This thing I refer to as My Life

Yup! Today was my LAST day of Medical School!

H3LL YES!!

Oops! I forgot to cross-post this one from yesterday!

48 Hours or less...
03/28/07

Only TWO more days of medical school left! (Maybe only one depending on how generous the fellow on my service is feeling.)

(Almost all of the medical terms used here can be image-searched in google with very good results.)

I've been on the Urology service which is actually a very pleasant Sub-internship (Sub-I) from the standpoint of the schedule compared to many of the other SubI's. You pay your penance by having to put your finger up a lot of tooshies on Tuesdays and Thursdays. Those are the clinic days. Monday, Wednesday and Friday you can either watch in the OR (they do not seem "big" on letting students scrub-in) or you can help with procedures. As a student, you can actually perform the cystoscopy! (That's where you pass a small(-ish) camera up the urethra (usually of a male), fill the bladder with fluid (if it's not already filled with some "mysterious" yellow liquid) and visualize (on TV) the entire bladder--a section at a time. The end of the cameral is movable with a little thumb-wheel and the coolest part is when you turn the camera to look back upon itself. You can see the prostate pushing up on the bladder outlet, if it is enlarged. The only thing that is a little cooler is watching a ureter empty some of that "mysterious" yellow liquid into the bladder. It's like it burps it up!

The clinic days tend to be really busy from 9a until 4p. I try to see as many patients as I can, but occasionally I will get a little bogged down with someone that needs some extra care. Almost every patient receives a DRE (digital rectal exam) and I'm getting pretty good at determining the size of the prostate. I did not perform any DRE's for the prostate when I was an M3/M4 (until now) and only a couple of DRE's for rectal tone (that is done to check for spinal cord injure) or blood in the stool. But, I've done my share now! DRE's (the real Michigan Difference), however, are not the worst part.

Let me tell you about a spermatocele. From the view point of a budding radiologist, this is a procedure that is VERY difficult to watch: lots of sympathetic pain. Go google spermatocele and go to the eMedicine link. Scroll down and the pictures start to do this justice. Actually, the spermatocelectomy that I viewed had a much larger spermatocele! Much of the first half of the procedure I was just trying to make sure there was ample space in case I blacked-out. The second half I was just squirming in pain. Watching the scrotum being turned inside out is just WRONG. (I wonder if that is why they don't let me scrub-in?)

As strange as all of that sounds, I don't think the above are the events are what have really defined the rotation for me. A couple of weeks ago, we were on morning rounds seeing our handful of in-patients. One of the patients had been recovering well from his cystectomy with ileal conduit (due to bladder cancer) and I was asked to remove his IJ line. (Well, first they asked me if I knew how to do it and then they asked me to do it.) The rest of the team went off to the OR and I help the nurse move the patient from his chair back to his bed. He was breathing a bit heavier than I thought he should be so I waited for his breathing to calm a little. I flatten and tilted the bed so his head would be lower than his feet. He was still breathing a bit heavy and I asked him if he would be able to hum for me. (It is best to pull the line with a little valsalva to help keep air from getting into the venous system and it is easy to tell when someone has stopped humming for a moment.) He looked at me and shook his head, no. I looked at the nurse and said, "He needs this accessI'm not taking it out." She agreed and we decided to get respiratory therapy to give him a breathing treatment (because it had helped earlier that morning) and to take an ABG (arterial blood gas) and a portable chest X-ray. Of course I cannot really order any of this, I paged my resident and asked her to put in the orders and asked her to come over when she could. The patient was still laboring to breath but started doing better during the breathing treatment. That is about when the resident arrived. We went back to the OR but, since I was not scrubbed in, I periodically checked up on the patient throughout the rest of the morning and early after noon. Late morning he was doing a little better, but not exactly normal. His ABG's and labs looked okay, but not great: As the day went on, he started to look fatigued and I became increasingly worried. Shortly after lunch I told one of the other (residents who was not in the OR) what had been happening over the day and asked if he would go look at the patient with me. I told him that I was worried that he was going to fatigue and if it were up to me, I would be inclined to intubate him. This brought on a several minute lecture about how I should not be "that guy" that rushes to intubate everyone and that I don't want that reputation and that the patient's numbers really did not warrant intubation. I listened and appreciated (genuinely) the advice because I know that intubating is not a casual thing and there can be serious consequences to doing it. We arrived at the room and in less than a minute the resident told the nurse to contact ICU because we need to move him there and to have anesthesia meet us there to intubate the patient. The resident asked me to stay with the patient until we got him moved to the ICU and he patted me on the back and said, "that was a good call." It was determined, later that day, that he must have aspirated some emesis the night before given the clinical scenario and radiologic findings.

I tell you that story not because it is ego boosting. Rather, I take it as a good indication of how far I have come in my clinical assessment skills and that I know when and how to look beyond the numbers and treat the patient. It helped me feel ready to be an intern. There is certainly plenty of material to be learned and skills to be mastered, but I'm ready for it!I hope.

I (or rather we) matched at University of Maryland for Radiology! And St. John's hospital (Grosse Point) for transition year. So, we'll be here in MI for a year then to Bal-more!!

