"How are you able to continue working after witnessing a death like that?"

I had a great question from a very insightful medical student after the first case of our day was to Code Blue that did not get any better. The code was on a young patient in my primary care. She was very unwell, and I'm sure nothing would that have changed the outcome. Tragic, true, circle of life type stuff. 

Initially, I felt really upset with myself. How could I just move on? I know this woman and her family quite well. Should not I be more upset with what just happened?

With every death, every code, I ask my team to do a quick debrief with me (longer if needed) to ensure that we did all that we could, and needed to do. I go over everything in my head as well. Where could I improve next time? Were we all wearing PPE? Did I speak with the family in a respectful, clear manner ?

This time around, the police were with us. We're a small town, so all tragedies involve them. It's great, because they call victim services if needed, get in contact with distant relatives, chase after teens who "can not take it" and run off. They are a really good bunch. They surrounded me and checked in on how I was doing. Asking if I would talk to someone if things went poorly. I am telling me I was a rock star in the trauma bay, That the family completely trusted me and was incredibly relieved to know that I would be the one working on their loved one. Basically making sure I do not get PTSD from the event - something I try to do for them all the time but was not used to having it in return. 

I was a bit upset, but felt like I was not upset enough. That I was a big faker pretending to care. 

It was not until yesterday that I was able to figure out why it is that I can just pick up and go on. This was the third patient that description fit that died in front of me this year that I was able to continue working after their pronouncement. 

I have a therapist. Everyone should. She helps me figure out things like this that niggle in the back of my head but that I do not take the time to work through. She helps me figure out when the culture of medicine is nutso and I'm right to ignore the culture and do what is right. 

Here is the answer, finally, med student of mine. I have an incredible resilience built around patient deaths. 

When I first got into med school, I knew that someone like me with a soft hear t might have a hard time with death so I sought out situations where I would be challenged. I thought about each deat h as an unavoidable event and looked for the way that I could make it the MOST comfortable for the patient and their family and (even when the patient is a baby). I learned that I could cry with family in a respectful manner. 

Each of those links is a blog post I've done during my training and practice to reflect on death and my part in it. I see myself as separate from the patient and their family. I love them in a way that is not family or friend, but caregiver. My role in their life is just a step in their journey through this world. They hold the same role in mine. While our lives intersect, my goal is to make our lives both better for the experience. I learn my lesson, then a go to intersect with another life. The lessons I've learned stay with me forever, but they are not necessarily emotional. 

Sometimes they are. A patient died of malnutrition at a young age, and you bet your ass I got angry and looked to make change. But, because I want the rest of my patients to be healthy, because i was not dwelling on his passing. 

So, my thought process goes like this; reflect on the death changeable and my role in it, reflect on the interaction with family and colleagues, move on to the next patient who needs to see me. This might happen many times during the day following that death. I still wonder if I could have done more for my patient before she died, but that use as a way to be a better doctor, not to dwell on the past. 

Death is part of life. My job is to keep moving forward. I see my getting back to work and helping other people as a way of respecting my patients' lessons to me. 

Pregnancy in Medical School

"Remember people, well except medical students, typically reproduce before the age of 30."

MD, cardiologist

(via coffeemuggermd)

I’ve had this in my drafts for a while. It still pisses me off a bit. Not that it necessarily should, the cardiologist isn’t saying that no med students have kids before 30 but it’s atypical. 

What pisses me off, is that those who recognize that their life starts NOW, not after residency, or fellowship, or any other magical time, and want to have children are treated as wackos by most of our community. I know I rail on about medical culture and why it is not reflective of reality, but I’m going to do it again. This is another example of thinking that we need to change. 

There is research on just about everything that med students do. You’re the easiest population for medical researchers to bug, so they do.

However, I can’t find much research on being a parent in medical school.  This focuses on mothers (wall free article). It’s the only paper I could find (lots for residents by the way, probably because they are also leading a lot of the research). A lot of the young women I’ve spoken with felt they were treated poorly by the fellow students because they were getting “so many” allowances for time. The new dads in my class felt like they were expected to carry on as if there wasn’t a new sprog at home.  

Back to the paper, “Medical School-Mothers” in the Rhode Island Medical Journal. I’ve never heard of this paper, or this journal and I’m pretty damn excited about all things undergrad medical education and feminism. That’s disappointing. (Have you heard of it and I was just under a rock?)

They don’t tell us how many medical students were interviewed. I want to know what several means - is it 4? Is it 34? Help a sister in research out.

