The New MD

I must have looked at my Match Day appointment letter about six times. Part of me half-believing that my good fortune was some kind of error and if I just read it one more time it won’t actually say that I matched at my number one program. I have never wanted anything this much in my life and to actually get it–well, it leaves me speechless. The years of studying, stress, exams, planning and sacrificing all blur together.

I’m an emergency medicine physician with my first job at my dream program. It doesn’t feel real. 

Match Day was an incredible moment. I went up to the podium with my husband and had him open the envelope. When I looked down at the letter a rush of emotion came flooding in, the culmination of all of my hopes and hard work. I was so choked up I could barely speak. I had no idea I was going to react that way, but the emotion was too overwhelming. I’m not sure I’ve ever felt such joy. Probably because I’ve never worked this hard for anything.

I am so excited to start my career and the next chapter in this journey. Residency will be yet another blur of long hours, stress, sacrifice and emotion. It is terrifying and thrilling at the same time. The thought of the experiences that are to come makes me feel so thankful. I know it is very rare to find a job that you can be this passionate about, and even rarer to have a profession that challenges and pushes you daily–whether you want it or not. I couldn’t have asked for more.

Thank you to all of you guys who have been with me throughout the process and read the blog over the years! It has been a joy sharing it with you. Since I’m not sure just how much time I’ll have for writing I am moving things over to Instagram. Feel free to follow along! MD_Maja

 

 

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Finally here

Last week was a momentous occasion. I clicked submit on my ERAS application. Sitting in bed with my laptop, re-reading my residency application for the 10th time, I took a deep breath and hit submit. Everything I have done in medical school to ensure I Match in the residency of my choice came down to one click. Ah. Relief.

I can’t believe I actually made it here. It was the hardest thing I’ve ever worked on–becoming a doctor. While at the same time, the most fun I’ve ever had. I feel so lucky that I found my true passion in life.

Going for it wasn’t easy, or convenient, or even rational at the time I decided to enroll in my night organic chemistry class while working full-time. But I never looked back. Of course, I would have never been as gutsy without my boyfriend (now husband) telling me I would be crazy not to do it. When I talked about medicine (and it was pretty much all I talked about to him), my eyes would shine and reveal that fiery glow–he knew I would never be satisfied if I didn’t try (and I may never stop talking about it either). Girls: if you ever find a guy like that–don’t let him go!

Nine years later, here I am. Happy to say, I am just as passionate about medicine (and my guy).

Now that my apps are in and I’m done with my EM sub-I’s, I am currently enjoying a magical time known as 4th year of medical school. In the future, when nostalgia creeps up on me and I reminisce about medical school, I will think only of my 4th year and how wonderful life was. Of how happy, well-rested and fulfilled I was. This year makes all of the memories of stress, the lack of sleep, the endless book chapters, weekly exams, PIMPing sessions, awkward patient interactions, fumbling sutures, idiot mistakes, and otherwise feeling dumb–disappear. All I will remember is the amazing amount of free time I had during my 4th year of medical school.

I intend on taking full advantage of this amazing gift.

My husband and I just celebrated our 4 year wedding anniversary. Throughout our relationship we’ve constantly set goals and dreams of the type of life we want…”when this, then that.” Medicine is notorious for insisting on delayed gratification. But it dawned on us that life is what happens when you are busy making plans. Rather than planning ahead we are making an effort to just enjoy today.

Our priority for this year is simple–one word:travel. Now that I have time on my side we are excited to catch up on some well-deserved vacations.  I also realize that residency will be an extraordinarily tough 3-4 years and the time I have this year is precious. As it happens, things couldn’t have been better timed as there are some seriously exciting things happening in our families–including the birth of two nieces!

Here is to continuing my 4th year adventures…next stop: residency interviews!

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Away Rotations Explained

All across the United States during the months of July-September, 4th year medical students leave the familiarity of their home institutions and spend time on away rotations. What are these rotations you ask? Well, you can think of them as month long interviews. If you’ve ever been to an interview and thought a few hours with your potential boss was nerve wracking–try spending 30 days there.

