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does this car have any problems?

Last week and for this next week, I am the night float on our service.  I do the work of 3 people, except at night.  My life is totally nocturnal–I sleep during the days and am totally awake all through the nights.  I do this everyday.  One of the problems with night float is that you cover many patients, normally covered by multiple people during the day.  In my case, I am covering over 4o patients during the night that are normally taken care of by 3 people during the day.  Of course, the night isn’t as busy as the day–not as much stuff can get done during the night.  Unfortunately though, with that many patients, you’re bound to get a ton of pages for all sorts of random things.  Nausea, pain, … V-tach.  It can be painful.  But I’m prepared for it.  At least I think I am at the start of most nights.  That’s where I usually go wrong. 

What I hate most about the night float experience are the surprises.  When I show up in the evening, I get signout from 3 people who are exhausted from a long day’s work.  They want to get out of there so they fly through the events of the day.  If something happened that may happen again overnight I will ask about it, find out more, etc.–is the patient ok?  can this happen again?  what did you do for it?  did that work?  what did work?  who did you talk to about it? 

 This is good for me and good for the patient.  This is not good for the person who is trying to go home.  As a result, signouts go something like: patient x, nothing happened, doing great no worries; patient y, good day, nothing for you to do, etc.   The problem is when I get a signout like: patient z, “his creatinine bumped a little, has repeat electrolytes pending tonight, shouldn’t be a big deal, just check on them, and, oh yeah, his pressure was a little low so I gave him some fluid.  Not big deal, nothing for you to really do.”  [As an aside for those of you who don't know, creatinine is a reflection of kidney function and the higher it is, the worse that the kidney function is].  The next thing I know (of course, 15 minutes after the day guys have left), I get a page that the patient’s blood pressure is now 65/40 (very low–not good), having mental status changes (i.e. acting weird, suggesting not enough blood to the brain) and now his creatinine is 3.5 (not good at all) with a potassium of 6.2 (rather high, making the patient susceptible to fatal arrhythmias).  Oh, and did I mention the patient has a new oxygen requirement (needs supplemental oxygen–i.e. room air is not enough)?  Yeah, not good. 

I find that the night float resident is not too different from someone who goes out to buy a used car, while the day folks are the used car salesmen.  “Oh yeah, no problems!  No problems at all!  It’ll run perfectly smoothly!”  Uh huh.  My example is not typical, but it happens.  I wish you could blame the system but at the end of the day it comes down to apathetic residents who want to get the hell out of there and go home.  After a while you get to know these people so I know what to expect.  Then I still end up having to spend a decent portion of my night trying to find out what happened to these patients during the day so as to anticipate problems at night.  It really irritates me.  Don’t get me wrong, I want to go home too, but not at that expense. 

In any case, time for sleep in order to get ready for the big game tonight: 45 patients, 4 of them are really sick, 2 of them could die–try to figure out who they are!

The life of a resident.  Painful.

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yikes

Until recently, I didn’t know what it felt like to get 4 pages at the same time.  The pager makes this high pitched whining sound like it’s about to die.  By now I’ve almost reached the point where not much surprises me.  I know that if it can go wrong, it will.  If it can bleed, it will.  If it can stop beating, it will.  You get the point.  I’ve gotten more to the point where I am more limited by the number of hands, arms, Mudphudders I have to deal with this stuff.  What do you do overnight with essentially no oversite when you’re taking care of >40 patients most of whom could realistically crump?  (FYI, crump = really bad stuff–usually involves “shocking” someone or getting a machine to breath for them).  What do you do when you get 4 pages at once and all are about pretty serious stuff?  I gotta tell you, I’m glad I’m doing this stuff now and not earlier in the year.  It really tests one’s ability to triage problems.   It’s a great challenge.  But sometimes you gotta wonder how much of a razor thin margin of error there is for holding off on attending to one patient because you’re treating the other.  I mean, it feels pretty scary sometimes but I suppose the system (residency) is built this way for reason (i.e. maybe it’s not as bad as the butterflies in my stomach make it out to be).  At least I hope so.  Still though, I wonder how many is too many?   How much is too much acuity?   I think there are definitely services at every academic teaching hospital that push this limit all the time.   To be the physician on one of these services, though–wow.  It’s an amazing experience–exhilirating, exhausting, awesome.  Tremendous learning experience.  Running on adrenaline.   Like walking on a tight-rope.   I just hope I don’t fall off. 

Enough–I’m going to bed now.

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maybe there’s a reason

So I have been thinking about how long it has been since I posted an entry to this blog.  (It really has been a while).  I thought back to my experiences over the last few months, things that I could have shared, and  almost everyone of them was a painful experience.  As I write this, I am sort of smirking, because by pain I’m referring mostly to the typical bullshit one hears about in regards to residency.   I didn’t really believe it would happen to me–I thought it was mostly stuff you see on TV–but it happens.  At the time, it kind of sucks and sort of feels like a punch to the gut when unprepared, but in hindsight it’s kind of funny. 

I was discussing with a co-intern of mine some of the things we learned this year and our mutually agreed upon top lesson learned was how to take abuse.  Again, I’m chuckling while I write this, but it really is true.  Don’t get me wrong, we did learn A LOT of medicine and number two on the list is how comfortable we all feel taking care of patients on the floor.  But, number one is definitely how to take abuse. 

In some ways, you have to train at it.   Taking abuse that is.  And that’s what part of this year is for I guess.  There’s always the possibility for getting chewed out.  Every day, there are at least 50 things that I do, which could earn me a major chew-out.  Not through any irresponsibility, not through any laziness, not for lack of caring, not stupidity but just because.  There is so much shit to sift through–all simultaneously–that you’re bound to get caught up on something.  Take for example the time I was presenting a newly admitted patient and I quoted some findings from a previous discharge summary dictated by a random attending who was not part of our team.  This attending just happened to be sitting within earshot, and screamed at me–interrupting our AM rounds–that the details of my presentation were totally wrong, that all interns are lazy, that I’m lazy, that I didn’t do any work, that I didn’t read his notes, etc.  Now, what he was yelling at me for being wrong about was stuff that I took directly out of his notes.  Makes no sense right?  No sense at all. 

So all at the same time, I was dealing with a random chew out, dealing with the embarassment of getting chewed out in front of my team and on top of that, dealing with an attending who was yelling at me for not doing what I actually did do.  All of this on total sleep deprivation and you about lose your mind.  I remember just standing there trying to make sense of it all, and just saying “yes sir, yes sir, yes sir” (always a safe response) until I figured out what had just happened.  Except by the time I realized that I was just nailed for no reason, everything was over.  In hindsight, there was nothing that would have been worth doing at that time except for saying “yes sir”.  This guy was a complete ass who was having a bad day and had his facts mixed up, which he took out on me.  Fair?  No.  Normal?  Kind of. 

These days, I take that stuff with a little more grace.  I still keep my mouth shut and absorb it but I don’t get flustered and I keep my poker face on.  What else can you do?  I’ve seen so many different permutations of being treated like shit that I’ve been there, done that for most of my intern-related chew outs these days. 

I know that I still know there’s a world of shit out there just waiting for me.   But I’m up to it.  I think.

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dusting this thing off

Wow, it’s been a long time since I’ve done this.  (I hope this works).

As some of you know, I’ve been in the midst of intern year of my residency.  At some point in the winter, I backed off on the blog.  Too little “me” time.  Working as many hours as I had been (officially 80 hrs per week), there was little time to get any of my personal business done, let alone blog on a consistent basis.  But, I’m gonna try to get back into this.

Let’s try, shall we? 

More to come soon…  !

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finding a good mentor: asking the right questions

As I (and many many others as well) have previously written, finding a supportive mentor is all about asking the right questions of both the prospective mentor as well as the mentor’s trainees.  As you are going through the process, think about these qualities that you may find desirable in a mentor:

  • accessibility: does the mentor have an open door and an approachable attitude?  is the mentor around or often away on trips/conferences?
  • empathy: does the mentor have insight into what the trainee is experiencing?
  • open-mindedness: does the mentor have respect for the trainee’s individuality, autonomy, working styles and career goals that may be different from mentor?
  • consistency: is the mentor reliable in action and principles?
  • patience: does the mentor understand that success can sometimes depend as much on luck as hard work?  does the mentor understand that people make mistakes and learn at their own rates?
  • honesty: does the mentor communicate truth–whether good or bad–about the trainee’s work, the world and the trainee’s chances out there
  • savvy: does the mentor have a sense (and communicates it) of the pragmatic aspects of career development?
  • loyal: does the mentor value the trainee’s contributions and support as well as defend the trainee from outsiders trying to take advantage of the trainee?

I have previously written at length about finding a good mentor for both the research and medical careers and what a good mentor can mean.  I harp on this point over and over again because good mentorship is key to kicking off a successful career.  So if you are looking at a prospective mentor, try to hone in on these qualities and when talking to the mentor’s trainees in private, specifically ask.  Better to find out sooner rather than later when it may be too late.

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menthol opening your congested nasal airway?

It’s that time of the year again when the dry air irritates your nose and sinuses causing you to feel stuffy.  In all reality, isn’t it always that time of the year?  Allergies, dry air, colds–does it ever end?  I get stuffy a lot so I’m always interested in learning more about how to get some relief. 