They also don’t discuss fathers. I get that women in medicine is new and all, but I want my colleagues to be good dads. I don’t want any of my colleagues to be fondly remembered by their grandchildren because their own children never saw them. 

“As part of universal precautions, all female medical students who are sexually active with men should be mindful of potential pregnancy.” BARF. Shouldn’t our male medical colleagues also be mindful? This reminds me of the episode in 2014 where a female medical student was at risk of losing her funding to study in Cuba because she “fell pregnant”, while her XY partner was not reprimanded. BARF I say. IUSs, condoms, and access to family doctors for all med students who want them!!

This article is mostly focused on what Student Affairs type people need to know (which is fantastic). 

But. 

What I would like to see is something that talks to many more students to provide curious students with help making decisions, something that gets more into the pros and cons of an educated choice. No one knows when the time is right to have children. Everyone has an opinion on it though. 

I’d also like to see a nation wide mentorship program - to be paired with an attending, hopefully in your chosen field, who also was a parent in med school. Knowing you have someone who has been there and survived. 

I’d like a handbook for parents in med school. Tips tricks and downfalls to avoid. I’d like this to be an open topic of discussion that starts in Year one. I want the parental leave policy to be pointed out to all students during orientation week. 

I want to know how much post partum depression and anxiety are present in the learners having children. We are all pretty crappy at taking care of our mental health, and how many of us have med studentitis? (Pregnant med studentitis is like that on freaking crack - everything that could possibly go wrong, will and you will blame yourself, even though you would tell your patients to think better of themselves. My friend had 10/10 stress through the last 4 months of her pregnancy. Uncool.) 

I want there to be scheduled check ins with Student Affairs during pregnancy and post partum to ensure this isn’t an issue. My suspicion is that the numbers of sufferers in the medical community are high. 

I want to get rid of the shame associated with wanting to be a good parent when you are ready to be one. Seriously. If we don’t stop acting like families in medicine are bizarre while we’re in first year medical school, how can we expect attendings to respect their colleagues and learners’ choices?

One of my colleagues is pregnant. I’m over the moon for her and her MD husband. The amount of stress they underwent preparing to tell the rest of the team about the (wanted, expected) pregnancy was overwhelming to ME. I’m not having a baby. Jeepers. They felt they needed to make it very clear that they do not want to stop practicing for more than 2 months each (like it’s not bad enough that they don’t get parental leave from our governing body). They were shamed into divulging the information much sooner than they wanted due to morning sickness. Our colleagues (all XY but me), have children with stay at home moms and incredibly twisted senses of what parenthood should look like with a physician parent. 

This has got to stop guys. We need to treat each other better and watch each others’ backs. 

What would you add to my list to make it happen?

Can I possibly improve my blog? Maybe.

For kicks, I decided to look on PubMed to see if there was any research done on blogging. There is. Actual research done on how docs blog. Cool. But it's Saturday, so I'm only going to look at 2 of them.

First of all, did you know about Web 2.0?? I sure didn't but I've been using it like a mad person for years. Web 2.0 describes web sites that use technology beyond the static pages of earlier web sites.

This article makes a point I've been considering for a while - making my blog searchable in a way that will make it easier to match experiences I've had with my progress in my training and any applicable social aspects. They propose that bloggers use the usual tags they use (my favourite seems to be 'note to self''), they call these folksonomy - plus a diagnostic code from the ICD-11. The blogs that the researchers suggest these tags be used include WebMD, Kevin MD, and CasesBlog. My blog has little to do with these blogs - it's just me, I'm trying to learn more about myself as a physician not necessarily educate others (though I hope that's a happy bonus), and, for the most part, I hide my patients' true diagnosis. If I choose to follow the proposed system in this paper, which frankly isn't terrible, it makes it more difficult to hide my patients' identity. Unless, I use the ICD codes only for my rants on specific topics like suicide and HIV, and ignore the diagnoses of the cases I dissect. Which certainly is something worth looking at.  While I won't follow their algorithm to the letter, I will try to remember to tag liberally.

Another set of researchers looked specifically at learners' blogs. It's like they were looking over my shoulder. They found that learners used their blogs to reflect on their experiences. Their table 2 looks at the analysis of the blogs and what is covered and offers a few suggestions. My absolute favourite is the suggestion to share coping strategies with peers. Personally, I would have put it under "emotional distress" not "interaction with peers". I think that many learners are looking for other learners' blogs to find out how they deal with the big stuff in their lives - exams, residency matching, patient death... Having a fairly anonymous way of talking about things we are afraid of telling each other face to face would be helpful. There are many conversations taking place on twitter and in medical journals about burnout. It seems to me that using each other via the anonymity of Web 2.0 is one way to seek help without worrying about repercussions.