For those of you unfamiliar with how your doctor got his job, the path towards becoming a bonafide, board-certified physician in any specialty starts with residency training–and residency starts with something called the Match. How do you get to the Match?–you interview at multiple training sites and then you rank them. The training sites rank all the candidates they interviewed and in the end a super secret, proprietary computer formula spits out a theoretical Match made in heaven.

The away rotations come in for several reasons. One is to simply get to know a program you may want spend 3-7 years training at and the other is to get letters of recommendation so that these places want to interview you! Either way, these away rotations can kind of make or break your application.

The whole process is fascinating to me because so much of your life is decided for you. When you apply for the Match you also sign a binding contract saying that whatever the computer decides is where you’ll go. You are locked in and you don’t even know where you are going. It’s kind of like that name your own price tool on Priceline. You put in your credit card info and if it matches what you are looking for you are committed to going there– yeah…well this is just a really long hotel stay.  Again, away rotations are that much more important because you get to picture yourself at that institution. You get a test run.

I just had my first away rotation. I have to say, I got pretty darn lucky.

The nervousness of being at a new hospital with a new computer system and all new hallways to get lost in was short-lived. I don’t know if it’s the 300 days of sunshine, the beautiful beaches or the focus on work-life-balance but I have never seen such happy attendings and residents. I really did my best searching out for the grumpiest, unhappiest guy in the bunch, thinking he’d be the best person to ask what is terrible about the program–but I never found him.

I imagined that I would show up and be just another face in the crowd, blending into a sea of medical students that rotated before me. Instead I got a super warm welcome and genuine interest from everyone I came across. If you accepted their challenge this place really allowed you to step into the shoes of resident intern, pushing you to think of yourself not as a medical student but the doctor you will be in a matter of months. I absolutely thrive in that environment. Give me an inch and I’ll just run with it. Having someone put trust in my assessments, physical exams, ultrasound findings and differential makes me work that much harder. Every day I showed up and tried to push myself a little further. That attitude does not go unnoticed so as a result I had some amazing training opportunities.

I’m really glad that my first Emergency Medicine rotation was at my home institution. It was a safe place to fall a little bit and get helped up along the way. EM is a very different specialty and it takes some time to get used to the focused exams, presentation style and the way EM physicians think. My home institution prepared me extremely well in pointing out what I was doing wrong in those aspects. I had some  wonderful residents who provided actual constructive criticism. Even though it is hard to hear that you forgot something obvious, I can promise you that the next time I have a patient with a headache I will never forget to walk them and check their gait before presenting to the attending. By the time I arrived at my away rotation I had the basics firmly in hand and could start to build on my skills.

During my month away, I came across another group of amazing teachers. People with genuine excitement about working with physicians in training. You can’t fake that kind of attitude and it was contagious. As a result I can now say that I’m entering residency having done two lumbar punctures, a chest tube placement, an intubation, a thoracentesis, a paracentesis, a cervical headache block and that I&D I somehow missed earlier. That in itself is amazing training!

The best part about 4th year has been rotating in my actual specialty and feeling like I am among my own. People who share my enthusiasm for crashing patients, multi tasking, having a good sense of humor and being accepting of anyone and everyone.

I have grown tremendously in the past month as a student, which is all I could ask for. I am really looking forward to one more away rotation…and another opportunity to keep improving.

 

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The real “ER”

When I think about my childhood and what I imagined I’d be doing when I get older–Dr. Mark Green from the series “ER” comes to mind. I grew up every Thursday night watching the show with my mom. I loved everything about the gritty, fast-paced drama. When some gruesome scene of a thoracotomy came on, my mom, turning away from the screen with a look of horror and disgust, would say, “you really want to do this in life?!” And I would sit there grinning, wide-eyed…and nod my head, yes, I can’t wait.

I’m very much still the same person who turns towards the terrible things in life. Twenty years later, it is in the Emergency Department where I feel most comfortable in the vastness that is medicine. It is unpolished, unapologetic, rough around the edges, a meeting ground of people from all walks of life. It takes a certain personality to want to spend time there. I am privileged and humbled to be there to help.