Ever wonder why the smell of menthol can cause an enhanced feeling of air moving through your nose?  In another post on the use of nasal irrigation for allergies and sinus problems, I mentioned that nasal rinses with menthol may help with the symptoms of nasal congestion.  Why is that? 

The epithelial cells that comprise your nasal mucosa (the lining on the inside of your nose) have special temperature sensors on them, which belong to a family of proteins called TRP channels.  When you take a deep breath in, cooler air (than the warm air in your nose) whooshes over those receptors which sense “cold”.  This positive “cold” signal is relayed to your brain, which interprets it as “air is moving through my nose”.  Menthol is chemical that activates these receptors without requiring the cold air to move through your nose.  This is why when you are congested (i.e. not moving a lot of air through your nose), but you (for example) use either a nasal rinse with menthol or Vick’s vaporub, your nose feels as though it is opening up.  For more information, check out these studies by Lindemann et al (more clinical) and Bautista et al (more basic science).

Pretty neat, huh?  Now if I can only find something to relieve the sleep deprivation associated with residency.

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who has a patent?!?!?!

Just like you want to know how many NIH grant the guy down the hall has, you’re probably also wondering if he has any patents.  While you toil away at the bench or in the clinic, this dude is probably raking in the dough from his patent on the little floaty things that hold eppendorf tubes in the hot water bath.  Do you want to find out?  Then go straight to the US patent office website and do a search!  This will take you to the advanced search page and just type in: IN/[LastName]-[Firstname] (for example: IN/doe-john) or you can leave the first name off (for example: IN/doe).  You might be shocked at what you find…

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an observation

Why is it that when I wear my white doctor’s coat, people call me sir but when I’m wearing jeans and sweatshirt people ask me for an ID when I pay by credit card? 

Hmmm….

Although these days I’m not so sure that my white coat even has much power left.  Maybe it’s all the dirt and nastiness on it. 

You may have heard about the “white coat effect”–that patients tense up around physicians (e.g. in the doctor’s office) and their vital signs, like blood pressure, may be on the high side.  The last few times I’ve been in clinic and manually taken blood pressure on my patients, their pressures are just fine.  So either I have a calming effect or my patients aren’t taking me seriously.  My money is on the latter.

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a million stories

  Have you ever walked down a hospital corridor and looked around?  I mean really look around?  Noticed the scratches, dents and marks on the walls?  The hospital is filled with a million stories.  We turn around patients all the time–people coming and going–but their visits often leave their marks on the hospital.  I’m not trying to be touchy feely or anything, I’m talking about mostly inconsequential marks but reminders to all of us that the craziness existed long before us and will continue long thereafter.  Each mark, dent or scratch, a patient in hospital bed being pushed to a stat CT scan, to the OR, to interventional radiology.  Residents who’ve banged equipment into the walls while trying to get a last minute procedure done before leaving for the night.  Food services employees who run that damned gigantic food tray transport unit into every fucking thing, including my foot.

  Time moves quickly.  I’ve been going through the drill for about 4-5 months now and I’m sometimes so focused on surviving that it is easy to forget how many stories–interesting, tragic, or even annoying–happen everyday, for like a hundred years and to go on for even longer. 

  Makes me feel like a pimple on the ass of this hospital.  I’ll come and go.  Many came before and many will come after.  And maybe, just maybe, I’ll manage to turn into an abscess that needs to get drained and those who come after me will look at my scar and wonder what pain in the ass did that.

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here comes more trouble

  Clinic.  The worst.  Writing H&Ps even worse.  New admits at two minutes before my shift is over–a dagger in my eye.  But the pain is sometimes happily abated when you get a fairly straightforward (from the standpoint of medical history) patient with few medical co-morbidities. 

  Then I look down at the chart or an old note and see “end stage renal disease (ESRD)” and I know I’m screwed.  These patients are almost always quite sick with a lot of medical problems.  The reason is that people don’t typically lose their kidneys for no apparent reason.  And to lose significant kidney function usually requires a lot damage–in other words, a lot of chronic systemic diseases.  This usually means hypertension or diabetes.  Not so fast there because long term hypertension and diabetes cause a whole host of problems from heart disease, cerebrovascular disease and peripheral vascular disease in general–all of which make medical management much more painful.  Pain pain pain pain. 

  A patient that should be nicely and quickly tucked in becomes the dude you spend all night figuring out what to do with and then you are worrying about every second until you get your eyes on him again no matter how carefully you manage him. 

  Bottom line: don’t these people know that I need a break??!?!!?!?  Why do they have to be so sick?  ;-)

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at least i’m still a mudphudder

  I’m tired.  I’m beat down.  Some days I’m just like, I don’t know.  Some days I don’t know if I’m gonna make it through.  I mean, I’m like 4 months in now, which is good, but there’s at least another 8 months left and that’s just internship.   Whatever, at least I’ll always have my pieces of paper.  The ones that say MD and PhD on them.  They may not help me much when I’m the “Welcome to Walmart” guy, but at least I’ll still have them. 

  Welcome-to-walmart-guy, M.D., Ph.D.

  That’s funny.  I’m going to bed now.

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choosing poorly

Mudphudder before graduate school

Mudphudder before graduate school

I’ve made out pretty well for myself but I am constantly reminded of choices that I could have made better.  Much better.

 

Examples: (have I complained about this stuff before?) an acquaintance for scored 3 articles in the C/N/S journals all in the same week.  If you added the impact factors of all of the journals I’ve published in (double digits), it wouldn’t come close to the impact factor of one of those journals.  Former co-graduate students who formed “alliances” with each other and now they all appear on all of each other’s papers.  I look at the author lines on those papers and I see 12 names but know that only 3 people did 99% of the work.  Bullshit.  Yeah yeah I know that those papers are just meaningless filler on the C.V. but when you have your work too, a few extra lines doesn’t hurt.  Bullshit.  I won’t even get into the social structure around the alliances in our old lab.  But it was there and now all of those wankers end up with like 10 extra papers for nothing.  Maybe I should’ve hung out with them more often. 

Mudphudder when he looks up old labmates on pubmed

Mudphudder after he looks up old labmates on pubmed

 

 

Sigh, I definitely could’ve made better choices.

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romanticizing me

Well not me but, rather, health care workers in general. 

God, this looks like a retarded show.

God, this looks like a retarded show.

Has anyone else noticed a recent slew of medical tv shows coming out?  So far I’ve noted several new tv shows about nurses and at least one about EMTs.  All (at least from the commercials) greatly romanticizing the roles of each group–here’s a line from a commercial for a TV show about EMTs called “Trauma”: “when everyone runs away from a disaster, they run towards it”.  Ahahahahahahahahahahahaha!!!!  Most of them are too out of shape to “run” towards a disaster.  AHAHAHAHAHAHAHAHAHA!!!!  I’ve met some pretty good and knowledgeable EMTs but I’ve met some really bumbling ones too.  My favorite was the one who walked out of the ED with an apple jammed in his mouth and the location of the chest pain patient’s EKG rhythm strip unknown (probably in his back pocket). 

I don’t remember any lines from the shows about nurses but I do remember a lot of nurses yelling at the

AHAHAHAHAHAHAHA!!!!

AHAHAHAHAHAHAHA!!!!

actors who are supposed to be the doctors.  Maybe I remember that because it hit so close to home.  I’m pretty sure that for TV viewers, like for me, watching nurses annoy the shit out of doctors will get old FAST.  I mean, how many different ways can the writers come up with for whining and complaining, interspersed with pages to the overtired, overworked resident at 3am that says: “FYI: pt XYZ’s BP- 120/70, HR- 76, T-98.6″.  IS THAT WHAT YOU WOKE ME UP FOR????  Arrrrggggghhhhh!!!!!!  (note those are all normal vital signs). 

The shows on TV about doctors are just as bad AND we’re portrayed as a bunch of bumbling malcontents (which, to be fair, may not be that far from the truth).  Sometimes I actually think the reality TV shows about doctors are the best because you get to see the real life dysfunction. 

Okay, let’s hold it for a second.  If it came across that way, my intention is not to hate on anyone.  Nurses, EMTs and doctors–there is a gradation of quality terrible to really great as well as a gradation in their aproach to work from just a job to a calling.  There’s nothing romantic about it.  In fact, the same person can be superstar or dud depending on the day of the week.  Take me for instance, there are days when I hate life and the rotation I’m on and then there are days when I’m a freakin’ inspired doctor.  Very much like the dude at your local footlocker who sometimes hates life because he sells shoes for a living but then sometimes takes the approach that his job is important because he helps people find comfortable shoes.  Whatever.  Most of the time I would think that medicine is not that interesting to the lay person.  Hell, I wouldn’t want to watch most of what I do on TV.   Fillng out paperwork, fighting with everyone from other doctors to phlebotomy to the freakin’ CT scan techs in order to get something done.  It’s usually the end product of a lot of uninteresting stuff that is cool–a patient who is healthier.  Note that I didn’t even say cured because there is very little that actually gets cured.  Does that sound interesting, dramatic or romantic to you?

