Done

In 1999 I started taking premed classes. This morning, 13 years later, I just got home from the last shift of my residency. Feels pretty damn good to be finished.

Getting closer

It's hard to believe, but a scant 12 years after starting premed classes in 1999 (!), I'm down to 10 months left to go in medical training. Although there's a lot left to do between now and next July, the end is finally in sight.

All of which means that pretty soon it's going to be time to start looking for a job. Starting from first principles, here's an interesting page from the CDC web site about Access to Trauma Care in the U.S. If you scroll down you'll find a map of the U.S. The purple areas are within one hour of a Level I or II trauma center. The white areas are not. Food for thought....

R.O.C.K. in the U.S.A.

As my cohort of fellow medical students heads off to start intern year we're understandably a bit nervous about the prospect of the responsibilities we're about to face. In particular, quite a few of us worked in other countries during the last six months where we had a chance to see how doctors are trained elsewhere. And let me tell you, it was pretty humbling. In the U.S. we're required to take (and beat the curve in) three or four years of premedical basic science courses before we even start, after which the first half of med school itself consists largely of another two years in the classroom. It's not until the last two years of med school that we really get out and work with patients directly. But even then, the curriculum has changed in the last couple of decades (in large part due to a combination of legal pressures and specialization) so that we're extremely limited in the procedural training that we actually receive. I personally don't know any American medical students who feel that they've gotten the practical, hands-on training needed for what they'll be expected to do as interns.

In contrast, a common model in many other countries is for med school to start directly after secondary education, so that students are trained to do procedural work with patients much earlier. The result is that, although our foreign counterparts may not have our command of biochemical minutiae at this point, they are way ahead of us in terms of their practical abilities on the hospital wards. Although it all evens out down the line (we hope), more than a few of my U.S. companions sure wish we'd gotten more training in procedures during the past few years, even if it came at the expense of some basic science in the classroom. This is echoed by the old-school clinical professors who will often remind us that when they were medical students they already knew how to do more in the hospital than most interns do today.

However, although I may wish I had more practical training going into residency, it occurs to me that the U.S. is pretty much the only place where I could do what I'm doing at my relatively advanced, non-traditional age. (I'm the oldest student in two or three consecutive classes at my school, and an outlier on the age chart for any med school in the country.) It's common in other parts of the world for even a few years taken away from medical studies at a young age to disqualify a person from becoming a doctor (or at least become even more of an obstacle than it is here). So for those of us in the somewhat older, medicine-as-a-second-career club: go USA!

Pomping the circumstance

Finally managed to fulfill my bloggy tourist responsibilities by getting a few pictures up from the recent Mexico adventure. Tomorrow is graduation so Lady M and I are getting ready for an influx of house guests and other visitors, as well as a round of social events. It still hasn't really sunk in that medical school is finally over. Lemme tell ya, it seemed like it would never end....

But here we are. Several days of frantic formal fun, and then it's time to move to San Francisco.

First editions

What to do with my time off? Well, this afternoon I stopped by the John Martin Rare Book Room. The librarian very graciously pulled a first edition of De humani corporis fabrica off the shelf (and let me browse through it!), as well as pointing out the the exact spot in a first edition of Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus where William Harvey first introduces the concept of circulation of the blood (at the beginning of Chapter Eight). It was all quite a treat for a bibliophile like me.

Done!

I can hardly even believe that I'm typing these words, but I finished medical school today! There's going to be some misbehaving tonight....

One... more... day...

Tomorrow is my very last day of medical school. What am I gonna do with myself next week?

Letting it all hang out

This week finds me in la cirugía -- surgery -- so this morning I go to the supplies window in the operating room suite to be issued my scrubs for the morning’s cases. The students here get disposable scrubs made of papery fiber and so that’s what I get, along with my ration of mask and shoe covers. I change clothes and head on into the OR with my usual enthusiastic how-can-I-help-you smile where, after being introduced to everyone, I grab the patient’s chart to read about the upcoming case. What a dedicated medical student! Looking down at the chart under the bright lights of the OR, however, it occurs to me that I can see my socks awfully clearly through the legs of my scrub pants. Horrified, I realize that my thin papery scrubs are practically see-through! At first I’m hopeful that the worst of it is just being able to see my socks, but a discreet and increasingly mortified inspection reveals that I am basically standing there in a room full of anaesthesiologists, surgical residents, and nurses in my underwear. What can I do? I opt for a lengthy examination of the patient’s chart, but with the chart held a bit lower than usual.

