Countdown to July 1: Attending

The last July 1st with any significance is after the last year of residency. At that point, a resident (AKA house officer, physician in training, indentured servant, scut monkey, etc.) completes his training and is board eligible. If you ever wondered what BCBE stands for, it's 'board certified / board eligible.'

Uniformly, residents discover that they have a limit to the amount of residency they can take. After a certain point in time, residency becomes intolerable. It is a continual nightmare having your judgment questioned continuously, and having your clinical decision making process derailed by someone who potentially knows less than you. In fact, most residents in their final year may know as much if not more factual medical knowledge than their superiors.

But practicing on your own is a different beast. There's no one questioning what you're doing, but there's also no one to offer advice or reassurance. There's no superior to appeal to.

It is an intensely isolating experience, and all those years of medical school and residency suddenly feel very empty. I thought that I was ready to be an attending when I was done with residency, but what I discovered was that there is no preparation for being your own doctor. At some point, you have to trust that you are right, and that can be hard to come by.

Advice to the new attending:
-Sometimes making any decision is more important than being right.
-Never let them see you sweat.
-Do not pull the 'Who's the doctor? You or me?' card unless you really mean it.
-Most importantly, trust no one.

Countdown to July 1: PGY1

It is somewhat common knowledge that if you're going to pick a day to avoid the hospital, July 1 is the day. The hospital is awash with not only new interns but also senior residents still green with inexperience. And if you are a PGY1, welcome to Hell.

I remember the day after I graduated medical school, I was driving down the highway and saw a car run off the road and crash. As I drove by, I thought to myself, 'That person could really use a doctor...' Then it occurred to me: OH FUCK, that doctor is me!

The nightmare of intern year has been immortalized in the book, 'House of God' by Sam Shem, and I am sad to say that for the most part it still holds true after 30+ years. Intern year is still the singular worst one year period of medical education.

It is dehumanizing. It is humiliating. It is frustrating. And it wipes away any confidence or boldness carried over from medical school. MS3's complain that they've never felt so stupid as during third year, but that pales in comparison to intern year. At least during third year, your ignorance didn't hurt anyone but yourself. Now, what you don't know kills people.

The training goals of intern year are to learn patient care and disease management. However, what I walked away with was this: I learned what kind of doctor I am. The intern will learn what kind of doctor he is. Is he someone who fudges records? Does he take shortcuts? Does he stay late every day to tie up loose ends? Is he overly confident? Is he gun shy? By the end of PGY 1, an intern will know what kind of doctor he is, and he will spend the rest of his career either accepting that fate or fighting against it.

Some advice for new PGY1's
-If you can, wear scrubs all the time.
-Making friends with the nurses will improve your Rounding-Fu*.
-When you go home, leave the patients at the hospital.
-Make yourself a 'Laws of the House of God' checklist.
-Finally, but most importantly, the most valuable thing I learned during intern year was: sleeping is more important than eating.

*Rounding-Fu: How badass you are during rounds

Countdown to July 1: MS3

Anyone familiar with the medical education process knows the significance of July 1st. It is the day that everyone moves up a peg. MS2's become MS3's. MS4's become PGY1's. PGY3's (or 4's or 5's) become attendings. There's a lot of significance wrapped up in July 1st.

Third year of medical school is a funny thing. It is an unpredictable experience. It is rough and wonderful and glorious and terrible. It is amazing and disturbing. And the thing about the third year of medical school is that it changes people. At the beginning, everyone starts bright eyed and eager, and by the end, students are profoundly different.

We all imagine that if we were in battle, we would be leading the charge, but what we may discover is that we are the ones hiding in foxholes, shitting ourselves. And that is what you find out about yourself in third year. You find out who you are. You discover if you are vengeful or vindictive, apathetic or aggressive, kind or cantankerous. Your own true nature is revealed.

There are many reasons for this. The MS3 is sleep deprived. He is rotating through different rotations and always a little disoriented. He has not eaten breakfast in 10 months. He has not seen the sun except through patient room windows. He has been constantly pimped about every piece of medical knowledge currently known.

Although we have been trying to change the process of medical education, the MS3 experience is still one of being crushed down, and then being rebuilt better than before: better, stronger, faster. However, that means that some soul crushing has to take place... As nice as it is to be done with the process and look back on MS3 with nostalgia, having your soul crushed is a uniquely painful experience.

Some words of advice to the new MS3:
-Take a shower, no matter what.
-Work hard, play hard.
-No one likes a kiss ass.
-Wear comfortable shoes.
-Your attending wants 3 things from you: honesty, enthusiasm, and diligence (if you have none of these qualities, learn to fake it).