They also found that blogging learners were likely to preach the benefits both of collaborative learning and having a solid support system. Of course they do. Blogging learners rock.

Pinilla et al also makes some suggestions about how medical educators can use their students' blogs to enhance their learning. One suggestions is that the educators look for where their learners are having problems with exams, etc. This creeps me out. If I had any inkling that my teachers were looking at my blog I would have stopped writing. Or at least edited my posts to the point of ruining the point I was trying to make. Random, unknown educators would have been welcome to peruse, but not my own teachers. Looking at broad themes and concerns of the bloggers in general is a great idea. That it might even be an option makes me happy that I've stayed the Imposter.

So, to recap what I've learned:
1. Tag my blog liberally so that finding information in the future will be easy, both for me and for my readers.
2. Encourage the use of blogs as a way to share coping strategies.
3. Blogging learners rock.
4. Educators should not follow their own learners' blogs. It's creepy. But I'm all for qualitative research. Especially when it's done by someone else.

My thought process when choosing where I would practice

In my first year of residency I started to look for where I wanted to practice. I needed to know there was going to be a light at the end of this very long dark tunnel. Seeing how some practices ran, I had a better idea of what I needed in my own and things I wanted to avoid.

I wanted a team that acted like a team. Secretaries and nurses who felt empowered to deal with fires and update me later. Fellow docs who worked together and seemed to have each others' backs. An office manager who was excited about what was happening in the clinic. If the team wasn't able to at least fake this on my visit, they didn't get considered.

A clinic across the street from the hospital. I want to have inpatients and need to feel that I can run across during the day if one starts to decompensate, or starts pushing out a baby.

Hospital nurses who didn't glare at me. If they feel that poorly about a new doc, what must they think of their old ones?

A town within an hour-ish of friends and family. Not too close of course.

An office of my own with a door.

A clinic that allows docs to choose how quickly they'll see pts. Double booking two every ten minutes was not to going to work for me.

A clinic that doesn't need much fixing to make it amazing. I spent quite a bit of my med school career fixing curriculum and have no intention of doing the same while trying to figure out how to run a practice.

I want to teach so having learners regularly was important.

I want to be taught, so having fellow docs who are willing to guide me along was essential. I didn't want to be with docs that are burned out or just as new as me.

Finding a clinic where the docs love their job means that they will be good examples of how to set up my practice to avoid burnout.

I wanted a practice where I could work in the Emerg, deliver babies, help in the OR, see inpatients, and have a diverse group of patients in my out patient practice.

I want to be able to walk to work.

Having a town where housing prices weren't ridiculous was a bonus. Access to nature - hiking trails, water - was essential.

I'm blown away that my wish list was fulfilled. I'm truly looking forward to beginning practice (assuming I pass the damn test - only ten ish more days waiting).

Anything you would have added to your wish list?



- Posted using BlogPress from my iPad

Grief

People try so hard to be helpful with those dealing with the loss of a loved one. They hate to someone they care about in pain.

My advice to anyone in this situation - "should" is a bad word. You mean well, I know, but telling someone they should take dance lessons or should get out more or should lay down and cry is only adding to any guilty feelings they already have.

Instead, if you know of someone who found dance lessons helpful, "I know my friend Sally found dance lessons got her out of the house and gave her a chance to talk with people who didn't know Stanley. I don't know if that's the sort of thing you like, but I know it made Sally happy." Now your friend Sue doesn't feel she's letting you down if she doesn't want to tango.


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Residency has tough moments

Telling a medical student what they need to do to pass. Encourage them to do what needs to be done, but let them make the decision to not fulfill any real objectives. Watching someone choose to fail at medicine is very hard to do.


- Posted using BlogPress from my iPhone

My Thought Process When I Decided to Apply to Medical School in the First Place

Perspective, like I often say, is a brilliant thing.

I want to remind myself of the gift I've been given by being accepted to medical school in the first place. It's such a gamble to get in; having the right MCAT score for that year, picking people who are able to write a competent letter of reference, the most compassionate interview committee. I'm such a lucky person to have been accepted anywhere given my, err, colourful background.

That I've got to this point in my medical career and haven't been kicked out means to me that I made the right choice. People say that it's hard to be kicked out, but it's not that hard. I've seen it happen several times.

