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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.



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.


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.


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…


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.


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. 



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.


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.


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.


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.


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
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.
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.

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.
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…


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…


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:


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.


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. 



response to a reader

While I was away on vacation, a reader emailed me the following question:

Hey Mudpudder….I am in a combined BS/MD program in NYC and I really need your advice. I am asking you for advice because you are one of the few physicians I have encountered that are honest and open about their profession.  As mentioned before, I am in a BS/MD program that allows me to complete my undergrad and 2 years of my medical education at a University and the last 2 years of my medical education (rounds) have to be completed at a participating medical school. Now I just finished interviewing at SUNY Downstate, SUNY Stony brook, and NYU. They all have their pro’s and con’s.  My main goal for the last 2 years of medical school is to learn as much as I can from the wards, so that I can really decide what type of residency to apply for. Essentially, I want experience so that I can make the best decision regarding the residency to pursue. However, I am not too sure which medical college is right for me.
 NYU med is a world renowned institution with a lot of NIH funding, prominent faculty, with high tech facilities, etc. Most of all it is in NYC, so I will be exposed to a diverse population with different medical needs. However, it is a really expensive school and affiliated with mostly private hospitals. I do not know if I would really get a chance to practice my clinical skills in a private hospital. I have heard that private hospitals limit medical student/patient interactions because we are a liability. Is this true? SUNY Downstate is located in an underserved community in Brooklyn.  In addition, it is affiliated with mostly city hospitals and most of the hospitals are understaffed, so I know I will get a lot of experience. However, Downstate does not have as good of a reputation as NYU or Stony Brook in terms of research funding, facilities, etc. I am afraid that the reputation of my medical school I attend may negatively affect my residency match process in the long run. I want to do my residency in an institution that is renowned for whatever residency I choose. Does the name of your medical college have a big impact on your match process? As for Stony Brook, it is a great school that is expanding drastically in terms of research and is making a big push to attract prominent faculty. However, it is in the middle of nowhere and its affiliated hospitals serve a racially homogenous population. So I do not think I will be able to experience as many clinically diverse medical cases as I would as in an urban hospital. Now that I told you about all the factors revolving around my decision, what advice can you give me? If you were in my shoes, which medical college would you pick? And why?

First of all, I won’t tell you which medical school to pick, only what kind of logic I’d use to make the decision. 

What is the purpose of medical school?  In my opinion, to 1) prepare you for residency and 2) get you to residency. 

Your question touches on both of these points.  Let’s tackle number 1 first.  Where would you get the best preparation for residency?  Well that’s broken up in two parts too: the academic training and the clinical training.  You seem to be focusing more on the clinical training part.  Yes it is true that medical students (as do residents) get less hands-on experience at private hospitals compared to academic or low-income community hospitals.  Think about it this way, the more that patients pay, the more they expect the attending to do and the more they get pissed off when a medical student sticks them 5 times to get an IV in.  You know what I mean? 

However, it is my personal feeling based on my experience and those of friends as well as other residents is that the clinical training you get in medical school is, in general, pretty minimal.  Really.  Sure there are differences between the experience you get at different schools, but how big are those differences?  So you get to do a few more procedures at one place vs. another.  So what?  Putting in one central line vs. five or ten as a medical student under supervision of a resident still equates to zero when you start internship and you become submerged in that stuff all of the time.  There may be varying degrees of comfort between interns at the start, based on where they went to medical school, but those differences become virtually indistinguishable after one to two weeks of internship.  It’s actually quite interesting.  At no medical school will you be the intern or the resident.  Simply because you will be a medical student.  You will not spend your days doing procedures anywhere because the residents will be doing them since they need the experience more than you will as a medical student.  Make sense?  You will occasionally get thrown a bone as a medical student, which may depend on where you are training (e.g. community hospital vs. academic hospital) but again, I wouldn’t put this too high on my list of factors determining where I go to medical school.  In terms of procedures, the only thing I can think of that you should be sort of comfortable with after finishing medical school is suturing/tying knots and that’s only because you will have to do it to some degree in every residency.  Again, you don’t even need to be good at it–no one I know was good at it at the beginning of internship–just be familiar with it. 

When you start internship and you have to do pleural taps, put in central lines, suture, etc, you will do it so many times (initially under supervision) that it really won’t matter where you went to medical school.  If you want to get good at some of these things during medical school, it will mostly fall on you to practice (what you can) outside of school.  So to put it more directly, I don’t believe that going to any one of those schools that you named will give you any significant additional exposure to doing procedures.  Where the quality of your medical school plays a role in these procedures is in terms of what kinds of colleagues and residents you will have around you to teach you or to bounce ideas off of.   I learned a lot of useful tips from my residents or other medical students.

More along this route, the facts you need to learn are pretty much the same no matter where you go to school, right?  The side effects of an ACE inhibitor are the same whether you go to school A or B.  And you will have to work equally hard to memorize all of that stuff.  However, the more collegial the environment and the higher quality of medical students/residents that you surround yourself with, the more likely it is that you will get tipped off on that useful pnemonic or website that will help you to learn X, Y or Z. 