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right of passage

  Is it some kind of bullshit right of passage that everyone who enters residency/internship is supposed to break down and cry at some point? I don’t know if it’s just the feeling that comes with having to get used to a really difficult

This is residency incarnated and he wants to kick my ass.

This is residency incarnated and he wants to kick my ass.

lifestyle/job but sometimes it feels like that. There are days when I feel like there are older residents even nurses who have that look on their faces of “is this the day that he cracks”?  And mostly it feels like people are looking on in eager anticipation rather than in empathy.  I’m not saying that anyone purposefully does anything with the intention of causing one to cry (mostly at least–going through the process of residency has definitely fucked up a few people in the head).  But I’ve definitely gotten the evil smile. That would be the one I get in response to the look of abject terror when after AM rounds I look down at my census of 40 really sick patients each with a bunch of empty boxes next to their name that need to get checked off.
  I’ve come to the realization I’m living in a Rocky movie. (Note that whenever I need to find an explanation for the seemingly inexplicable, I turn to the universal wisdom of Rocky). In my version, residency is like Ivan Drago, where he stares Rocky down and he’s like, “I must break you”.  In fact, Ivan Drago says like 6 things in the course of that movie:

  • “You will lose.”
  • “I cannot be defeated” “I defeat all man.” 
  • “If he dies, he dies.”
  • “I must break you.”
  • “To the end.”

 All of which suggests to me that residency is willing to go the distance and has only the singular goal of crushing me.  At least in my version, I’m Rocky.  Then again, Rocky did lose like half of the fights in his movies…

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here comes trouble

  This isn’t meant to be an educational post about fibromyalgia but for those of you who aren’t familiar, here’s the brief wikipedia explanation:

 Fibromyalgia, meaning muscle and connective tissue pain (also referred to as FM or FMS), is a medically unexplained syndrome characterized by chronic widespread pain and a heightened and painful response to pressure (allodynia). Other core symptoms are debilitating fatigue, sleep disturbance, and joint stiffness. Some patients may also report difficulty with swallowing, bowel and bladder abnormalities, numbness and tingling (paresthesia), and cognitive dysfunction.  Many patients diagnosed with fibromyalgia also have psychiatric disorders.  Because fibromyalgia involves more than just pain, the term “fibromyalgia syndrome” is often used; not all affected persons experience all associated symptoms.

Also, nor is this post meant to bash fibromyalgia.  However, if the disease process isn’t clear to you or you’re confused, then you’re starting to catch on.  Clinically, fibromyalgia is diagnosed with the following criteria (from the Mayo Clinic):fibromyalgia-pressure-points

  •  
    • Widespread pain lasting at least three months
    • At least 11 positive tender points — out of a total possible of 18

Seems kinda wierd to me.  But that’s probably the just the fear of the scientifically unknown coming out in me.  I’m not trying to be sarcastic either.  I believe that there is probably some pathophysiologic process underlying fibromyalgia but who the hell knows.  These patients are definitely experiencing “pain” but what is the source of that pain?  Is there even a tangible source?  When you think about it, pain is really just our subjective interpretation of noxious stimuli.  You can have noxious stimuli without pain (e.g. with anesthetic), and you can have pain without noxious stimuli (called allodynia). 

  I gotta be honest here, after all that I still don’t know what the hell this disease is.  I mean, I’ve been in constant pain since July and my whole body aches but I’m pretty sure that’s from getting my ass kicked on a near-daily basis and not fibromyalgia.   But I digress. 

  Anyway, is it just me or are most of these fibromyalgia patients a little weird?   (Losing readership losing readership… AHAHAHAHAHAHAHAHAHAHA)  NOTE: I did not say ALL–just most of these patients.  I don’t know if there’s some pathophysiologic connection between the cause of pain in these patients and weirdness (I mean like borderline schizotypal weird and not ”enjoys lobster-flavored ice cream” weird), but there you have it.  My personal “N” for seeing these patients is small but I’ve heard it from a lot of other physicians too.  Probably insensitive pricks like myself.  But to be fair, I don’t know if it’s on the patient or if it’s on the doctors.  Most of these patients’ doctors I think get so frustrated with their non-specific and recalcitrant symptoms that they end up putting these patients on so much pain killer and anxiolytics that it would be hard not to be nuts.  Actually, now that I think about it, everyone I’ve seen with fibromyalgia has been on a shit-load of meds so this could very well explain it. 

  Probably a little of both.  But find out for yourself.

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md/phd residency interview experience

 Alright Andrew, you win. 

As an MD/PhD student residency interviews tend to take a unique twist as there is the very obvious 4-6 year old elephant in the room, which clearly differentiates us from other candidates who went straight through medical school.  Below are some questions/issues that came up during my residency interviews and those of some fellow mudphudders that I felt were particularly specific to being an MD/PhD student.  (Note that while these questions/issues may be more likely to come up if you are an MD/PhD student, they may be likely to come up as well for medical students who’ve taken a year or two to do research). 

  • The one issue that came up and I felt particularly annoyed about was how I would feel taking orders from people younger than me that may be more senior in the residency program.  I think I’ve written about this before, quite annoyed, in that this question quite frankly implies that MD/PhD students are all arrogant asses.
  • You will get questions about your research.  This should in theory be really easy address since much of graduate school is spent describing ones research for presentations and in articles.  Most questions will require a superficial but eloquent answer/explanation but you will occasionally get quite in-depth or more involved questions.  The most involved question was actually a very open ended one where an interviewer asked me to describe one project that I worked one from start to finish.  The impression I got was that they wanted background, methods, etc.  So I just slammed them with my thesis seminar.  I had given that talk so many times (from previous lab meetings) that even though I hadn’t given it for about a year, I had it memorized stone cold.  Just know your research backwards and forwards.  This isn’t really something that you practice the night before the interview (although you should), this is just something that will come over time with practicing this over and over again.  Sounds painful but remarkably similar to what I’m going through in residency right now…
  • You may be asked if you would want/willing to take time off during residency to do research.  This may be particularly important to some programs or residencies in general.  Know if this is the case and be prepared to respond as truthfully as possible because you will be held to your word.  If you don’t want to take more time off in the middle of residency, then you should explain why.  I’ve written about my personal opinion about research during residency before.  In short, I think it’s worthless for an MD/PhD student.  But you need to come up with your position and be able to eloquently explain/defend it. 
  • One question I often got was regarding how my phd research would be applicable to my chosen clinical field.   In short, it didn’t superficially but the benefits of graduate school go so much deeper.  I think I’ve written about this before in response to a reader’s question.  Read on to be reminded of my annoyance. 
  • You may occasionally get few comments on the quality of your publications.  Some good and some bad, meant to get a rise out of you.  Don’t fall for it and don’t take it personally.  You will spend/waste a good chunk of your scientific career having to defend your work against pointless criticism so get used to it.
  • You may be asked about how your lab experience might be beneficial to your time on the wards.  This is a freebie so be ready to nail it.  I personally took the approach that many lab experiences can be used to illustrate my capacity to handle the wards.  For example, working in a team at all levels from a newbie to being a leader, dealing with problem coworkers, thinking on your feet, bringing different people together to solve a common problem, etc.  If you are lucky enough to get this softball, make sure you knock it out of the park. 

Here are some questions posed to me by the reader who’s pushed me most into writing this post:   

  • Were you a prized possession?  Yes and no.  It really depended on who and where I was.  I think it definitely gives you an edge but then there some fields and some programs where everyone is a mudphudder so sometimes it doesn’t really seem to help much at all.   
  • Or perhaps treated with bemused disinterest by non-reseach/clinical-only faculty? Sometimes.  But in my opinion, it’s then on YOU, the interviewee, to find a connection between you and the interviewer that will spark an interesting debate.  Once again, you will spend a good portion of your scientific career trying to get people to be excited about your work (i.e. see the significance of it) for funding, if for no other reason.  And, interviews, if nothing else, are a test of your ability to engage your interviewers in a positive way.  When I found myself in a situation where a clinical faculty member didn’t know too much about my area of research or just wasn’t interested, I tried to find a way of communicating the significance of the work in the bigger picture and relating it to something the interviewer may have been interested in.
  • Were you ever challenged with specific questions about one of your publications or asked to give a formal presentation of your work (I know the latter has happened with people).  Yes–see above.
  • Also, did you consider any of those PSTP programs that combine research with residency? Yes, but you need to be careful to weigh the pros and cons of these programs.  Namely, the advantage of getting to post-doc level research sooner vs. the hit that you will obviously take to your clinical training. 

If anyone has anymore questions regarding the mudphudder experience in residency interviews or if you any particular insights you’d like to share, feel free to leave a comment.

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the post-call hangover

Post call.  The day after your night of being on-call at the hospital.  You usually get out early (anywhere between 8am and 12pm in my experience so far) and then you go home and sleep. 

When I get home, I’m usually okay.  I’m wired from being awake for that long and I’m usually hungry so I’ll get something to eat.  I’ll get home and plop down on my couch, unwind with a little tv.  Usually it’s just the notion that I need to sleep that makes me go to bed rather than passing out.  That’s a little weird but I think I get pretty wired when I’m on overnight call.  Anyway, as soon as my head hits the pillow that’s when I realize how tired I am.  And then I’ll sleep for 3-5 hours before I’ll get up and take care of a few errands with the remaining hours in the day. 

