could be an off-season task for the BCS brain. Like the bowl placements, there will be folks happy with the outcome and folks that are not.

By the way, which are the other professions than medicine that use similar systems for job placement as that for medical residents?

• The Military
• Professional Sports
• Anything else?

Match, Smatch... They should just call it what it is. Today is Draft Day!

Gifts From Patients

Last week, one of my patients gave me some elk jerky cured from a buck his 14 year old grandson shot last season. Read about my experience at the Medscape blog. Of course you'll need to use or sign up for a free login to read it.

I Would Walk How Many Miles?

I'm working on a post over at The Differential about all the traveling I've been doing to interview at residencies around the country, and am curious about the number of miles that residency applicants travel (by plane, train or auto) in a given interview season. Anyone have any ideas?

Ethics in the ER

This recent Wednesday was the first meeting of the Ethics in the ER course that I am co teaching with Harborview ER doc Stephanie Cooper. Our goals are to expose medical students to how the complex medical decisions made in the emergency department often demand a quick assessment and resolution of ethical dilemmas. The ER (especially in urban hospitals) is one place where physicians will rely on ethical principles every day.

So we've put together a course that features 20 minutes of lecture, 30 minutes of instuctor-led case reasoning, and an hour of student group reasoning. As the class moves forward, we will increasingly role play the fast pace neeed in the ER.

Since I'm a blogger, we're using a blog to enhance learning. If you want to follow along, feel free to stop by and read the students' posts. I'll be posting thinking exercises and links to relevant stories over there every week. There is also a course website, where you can peruse our reading list and syllabus. We're hoping to publish some of our motivations and experiences with this venture, as we are unaware of other efforts along these lines...

Last Day

Today is going to be crazy. Just like the last 70 days.

After ten consecutive weeks of psychiatry, I'm going to miss hour-long interviews, the wait and see approach to care, the challenge of nurturing behavior change and all of the talking. I'll also miss the daily case studies of brain pathology.

• The amazingly disorganized schizoaffective homeless man who saluted me every time I asked him a question and could recount amazingly accurate historical accounts of the Pacific Theater in WWII.
• Entering into the dark, empty, wide-open room at the edge of a cliff and offering one pinhole of light (i.e. Washington Sate Law) to move a suicidal patient to the next day.
• Having to stand back when an extremely psychotic patient is immobilized for her own safety and then being there when she is able to speak in cogent sentences.
• Seeing the effects of drugs and alcohol that all of the commercials warn about.
• Learning that it's actually not uncommon for a manic person to be found naked, directing traffic. In fact, it's pathomneumonic for mania.

Psychiatry, you've been good to me. I'll see you again soon.

Clinical Knowledge

My USMLE Step 2 Clinical Knowledge score came back in record time. As you will recall, my score on the costly sandwich (CS) exam was PASS. Today, three weeks to the day after taking the 9 hour computer exam, I received my score report. I PASSED, and scored higher than I did on Step 1 (which I took back in 2003).

Since my score was higher than I expected, and lower than most of my peers, I've decided to share some data about how well the USMLE World practice software package prepared me and the accuracy of one practice exam score predictor, provided by medfriends.org. Those who know I'm an engineer at hear will not be suprised by the following chart.

Plotted on this graph are score estimates from sequential practice exams I took using the USMLE World software. That software grants you acces to a couple thousand practice questions and prepares exams composing of 46 questions each. I averaged the raw scores of the six most recent exams made of questions I'd never seen. That average was input into the medfriends.org tool and plotted on the date. The averages are rolling. The turnover was 4 exams (adjacent data points share from 1-3 individual scores in their average. On the scale above, the horizontal line is 184, or passing. You can see that my trend was dangerously close to that cutoff. But considering my poor showing on Step 1 back in '03, I knew I needed to buckle down.

Shown in red is my actual score - a 209. This is below the national mean, but right about where I'd hoped to be. The one data point immediately before the exam - that was the free USMLE practice exam provided by the exam company. I recommend you take it. not only, will it make you feel better, my experience was that combined with the score estimator, it was a better predictor of my actual score.