Finally, the name of your medical school does make a difference for residency applications.  It’s kind of bullshit that it should, but on some level it makes sense.  It’s bullshit because, in my opinion, the top performers at any medical school can usually always compete with each other (i.e. the top medical student at small medical school is usually in the same league as the top medical student at big-time medical school).  So I find it unfortunate when top medical students from smaller schools are passed over, especially for lesser students at bigger medical schools.  It happens.  More practically, if you are a “good” student, which most of us are, are a big school, then you will definitely get more looks during residency interviews than a “good” student at a small medical school.  It may be unpleasant to think about but it’s true. 

You mentioned the fact that one institution you are looking at may have better research and science, etc.  I’ve argued before that this doesn’t make much of a difference for medical training.  And, I stand by that.  However, being around smart people–clinical or research–is always good.  A lot of intangible characteristics get rubbed off on you just by being around them.  So while you may not “learn” anything about the side effects of ACE inhibitors from being around top notch scientists, you will however pick up lesser appreciated/unrecognized pearls such examples of how to look at problems in different ways, how to balance clinical and research careers, how to be a collegial participant in academics, etc. (some of these will apply more than others). 

Okay, so there you have it.  I think I’ve addressed the concerns you brought up and it’s probably pretty clear which way I lean, but I think it’s more important that you see my reasoning.  Maybe you agree or disagree with some or all of my points but then you can take that into account as you make your decision. 

Moreover, if any of the readers have any thoughts, please offer them.  I’m sure this reader will appreciate it.


taking care

As I sit here, on vacation in Acadia national park, I am reminded of the patient recovering from a spinal injury who asked ME how I was doing. It really is a sad commentary when the patient who is recovering from bilateral lower extremity paralysis is concerned with how the resident doing. But the point is that to take good care of our patients, we need to take care of ourselves. This has been a good vacation. Lots of good food (probably >20 pounds of lobster) and lots of good rest. I’m feeling recharged and ready-to-go for Monday morning.
I’m actually surprised by how prevalent the thought is amongst higher-ups in residency that to take good care of patients, we gotta take good care of ourselves. Don’t get me wrong–it’s not that prevalent–but I’ve been reminded of this a few times. So now in my moment if clarity, having consumed mad quantities of lobster, carrot cake and ice cream, I pass this on to anyone else in the game who may have missed the memo. Take care of yourself. It’s good for you, it’ll make you feel better and all of that will transfer to over to patient care.
Now, I’m gonna continue taking care of myself and go to bed…


MIT opencourseware

MIT OpenCourseWare (OCW) is a web-based publication of virtually all MIT course content. OCW is open and available to the world and is a permanent MIT activity. If you’re looking to supplement your class notes with extra material or if you’re looking to brush up on a specific subject, why not start here? Most classes give access to syllabi, class notes and examinations.


What is MIT OpenCourseWare?

MIT OpenCourseWare is a free publication of MIT course materials that reflects almost all the undergraduate and graduate subjects taught at MIT.

  • OCW is not an MIT education.
  • OCW does not grant degrees or certificates.
  • OCW does not provide access to MIT faculty.
  • Materials may not reflect entire content of the course.

How do I register to use MIT OpenCourseWare?
There is no registration or enrollment process because OCW is not a credit-bearing or degree-granting initiative.

Can I get a certificate?
No. MIT OpenCourseWare is a publication of the course materials that support the dynamic classroom interactions of an MIT education; it is not a degree-granting or credit-bearing initiative. However, you should work through the materials at your own pace, and in whatever manner you desire.

How do I find what courses are available? How do I search your site?
A site overview is available for MIT OpenCourseWare. You can also browse courses by department or use the advanced search to locate a specific course or topic.

High school students and educators should check out Highlights for High School.


my limits

My opinion is more and more that the point of internship is to push us to our breaking points. And then a little more. I’m fairly convinced that it won’t stop even at the breaking point. I’ve already seen a few people hit that wall and it hasn’t been pretty. Especially since after all the tears, all the screaming, the work is still there to do. 

I don’t know, has anyone who has done this or is in it now, ever had the thought, “I’m only ONE person”? I have that thought like 50 times a day. Today it was like a thousand times. I tweeted today that I felt like I was gonna cry. The old school doctors are all about telling us residents how weak we are, etc. but the fact of the matter is the amount of work that needs to get done hasn’t decreased since the introduction of work hours, etc. In fact, it has probably increased. The expectation is just that now we’re expected to get it all done in a limited amount of time. And that’s it. Get it done. Don’t ask, don’t make excuses, just get it done. I got des-troyed today. A huge service, discharged 7, admitted 3. Plus anything that could go wrong did. Patients changing their minds about wanting to take their medications, patients who were doing great yesterday were feeling like crap today or having intractable pain. And of course I’m the one all the nurses come to.  Pages all fucking day. My favorite is the two-fer. That’s when two pages come in at the same time and the pager makes an especially high-pitched squeal. It’s good stuff the way that a rusty nail is good stuff to step on.  