Damn.

Damn.

This is when the hangover hits you hard.  After the post-call nap or snooze.  You’re tired but you know you have to get up and do something.  Errands, go to the gym, goof off, whatever.  But you have to take advantage of being home early.  You’re a little anorexic from your internal clock getting thrown off and food doesn’t taste quite as good.  You’re just–off.  But for me, the most troubling part of the post-call hangover is what I call donkey dick breath.  It’s a bit of a misnomer in that it’s not really my breath but more a nasty taste in my mouth.  As though during the period that I was asleep, there was a donkey dick in my mouth the whole time.  (I will stipulate at this point that I don’t actually know what a donkey dick tastes like but I would imagine that it tastes something like this.)  Anyway, I’m not sure where the donkey dick breath comes from because I brush my teeth before and after sleeping and strangely it only happens after my post-call naps (or short naps after geing awake for a long time).  Someone has to know what I’m talking about.   It usually takes all day to shake.  I’m post call now and I’m still trying to shake it.  Yuck.   

So I write this post for two reasons.  1) To see if anyone has any advice regarding the donkey dick breath.  2) To empower others who also suffer from post-call donkey dick breath.  You are not alone.

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residency interviews…

…Suck.  Easily one of the most painful periods of the last few years for me. 

  And, I just realized it’s that time of the year!  Yay!!!!!

  I think I wrote a number of posts about residency interviews last year, so if there are any interviewees interested in reading those, just search for “residency interviews” on the blog.  Otherwise, I will go on. 

  I have the benefit now of 4 months of internship under my belt to color my recollection of residency interviews.  I was pretty stressed out about them all.  And to some extent, rightfully so, I guess.  Internship is tough and you want to make sure you end up with good people.  Note I didn’t say good place.  I am on survival mode right now.  I hardly have time to give a shit where I’m at for residency.  What keeps me going and what I do think about (because it’s right up in my face) is who I’m working with.  I have to say that I’m with a great bunch of interns and I’m really happy for that.  My senior residents are also for the most part really awesome.  I think no matter where you go, you will find senior residents that have just been totally fucked up by the process of residency (perhaps I’ll turn into one of those people in a few years… or months).  But it makes life so much nicer when your seniors are awesome. 

  I think I’ve gained new appreciation for the importance of who your coworkers are.  I really didn’t give it any thought in medical school or graduate school.  Not sure why exactly.  I think medical school and graduate school are more solitary endeavors.  Plus, there’s never a question of “am I gonna make it past today?”, which happens on an almost daily basis for me now.  Having the support of good people is key.  On that day when you don’t know if it’ll all get done and you’re sure you’re gonna be there for 3 days straight, the last thing you want is some ass who is gonna pile more shit on you.  I’ve lucked out in that I haven’t had this happen to me (yet) but the thought has often crossed my mind and it makes me shiver.

  During my residency interviews, I didn’t pay so much attention to that.  At least, it wasn’t high on my priority list.  I will say though that when I interviewed where I’m at, I remember thinking to myself that I could really hang out and get along with these residents.  So I guess it played into my decision making but not as much as it probably should have. 

  So there you have, after all the glam and glitz of where you’re going for residency, you won’t even have the time to remember it.  Think about that.

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while we’re on the topic of genitals…

  All I can say is, FRRREEEEEEEEDDDDDOOMMMMMM!!!!!!!!

  I recently finished a rotation after which I will never ever, ever ever, ever ever ever ever have to do another pelvic exam ever again.  For as long as I live.  Ever.  Never. Ever again. 

  Never ever.  Ever.

  I’m quite pleased with that fact.  No offense to the ladies, of course.  There are plenty of unpleasant physical exams (for both doctor and patient), including the male prostate exam.  This is all bourne out of my own ignorance with the pelvic physical exam. 

  Really it all comes down to the fact that I get really uncomfortable when I have to do something for a patient that I really don’t know how to do–much less to do with the yuck factor.  I hate doing rectals and prostate exams too but during medical school I ended up with an attending on one rotation who made me do a prostate exam on every freakin patient that came through his clinic.  By the end of that rotation I still hated doing rectals/prostate exams but at least I knew I how to do it.   In medical school I never got the chance to practice the actual pelvic physical exam all that much.  I did my ob/gyn rotation before graduate school (like 6 or 7 years ago) and even then most of the women seen in the clinics weren’t comfortable with a male medical student.  I guess I really can’t blame them.  But as a result, I spent most of my clinic time during that rotation checking email. 

  But here I am 6 or 7 years later except now I’m “doctor so-and-so” and I’m expected to know this stuff.  Can you say ”mudphudder is fucked”?  That’s what I was saying all through that last rotation. 

 With a pelvic exam, there’s a particular set up (i.e. you don’t want to have to run out of the room looking for stuff in the middle of the exam), there’s a whole formality to it, and then there’s the actual exam: you have to use a speculum, find the cervix, identify discharges…  1) half the time I can even find the cervix.  2) When I do find it, what the hell does a normal cervix look like anyway?  Sort of like a pink cherio?  But sometimes it’s normal for it to be a little red.  Maybe.  I’m not sure.  3) Discharge?  There are normal discharges (which at least to me don’t look that normal) and then there are a gazillion different abnormal discharges.  Do you know what an expelled fetus looks like?  I don’t and I don’t want to know.  I’ve heard it looks mucousy, like snot.  This is what someone named ”doctor” told me.  SNOT?!?!  It all looks like snot!  What the fuck?  4) And then, what the hell am I supposed to do with a discharge? Culture it maybe.  I don’t know.   5) And then you have random things that pop-up.  Like, one time when I was all, what the hell is that string?  And then I found out what that string was for. 

  This is making my head hurt.  Is my level of discomfort palpable?  Yes.  I think it is. 

  Never ever.  Ever again.  Ever ever ever.  Done.

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score “one” for the home

  Anytime a man can do something nice for another, it’s a good feeling.  Anytime a man can do something to save another man’s penis from rotting and falling off, that’s a special feeling. 

Ouch ouch ouch ouch ouch.  Ouch.  (courtesy of eMedicine)
Ouch ouch ouch ouch ouch. Ouch. (courtesy of eMedicine)

  I saw a patient who was complaining of a “swollen penis”.  There are about a million jokes I or you could throw in here, so let’s everyone pause for a minute, think about your favorite “swollen penis” joke and insert here
–> <–.

  So I took a look at this patient’s penis and it took all of my restraint to keep from saying “DAAAMMMNNNN”.  This patient had what is called a paraphimosis.  For those of you who aren’t familiar (hopefully there aren’t too many of you who are familiar), a paraphimosis is when the foreskin of an uncircumcised man is pushed back too far, gets stuck and acts like a rubber band around the penis preventing return of venous blood from the head of the penis (“the glans” for the sake of making this sound somewhat doctorly)–note that arterial blood continues to pump into the glans because arterial pressure is usually high enough to overcome the restraint of the paraphimosis.  So with continued arterial inflow and obstructed venous outflow, it’s not hard to imagine that one ends up with vascular congestion and swelling distal to the paraphimosis, which makes it even more painful and harder to fix (pull the foreskin back over the glans).  If a paraphimosis goes unfixed it can become a urologic emergency since once the pressure in the glans grows very high from the congestion and swelling, eventually arterial blood can no longer enter and the glans necroses from lack of blood supply.  I.e., the head of the penis rots off.  Not a good thing. 

  Anyway, this dude’s penis was majorly swollen (like in the picture).  We contemplated calling urology but the decision was made that I should try to reduce it first.  The objective in reducing a paraphimosis is to somehow reduce the swelling in the glans so that the foreskin can be pulled back over and therefore eliminate the rubberband-effect.  Unfortunately, when you look online at how these things are reduced, they often get bloody–many times involving a tear or cut in the foreskin to accomodate it over the glans.  I was hoping to avoid this.  Using a combination of thought and guy-knowledge, here’s what I did. 

  I wrapped my patient’s penis with an ACE bandage.  Starting from the top and working downwards, wrapping it quite tight in order to use the constant pressure from the bandage to push the pooling blood past the foreskin but leaving the base of the penis uncovered.  Once wrapped, I went over it once more with another ACE, this time a little more tightly.  Then I summoned a little thing that all men know as shrinkage.  I grabbed a couple of ice packs and had my patient hold them on his penis for about 30 minutes.  

BOOM.  That's the sound of Mudphudder dropping the bomb on that paraphimosis (courtesy of eMedicince)

BOOM. That's the sound of Mudphudder dropping the bomb on that paraphimosis (courtesy of eMedicine)

  When I took the ice packs off, unwrapped the bandages, I was able to pull my patient’s foreskin back over and he felt much better.  Interestingly, so did I.  I came out of the patient’s room and everyone heard the good news, and it was like something else.  Let’s just say there were a lot of high-fiving going on.  Yup, as my attending (also a guy) said, “score ‘one’ for the home team”.  You said it brother.