The heart of emergency medicine is what we call the “undifferentiated patient”–in layman’s terms, a patient with a complaint but no diagnosis–it is up to us–the Emergency Medicine folks to try to figure out what is causing your chest pain, stomach pain or swollen calf. We hone in on your story, symptoms, vital signs and labs to begin to narrow down from the hundreds of possible diagnoses the two or three life-threatening ones. It is our job to make sure you don’t have them and treat if you do.

Every patient is a mystery diagnosis. We don’t know you. Many times we’ve never met you or have the luxury of previous notes from your regular physicians. Yet we get to figure out what is wrong with you. Our job has been described as the most exciting 60 minutes of every speciality. And it is true. We get to see almost every diagnosis in medicine.  

Unlike the TV shows, our job is not always full-throttle, chest tubes flying, ribs cracking, shocking people (we don’t even use those paddles any more). It is some combination of charting, bedside procedures, discussions with patients, discussions with consultants and juggling a million and one tasks at once. I will say, twelve hours in the ED can fly by in a blink.

As I finish up my second month rotating in the speciality, here are the most exciting, the most typical and the most unusual things I’ve come across:

  • The normal stuff-Charting: No TV show ever shows just how much time we spend documenting. It would bore most viewers to death if they had to sit through our clicking. But that is a huge part of what we do. We pick up patients when they turn “red” on our screen (that is, the patient is finally in a bed after waiting for a very long time for that bed to become available) and after our 10 minute conversation and physical exam, we spend often double that time making sure we meticulously document our encounter. In today’s age of complicated medical coding systems and reimbursement it is just part of the job.
  • The normal stuff-Placing orders, waiting for results: After we meet you, our investigation begins. Even before we set foot in your room we begin critically thinking about the potential causes of your complaint and what path we’ll need to go down. Emergency medicine is very chief complaint driven. That is, whatever symptom is bringing you here must have a cause and in our department we love ruling things in and out-specifically the scary stuff. We geek out on pre-test probabilities, most likely scenarios, typical presentations and making sure we never ever miss anything that can kill you. That is our job in a nutshell. We place orders to relieve your symptoms and investigate the cause. Often this means juggling multiple patients and checking back on our results, re-accessing, going down a different path based on what we find. TV shows never show just how calculated our job is. Emergency Medicine doesn’t exactly have the best reputation of being the “thinking” speciality, but I beg to differ that we actually ponder and digest just as much if not more than the internal medicine folks–for us things are just done at a faster pace. Things can change in an instant and we are constantly on guard, re-prioritizing, changing course and staying on top of the very dynamic place we call the ED.
  • The exciting stuff: Yes, Emergency Departments get the sickest patients. We have to move quickly when things are going terribly wrong. We get to put in airways when you are about to stop breathing; chest tubes when you collapsed your lung or have a pleural cavity filled with blood; we place central lines when your blood pressure is low and your body is in septic shock; we even put needles into the sac around your heart when there is blood constricting it from beating; we stich up foreheads after bar fights and reduce shoulders that have popped out of their socket. We pretty much get to do lots and lots of amazing, adrenaline inducing procedures. But those are the sorts of things that break up your shift, most of the time we are just seeing patients, thinking about them and charting.
  • The abnormal but normal to us stuff: We get to see some of the oddest things that can happen to a person. Some visits are heartbreaking. Some are humorous. Some are really annoying. Others catch you off guard. We see the best and worst of humanity. You absolutely never know what is about to walk through the door and that makes our job so unique.

The past two months have been the best. I love all the mundane, the exciting, the normal and the difficult parts of my future career. Each of my rotations has been very different, building on my skill set and continuing to add to it. I’m so excited about the career path I have chosen and very proud to call myself a future ED physician. I have one more EM rotation ahead of me and then the process of applying for residency!