Fortunately I manage to communicate to the friendly and helpful Dr. Gomez the fact that I would like to change my scrubs. Like most operating rooms this one is kept a bit on the cool side, so he asks if I want to change because I’m cold. (Can this possibly get any more humiliating?) I’m happy to let him run with that theory, however, because if I tried to explain any more in my limited Spanish I’d probably be arrested. Or sent to the Psych floor. I’m beginning to realize why so many people here seem to either bring their own scrubs or wear long coats.

At this point it’s all I can do to just keep looking straight ahead, repeating over and over to myself “it’s not what you wear, it’s how you wear it.” I reluctantly give up my modesty-preserving chart and Dr. Gomez escorts me down the hall back to the formidable woman guarding the supplies window. Dr. G asks the gatekeeper if I could get a robe or coat, but that is absolutely out of the question—“they’re only for doctors, not for students!” Finally he manages to talk her out of a set of real cloth scrubs. The pants legs only come down to mid-calf on me, and the shirt only just barely reaches the top of the pants, but at least they’re opaque. Now I can return to the OR without living the nightmare where you walk onstage for your trombone recital and realize that you’re stark naked.

And so, clinging to my last shreds of dignity, I scrub in for the surgery. As things turn out I get to do a lot of suturing and Dr. Gomez teaches me a stitch I’ve never used before, earning me a “¡muchacho!” from the junior resident.

At least, I hope the comment was for my suturing….

Rear end

Lately I spend my days roaming the hospital as part of a white-coated, infection-fightin' posse. As the medical student, and thus junior member of the team, I generally walk at the back of the group, following those with more advanced training at a respectful distance. I am the caboose on the train of medicine.

Bugs & Drugs

My latest rotation is on the Infectious Disease consult service in the hospital. It's turning out to be a great experience -- fascinating cases (although sometimes a bit harrowing, since many of the patients are very, very sick), pleasant people to work with (something you can't always take for granted in medicine), and tons of information that will go straight to the bottom line next year in the ER.

However, next week is the Match, when we find out whether and where we get residency spots, so truth be told it's kind of hard for us fourth-years to think about much else these days....

Eye-mergency!

Things were eventful yesterday in eye clinic. Upon hearing the description of a patient's upcoming eye surgery, the patient's spouse collapsed. It caused quite a commotion -- we don't run many codes in Ophthalmology. We got this person revived and up in a chair, when my staff told me that another patient was having chest pain and could I transport to the ER? I stole the wheelchair from the first room and made the delivery. Upon arriving in the ER I found that none other than the director of our EM residency program was staffing -- so I had a chance to chat about the upcoming residency match in the context of some actual on-the-fly emergency medicine. Fortunately all patients' eye problems, loss of consciousness, and chest pain were under control by the end of the afternoon. Today we stuck strictly to eye issues.

Up to my eyeballs...in eyeballs!

Today I went back to a clinical clerkship in the hospital for the first time in two months. Although the last eight weeks of traveling and interviews and board exams haven't exactly been a vacation, it kind of feels like I'm coming back from one. So I started ophthalmology today. I should learn some useful stuff and if nothing else there are only 12 weeks until graduation! I may be a student ophthalmologist now, but I won't be a pupil for long....

Board Exams

In order to apply for a medical license in the U.S. you have to pass all three parts (Steps) of the United States Medical Licensing Examination (USMLE). I took Step 1 last year, a grueling, all-day testathon that Wikipedia describes as "arguably the hardest and most important examination a medical student will take during his/her career." And that's sayin' something. Made it through that one okay, and now Step 2 is coming up fast. Next week I take the written part of the test (another day-long gruel-a-thon), followed in a few weeks by a full day (in Houston, perhaps) of being observed on video camera examining a string of standardized patients.

So, as you can imagine, my days lately consist of reading Board exam review books, punctuated by sessions of doing practice exam questions, after which I go back and study some more. The big thrill for me is that I just got a new review book. (Sad, no?) Most review books consist of hundreds of pages of outlines, but I'm loving this one because it includes practical, real-world advice. For example, after an introduction to the etiologies of shock the author tells us "Your job is to figure out why the patient is in shock while keeping him or her alive. Give fluids while you're thinking." Sound advice.