I've whined about not getting my number one choice in residency. Poor poor me. I made it to residency. This is a huge gift.

So, now I want to look at the criteria I set for myself when I applied for med school in 2006. That seems so long ago now. Apparently they were good criteria since I got in with one just the one application.

1. I took a good look at why my marks were so terrible (really terrible, worse than your worst) - it was something I could easily fix and did. Essentially, I needed to stop drinking/partying and learn how to study. I made a plan. I also set up my office so that everywhere I looked I saw things that encouraged me to keep studying.

2. I took a leave for a semester to test myself and see how I could do. Given my past credits, I was able to take a 4th year physio course that is known to be a killer. I told myself if I could get an A, I would let myself continue back to school full time. I got a 92.

3. I talked with EVERYONE I could about their jobs - techs, nurses, docs, surgeons, everyone. If I was going to start over, I wanted it to be worth something at the end and wanted to make sure it was what I thought I was going for. Happily, it was.

4. Rather than just getting enough credits and doing the bare minimum, I did a full second degree in something that I loved and that would lead me to a great plan B career. For me, my plan B was a masters in Health Economics. It was a way I could help Canadians' health if I wasn't a physician.

5. I spent the money on the Princeton Review classes. Not cheap to be sure, but so worth it in the end. Part of my poor marks initially was that I didn't know how to take MC exams and the PR helped me with that. I'm sure any other class would as well, but PR fit my schedule.

6. I looked for EVERY resource available at the school for helping me succeed - how to read papers, math lab help, essay editing, study hints, how to learn - it made me a better learner and set me up for success in med school. While you're never too old to go back to school, it doesn't get any easier.

7. My partner and I realistically discussed each of my intermediate goals and what each meant (graduate from undergrad with poor marks, get into a masters program but not MD, would I try to apply a second time etc.) Having a good idea of what to expect from each other along the way was useful and kept me focused and on my game. For me, I would have applied twice but then called it quits.

8. I really want to practice rural medicine. I kept a painting of a rural scene by my desk in undergrad and during med school to keep me focused on what I'm doing.

9. I kept my social connections tight. Just because you have this brilliant plan for the future doesn't mean you shouldn't be living right now. Balance is key. If you can't balance your life in a way that makes you happy, you're doing something wrong. This has been the plan that worked best for me in my medical studies. So many people, especially med students think that they will be able to start living once med school is over...once residency is over....once they are done with locums...once they have kids and their own practice....whatever. Now is when we live, not later.

10. It feels like there should be a 10 but I can't think of one.

Interview Invitations

Invites for our residency invitations begin coming out a day or two after our CaRMS applications are submitted. Some programs that don’t fill up regularly in the first iteration will send invites before even going over the apps. These are lovely to receive - to know that you will indeed get at least one or two interviews!

Then you wait for the programs you actually want to go to.

These are scary days. One program in particular was a bit evil to me. They sent out invites to one half of the alphabet before the second. Five days before. I thought for sure that despite all my efforts to learn as much as I could about Family Medicine and all the time I’d spent on research and picking electives, not to mention the application preparations, were all in vain. People who were, in my awful opinion, less worthy than I was for an interview. I was terrified to think that those people were getting interviews and I wasn’t. Did my references fail me? Was I an undesirable candidate after all?

Interview invites came in over a month or two. Some of the people in my class didn’t get invites until the week before the CaRMS interview period had begun. That’s scary.

Once the invites are in, you need to decide how to schedule them all efficiently. You can literally be flying from Halifax to Vancouver to Montreal to Calgary. Expensive, especially if you have more than one specialty you are applying to. Some of the people I know have close to twenty interviews. Trying to coordinate all these interviews in all these cities can be confusing and really make you wish you’d paid more attention in computational mathematics.

There are emails and phone calls to make to program secretaries as you beg them to fit you into another day to maximize the number of interviews you can get to. Online purchases of flights, train tickets, bus tickets, reservations of hotel rooms and B&Bs. Deciding whether or not to room with classmates - in the program or not? Will they stress you out or make you feel more confident? How much money will you save really?

Our credit cards all had an incredibly workout in the weeks leading up to the CaRMS interview period.

I mentioned before that I decided that going across the country was not as important for me as saving the money for a trip in the future. It was a difficult decision but enough people were doing the same thing that I felt convinced that it was going to be safe for me to just apply within Ontario. Especially since that’s where I plan to stay.

But I was lucky enough to get invites to each program I applied to. Not all my classmates were as lucky and needed to do the travelling.