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flow cytometry protocols, facilities and online protocols

Here’s a cool compilation of online flow cytometry resources offered by flow facilities from around the world that I found on website of the flow cytometry core at the Salk Institute in San Diego. For future reference, I’ve added this table to the flow cytometry page under Lab Resources and will continue to update it as I get more information. If your university has a good flow cytometry core website, please let me know and I’ll add it to the list. From my own experience, I would recommend trying the Purdue University links first…

Home Page Institution More Links Location
MyCyte.org MyCyte.org [Forum]

[Blogs] [RSS Feeds] [News] [Events] [Links/Sites] [Products] [Standards] [Education] [Cytometry Abstracts]

US-OR
Purdue Purdue University Cytometry Laboratories [Cytometry Mailing List]

[Flow Cytometry Software]

[CD-ROMs project]

[Links/Sites]

[Protocols]

[Suppliers]

[Confocal/Microscopy links]

[Meetings]

[Courses]

[Rates Summary Table]

[Lecture Slides]

[Education/Books]

[Images]

[Jobs]

US-IN
Cancer Research UK LRC Lincoln's Inn Fields [Cell cycle analysis]

[Apoptosis]

[Functional studies]

[Sorting]

[Multicolour]

[Stem cell analysis]

[Data analysis]

[Links/Sites]

[Laser Scanning Cytometry]

[Flow Club]

UK
JCSMR John Curtin School of Medical Research, Canberra [Tutorials][Data Analysis][Statistics][Software:Facsimile][Facscan Tutorial test][LSR][Literature][Protocols][Links/Sites][Rates] AU
Albert Einstein Albert Einstein College of Medicine Flow Core [About flow][Instrumentation][Fluorophores][Fluorescent Proteins][Protocols][Links/Sites][Rates] US-NY
CytoRelay MPI-Biochemie, Martinsried, Germany:Cell Biochemistry [Links/Sites][Suppliers][Cell Function][Aquatic Links][Software links/Mailing Lists/FAQs][Education/Books][Consensus/Ring Trials][Microorganisms][Purdue mailing list mirror] DE
WEHI WEHI Cytometry Lab [Overview] [Links/Sites][Fluorescence][Fluors][Sorter Comparison][Rates][FCMDesigner (Java)][Software:WEASEL][Links/Sites][Publications] AU
Aberystwyth University of Wales Institute of Biological Sciences [Links/Sites][Publications][Instrumentation][Software][Sample Prep][Microcyte cytometer] [Microbiology] UK
Cytonet UK Cardiff, UWCM [Flow basics][RMS Cytometry][UK Jobs/Notices][UK Meetings][Software:Cylchred][Links/Sites][Suppliers] UK
Salk CCMI Salk Institute for Biological Studies CCMI [Links/Sites][Compensation Howto][Fluorochrome Table][Protocols][Lasers][Software] US-CA
TSRI Scripps Research Institute Flow Core [Home][Turbosort][Sort Recovery Calculation][FACStar] / [Vantage jet optimization][Protocols][Software:WinMDI][Sites/Links] US-CA
IACF Immunology Applications Core Facility, University of Chicago [Technical protocols][Sort prep][Protocols][References][Rates] {Flash required} US-IL
Prague Centrum Pr?tokové Cytometrie [Basics][Sorting][Data analysis][Instrumentation][Cytometers][Rates][Protocols (Czech)][Links/sites] CZ
St Mary's Imperial College, London [PowerPoint presentations][Rates][Sorting][Flow Course] UK
NCI ETI NCI ETI Branch Flow Core [Protocols][Spectra][Sorting][Facscan/Calibur info][Advanced projects/protocols][Links/Sites] US-MD
UTMD MD Anderson Cancer Center Cell and Tissue Analysis Core [Flow][Protocols][Quantitative][Side Population][More Protocols][Compensation][Links/Sites] US-TX
Berkeley UC Cancer Research Lab [Flow Basics][Compensation][Rates][Instrumentation][links/Sites] US-CA
HSS Fannie E. Rippel Foundation [Instrumentation][Rates] US-NY
ISAC International Society for Analytical Cytology [Cytometry journal][Conferences][Tutorial material][FCS 3.0][Biosafety][Software] US
Fluorophores.org Fluorescent dyes database [About][Browse][Links/Sites] Austria
Olomouc Institute of Experimental Botany Molecular Cytogenetics and Cytometry [Plant DNA FCM][Flow Cytogenetics][Plant protocols][Reagents][Suppliers] CZ
Roswell Park Roswell Park Cancer Institute Laboratory of Flow Cytometry [About][Software][Services/Rates][Instrumentation][Courses/Powerpoint slides][Programs/Outreach][Links/Sites] US-NY
Herzenberg Lab at Stanford Herzenberg Laboratory [Protocols][FACS Development Group] US-CA
Stanford Stanford Shared FACS Facility [Flow overview][Rates][SOPs]][Instruments/Fluors][Documentation][User Guides] US-CA
UIowa Holden Comprehensive Cancer Center at UIowa [Flow fundamentals][Protocols][Rates] US-IA
Vanderbilt Vanderbilt HHMI Flow Cytometry Facility [Overview] [Rates] [Forms/Protocols][Links/Sites][Overview] US-TN
Baylor Baylor Flow Cytometry Core [Instruments][Rates][Protocols][Links/Sites] US-TX
Beth Israel Flow Cytometry and Sorting Facility [Core][Policies][Rates][Links/Sites] US-MA
Bremen Max Planck Institute for Marine Microbiology [Overview][Links/Sites] DE
CTEGD University of Georgia [Overview] [Instruments] [Rates] [Links/Sites] US-GA
HUGTiP Hospital Universitari Germans Trias i Pujol [Applications][Links/Sites][Rates][Journals/Books] ES
IMMAG Medical College of Georgia Institute of Molecular Medicine and Genetics [Instrumentation][Guidelines][Rates][Links/Sites] US-GA
Kiel Forschungs- und Technologiezentrum Westküste [Phytoplankton][Flow Overview][Sorting Overview][Links/Sites] DE
LSU Louisiana State University School of Veterinary Medicine [Instruments][Rates][Protocols][Links/Sites] US-LA
Penn SDM University of Pennsylvania School of Dental Medicine [Flow Primer][Protocols] [Links] [Rates] US-PA
AEFCG Australian Environmental Flow Cytometry Group [Research] AU
SUNY USB Research Flow Cytometry Core [Overview] [Rates][Links/Sites][Clinical] US-NY
UAMS University of Arkansas Microbiology and Immunology Flow Core [Overview][Cytometric Bead Array][Biohazard Review Form][Sample Submission Form] US-AR
UCLA Janis V. Giorgi Flow Cytometry Core [Protocols][Biosafety][Rates][Policies] US-CA
UPCI University of Pittsburgh Cancer Institute [Worksheets][Rates] US-PA
Cornell Cornell Biomedical Sciences Flow Cytometry Core [Protocols][Sample Prep][Rates][Software] US-NY
Bern University of Bern Department of Clinical Research Flow Cytometry Lab [Overview][Links/Sites][Flow Course] CH
Bigelow J.J. MacIsaac Facility for Aquatic Cytometry [General][Aquatic][Plankton] US-ME
Calgary University of Calgary Faculty of Medicine [Overview][Links/Sites][Rates] CA
Cooper Hospital/UMC Camden, New Jersey [Methods][Reference Ranges][Publications] US-NJ
Cornell Cornell University Flow Cytometry Facility [Overview] [Rates][Links/Sites] US-NY
Hopkins Immunology Johns Hopkins Immunology [Analyzer guidelines][Sorting guidelines][Contact][Billing][Links/sites] US-MD
Hopkins CFAR Johns Hopkins Center for AIDS Research [Overview][FAQ] [Links/Sites] US-MD
Iowa State Cell and Hybridoma Facility [Protocols][Sites/Links] US-IA
Mario Roederer Mario Roederer's Home Page [Compensation Tutorial][Antibody Conjugation] US-CA
McMaster McMaster University Flow Facility [Links][Facscan Operation][Rates] CA
MIT Flow Cytometry Core Facility [Rates][Protocols][Links] US-MA
Newcastle University of Newcastle Department of Surgery [Description] [Research] [Courses] [Links] UK
NIAMS IRP National Institute of Arthritis and Musculoskeletal and Skin Diseases [Protocols] [FRET] [Links/Sites] US-MD
OHRI Ottowa Health Research Institute [Overview] [Rates] [Links/Sites] CA
Prague Institute of Botany, AS CR [Plant FCM][Plant DNA][Protocols][Links/Sites] CZ
Princeton Princeton University Flow Cytometry Core [Instruments][Protocols][Links/Sites] US-NJ
Rockerfeller FCRC Flow Cytometry Resource Center [Rates][Operation/Tips][Instruments] US-NY
Roscoff Station Biologique de Roscoff, France [Phytoplankton][Software:CytoWin] FR
RRC University of Illinois at Chicago [Description] [Protocol links] [Rates] US-IL
Sheffield University of Sheffield Division of Genomic Medicine Core Cytometry [Rates] [Protocols] [Links/Sites] UK
TIG Therapeutic Immunology Group, Dunn School, Oxford [Protocols] [Tutorials] [Instrument operation] UK
UCHC UCONN Health Center Flow Facility [Flow description][Links/Sites][Rates] US-CT
UMN University of Minnesota Cancer Center [Protocols][links/Sites][Instrument operation] US-MN
Urbana-Champaign University of Illinois Biotechnology Center Flow Cytometry Facility [Cytokines] [Apoptosis] [Links] US-IL
UVa University of Virginia Flow Cytometry Core Facility [Protocols][FAQs][Rates] US-VA
Amsterdam Microscopy and Cytometry Software: Ron Hoebe [Software:Flow Explorer][Refresh Ratio][List Math] NL
NECyt New England Cytometry [Tutorials/Presentations][Biosafety][Links/Sites][Jobs][BBG][Mailing List][Meetings] US-MA
Caltech Caltech Flow Cytometry Facility [Policies/Rates][Links/Sites] US-CA
EOSHI/CINJ Rutgers Environmental and Occupational Health Sciences Institute [Description][Rates] US-NJ
HMDS Leeds Leeds Flow Cytometry [Flow Overview][Fluorochromes] UK
Frank J. Jochem Dr. Frank J. Jochem [Oceanography][Phytoplankton] DE
Keith Bahjat Antibody Cross Reactivity Resource [Antibody Crossreactivity Resource] US-FL
Newcastle FACS University of Newcastle Biomolecular Research Facility [Description] [Rates] AU
NFCR National Flow Cytometry Resource [Overview/Research] US-NM
Novosibirsk Institute of Chemical Kinetics and Combustion, Novosibirsk, Russia [Scanning Flow Cytometry][Flying Light Scattering] RU
UCSD UCSD Cancer Center Flow Cytometry Shared Resource [Protocols][Rates] US-CA
Umass/Amherst Facility closed 2000 [About][MFI Software] US-MA
UMass/Worcester Core Flow Lab [Instrumentation][Rates][Links/Sites][Protocols] US-MA
UNM Cytometry Bioengineering Consortium [Bioengineering Consortium][High Throughput] US-NM
UNM University of New Mexico Shared Flow Cytometry Resource [High Throughput][Rates] US-NM
Utah cores.utah.edu [Sorting][Rates][Links/Sites] US-UT
UWashington Immunology University of Washington Immunology Cell Analysis Facility [Protocols][Rates] US-WA
Birmingham University of Birmingham Animal Cell Technology Group [Links/Sites] UK