 

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I’m Back, Let’s Recap (Step 2 board stuff)

To my amazing readers:

We really need to catch up! My last post left you somewhere near the end of third year. I was grinding out my last two rotations and feeling fairly uninspired. You see, it took all the reserve I had left to keep coming into clinic just as excited as my first day of rotations. I ended the year with ambulatory and family medicine. Two rotations that are classically considered “easy.” Working less than 40 hours a week, having weekends off and getting home by 5 pm was so foreign to me. Paradoxically, I tend to be less productive the more free time I have. A combination of a really long year and a lack of stress propelling me forward left me struggling internally to maintain my tireless enthusiasm. There was no sense of urgency. Even the medical cases were non-emergent. Well, I did have one blood glucose stick of 38 we had to call an ambulance for–and that was the most exciting thing that happened.  Needless to say, those two months dragged. I reconfirmed that my type of medicine is the worrisome kind–at least ruling it out.

I moved from one day being the last day of my rotation to the next day starting 4th year. I began the year with a Step 2 study block.

Board exams are basically the worst thing you ever have to do in medical school. Period. No matter how prepared you are, they are always terrible.  I tried to take away some lessons from my Step 1 experience–mainly that I needed to calm down, so I approached the 4 weeks I had to study much more relaxed this time. I was surprised I didn’t freak out once. Probably because I spent the last two days before the exam dancing around my living room. Doing the Dougie, even terribly, will kill all last minute nerves. Try it.

My study schedule consisted of waking up at 8 am, doing question blocks in Uworld, taking notes, reading my notes, and doing more questions, then going to bed around midnight just to wake up and do it all over again. I kept an excel spreadsheet and ended up doing about 2,900 practice questions. I also took three practice NBME exams. NBME number 4, 6 and 7. My actual score was within 2 points of NBME 4 and 6 and 18 points higher than NBME 7. (Don’t waste your time taking NBME 7 unless you are doing it just for additional practice questions.)

The exam itself was just as terrible as Step 1. 9 hours of answering questions leaves you feeling miserable and delirious. Even though I felt I totally failed, I did not sit and cry in my car this time, instead I took a celebratory selfie and moved on. I purposefully didn’t allow myself to think about the exam at all. If I felt my mind slipping back there I immediately redirected my thinking. This was because I actually thought I failed the exam. Only to find I did incredibly well. So just remember, feeling like you failed is inversely related to your score. The worse you feel, the better you did!

With that monstrosity behind me I FINALLY began what I have been waiting for: my Emergency Medicine rotations!!

Since I will be matching into EM, the beginning of my 4th year is filled with three, 1 month EM rotations: my home institution, a Kaiser hospital and a county program. Because EM deserves its very own blog post I will leave you here. All I will say is Emergency Medicine is awesome and any feeling of lassitude immediately dissipated the second I saw that neon Emergency Room sign. It is perfect for me.

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Photo I took during my away EM rotation. Southern California.

 

 

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Surgery

A few months back I had this dream. Nothing but water all around– I was walking on a rickety boardwalk, wearing my light blue surgery scrubs. I could taste the sea. The ocean spray on my face. My body was haggard. It was with my last ounce of strength that I moved my legs. I lifted my hands, they floated there for a moment, the breeze kissing my fingertips. I felt free. 

I imagined finishing 8 weeks of surgery would feel just like that–a release perfectly timed with my last bit of strength. So many mornings waking up at 5 am I cursed the path I had chosen. Cranky that I could not crawl back into my warm bed (it would sit empty for another 18 hours) instead I was off to the hospital. When you are in the thick of it–that release is all you can think of. Now that I made it–mostly what I feel is nostalgia.  It is funny how quickly you forget the tired mornings and late nights. All I remember now are the exhilarating highs.

Surgery was the most fun I’ve had in medical school.

I will not be a surgeon. I am going into Emergency Medicine and knowing that this rotation will likely be the only time that I’ll be spending in the OR, made it that much more exciting. I transformed from a clueless 3rd year med student, hands shaky, stupidly holding my needle driver like scissors…to a confident, somewhat less-clueless surgical student. By the end of two months I was able to read ventilator settings, remove chest tubes, tie knots, close a surgical wound nice enough to have the ultimate of critics–the scrub nurse–utter the words “beautiful.” I could prepare for rounds in 30 minutes flat, knowing every lab, urine output, nutritional status, vital sign and Flowtrack indicator for my patients. This training came at an incredible price. I stayed late. Studied even later. And walked around for 8 weeks sore as hell.