I mean some of the stuff that comes my way is ridiculous. I was dealing with a patient who wanted to do harm to himself (without getting too specific) and received 3 pages from one nurse, each increasingly angrier than the last about giving an other stable patient something for gas. And then when I went to call back, I got a ton of attitude. I gotta tell you, on some level that hurts. I really think that the worst is when you kicked while you’re down. For me personally, that’s why I always try to be nice. You just never know when you’ll run into someone who is having a miserable day and that niceness will actually do some good. Attitude, meanness and being an asshole do not Mudphudder a happy camper make when he is getting crushed. But, what can I do?  It’s not my style to really retalliate or get into it so I just do my thing and hope that my work gets done. 

So back to my original point, I really think that each day things are made a little tougher than the previous day just to see if that’s what pushes me over the edge. I know that’s really paranoid sounding and I don’t believe it either but it sure feels that way. I got some help down the stretch today from some students on our service in getting things ready and together for evening rounds. And we just barely made it. Not only in time for evening rounds but also making it through evening rounds. After rounds I thanked the students (you gotta do that–they work so hard and you just can’t forget what it was like to be a med student) and I expressed how I felt that today our little team was very much like a rickety old boat held together by duct tape and with bubble gum plugging the leaks. We were seaworthy, but just barely, and we wouldn’t have made it without every single little contribution. It was close. Sometimes I wonder how one person can be expected to do everything in one day. Sometimes it can be ridiculous. But somehow it (usually) all gets done. 

I don’t know, maybe I’m just whining too much. I’m definitely learning a lot. Not so much through active effort (too little energy and time) but because I have to do the same crazy stuff so many freakin times that it’s hard to forget. I’ve actually started dreaming about my patients and discharging them. It’s so sad–I used to dream about other things. Right now I’ll just settle for some sleep. 

Well, now I can go and get some sleep. This weekend I work over saturday night, so I can at least sleep in tomorrow. Hopefully it won’t be too bad but it probably will be. Whatever, though. If I didn’t cry today, I won’t cry tomorrow either–probably because I won’t have the time to.


the residency gods are fair… mostly

I have come to grips with the fact that at the end of the day, the residency Gods are mostly fair. I think. At least so far. On some days I take the worst beating of my life. On those days I feel like I have done something to anger the Gods. More than likely though, they just have forgotten about me and are instead tending to the many other residents who need the help more than I do. However, then there are days when the residency Gods smile upon me. On those days, I am spared the bullshit that turns a routine 13 hr day into a 15 hour day. On those days, I get to hit the gym before heading home for my fifteen minutes of tv and dinner before bedtime. When I first started, I was getting routinely crushed so my general feeling was that I had been forgotten by the residency Gods but now, well, I’m starting to realize that in the end, it all evens out. So I guess on average, the residency Gods think of me as, “mehhh”. I guess that’s better than not at all.

My suspicion is that there will be days when I will rescind this post and say that I have been cast into residency Hell and there will likely be days when I will be in residency Heaven. I guess we’ll take those times one day at a time. In the meantime, with the benefit of the clear thought that comes from a golden weekend, I’ll just stick with “mehhh”.


nih grant codes – is k08 a grant or a type of submarine ?

How many times have you heard people talking about R01 grants or K22 grants and you’re like, “what the hell is he talking about?”  A lot for me.  Many years went by in medical and graduate school where I would hear people talking about these different NIH grants without any clue about what each grant was for.  Eventually I learned about some of them through just talking to people but then I recently discovered the internet and looked up this comprehensive table at the NIH website.  If you want to sound intelligent or be able to participate in conversations about the K02 independent scientist award, check out this site:

Sooner or later if you stay in academia, you’re gonna have to get awfully familiar with these grants…


an apt comparison

Where I spent four years of graduate school.

Where I spent four years of graduate school.

Not too long ago, someone happened onto the mudphudder blog by searching:


are med school and grad school the same


Are med school and grad school the same?  No.

Having been through both now, the best way I can put it is that medical school is like a four year jail sentence: you go in knowing you have to put in four years of hard time and along the way you take it up the ass occasionally.  Graduate school, on the other hand, is like solitary confinement: you’re wandering around in the dark, not knowing how much time has gone by or even what year it is, slowly losing your sanity until one day someone opens the door, you see the light and you’re out–smelly and a shell of your former self.  And you still have to take it up the ass occassionally.



Here’s a post I wrote earlier today on my phone:

I’m not normal and my life clearly is not normal. I live in the hospital except for the few hours of sleep I get every night. I get my vitamin k  vitamin D (or lack there of) from fluorescent lights.  I’m wriing this entry as I stand in line in the hospital cafeteria for a grilled cheese sandwich. I wear pajamas all day long at work.  In my profession 80 hrs is the lower limit of acceptable time spent workig in a week. Actually, I don’t think the word “acceptable” is even accurate.

But in any case I am of the opinion that sometimes it’s nice, even therapeutic, to feel normal. So I do two things everyday to feel normal: 1) I come to work in jeans and a tshirt (ie civilian clothing) everyday. There’s something really relaxing, almost cathartic after 15 hrs in the hospital to put on a pair of jeans and go home.  It only adds an extra 4 minutes to both ends of my day to change, but it’s worth it. 2) I try to take 5 or 10 minutes everyday to sit outisde either in a hospital courtyard or even out in front of the hospital. I’ll get an iced tea +/- a chocolate chip cookie and just take in some fresh air.  It’s nice and also very normal feeling. As a sidenote, I’m not sure yet how I’ll adapt this to Boston winters but I’m thinking about it now. 