Eating healthy

I often field questions about dietary supplements and vitamins. What do I think about co-enzyme q10 or high dose vitamin E or beta carotene? Flax seed? Ginkgo? Tons of stuff like that. For the most part, we don't know a lot about dietary supplements. No one has studied these things in any really meaningful way. But in reality, eating healthy is such an easy task that it doesn't require much thought.

If everyone simply did two things, then we as a country would be much healthier. If we (1) ate less, and (2) ate less packaged and prepared foods, we would be miles healthier, diabetes would be far less prevalent, and we would stop being the fattest country in the world.

...but at the same time I'm telling patients this, I have a cheeseburger with fries for lunch waiting for me in my office.

Convince me

There's a lot of science in medicine. It is often called the youngest science, and rightly so. However, the practice of medicine is quite different from most sciences because it is so intimately tied with dealing with people. And one of the problems with dealing with people is that despite whatever evidence you may have, people need to be convinced.

One of the tremendously annoying things I discovered in med school was immunization of children. So many parents had so many bizarre (and frankly ludicrous) reasons not to immunize their children. After a while, it just wasn't worth fighting over. Now, it's not uncommon to see outbreaks of mumps and measles. Measles is a disease I can't even recognize. I've never seen it.

But immunization is only the tip of the iceberg. I fought over the phone and in person with a patient over the course of a day to agree to have a cardiac catheterization. Once in the lab, they saw left main and triple vessel disease.

One of the things I love about adult medicine is simply that: it's adults. If someone wants to make a tragically bad decision, at the end of the day, if they were properly informed, it's their terrible decision to make, and I can sleep easy at night.

Keeping sharp

As a general internist, there are a few different jobs that I am trained to do. I am able to see patients in the clinic, outpatient medicine. I am able to see patients in the hospital, hospitalist. I am able to address urgent issues, emergency and urgent care. Not a lot of internists still do emergency, with the rise of emergency medicine as its own specialty. That leaves the hospital and the clinic.

Everyone has their own preferences. Some like the clinic more, others the hospital. I’m not a big fan of hospitalist care. Not that I disapprove. I just don’t enjoy it. I went into medicine for the continuity of care. However, the clinic has its downsides as well. The one true thing though is that if you do one or the other, it’s easy to get rusty. If all you do is clinic work, then the hospital is a pretty intimidating place. There’s a lot of aspects to acute care that are challenging and require a lot of coordination. If all you do is the hospital, then the clinic is really difficult. Results come back in weeks, not hours, and dealing with patients with chronic illnesses is challenging.

The one thing I’ve noticed about myself is that I’m not feeling very sharp with either. I’m losing that sharpness I had in residency in the hospital. I don’t have all the answers. I’m not ‘the man’ anymore. In the clinic, I’m not as sharp as I could be, often taking weeks to take care of relatively simple issues.

To me, it seems like the traditionalist is not a sustainable model. Precious time is split too much, and there’s no expertise. And the shame of it is that I want to be an expert at something.

The things you learn in med school

When we talk about medical school education, there's the actual didactic material, and then there's the 'hidden curriculum.' For those not familiar with education lingo, the hidden curriculum is a set of norms or values that are imparted to students unintentionally. It is not written down. It is not testable. It is simply something learned through the process of going to medical school.

In medical education, some examples of hidden curricula are that men shouldn't go into OB/GYN, or women shouldn't go into surgery. You should have no life other than medicine. Everything comes second to your medical responsibilities. Sleep is for the weak. There's no crying in medicine.

Sometimes, these lessons are reinforced though things like lectures on professionalism or the patient-physician relationship. Some schools even try to direct their hidden curricula, taking it into the open light, for better or for worse.

For me, I found my own hidden curriculum from medical school. In the process of going through school, I learned a lot of things that med school never intended to teach me, but they're some strong lessons for life:

The friends you make over a bottle of $200 scotch at 4 AM are probably some of the best friends you'll have.

Thanksgiving and Christmas are precious, and when you can't go home for your own family's holidays, then finding a family to take you in is invaluable.

Medical school is some of the hardest work you'll do. Work hard, but play hard too.

While there are many other such lessons, the one that stuck with me is that at some point in your schooling, you will find that you will have to choose to give everything to medicine, or hold back. And you will discover what kind of doctor you really are when you're faced with the hardest choices between what you want to do, and what other people need of you.