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the waiting

I swear, the hardest part of internship is not the long hours or the work load, it’s the waiting–the anticipation of impending pain.  The worst is when you’re sitting there on the eve of a painful 12 day stretch and you can just imagine how bad it’ll be.  Of course it’s never that bad but you can just imagine that it will be. 

All I can think about in those situations is the worst case scenario for each day.  And then I imagine having to deal with that worst case scenario day after day after day.  It never turns out that badly but of course the one time that I assume it won’t turn out that badly, it will. 

Or even a far more benign thing like a good day on the wards.  You know that by the law of averages, it’s only a matter of time before you get the clinical equivalent of a sack of bricks upside the head.  The bad day is coming. 

Yeah yeah, I’m just being neurotic but I’ve heard this from more than a few other co-interns: the anticipation will kill you.

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that’s gotta hurt

Here’s one of those posts that medical and non-medical readers might find interesting out of the same morbid curiosity to see some extreme (-ly painful) medicine. 

This wasn’t a patient of mine but rather one of those times where you see another group of doctors around a computer looking at an x-ray and collectively hear them say “DAAAAAAAMMMMMMMNNNNNNNN” so out of morbid curiosity you have to go over and see what the fuss is all about.   

Everyone together now--DAAAAAMMMMMMMNNNNNNN

Everyone together now--DAAAAAMMMMMMMNNNNNNN

I present to you a patient who fell poorly on the right ankle and destroyed it.  At least that’s the story.  You question my skepticism?  Look at that film–that’s pretty bad for a fall. 

Anyway, you see all of those red arrows I added to show all of the different places where this patient’s ankle was broken?  That’s not normal.  That’s not even the typical ankle fracture.  And I caught a glimpse of the patient.  This patient was in a world of hurt.  A world of hurt. 

So this would be a comminuted tibia/fibula (tib/fib) fracture.  It’s not an “open” fracture since the bone wasn’t sticking out of the skin but it was close.  Like bone right under the skin close.  But, I’m not an orthopedic surgeon so I won’t even pretend to know much about different fracture types, etc. so I will refer you to wikipedia…  In any case, this patient’s ankle is a bag of bones at the moment and will be going to the OR in the very near future.  And, will likely have a very difficult recovery ahead. 

One thing I will say about medicine is that just when you think your day was about as bad as it could possibly get, you see something like this and you realize things can always be worse.  Like having to manage 25 really sick patients, do 3 admissions and discharge 8 patients on a shattered ankle.  Although, on a more serious note, I will say in hindsight that there were days in graduate school where if you had taken an x-ray of my dreams/hopes/desires/career prospects, it would have looked something like this.  Who knows what I’m talking about?  That’s right, everyone with a PhD should be raising their hand.

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non-r01 nih grants for new investigators

So if you’re starting out as a new investigator, you’re probably not going to get an R01 grant right off the bat.  There are, however, many NIH grants that are specifically aimed at new investigators for career development as a stepping stone to future application for an R01. 

I have a few buddies who are going through this process now and applying for many of these.  For those of you who aren’t up to this point yet, it may be useful to get familiar with some of these grants–at least know what they are referring to.  You will hear these terms being thrown around a lot in conversation and more importantly, it won’t be too long before this will be useful information for you to know. 

Code Description
R03 NIH Small Grant Program

  • Provides limited funding for a short period of time to support a variety of types of projects, including: pilot or feasibility studies, collection of preliminary data, secondary analysis of existing data, small, self-contained research projects, development of new research technology, etc.
  • Limited to two years of funding
  • Direct costs generally up to $50,000 per year
  • Not renewable
  • Utilized by more than half of the NIH ICs
  • See parent FOA
R15 NIH Academic Research Enhancement Award (AREA)

  • Support small research projects in the biomedical and behavioral sciences conducted by students and faculty in health professional schools and other academic components that have not been major recipients of NIH research grant funds
  • Eligibility
  • Direct cost limited to $150,000 over entire project period
  • Project period limited to up to 3 years
  • All NIH ICs utilize except FIC an NCMHD
  • See parent FOA
R21 NIH Exploratory/Developmental Research Grant Award

  • Encourages new, exploratory and developmental research projects by providing support for the early stages of project development. Sometimes used for pilot and feasibility studies.
  • Limited to up to two years of funding
  • Combined budget for direct costs for the two year project period usually may not exceed $275,000.
  • No preliminary data is generally required
  • Most ICs utilize
  • See parent FOA
K01
Mentored Research Scientist Development Award (K01)
  • This omnibus NIH K01 program is supported by NHGRI, NIA, NIAAA, NIAID, NIAMS, NIBIB, NICHD, NIDCD, NIDDK, NIDA, NIEHS, NIMH, NINDS, NINR, NCCAM, NCRR, and ODS. The purpose of the K01 program is to provide support and “protected time” (3-5 years) for an intensive, supervised career development experience in the biomedical, behavioral, or clinical sciences leading to research independence. Awards are not renewable, nor are they transferable from one principal investigator to another.

The Bernard Osher Foundation/NCCAM CAM Practitioner Research Career Development Award (K01)

  • This program is supported by NCCAM. The purpose of this K01 is to provide research training support for CAM Practitioners with clinical doctorates, who have had limited opportunities for research training, but a strong desire to pursue a career in CAM research.

NCI Mentored Research Scientist Development Award to Promote Diversity (K01)

  • The NCI invites K01 applications from individuals representative of groups that have been shown to be underrepresented in health-related science, who have been recipients of an NIH Research Supplement to Promote Diversity Award, any NRSA (individual F31/F32 or institutional T32), or can demonstrate that they have been supported in a mentored capacity within any research grant equivalent to an NIH peer-reviewed research grant.

NIDDK Mentored Research Scientist Development Award (K01)

  • The NIDDK invites K01 applications from advanced postdoctoral and/or newly independent research scientists (usually with a Ph.D. degree) in biomedical or behavioral sciences who are pursuing careers in research areas supported by the NIDDK.

NINDS Career Development Award to Promote Diversity in Neuroscience Research (K01)

  • Supported by NINDS, the objective of this program is to promote diversity among faculty-level neuroscience investigators who are competitively funded to conduct independent research.

NINR Mentored Research Scientist Development Award for Underrepresented or Disadvantaged Investigators (K01)

  • The purpose of this NINR K01 is to encourage the development of qualified underrepresented or disadvantaged nurse scientists to become independent investigators in research settings.
K02
Independent Scientist Award (K02)
  • This omnibus NIH K02 program is supported by NHLBI, NIA, NIAAA, NIAID, NICHD, NIDCD, NIDCR, NIDA, NIEHS, NIMH, NINDS, and ODS. The K02 provides support for newly independent scientists who can demonstrate the need for a period of intensive research focus as a means of enhancing their research careers. The K02 is intended to foster the development of outstanding scientists and to enable them to expand their potential to make significant contributions to their field of research.