The Match and Scramble

Okay, so I just tried to explain the match to a friend of mine and I thought I would post that explanation here....

(Note: the word "algorithm" refers to the computer program that does the match, the word "program" refers to an residency program.)

The programs interview about 10 people per spot and most programs have about 8 spots per year.

I rank the programs from my most favorite to my least favorite. I am not supposed to rank any program that I do not think I’d be happy at, however, if I were to fail to match, then I would possibly end up somewhere worse, if I ended up anywhere at all!

The programs rank their applicants from most favorite to least favorite, too. And, they are not supposed to rank any student they do not want to attend.

The algorithm is supposed to work like this: it picks a random student (A), looks at their first choice. Then it goes to the school to see if (A) is on their list at all. Say, the program has ranked (A) #10 but they only have 3 spots. Since there is no one else in the program yet, then (A) is put in spot 1. The algorithm goes to the next random student (B) and say (B) has ranked that same program #1. The program, however, did not rank them. So the algorithm goes to (B)’s second choice. That program ranked (B) #5 and they have 8 spots. (B) is matched at the his/her second choice because no one can bump (B) lower than the 5th spot. The algorithm goes to (C), which has ranked the same program as (A) and (B) for #1. That program has (C) ranked as their third favorite applicant, which is above (A). (A) is moved down to the second spot and (C) takes the first spot. The algorithm moves to (D) which has the same program #1 and the program ranked them fourth. (D) then takes the second spot in the program and (A) is bumped down to the third spot. Applicant (E), who was the best applicant in the entire pool, had been ranked by that program #1. They want him there really badly. However, (E) decided that the program is WAY to hostile and no one wants to live in f*ing St. Louis, so (E) did not put that program on his list. Instead, he put Stanford…I mean a different program from the two mentioned above as his #1. Stanfor…I mean this third program does not have anyone in it yet and (E) is number #1 on their list, so (E) is match at Stan…I mean that third program and on one will be able to bump him out. Applicant (F) followed the thundering masses trying to get into St. Lou…I mean the program that was ranked first by (A), (C) and (D) and that program ranked (F) as their second favorite applicant, so (F) takes the top spot, (C) is bumped to the second and (D) has the third and (A) is bumped out. Remember, they only had 3 spots. The algorithm goes back to (A)’s list and to (A)'s second choice. And that is how the match is reported to work.

The claim is that it is weighted toward the student, but as you can tell, the school really has the final say-so. And they St. Louis program has way more than 3 spots. I think it has 18 spots, but that would have taken too long to make the point. And, more importantly, St. Louis did not even interview (E). Those F*ERS!

Okay, now let’s talk about the scramble. Say (E) was really pigheaded and just assumed that Stanf…I mean his #1 choice was going to rank him in one of their top 8 spots. (That would guaranty a match, theoretically.) So, (E) only ranked that one program on his list. (Which, of course, (E) would never actually do, because (E) understands statistics and that computer programs are not always written correctly and he knows he might accidentally piss someone off during an interview.) Let’s say that (E) did just that! He was late to the interview and a real arrogant SOB to the coordinating secretary. (They actually hold 99% of the power and, of course (E) would never have actually done such a thing because that is not who (E) is.) So that program in California didn’t even rank him. So (E) would go unmatched. Then (E) would have to do what is called the scramble. (E) would have received an e-mail on Monday saying that (E) did not match. The medical school that (E) attends would have received similar notice. Tuesday, at noon, the people in charge of the match, post all of the programs (in all fields: radiology, surgery, medicine, etc.) with unfilled spots. (E) would meet with his adviser on Tuesday and come up with a list of places (E) would like to try to get in to. Radiology frequently has no unfilled spots, so (E) might have to pick a different career!!!!! (From the dregs of the career pile, although rumor has it that there are several spots in Rad-Onc that went unfilled.) See how much is riding on one f*ing grade (step 1) and a set of interviews. So, on Thursday at noon, (E)’s adviser would start calling and Faxing the programs with open spots. It is something of a free-for-all, if you can imagine. If (E)’s adviser is unlucky and unable to get anyone on the phone/Fax, (E) is f*ed! (E) would have to do some lame research for a year and try again. Or, just f* it all and go into high finance where he could repay his loans in a matter of months. Or, go into patent law and pay back the loans in a day. What the h*ll is (E) thinking?!?! If (E)’s adviser does get hold of someone, (E) would go through a telephone interview and may, or may not get the spot.

For those that did match (like (E)), they do not find out where they matched until after the scramble is over which is Thursday at noon. In theory (E) could log onto a web site and find out, but (E)’s school makes a big lunch deal over it and randomly calls up students and surprises them with the location of their match.

Disclaimer: Any resemblance to any real person, place or program in the above demonstration is purely coincidental and only used for illustrative purposes. But (E) really does hope to match at Stanfo....(E) means that program in California...but, (E) will be happy where ever (E) matched because (E) is just a happy guy.

I matched!!! (That means I will be entering a Radiology residency.) I will not know where I matched until Thursday...