I know a lot of residents who deny themselves the chance to feel normal, either out of arrogance or feeling like they don’t have the time, but I thnk that’s a bad idea. My sense of normality is one of the ways through which I relate to my patients.  Everyone wants to be “normal” sometimes and everyone wants to relate to normal.  It’s why despite sleepiness and a list of boxes that need to get checked off pages long, I love sitting down to talk baseball with a patient.  It’s also why the same patient with untreatable cancer, for a even period of 5 minutes, will baseball with me.  Everyone wants to be normal sometimes.  Finally, occasional normalcy is also a reason why I haven’t and hopefully won’t turn into a complete asshole when the going gets tough (although some may disagree with my assessment that I’m ready not an asshole).  In any case, I should say when the going get tougher.  Plus, trying to be a little normal really doesn’t take that much time.  And as I like to say: even in medicine, 10 minutes never killled anyone, unless of course it was a code.


13 hours later…

And the first day of internship is done. Can’t complain–13 hours is not that bad even if I was hustling around the whole day. Picking up some thai food as a treat and then I’m going home. Thank you all again for the love that you have heaped on me in the last few days. I sincerely appreciate it.

Mudphudder out.


the final countdown

So the regular readers of this blog probably thought this post was just going to be the video clip of “the Final Countdown” by Europe that I post every so often, but NO! it’s not!  :-)  So if you haven’t already flipped back to google, here we go.

my first page (non-official)

My other first page (non-official, from me to me)

Tomorrow I start internship.  Crazy.  I last wrote about my fear of totally messing up this thing and I appreciate your kind comments suggesting the contrary.  At this point, I just want to get in there and fire it up baby.  I’ve spent this weekend going in, rounding with the current team, writing orders, learning the system, etc.  I put in my first official order as a physician.  I called my first consult as a physician.  I did my first discharge summary as a physician.  I received my first page–well, my first official page from someone else–as a physician.  Even better, my first page was back to a number that wasn’t working.  That’s not a good sign.

But I’ll make one last comment on the craziness of this all.  As medical students we get to write orders occasionally–mostly in advanced rotations (e.g. sub-internships) but those orders are always cosigned.  So while you are always approaching the process as though you are the doctor, deep down inside you know that someone will (has to) be double checking you on any little thing that could affect the patient.  I suspect the next few weeks won’t be too much different as an intern but quite frankly, my senior residents won’t be able to double everything that will affect the patients’ well-being.  So it is with some (serious) thought and rethinking and re-rethinking and re-re-rethinking that I am putting orders in right now.  I hope and I suspect that I will build up my confidence with time and experience but for now, I’ll just have to be inefficiently careful to the extreme.  Patient wants tylenol?  Hmmmmmmmmmmmmmmmmmmmmm.  Hmmmmmmmmmmmmmmmmmm.  Is there any reason not to give this guy some tylenol?   Hmmmmmmmmmmmmmmmmmmmm.   Hmmmmmmmmmmmmmmmm.  You get the picture.  But I’m happy that this kind of thought process is not sustainable throughout residency so at some point, I’ll have to get faster. 

Anyway, the last couple of days has seemed cautiously do-able.  I’m always discovering some new, critical responsibility that the intern is responsible for on our service, so I hope that I don’t bring the service to a screeching halt tomorrow.  But we’ll see.  100% is all I can give.

Wish me luck (although most of you already have, so thanks again).

I’ll write to you from the other side.

Mudphudder out.


footwear for the wards

As of late I have made some fuss about my footwear to start off internship.  Yes, every young doctor secretly or not-so-secretly wants to be pimpin’ and for some, footwear is a big part of that.  I may have given that impression in the last post I made but for the sake of the youngins, I’ll clarify. 

First of all, you know me.  The mudphudder.   MP.  We already know that I’m the “why?” in “stYle”.  But make no mistake about it, when it comes to footwear and the wards, style is an afterthought.  Walking the wards for a sub-internship or any time consuming medical school rotation is no joke.  It kills your feet.  I suspect residency will be no different.  Going to the wards is like going to war.  And the preparation starts with your feet.  Without healthy feet, you can’t walk the wards or stand in the OR for 12 hours a day.  So when it comes to your feet, you gotta go with comfort and durability before the style factor even comes into play.  And I’m talking socks too: comfort and durability. 

You can always tell the newbie medical students on the wards: wearing pimped out shoes with dress socks.  I was one of them too once.  After a few weeks or months, spending evenings with your feet up on pillows wrapped in ice, it dawns on you that it may not be worth it.  True dat.  For the last few years, I’ve been wearing dansko clogs and sweat socks.  I love it.  It works–my feet don’t kill me when I go home (as much).  Plus, I can kick them off at anytime during conferences, lunch or even when I’m talking to patients to let my puppies breath a little.  Oh yeah.  Some of you know what I’m talking about.  Like when you’ve been on your feet for 15 hours straight and your feet hurt so bad that they’re numb and then you sit down, kick the shoes off and it feels so f’in good.  And to be quite frank, I don’t give a rat’s ass that some people may not like the white sock/black shoe look.  It’s comfortable and it’s professionally acceptable so all the haters out there can just eat it. 