K08
Mentored Clinical Scientist Research Career Development Award (K08)
  • This omnibus NIH K08 program is supported by NCI, NEI, NHLBI, NIA, NIAAA, NIAID, NIAMS, NIBIB, NICHD, NIDCD, NIDCR, NIDDK, NIDA, NIEHS, NIGMS, NIMH, NINDS, NCCAM, and ODS. The K08 represents the continuation of a long-standing NIH program that provides support and “protected time” to individuals with a clinical doctoral degree for an intensive, supervised research career development experience in the fields of biomedical and behavioral research, including translational research. Individuals with a clinical doctoral degree interested in pursuing a career in patient-oriented research should refer to the NIH Mentored Patient-Oriented Research Career Development Award (K23).

NCI Mentored Clinical Scientist Research Career Development Award to Promote Diversity (K08)

  • This NCI-sponsored K08 award is specifically designed to promote career development of racially and ethnically diverse individuals who are underrepresented in health-related science and for those who are committed to a career in cancer health disparities, biomedical, behavioral or translational cancer research.
K22
K23
Mentored Patient-Oriented Research Career Development Award (K23)
  • This omnibus NIH K23 program is supported by NCI, NEI, NHLBI, NIA, NIAAA, NIAID, NIAMS, NIBIB, NICHD, NIDCD, NIDCR, NIDDK, NIDA, NIEHS, NIGMS, NIMH, NINDS, NINR, NCCAM, and ODS. The purpose of the K23 is to support the career development of investigators who have made a commitment to focus their research endeavors on patient-oriented research. Clinically trained professionals or individuals with a clinical degree who are interested in further career development in biomedical research that is not patient-oriented should refer to the Mentored Clinical Scientist Career Development Award (K08).

NCI Mentored Patient-Oriented Research Career Development Award to Promote Diversity (K23)

  • The NCI announce the availability of the K23 award for career development of ethnically and racially diverse individuals with a health professional doctoral degree from groups that have been shown to be underrepresented in health-related science.

If any of the readers have had experience with these grants or applying for them, please share your experience or any tips that you may have to offer in the comments…

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CRISP – the nih grant database

Be honest, you want to know what NIH grants the PI down the hall has.  Right?  Of course you do.  You want to know how good he’s got it and how that compares to your NIH funding situation.  Well, the completely open thing to do would be to ask but then you look nosey and the other PI might figure out your ulterior motive.  But you have another option: the CRISP database.

To quote from the CRISP website:

CRISP (Computer Retrieval of Information on Scientific Projects) is a searchable database of federally funded biomedical research projects conducted at universities, hospitals, and other research institutions. The database, maintained by the Office of Extramural Research at the National Institutes of Health, includes projects funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Health Care Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH). Users, including the public, can use the CRISP interface to search for scientific concepts, emerging trends and techniques, or identify specific projects and/or investigators.

So you can use this database to spy on any investigator’s NIH funding status.  But in all seriousness, the CRISP database can be a really useful tool if you are thinking of writing a grant or even starting a new project because you can see if someone is already funded to work on your project.  It can potentially save you a lot of time in not writing a grant that someone else already has (or at least give you an opportunity to sufficiently distinguish your own grant).  Moreover, by knowing who else is working on a similar project, you can either know who to contact for collaboration or help (if you need it) or in contrast, you’ll know who to hide your work from…

Addendum:

Thanks to the readers who pointed out that CRISP is no longer up and running.  But, for those of you who still have the morbid curiosity to see which cocksuckers have NIH funding while you languish away barely making ends-meet on foundation grants, there is the RePORT Expenditures and Results query tool at: http://projectreporter.nih.gov/reporter.cfm

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reality check

Just two and a half months gone in internship? Feels like 2 and half years gone by. Love the work but it’s no walk in the park. Time for a reality check: it’s Final Countdown by Europe.

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the problem patient

Yes, the dreaded problem patient.  They come in all shapes and forms but they are the bane of every health care worker’s existence.  I used to think that it was only the bane my (the intern’s) existence but thinking about it now it’s probably worse for a lot more people. 

Most of you know what I’m talking about when I say “problem patient” and most of us have been a problem patient at one time or another (probably more frequently for those of us in health care).  As I said, there are many flavors of the problem patient so it is hard to define, but you know one when you see one. 

  • If the patient is admitted to the hospital without any medical indication for inpatient care because he/she knows an attending, you might have a problem patient on your hands.
  • If you get 5 pages over the course of 4 hours just regarding the patient’s request for you to change the pain medication dose from 4 to 6 to 4 to 6 to 4-6, you might have a problem patient on your hands.
  • If the patient writes down the name of every doctor who comes into the room, you might have a problem patient on your hands. 
  • If the patient wants to have the doctor confirm in person every order he has placed (note: not explain, just confirm that he ordered it), then you might have a problem patient on your hands.
  • If the patient has nausea and dry heaving without vomiting every time he/she is told that they can be discharged today and then goes on to have a full dinner when he/she is told they can stay for tonight, you might have a problem patient on your hands. 
  • If the patient says, I’m not leaving until I’m back to 100% my normal self even if it takes 6 months, you may have a problem patient on your hands.
  • If the attending is yelling at the patient, then you might have a problem patient on your hands.
  • If the patient tells you that he/she is deciding which oral pain medication he/she will have you switch him/her to, then you might have a problem patient on your hands.
  • If the patient tells you that it is ridiculous to be discharged from the hospital at 4pm in the afternoon, you might have a problem patient on your hands. 
  • If the nurse–the freakin’ nurse!!!–is fed up with the patient and prefaces every phone call with “I’m sorry to be calling again”, then you DEFINITELY have a problem patient on your hands.  (this one has 100% specificity)

Again, these are just some signs.  They are not 100% sensitive or specific (except for that last one) but they can be indicative.  Moreover, this list is not nearly comprehensive but I think you get the point.

What are the common denominators here?  1) the desire to not leave the hospital despite being medically cleared and 2) the desire to micromanage health care. 

On some level, I can understand both of these underlying issues.  Before I knew more about how nasty hospitals are, when I was sick, I’d want to be in the hospital and when I had surgery I wanted to stay there until I was all better.  What people I think fail to realize sometimes is that hospitals are just filthy places.  And that’s understandable in my opinion since hospitals are where SICK people go.  And not sick–my belly is ow-y sick, but I’m talking more like I have C. Diff colitis and blowing diarrhea all over the place sick or I have disseminated MRSA septicemia sick.  We can discuss the role of the health care providers in spreading the nastiness another time but no matter how it is spread around, hospitals are not clean places.  Sometimes I sort of feel like the guy who works at burger king and knows what goes on behind the counter so he can never bring himself to eat there ever again.  So the end result of people who don’t want to leave the hospital is inevitably a nosocomial infection.  I’ve seen it happen and it kills me every time.  A patient delays leaving, delays leaving and just when it is about to happen, comes down with a nasty infection.  It kills me.

Some of you cynics may have the thought that my main reason for getting on patients who want to stay longer than necessary is out my desire to have less patients to deal with.   This is not correct.  In fact, the opposite is true.  Patients who stay beyond the necessary amount of time typically have the fewest real or pressing problems to deal with because they are healthier than most other patients.  On days when you are getting 3 pages at the same time: #1- patient x having acute change in mental status, #2- patient y having fever of 105 and #3- patient z wants to talk to MD about his/her lab values from this AM, it is really easy how to triage at least one of those pages.  And, with a limited number of beds, filling them up with patients who could have been home, means less work for me.  It’s the senior residents and attendings I feel bad for.  They have to figure out ways of getting these peoples home because when the patient gets pissed at me for telling him/her that it’s time to go home, it’s then the higher-ups’ job to step in and convince the patient.  And, it’s the higher-ups who spend the mornings determining these patients’ plans. 

The other aspect of the problem patient is the desire to micromanage their health care.  Medicine is based on the principle of maintaining hte patient’s autonomy.  That is, we inform the patient and the patient makes the choice.  And that continues to be true but when patients abandon trust in the physician’s expertise/knowledge and exercise this autonomy to the level of small details, it can become a logistical nightmare.  It would be ideal that I could explain to every patient why they are on drug x vs. y for each and every problem but there just isn’t enough time.   I try my best–but for some routine things, like pain medications, it’s impossible, or at least it’ll take some time.  I have no problems meeting patient’s requests for things that are not dangerous but it can be brutal on busy days.  I made all of the changes requested by the patient who wanted dosing on his/her pain medication changed from 4 to 6 to 4 to 6 to 4-6.   The other patient, however, who no longer wanted to take his/her antibiotics because he/she didn’t feel like it anymore, on the otherhand, I had to take a good hour of time to explain why this was not a possibility.   I mean it’s all good of course and I’m happy to do it but when it’s just me dealing with the entire floor and everything from the emergencies to admits to discharges, this kind of stuff can really slow the pace of the day. 

Unfortunately, there’s no solution to any of this.  I’d tell patient’s to trust their doctors more often but then there are enough dumbass doctors out there that it’s probably worth it for patients to have a healthy degree of skepticism and to ask questions.  I guess the only thing to impress on people is that the hospital is not where you want to be–it’s nasty–where sick people go.  With that one point understood, I guess we the residents will just have to keep on keepin’ on.