Finally, you may ask: why is he advertising such a low score? Well - there's a good chance that residency programs already know my score. If you're reading this because Google brought you here, maybe you'll appreciate seeing a self-reported score that isn't in the 240 range. If you're reading this because your my friend, thanks for being my friend!

If you haven't taken the exam yet, hang in there. Take some time to focus on the material, practice with question sets, and try to take some time off to prepare. I wouldn't, for example, recommend studying at the same time as taking a required psychiatry clerkship.

Physician Heal Thyself

I've been a bit under the weather lately, and considering that I currently cannot see more than 50 feet out my window which can typically see mountains 50 miles away, that's saying something. Getting sick as a health provider adds conflict to the first directive of "do no harm" and lumps additional irony to the proverb, "Physician, heal thyself." Medical student status adds another wrench to the mix. I've written more over at The Differential.

Take This Class

Click for a larger image. Email me with questions.

Clinical Skills

I am pleased to report that the United States Medical Licensing Examination has found me:

• capable of integrating a clinical encounter
• competent with communication and interpersonal skills and
• proficient with spoken English.

In sum, I passed the clinical skills portion of USMLE Step 2. Step 2 CS. The CS stands for Costly Sandwich. As in $1500. Or in my case, $500 each. For those outside of the medical education circle, this is the exam where senior medical students (or international medical graduates) fly to one of 5 American cities to take an 8 hour examination that consists of interviews with 12 standardized patient actors. The closest spot for me was in LA. The exam costs about $1200 not including lodging and airfare. There is a "free" lunch.

Practice Question

A 30 year old colleague approaches you for a curbside consult. A friend of his who is 4 days status post a recent comprehensive psychiatry exam is now complaining of malaise, headache and frequent urination. He has rhinorrhea, and is complaining of frequent sneezing and a "throat tickle" that requires frequent clearing of his throat. He denies throat pain, ear pain, nausea or vomiting. Your colleague humored his friend with a brief physical exam. On exam, there were engorged nasal turbinates with profuse clear discharge, there was a mild white discoloration of pretonisilar pillars; tonsils were absent. His breath smelled faintly sweet. Bilateral mobile, tender, 3 cm sub-mandibular nodes were appreciated. Chest exam was clear. Further history revealed nocturnal urinary retention and dry mouth that awakens him several times at night. A thorough social history indicated the 'friend' felt a sense of impending doom, especially when presented with web-based tutorials. Your differential diagnosis includes:

A) Antihistamine use
B) Panic Disorder
C) Viral upper respiratory infection
D) USMLE Step 2 CK
E) Sleep disorder NOS
F) Caffeine dependence, sustained
G) Specific Phobia

Eloped

My latest article at The Differential is about the medical use of the word, "elope." It probably won't get as much interest and commenting as my last article about firing patients and abortion.

Some of the critical comments responding to my entry suggested it was inappropriate for me to draw similarities between firing psych patients because you cannot help them any more and referring patients to another provider if you are uncomfortable not performing a procedure (namely, abortion). At the core of my argument is my concern that patients get the best care available, and that they should seek said care from the best individual able to provide it. Most of the rest took the opportunity to voice their own opinions about abortion in medicine. Some of my critics argue that all doctors should be willing to provide abortions (that's not going to happen). One reader questioned my disclosure that I was 'uneasy' with providing abortions myself. I'm not sure how to respond to that... Finally, one reader has argued that we must get over the fact that the country is divided about abortion. I would argue that adopting this perspective would effectively invalidate half of your patients' beliefs.

Controversy!

Abortion, psychiatry, firing patients: three issues that elicit strong emotions. So if you suffer from a panic disorder, you may not want to...

Read my latest entry at The Differential to get my take.

Otherwise, carry on!

ERAS

I just finished uploading my personal statement, applied to 30 emergency medicine programs and shelled out $365 to the Electronic Residency Application Service (ERAS). That's just one dollar a day to feed an orphaned... wait, that must be something else. I'm just glad I have the opportunity to continue my training to be a physician. Since my wife and I are both applying, we have selected ten cities that have programs that appeal to both of us. They include (from west to east):

The Bay Area
St. Louis
Chicago
Atlanta
Pittsburgh
DC/Baltimore
Philadelphia
New York
New Haven
Boston

This is the end of one stressful task (applying), and the beginning of another (hopefully, interviewing!). Read my personal statement here.