They are becoming very competent travellers. One friend has perfected the art of packing to be able to pack all she needs for a two night stay and an interview into one backpack. Impressive no?

The CaRMS Process; Years 1-4 prep

For the uninitiated, CaRMS is a mysterious thing. For those of us going through it, it is also mysterious, but with the extra added benefit of being terrifying.

Here’s how it works...

In first year of med school, some of us decide what we want to be when we grow up. Others don’t. Some of us have known for ever. Some are gunners for their particular specialty and start doing research in the first year and setting up appropriate observerships. We all join clubs and go to conferences and speeches and try to learn as much as we can about what we can do in the future.

In second year, many students who hadn’t previously chosen what they wanted to do begin to have an inkling. Some of these students see what the gunners have been doing and freak out, thinking they need to get to work as well. Some of the gunners decide they must have been nuts and start to change their research focus to something else. Other students remain comfortable in not really knowing what they are going to do since that is the situation of so many others.

In third year, lots changes. We experience the clinical side of medicine and rotate through different core specialties. We also need to choose our ‘electives’ for fourth year which will display our desire for one specialty over another. It’s a stressful choice to make for most of us. We need to make sure that our faces are seen at all the programs we plan to apply to during CaRMS. But most exciting is when we figure out that everything we’ve been planning is for something we don’t even want to do anymore.

So many of my classmates figured out in the last few weeks before beginning electives that they were looking at the wrong specialty. This is exhilarating and terrifying. Electives need to be rearranged at the last minute across the country but doing so means that you are showing so much passion for a field of medicine they now love. It’s something that we are told will happen in first year but we never believe them until it happens.

In our final year, it’s time to enter the CaRMS process. We find consultants who will write us reference letters, then dwell on whether or not these consultants were the right choice. Will they say something that the programs will take the wrong way? Which consultant will put us in the best light? Did I really spend enough time with this person for them to know enough about me to write a good letter? Will they resent me asking?

We need to choose which specialty (s) we are applying to. Should we back up with a less competitive specialty just in case? Should we apply to all the schools in Canada? Am I planning on couples matching? Can I stand to live in these places for years?

We write letters and essays about why we’ve chosen our specialty, what we’ve learned about ourselves and why we want to be in the program we’ve applied to. Then we fret about whether or not we have said the right things, that our examples are beefy enough or that we have accidentally left the wrong specialty or program in the letter when we copy and pasted the lines from one letter to another.

We also need to chose which comments from our third year evaluations will best communicate the type of resident we will be. Which of the ‘code words’ used by the consultants are most flattering.

All those clubs, conferences and research need to be pared down into something that will fit into the CaRMS prescribed CV template. Choosing which should be included and which discarded is something else entirely. Anything included is fair game during the interview. We want to look well rounded but not flakey, responsible but still like we’d be fun to work with.

The week that we need to finally submit our application is terrifying as we go over everything again and again to make sure it’s all there. Birth certificate, photo. letters, essays, transcripts.

Submit.

Wait for the interview invitations to come.

Do what you love and the rest will follow

'Do what you love and the rest will follow' is advice that I have passed on to anyone wishing to apply to Medical School. It really doesn't get more simple than that. I love swinging in the park, hanging out with my brother's kids, eating chocolate and drinking coffee, hitting the gym and cooking. I loved my jobs, the volunteering I did before I got here and the degree I was studying. That shone through on my essays and in my interview. If I had done everything by the book and volunteered in an emergency room or done a degree in biomedical sciences, I'm not sure I would have been admitted. That's the selfish side of doing what you love.

The practical side is that it makes everything you do easier. When we're little and have to go somewhere we don't want to, we dawdle. I'm sure it drove our parents nuts. It takes forever to get a kid that doesn't want to go somewhere out the door. Putting on shoes, finding coats and remembering to go pee can take an hour. I wonder if it's fair to assume that when I'm taking forever to get to my early morning meetings with faculty and administration if it's just that I don't want to go there. The days that we have early morning clinical methods however, I'm out the door like a shot.

I'll try to pay attention next year during clerkship to find out what gets my feet moving in the morning and what will make it easier to leave the house. That might finally let me know which specialty is calling my name!

Here is a set of links to advice from the women at 'Mothers in Medicine'. They are what these women would have wanted to know upon their acceptance to med school. Things like don't lose yourself, don't do it for the money, you will miss and love the classmates you currently want to throttle, the happiest med students are in their mid twenties, all the crap will be worth it, take a calcium supplement, don't let yourself get too fat, write in the school paper, it will all work out, you're never alone.