I will never forget the cases I came across. Terrible calamities. Now part of my training forever. A stabbing in the middle of the night. Gun shot wounds. Flesh eating bacteria. Total body burns. Fulminant sepsis. Amputations. Tumor in the heart. Every day I felt lucky to have the privilege of being in that OR.

Of all the specialties surgery will always have a special place in my heart. It was the only one that gave me pause. Ultimately, it is not right for me, but this rotation will be one I won’t soon forget.

 

 

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My Life as a Heart Surgeon

Ever wondered what it’s like to be a heart surgeon? Since my last blog post, I’ve gotten a chance to find out. I am doing my surgical rotation on the Cardiothoracic service. I haven’t settled on how I feel about it. Over the last two weeks I’ve gone from absolutely dreading it…to pure enjoyment.

My team is small. Just myself, my resident (R3) and our attending–the only cardiothoracic surgeon at our institution. Partly out of necessity since my  first morning I’ve been pushed into the role of “acting” sub-I/junior resident. At first having such high expectations thrust upon a meager 3rd year med student was terrifying. I felt as if I was failing at every step (and I was). My confidence crumbled as my inadequacies were brilliantly pointed out every morning. This was my first introduction to intensive care medicine. I knew nothing about management of drains, chest tubes, cardiac output monitors, ventilation settings, etc. I stared wide-eyed during am rounds as I had never even heard of most of the things my resident asked me to do. She pushed me at every opportunity. She knew exactly how uncomfortable she was making me. And she did it with just that purpose. Here was a person who was interested in seeing me grow. She was dedicated to my education.

So often as medical students we are given an easy pass…don’t know something, well that’s ok, you are “just” a med student. Not on this team. Every time I didn’t know something, I looked it up, wrote it down in my handy mini moleskin notebook and burned it into my brain. The embarrassment alone was enough not to let me forget it. Nothing was ever overtly said, but not knowing the answer to something is unacceptable to me (I put a lot of pressure on myself to be the best I can). I feel so lucky to have my resident on our team. She pushed me out of my comfort zone–in the process, I face-planted. Only to get up feeling like I actually can be a resident next year. Every day, I am starting to feel more comfortable about the non-theoretical medicine stuff. Like what meds we actually use to replete mag, how much do you give? When is it time to take out a blake? What CVP are you comfortable with? What are extubation criteria? How to remove a chest tube without giving your patient a pneumothorax. Nitty gritty medicine, you don’t want to waste time intern year having to look-up. After a 6-7 hour open operation our patients are fragile; their kidneys do funny things, their hearts get funny rhythms and there are a million reasons why we manage them in the ICU. With each passing day I’ve grown less terrified about how it all works.

As in most surgical specialties the days can be long. Really, really long. My record was starting the day at 4:30 am and not getting home until midnight after two long open heart surgeries. At the end of that day my feet felt like I just climbed Kilimanjaro. (Hint: I ordered compression stockings for rush delivery that night). I am in awe of our CT surgeon who is a mythical creature. He works like a machine. Never needing to use the bathroom. Barely eating and always up for adding on an additional heart case no matter how late in the afternoon the consult is. Heart surgery requires such a person. I have convinced myself that for 4 weeks I can assume the role of a machine, but not a day longer than that.

The surgeries themselves are amazing. Who doesn’t want to spend the day staring at a human heart. Stopping it. Then bringing it back to life again. Heart surgery is surprisingly formulaic and now having done 7 or so surgeries I can start to anticipate the next move. I know where to suction, how close to cut the suture, when to retract, when it’s my turn to step in and help with opening the thoracic cavity or what closure suture to use. Now that I know what I am doing, I enjoy the OR very much.

I didn’t know what to expect starting this rotation. I have been pleasantly surprised at how much it has challenged me. My resident is an amazing mentor. She’s found the exact style of learning that will take me to the next level of my training. A combination of uncomfortable pressure with the generous reward and satisfaction of knowing something I failed at before. If I can make it through this, who knows what else I’ll be able to accomplish.

Sometimes you have have to fail at something to learn.

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