Me, In A Page

Lately, I've been diverting most of my wordsmithing to a one page document that may be the single determinant of where I spend the next four years of my life. Putting these ideas about science, medicine and society into a page has me really excited about a career in emergency medicine.

*****

One late summer night in Harborview Medical Center's emergency department, an exasperated medicine resident turned to me with a rhetorical question: “Who would want to treat homeless, drug-using prostitutes?” When I immediately thought, “I do,” I knew I was home. This epiphany at the end of a month in Seattle’s level one trauma center cemented my commitment to a career in emergency medicine. Contributing to the trauma team, working with a diversity of cases, the rapid progression from presentation to diagnosis to treatment, and the societal issues I pondered after each shift all conspired to entrench my connection to the ED.

My path to a career caring for the acutely ill started with dreams of building life support machines. As a clinical technician for the University of Pittsburgh's artificial heart program, I learned that invention and patient care have a tendency to interdigitate. The image of science and medicine clasping hands framed my motivation for earning a bioengineering PhD. I developed innovative new surgical, molecular and tissue engineering techniques as part of my thesis project to improve the viability of embryonic stem cell-derived cardiac tissue replacements for use after myocardial infarction. Long hours in the lab doing thoracotomies on mice and measuring with echocardiography the extent to which we were repairing infarctions introduced me to the importance of intellectual and manual dexterity in medicine. Experience suturing hundreds of rodents enabled me to consider each human laceration repair a new artistic challenge. My first successful ultrasound-guided basilic vein cannulation opened wide my appreciation for sonography in the ED. Emergency medicine requires mastery of numerous techniques and knowledge from many disciplines; this environment of collaborative innovation makes EM a perfect career for someone like me who wants to combine multiple skills and interests to provide the best care for patients.

The notion that today’s scholars have to focus narrowly on subdivided fields in order to make contributions to society contrasts with my perspective that the actors of social change must think deeply in multiple fields. As a graduate student working with human embryonic stem cells, I learned firsthand not only how scientific research occurs in the context of social and political concerns, but also that scientists and physicians are obligated to contribute to public dialogue. I am as proud of defining 'blastocyst' and 'in vitro fertilization' for stem cell research legislation in Washington State as I am of my labwork to further the potential of cardiac regeneration. Through a science policy group I co-founded, I planned campus-wide conversations about genetically modified food that spurred constructive conversations that continue more than three years later. Hosting President Clinton's science advisor to engage the University of Washington about the future of research funding in America offered a glimpse into the importance of sound science policy.

However, one needs look no further than county hospitals' waiting rooms to see that innovation in patient care is not merely a scientific enterprise – it needs to be a social one. Our current policy morass of underserved health care in America establishes emergency medicine as the front line for individuals seeking to heal people and the system. Solutions are not easy to find, especially from within the academic ivory tower; some of my understanding of the complexities of urban health care is grounded in relationships I've built over four years as an STD counselor for homeless teens. I aspire to be the emergency physician who draws on experience treating the neediest of patients to facilitate difficult conversations about health policy.

The ED is not merely a safety net. Challenging ethical dilemmas that emerge from a diversity of diseases, the urgent presentation of humanity in crisis, and the varied manner in which people respond to acute illness demand that emergency providers have ethical reasoning skills at the ready. The emergency room is a laboratory for teaching medical ethics; I hope to translate an “Ethics in the ER” course I developed for medical students at the University of Washington into a training tool for tomorrow's doctors. My experience designing this course has helped me understand better that educating others is a critical element of the practice of medicine. Teaching forces me to shore up topical understanding and requires communication accessible to a range of individuals: patients, students and colleagues. I look forward to an EM residency that provides both teaching role models and opportunities to refine my own skills.

Scientist, activist, writer, ethicist, engineer, doctor: for me, each of these roles supports the others. Rather than a collection of titles in separate contexts, I prefer the simple title of citizen-physician. There is deep meaning in the patient-physician interaction, both in the literal space of a sick person seeking care and as a metaphor for how physicians can improve society. My diverse and well-developed interests are ingredients for a career in emergency medicine that steps beyond discrete disciplines to address patients’ immediate health needs and improve the practice of medicine.