Anyway, once the shoes have been narrowed down for comfort and durability (I once knew a crazy ass resident who actually used one of those podometers to calculate he walked an average of 5 miles per day in the hospital), then go for style.  I’m personally sticking with my trusty dansko clogs.  My bad-ass Johnston and Murphy shoes are strictly for walking Boston on my days off.  Yes, they’re comfortable but they’re not made for long hours.  My new Bruno Magli’s (I still love the fact that I have a pair) are strictly for *occasional* clinic use.  Yup–Even those bad boys I’m gonna be careful about taking out.  At the end of the day, despite my pimped out arsenal of footwear, I’ll mostly be relying on my clogs.

So to conclude, being pimped out is important but not at the cost of the feet.  Furthermore, being pimped-out is a state of mind so the “Superfly” should come across regardless of the footwear.  And if it doesn’t, then the fur on the collar of my white coat should give it away.


md/phd students are assholes

Or so some people must think.  I still owe you all a post on the MD/PhD student experience of going through residency interviews but one aspect of my interviews came to mind today and I wanted to write about it in a separate post.  (For the non-medical readers, if you didn’t catch my rants on the residency interview process, here’s a previous post I wrote as background).  One question that I was asked at a number of places was, “do you think you will be able to take orders from a more senior resident who is younger than you?” 

And my response was: “No.  If I am older, then I MUST know more than anyone younger regardless of how many years of residency the other individual has been through or that I have no experience in residency.”

What the fuck?  (yeah I’m writing it out).  Is it just me or was the interviewer essentially asking me if I’m an arrogant asshole?  It was even worse when I’d get the same question from different interviewers at the same place.  And it wasn’t just directed at me (although you may be thinking that), because I’ve heard other MD/PhD students getting the same question. 

The interviewer follows up: “Because some MD/PhD students have a hard time taking orders from younger residents.”

Here’s some breaking news: there are assholes in every field and every sub-group of people.  Sure there are jerks amongst MD/PhD students, but there are also jerks amongst regular medical students and residents as well. 

There are medical students and residents who walk into labs for their research rotations and having done some PCR several years ago, think that they are much better than graduate students or post-docs.  These people ultimately not only alienate everyone around them but also fuck up other people’s experiments through contamination, etc.  Yup, research people know exactly what I’m talking about.  And guess what–these fuck-ups are not MD/PhD students.  Yes, there are assholes everywhere. 

Now, my assumption is that these interviewers have had bad experiences in the past, which is why they ask.  And yes, I’ve even known MD/PhD students who have told me in the past that it’s bullshit to take orders from residents who are several years younger, but they were in the minority in my experience, and even before hearing that I would’ve classified them as arrogant.  

However, as I described above, I and others I know have had bad experiences with arrogant medical students and residents in the lab but that doesn’t stop me from giving them the benefit of the doubt to begin with.  In all fairness, though, I will acknowledge that the distrust does run both ways–yeah research people, I’m looking at you.  I remember in our lab the graduate students used to have a serious distrust and unjustified dislike of medical students, residents and fellows who rotated through the lab.  But that wasn’t cool either.  So let’s just try to get along people! 

Anyway, to end in a helpful and non-ranting manner, I’ll say how I always answer this question:

We all choose different paths.  That I may be older than many of the residents I’ll be working with isn’t because I was wasting my time–but rather because I was pursuing my own career goals through graduate school and getting a PhD.  In that time though, these residents have accumulated far more medical knowledge and experience than I have so there is absolutely no reason why I would have a problem learning and taking orders from them. 

That’s reasonable, I think.


career choice impacts your academic viability

What is the most consistent measure of academic viability?  Scientific accomplishment?  Enlightenment of fellow man?  Bettering mankind?  Not really.  In my experience the most consistent measure of the viability of ones academic career is funding/money.  When big-name scientists lose their funding, they get the boot.  When the dude who has never really accomplished much somehow gets his hands on several million dollars of funding, he becomes the star.  I’ve seen it happen.  It doesn’t quite seem right but I don’t think universities care, in general. 

I was listening to a story about a division head who is effectively being terminated because of the loss of major funding (and the inability to get more funding) and I couldn’t help but shake my head in sad acceptance.  “Sad” because the situation is obviously sad!  Moreover, I know this person’s work and it is good–like New England Journal of Medicine good.  And, “acceptance” because that’s academics for you.  Better to know the ground rules going in than be surprised.  Nothing surprises me anymore. 

Nonetheless, because this is a fact of academics, it is important to consider the fact that your career choice will impact the viability of your academic career.  As time goes on, our careers all become more differentiated but there is always opportunity for adapting our work strategy. 