Paging Dr. Gray

Today I got my senior picture taken. (Ahem, that's "senior" as in senior year of medical school, natch....) I got all dressed up in a coat and tie and figured the camera would be loving me. Not so much, as it turned out -- those were some pretty serious bags under my eyes. (Although perhaps someone will work some Photoshop magic on my behalf.) Med school really takes a toll in the appearance department.

But then I thought, maybe this will be a Dorian Gray kind of portrait. As I slog through the stress and sleeplessness of my residency the senior portrait will acquire dark circles under the eyes and a cynical squint, will lose any traces of empathy or exposure to natural light, and perhaps even develop the stooped back of too many 3:00 AM catnaps on a call room sofa. Meanwhile, I will remain perpetually a fresh-faced, well-tanned, idealistic-looking beacon of compassion, while envious fellow residents and admiring attending physicians wonder how I manage to keep that just-out-of-med-school look.

But who am I kidding? My fresh-faced idealistic look was long gone before I even got to medical school. I think my best bet at this point is to try to project a wisdom and maturity gained through hard experience. Or, failing that, try to project a minimal level of wakefulness.

Bouncing around in my head

A few nights ago I got to do a chest tube, which inspired me to read about penetrating trauma, which led to reading about gunshot wounds. Along the way I found some information about a particular mechanism of injury in gunshot wounds to the head: intracranial ricochet. This phenomenon can explain a discrepancy between the presumed path of the bullet and the patient's actual neurological findings.

I tell ya, emergency medicine never ceases to fascinate. Me, anyway. Other people may have less morbid fascinations.

Riddle me this

Today I gave a presentation that featured both Samuel Pepys and William Shatner. What was the topic of the presentation?

Ghosts

Today, coincidentally on the first day of my Urology clerkship, the department opened its temporary clinics and offices in the former OB/Gyn space in the oldest part of the hospital complex. This will be the Urology department's home for one year while their more modern space is undergoing a year-long refurbishment.

Oddly enough, this means that today I entered a men's room that, for years, was used by the men who were accompanying -- and waiting for -- the women in labor & delivery. There, on marble dividing panels, are decades of etched graffiti. A quick glance reveals the usual crude defacements, but on closer inspection these panels display something much rarer. I realized that many of the graffiti consisted of a name and a date -- a birthdate! Some of them even included a birth weight. Dozens of births were commemorated here. The first dates I saw were recent, but soon I found 2003, 2001, 1998, 1993, eventually finding dates back to the mid 80s -- over 20 years of births recorded here. And as I kept scanning, I found names followed by short ranges of dates, spanning days or weeks. I could hardly believe it, but there were multiple memorials to infants who had died. Some even included brief messages of love or remembrance.

When and how did it become a tradition to record the births -- and deaths -- of newborns on the men's room stall dividers? Once or twice seems somehow inappropriate, tawdry even, but there was a strange strength to the layers of names and years carved into the cheap marble. Even the intermingled crudities of traditional men's room scrawls seemed neutralized and made transparent against the background of all those babies' names. How many men were overcome by joy or loss or fear of the future and expressed it by adding to the list here? This afternoon I was searching for the earliest date I could find, but now, thinking back, I realize that since the OB department has permanently moved to another part of the hospital there is also a last name and date scrawled there, somewhere.

If any part of an old hospital is described as being haunted, it's usually labor and delivery. Today I found the ghosts.

Urology Lounge

My Urology clerkship starts on Monday, and an e-mail just arrived announcing that the orientation will begin at 6:30 in the Urology Lounge. I had no idea there was a place with such a delightful name in the hospital. The Urology Lounge--I love it!

Back out

Yesterday I spent almost twelve hours in surgical cases, culminating in an excruciating forty-five minutes holding a 100-pound leg at an intervertebral disc-popping angle. Then on the way out of the O.R. suite I was reminded by the posters and screen savers appearing around the hospital lately that September is Pain Awareness Month. Didn't have to tell me that twice. Maybe I can befriend an orthopaedic surgeon on this rotation who can fix me up after it's done.

Mallet, please.

I'm really digging the orthopaedics surgeries I've been scrubbing into. (That is, apart from getting to wear the super-cool space suit headgear.) A typical case involves power drills, reciprocating saws, various sizes and types of mallets, and mixing cement. In other surgical fields you manipulate tiny, delicate structures with subtle instrumentation. In ortho you saw off the end of a bone and hammer a long metal rod into it. Gotta admit that it's really fun. Hey, I'm a boy; what can I say?