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is it really necessary?

Why do people feel compelled to act like assholes?  I understand that you may be feeling frustrated, but why do you feel compelled to be mean? 

One thing that I’m not used to nor will I ever be used is rudeness from coworkers–be it nurses, residents or attendings.  I think it’s most hurtful from residents and fellows since I can clearly sympathize with the fact that no one wants to turn around and drive back into the hospital at 10:30pm, especially when they just got home, for a consult that is borderline questionable but needs to be done anyway.  I know it sucks.  Believe me I know the pain of sleep deprivation–or at least I know a little and will find out more later.  In any case, I can sympathize.  Plus we’re all in the same boat–I have no ill will for other residents or fellows–why would I put them through pain if I (or more likely my attending) didn’t think it necessary? 

I hate it when consult residents get pissed off at me because I have a sick patient that needs their attention.  I’m like, what the hell else am I supposed to do?  If the patient needs a consult, then the patient needs a consult.  Am I right or am I right?  I mean, what the hell?

Then what’s even worse is when I get a run-around and then I have to spend half an hour of my time trying to cut through the bull shit only to realize that yes, the patient still needs the consult.  Trust me, I prepare before calling consults.  I’m not one of those people who calls consults without knowing anything about my patient.  I’m on top of it.  But there have been times when I’m asked certain highly unexpected questions by the consults, the answers to which I don’t have, and then I’m told how inappropriate my phone call is without knowing X, Y or Z only to later realize that X, Y or Z has nothing to do with anything.  Seriously, I don’t know what goes on–are people trying to play tricks or are we just having some miscommunication?  It could be a little of both but there are definitely times when I’m sure I’m being fucked with and it really pisses me off.  Especially since I’m an intern and most consults know it and if I feel like an older, more experienced resident or fellow is taking advantage of my inexperience and wasting my time so they can sleep during their call night, then I get royally pissed off.  It’s a fucking call night–you’re supposed to get called!!!!!  It’s just not cool to be mean to the intern.

As a personal side note, I start every phone call with “hi, thanks for returning my call” and “how are you?”  Isn’t that fucking nice?  Geez, how are you gonna be mean to me after that?  And then I end my calls with “thanks again for your time”.  How the hell is someone just gonna hang up on me after that?  Even at 3 in the morning I do that.  I know you’re annoyed, but come on now. 

Well, whatever.  I’m not gonna change.  I’m just gonna keep on being sweet, collegial mudphudder.  And if you got a problem with that then, well, you can just have a nice day. 

Asshole.

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condolences to pascale

Pascale Lane, a twitterverse friend of the mudphudder’s, recently lost her cat, Denver the wondercat, after 18 years.  My condolences to Pascale.  Not too long ago, I lost my cat after 17 years.  It was heartbreaking.  I couldn’t remember a time, extending back to my youth, when I was without my cat.  And then he died. 

While for cynical me the experience was just another reminder of how cruel life can be and that everything good eventually comes to an end, Pascale has chosen to take a more practical approach and attempts to extract something useful from her experience as she reminds us that while Denver the wondercat died peacefully in his sleep, many people do not have that luxury and that we should specify advanced directives and/or discuss these end of life issues (e.g. whether to have life support–CPR, intubation, etc.) with our doctors ahead of time.  This is, of course, a hot topic item in light of recent health care reform discussions and the fact that Medicare does not cover the cost for patients to meet with their physicians to have such discussions.  I say “of course” but of course I have minimal insight on the matter as I spend most of my time as an intern and only recently found out that there even was a health care reform discussion. 

But I digress.  Pascale, you are so practical.  Time to grieve but I understand.  So in a show of solidarity and in support of Pascale as well as toward a lasting legacy of Denver the wondercat if we can get even one person to plan ahead, I too will make the pitch.  However, I am not quite as warm and fuzzy as Pascale so I will do it in my own cynical, bitter way. 

Here’s why people need to have these discussions.  1) Because they can and 2) because I don’t want to be the one making these decisions. 

I always feel especially bad when intelligent animals die.  They know and understand so much, and yet my feeling is that in the end they don’t really have an understanding of what’s about to happen.  In fact I don’t know that they have any understanding of death at all (note: animal people, DO NOT send me emails about how this species or that species does understand death–I’m speaking in generalities here).  Anyway, maybe that’s all for the best.  My cat understood health and life and enjoyed both.  You could tell from his reaction to illness and how he would seek out help from us when he was previously ill.  But at the end, I don’t think he understood the untreatable nature of his demise.  That was the hardest part for me to deal with.   He wanted help–you could tell–but there was nothing to be done.  I suspect it was similar with Denver the wondercat.  My suspicion is that if my cat or Denver had understood the impending end of the road, they would have made plans and requests in terms of how to be cared for at the end to best suit their comfort needs.  Cats are very responsible and self-centered in that way.  Of course we tried our best, but one never knows.  Only the cat did. 

Now, with people it’s a different story.  From about the time we’re 4 years old we know and understand that we will die.  It sucks but there’s no escaping it.  It’s like the direct admission that comes in 2 minutes before my shift is up every night–the one that keeps me there 3 hours past when I was supposed to go home.  It’s inevitable.  I pray that it won’t, bargain with God or Admitting (one and the same sometimes) but sure enough that direct admit will show up just as I am about to go home. 

So people have no excuse.  Don’t people want to be prepared for the end?  Is it carelessness or a selfish need to avoid an unpleasant truth?  In either case it’s plain irresponsible.  Plus, people are largely responsible for their own deaths.  Yeah, you, the dude who’s eating a big mac while reading this, I’m talking to you.  And I’m talking to me because I too am eating a big mac while writing this.   But seriously, when you think of the major causes of death, many of them are preventable (for the most part).  Heart disease, cancer (some types, e.g. lung), accidents, diabetes (type II), etc.   I don’t personally have any of these problems but I definitely see myself working towards at least 3 if not all 4.  In any case, we’re all killing ourselves slowly, so we might as well be prepared for when it happens.  Death is not a dignified process–better to make it as painless and orderly as possible. 

Which brings me to my next point.   I don’t want to be the one who has to make these decisions for you.  A lot of disorder and chaos is ensues when a patient codes and family members are arguing back and forth over how far to take the resuscitation effort.  It’s no good.  A doctor is always going to err on the side of saving a patient if advanced directives are not clear but I don’t think any doctor wants to put a patient through a lot of possible pain and discomfort during resuscitation if it’s not the patient’s wishes.  I don’t know, call us selfish or whatever, but we’d rather you made up your own mind.  You know what I’m saying? 

In any case, Pascale brings up a good point.  Think about it people and tell others to think about it too. 

Pascale, feel better my friend.

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something new

  So one of the major struggles I face as an intern is learning a new system in a new hospital. This is on top of having to deal with the new patient care responsibility. My suspicion is that learning the new system is as hard if not harder than the mounds if patient care responsibility. I am actually surprised. As a medical studnt I remmber watchng interns even residents struggling to learn our system: online order entry, online patient records, even where the bathrooms are. And, I was always a little confused about why it was so hard for them. Of course, my years of experience at that hospital probably biased my view of the ease of doing everything. Now, I have been feeling the pain for the last two months.  And I’m finally realizing one of the major benefits to stating at your home institution for residency is that you know where everything is, you know how the computers (and programs) work and you know where the bathroms are (that’s so key).  This is such a huge beneft on terms of avoiding pain. However, this advantage only lasts for about a month or two and then everyone catches up to each other. So, as I kept telling myself, my pain (at least in this regard) will only last so long. On the other hand, there are so many advantages to going to a different institution. Most importatly, the opportunity to work with new people and to see new things, experiences which can only broaden one as an individual. I think this is actually quite huge. Not only with regards to my education but also because it shows other institutions later on (eg when time cone to apply for fellowship or a job) that I can be serious about moving and starting fesh somewhere else. The institution where I did medical school is the kind if place where people stay forever.  There were definitely times when I felt that I was going to be there for going on forever since I was there for graduate school as well. And, during residency interviews, I always got the question of why should they believe that I would ever leave to go to another institution.  I always found this to be a sort of weird question–why would I spend $500 on travel and lodging for a residency interview if I wasn’t serious about it?  But it just goes to show the mentality of program directors, etc–every little detail can be interpreted in one way or another.
  So now I’ve been here for 2 months. I was asked by a close friend recently, don’t you miss [insert hospital name] and my response was NO!  It was an amazing place and maybe I’ll go back there some day (if they’ll take me as well) but if I had stayed there, I’d be in such a rut. After two months here, I’m still learning new things about how to manage patients and how the hospital works every day. And all of it is in comparison/contrast to what I learned before.
  My point is that it was very hard to break out of my 8 year rut, but now that I’ve gone through the painful process of learning a new physician order entry system, electronic patient record, PACS, etc, breaking the rut feels incredibly rewarding. For those of you who have to make the same decision or something similar (medical school, graduate school, fellowship, etc), the prospect of leaving “the known” can be quite daunting but it can be terribly informative/useful in the long run. I’m the king of staying put in my rut so if I’m saying this, there’s gotta be something to it (at least in my head).

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