So what am I talking about?  From the perspective of pure researchers, it is pretty straight forward I think (but correct me if I’m wrong).  Either get grant funding or get the fuck out of here.  My feeling is that the best way to maintain viability through constant grant support (besides the obvious: do quality work, do lots of it, and know the right people) is to be in a field that maximizes the ratio of funding opportunities to competitors seeking those funds.  And that’s a tough balance to strike because “hotter” fields, with many investigators, tend to suck up most of the funding dollars.  You think the NIDDK gives away most of it’s grant monies for research of irritable bowel syndrome?  Actually, I don’t know–that could be the case, but to illustrate my point, my guess would be most NIDDK research dollars go towards diabetes.  The field I did my PhD research in was really hot and also really competitive and cut throat.  As much as I’m always screaming that “I WAS ROBBED” when I get shitty reviews back on my manuscripts, a few of my reviews really did read like that reviewer just wanted to suppress our work.  But, then again there was tons of grant money for that area of research. 

What about clinicians in academics?  Here’s where it gets a little more complicated.  Academic physicians tend to fall into one of three categories: physicians, physician-scientists and physician-educators.  The one common denominator for job security to all three categories is the amount of revenue that the clinical practice brings into the department.  This is obviously applicable to the pure clinician who does not undertake much research or teach.  However, it is also applicable to physician-scientists and physician-educators because at the very least, if the money generated through research or teaching activities falls through, there is always the clinical practice to depend on until, for example, the next grant comes in.  Therefore, there will always be more academic job security for someone whose clinical field of practice generates more revenue than a clinician who doesn’t.  It’s a sad fact.  I’ve seen some junior faculty who are forced to near 100% clinical work in order to support their salaries (essentially guaranteeing the end of the research career) in comparison to some other physicians who can cover their whole salaries (even without grants!) by working 3 days per week.  That’s a big difference.  Moreover, for pure clinicians the clinical revenue from a full week’s work will significantly impact not only salary level but also promotions as well.  I’ve noticed this to be particularly hard on the general internist who practices in an academic center.  Deferring all discussions on the importance of the general internist for now, it has become a fact that these guys are some of the most underpaid physicians in this country.  Couple that with work in an academic setting and you have a recipe for failure waiting to happen.  Especially when these guys are compared side-by-side (in terms of revenue production) with colleagues in, for example, surgery.  The fact is that physicians practicing less lucrative fields in academics have to do something else (research, teach, etc) and that something else better generate some revenue or at least acclaim.  At the end of the day, it seems to me that we are essentially renting our faculty posts from the university (e.g. through grants, services or revenues generated).  And, in order to do what you want in academics, it is important to have some idea of how you can strike the balance between career, research, etc that will allow you to pay the rent.

I’ll end by saying I don’t think that tailoring your career or career path to one of high academic viability (lots of money) is how anyone should approach it.  I think first and foremost you have to do what you love and what you are passionate about.  But in my opinion, it is important to keep the reality of academics in mind too.  Academics is hardly the ivory tower that people imagine it as.  It should be approached strategically, with all aspects–the good and the bad–in mind, so that you can maximize the odds of being able to do what you love in the academic setting.


it’s all about the administrators

It’s amazing what a big role administrators can play in academics.  From the administrator in the graduate program office to the departmental administrator who puts in grant applications, administrators can make your life easy or extremely difficult. 

In my experience, I can tell you that the administrators in our MD/PhD office and my graduate program as well as thesis lab were key in making my life easy.  During the course of medical/graduate school, there are a lot of situations that can potentially come up where it is useful to have someone who will take care of things for you, e.g. deal with the registrar, dean’s office, budget office, etc.  As non-administrators, we don’t know many of the tricks that can, for example, cut the time it takes to get a hold of the right person at the registrar’s office from an hour to 5 minutes.  Who here has called an administrative office, like the registrar, and not received an answer?  Leave a message and we’ll get back to you–beeeeeeeeep.  Not cool when you need something taken care of in the next hour or even today.  In these situations, it’s nice to have someone who knows the right person to call as well as the right internal number that is sure to be answered (yes, these numbers exist).  Over time I’ve come to learn a few of these tricks but am not nearly as proficient as some administrators I know.  (as a sidenote, next time you get sent to an answering machine inside your university–administrative office or even within the hospital–try hitting the number zero; sometimes that will direct you to a phone that will be answered!!!)

The same can be said about the administrator of our graduate program who was extremely helpful when I was getting everything together to fulfill my requirements for graduation as well as our lab administrator who had my back throughout graduate school and took care of lots of little things that made my life much easier.  In contrast I have heard horror stories about administrators in other programs who not only don’t do their work but actually make life harder (e.g. losing things, not filing things).  One person I know almost didn’t get to graduate from graduate school because the program administrator kept losing the requisite forms that needed and were filled out by the student.  That’s ridiculous!!!!  Another person didn’t get reimbursed for conference expenses for over a year.  Can you really afford to shell out over $1000 for a conference and not get reimbursed for over a year? 

