It gets easier... right?

I had the chance to talk to a budding medical student last week, and it's strange to see the medical student perspective again. When I was going to medical school, I had a very self-centered experience. That is to say, I did not notice a lot of what was going on around me because I was so focused on what I needed and wanted.

Now that I'm done with the medical education process, I find I have remarkably little sympathy for the plight of the medical student. Everything seemed so dramatic at the time, but the thing about medical education is that every subsequent year is worse. MS2 is worse than MS1. MS3 is worse than MS2. MS4, while easier from the education side, is far worse with interviews and rank lists and the Match. PGY1 is pure hell. Subsequent PGY's are painful for new and horrible reasons. Being an attending is a whole new basket of terrible issues.

So it's hard to be sympathetic when medical students complain about med school. It's like complaining to a major league baseball player that a 70 MPH fastball is hard to hit. Yes, it is, but if you want to go forward, it doesn't get any easier. In fact, it only gets worse.

Caution if hepatic impairment

I was editing and reposting old entries from the old server, and ran across a post that reminded me of something I'd tried to forget. I had a patient in the ICU, barely holding on to life, with diffusely metastatic cancer, suffering not only from all the complications of the cancer, but all the side effects of the chemotherapy, with cardiomyopathy, neutropenia, anemia, and a host of other terrible side effects.

Even with inotropes [drugs that make the heart beat stronger] and pressors [drugs to increase blood pressure], her systolic pressure was a laughable 60 mmHg. She was having end organ ischemia, and her liver was failing. Her AST and ALT were in the 1000-1500 range. Her renal function was non-existent.

And as a result, we stopped all meds that were toxic to the kidneys and liver. That included her prozac. And every morning that she was conscious, she begged me for her prozac, and I had to tell her that her liver couldn't take it. Her organs weren't working. But she would beg me to give it to her.

Eventually, my attending started the prozac again, despite the miserable state of her liver. 'Ifinding, why not give her the prozac? With everything else going wrong, why not let her have this?' And I felt real guilt. I had been trying to protect this patient from the possible toxic buildup of the drug, but I had taken away the only thing that had made her life bearable. I was worse than the chemo.

And I learned then that the compassionate choice is not always the most medically appropriate, but far easier on the soul.

Gunners

I have a friend in med school, and he is continually worried about gunners. He's started clinicals and doesn't want to be shown up or embarrassed on rounds. To me, it's quite amusing listening to students complain about gunners, because it's all perspective.

When I was on internal medicine as a student, there was another student on rotation who was always chipping in or talking about some obscure thing he'd been reading about. He knew MY patient's labs, just in case I didn't. It's not like he told me the lab values. He just got them so that if I should falter, he'd have them ready so that he could look good and I would look bad.

But looking back on my surgery rotation, I showed up earlier than everyone, did all my pre-rounding, and helped the interns with pre-rounding, and I volunteered for all the dull procedures. I wasn't trying to shine. In fact, I just wanted to do my time and be done with it, but because I put in the effort, I was always first in line. 'Hey, ifinding has scrubbed in on like five lap chole's this week. He should get to come in on the Whipple.'

I had no desire to do surgery. Scrubbing in on the Whipple was six hours of absolute torture. I wasn't trying to show off or make other students look bad. I just wanted to have a good experience. After the rotation, I found myself complaining about gunners, and one of my friends elbowed me, saying, 'Yah, takes one to know one!' I was shocked, but after a while, I saw it. I'm a gunner too. Being a gunner is all a matter of perspective. We're all gunners.

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