I wish I could say that this nonsense stopped at graduate school but it never does.  A junior faculty member I know turned in a grant application two weeks before the university deadline only to find out that his administrator sat on it and forgot to turn it in.  When he asked her about it, she sent him to five different offices around the university looking for his grant application when he finally realized that it had not gone anywhere to begin with.  Are you serious about that?!?!?!!?  This was for a junior faculty member whose career depends on grants.  Unbelievable.

I guess my point is that administrators are an often overlooked part of our evaluation of new places we go for work.  Having more experience with an MD/PhD program, graduate school program and joining a lab, I can definitely attest to how important a good administrator can be during those times.  So, if you are going to be interviewing for an MD/PhD program, graduate school program or even for joining a lab, make sure you ask other students how good and supportive the administrators are.  It’ll be obvious from peoples’ reactions just how good or helpful the administrators are.  Just remember, these administrators are the people who are supposed to be helping you (at least, not hurting you) for a sizeable period during a critical point in your training.  It’s definitely something to consider.


academicians are pussies

Here is a comment that was recently left on this blog:

You’re a total pussy and judging by the comments above, that’s the norm in academia.

There is no justice in the world and there are no other lives where people get their karmic reward. You need to have the courage to tell people where to get off here and now, that’s the only way to beat the a-holes.

HAHAHAHAHAHAHA!!!!!  Sounds like someone who (1) isn’t in academics and (2) wasn’t loved enough as a child. 

But, it raises an important issue related to academics–how far do you take a fight?  Do you walk away, take a stand or take the fight to others?  It depends.  There are times when you will have to take it up the ass because the alternate would come at too great a cost.  But there are also times when it is completely appropriate and worth it to follow this commenter’s philosophy. 

However, “You need to have the courage to tell people where to get off here and now, that’s the only way to beat the a-holes” is the fastest way to get kicked out of academics in my experience, which is why I am writing this post.  In my opinion, the hardest thing you will have to do in academics is when at some point you will have to hold back on the urge to tell an asshole where to get off.  One of the barriers to always speaking your mind is the fact that your career (especially early on–but really until you become a departmental chair it seems) is controlled by a small group of people who all know each, were med or grad school buddies, talk to each other and hire based on each others recommendations.  Which is why pissing off the wrong person can totally destroy a career.  Moreover, someone is always trying to stick it to you in academics.  Papers, authorship, reagents, call schedule, etc.  Sometimes you gotta take one.  It’s called being a “team player”–a buzz word in medicine, for sure.  Even a reputation as someone who is not a team player can hurt. 

My point is that I’ve known a number of people who have adopted the general approach of “You need to have the courage to tell people where to get off here and now, that’s the only way to beat the a-holes“.  They have either been kicked out of or nearly kicked out of medical school, graduate school, residency and fellowship.  None remain in academics.  Which is why my empiric evidence suggests to me that you gotta be careful when it comes to getting into major conflicts.  You can be as courageous as you want to be but if it costs you your academic career or even an extra year or two in training, will it be worth it then?  Everyone I know who has gone through this would say that it wasn’t worth it. I agree that sometimes it is worth it to throw down.  I’ve had to a number of times as well and while it wasn’t pretty, it was the right move to make at that point.  But those occasions were few and far between.  More often than not, I and everyone else I know have had to take it.

Some people may call that being a pussy.  I call it being careful, calculating and deliberate.   I also think telling off every asshole that gets in your way is a poor career move and usually makes you appear to be an asshole as well.  Finally, I would be wary of anyone who suggests this as a general approach to life in academics.  This is not meant as an offense to the commenter but is simply based on the outcomes I’ve seen. 

So what to do?  As I’ve tried to relay before, I think the key is to first and foremost avoid such situations if possible, which is why I’ve been writing about my experiences in order to give suggestions for how to do so.  Second, I think you always have to be calculating and deliberate in what actions you do take.  If you decide to fight, then make sure it’s worth it.  If it’s not worth it, then walk away.  In either case, you can’t take a general willy-nilly approach to every circumstance. 

I’ve put out my experience on this but if readers from any stage in academia want to share their thoughts, experiences, or suggestions in the comments, I’d love to hear them since I think this issue of when and how far to take a fight is an important one for an academic career.


changing residency

I was gonna write about something else but then I noticed that someone got to my blog using the google search terms:

how to change out of my shitty fucking internal medicine residency

Dang.  It’s not that often I hear an internal medicine resident describe his/her residency as “…shitty fucking…” and it harkens back to some clinical rotations I’ve been on, which I would have described similarly.  You can’t help but feel bad for anyone who is that miserable in their residency.  It is unclear to me whether this was someone who just matched into this residency or is already there and just miserable.

This is unfortunately a not-so-uncommon thing–that residents regret their field of choice.  Residency is miserable enough to begin with–the abuse, sleep-deprivation, malnutrition, lack of free time, etc–but having to force yourself through that without even the motivation of enjoying your field must be hell.  So what are the options for someone who hates their residency?  It depends on the stage of the game.  If you just matched and signed/mailed in your form committing to your intern year, then if you ever want to practice medicine again, you had better do that intern year.  The good news is that many different residency programs will accept an internal medicine internship (similarly for a general surgery internship).  So for those incoming interns who are regretful of their choice, use that first year to apply to another specialty–preferably one that will accept your intern year so you don’t have to repeat it.  I know one guy who had to repeat his intern year.  Ouch.  That hurts me deep inside just thinking about it. 

For residents who are already in residency, there are few if any time-efficient options where all of your previous residency years would count towards your new residency of choice.  In fact, most of the time it’ll only be the intern year that can be applied toward another residency.  In this case, you’re just gonna have to suck it up.  Either finish up what remains of your residency or accept the fact that you will be losing a few years (although on the flip side, you will be more experienced than your counterparts). 

In either situation, I think you have to be open with your program director because if there’s one thing I’ve noticed that will get you black-listed for life in medicine it is leaving people in the lurch.  Sometimes program directors can be really helpful in finding something else or in the transition.  And any help that you can get is welcomed because switching residencies is an uphill battle.  Everyone is allowed to make mistakes but somehow this fact is lost in the desire of most programs to avoid any shake-up amongst their housestaff (including hiring a resident who has a history of switching residencies).  How well one will be accepted at another residency after switching will otherwise be affected by a number of other factors including the rationale for switching residencies (this better be damned good), previous academic track record and whether anyone is still willing to vouch for the resident.

Switching residencies is no joke.  It takes a lot of diplomatic maneuvering and will ultimately bring lots of grief for you.  But at the end of the day, you can’t do something that’s gonna make you miserable everyday for the rest of your life.  To switch or not to switch, pick whichever route will involve the least pain for you. 

If any readers are going through this now, please comment on what (if any) kind of approach has worked or not worked.


give it up

I’ve written before about authorship issues that I have experienced.  Getting papers snatched away or just plain and simple not being given any credit (where credit is due) can be painful but it is also a common thing.  Another issue I’ve alluded to is a situation when you have to recuse your authorship because you don’t agree with the work or the interpretations.  I’ve now had to do this twice.  I won’t get into the specifics of the situations (some which have already been described in previous posts) but while it hurt me both times to give up authorship (hey, I’m young and every paper counts here!), I don’t regret it. 

A similar situation recently happened to a friend of mine and he had to recuse himself from what would have been a nice publication on his CV.  Unfortunately, the people to whom this kind of scenario happens are often lower on the totem pole and therefore the people who would have most benefitted from the publication. 

We are recruited to participate in research project and we contribute valuable time and energy with an understanding of the goals/objectives that are being sought.  But what do you do if your results are interpreted in such a way that goes against both what you have previously published (thus making you look bad in print) and what you actually believe to be the truth?  None of us are ever recruited into a study knowing that this is going to happen or that the person with whom you are collaborating is going to pull a 180 so what are the options?  One possibility is proposing to do additional work (e.g. experiments) that would flush out whether one theory is more valid than the other.  Presumably, the fact that you are a collaborator indicates that your opinion is respected and therefore worthy of flushing out.  But that is not always the case.  Another option is trying to word the interpretation in a more objective fashion that reflects precisely what the results have shown, thus leaving open the possibility that both interpretations are possible.  Again, this depends on the fact that your opinion would be respected since you have supplied an necessary (and sometimes critical) part of the story.  And again, it is not always the case that your opinion is respected–just that your contribution is needed. 

My friend was needed to provide a service that only he could do.  He performed it and then was slapped in the face.  He didn’t know it was coming and tried working with his co-authors but ultimately gave up the fight and simply asked for removal from the authorship.  Instead he is now acknowledged.  And, better yet, his contribution is actually listed under someone else’s name in the “author’s contribution” section!  You gotta wonder what keeps people in academics sometimes.

The main issue with this is that neither I nor my friend nor young academics out there have the time to waste on a project that we will have recuse ourselves from because of dogmatic beliefs of a more senior collaborator.  However, we have to weigh this against the fact that collaborations are a necessary part of furthering our careers and they can even be really productive when it is a supportive relationship built on openness, communication and mutual respect.  (I better not getting any “dating help” hits from google).  So here are my suggestions, ask as many questions as you can think of to uncover any possible underlying agenda (philosophical, dogmatic, etc) when you are asked to collaborate on a project.  It is better to get it all out in the open than to spend your time on something that you ultimately won’t get anything out of anyway.  Moreover, it is a lot harder for people to go back on issues that have been discussed beforehand in contrast to issues that have never been broached.  Finally, if all else fails, you have to recuse yourself.  I write this mostly for the younger readers: it is NEVER worth it to put your name on something you don’t believe, regardless of where it’ll be published.  I’ve seen it ruin too many people.  And at the end of day, your scientific integrity is the only true and consistent predictor of the quality of your work.  Once you besmirch that, it’s all over–in both your own and others’ eyes.  I know it can be painful to give up publications and have to live with the fact that you contributed to a study that you don’t agree with but that is better than having to accept responsibility for that work (which is what authorship means, right?).  Moreover, look at each one of these instances as a learning experience that will inform you on finding productive collaborative relationships in the future.

And hopefully, my, my friend’s and other’s experiences will help prevent similar experiences for others in the future by offering some insight into how to approach collaborations as well as these situations when they arise.