Wednesday, February 18, 2009

Planning for my 4th year

"When are you going to be a doctor?" is a question I get asked by patients quite often.

I like to think they are asking because they are interested in my progress and eager to see me fulfilling my dreams.

More likely, however, the question is based on a thought process along the lines of:

"Is THIS GUY going to be a doctor soon!? He started out by asking me all these irrelevant questions - what's he thinking when he asks how many pillows I sleep with at night?* What's he going to ask next, what colour my blankets are?

Then... he moved on to a fumbling, shoddy excuse for a 'physical exam,' making sure he touched me in every part of my body. Why on earth is he "feeling for the pulses in my groin?" Is he making this stuff up? And now he is using his stethoscope 'down there,'** is he crazy?!...ohhhh dear, when is the real doctor going to show up??

Good heavens, how long until he is unleashed to practice his incompetence on me and my friends and family? I'd better ask so I can move out of town by then."

In my defense:

* This is how I ask about orthopnea, or increased difficulty breathing when you are laying down flat, a symptom suggestive of impending heart failure.

** I'm listening for bruits in the femoral artery, which could indicate arterial blockage or disease... and I always ask if its OK for me to proceed.

The answer to the question is, just under 1.5 years, and trust me, I'm even more frightened by the thought than you are.

More on fourth year...

As I get closer to graduating, however, a few more decisions need to be made. My classmates and I are at the point in our education where we are choosing what we want to do for our fourth year.

While our first two years were mostly lectures, and the third and fourth year are mostly clinical, the third and fourth years are quite different.

Our schedule is quite firmly set in third year - we rotate through a number of "core" specialties (internal medicine, pediatrics, surgery, obstetrics, etc), and the only thing we can have any input on is the order in which we do these (and even still, need to enter a lottery to decide which students get to pick first).

However, in fourth year, we have a huge amount of flexibility in that we choose a number of electives. These can take place anywhere in Canada, the USA, or in some cases, elsewhere in the world, as long as I meet the requirements for the individual programs (some American schools, for example, want you to take the US Medical Licensing Exam after my 2nd year of medical school, which is not required in Canada).

The dirty details (for those who care...or can offer me some help!)

Based on how I understand it, what a medical student chooses for their senior electives is prompted by a number of factors, such as -

  • the requirements of their school - I have to do at least 1 elective in each of the following: medical, surgical, primary care

  • the career and residency programs they are interested in - someone interested in Plastic Surgery will obviously want to do many electives in the same, and check out the cities and hospitals where they might do their training

  • geographic preference - a specific city might be chosen for an elective because they have a good residency program the student wants to check out, or because the student can easily arrange accomodation there with family / friends (it helps to avoid paying double the rent for the months you're away!), or simply because the student wants to visit a city they've never been to (my friend did a 3rd year elective in Pittsburgh so he could go watch a Penguins NHL game)

  • interest - a student applying to a generalist (i.e. Family Practice) or less competitive specialty will probably spend more of their electives experiencing a variety of specialties they find enjoyable and interesting, rather than ones they think they "need" in order for their application to be impressive

As well, I also need to consider some other things regarding when I do an elective, based on applying to residencies:

  • whether or not the elective has a lot of call - if so, it might be tough to work on an application for residency at the same time!

  • whether or not it's likely to yield a good reference letter for residency - this only applies to the first few electives until the reference letter due date - you're more likely to earn a good reference letter from a specialty in which you work with 1 preceptor quite often, rather than something like emergency medicine, where you are supervised by someone else every shift.

Here's what I'm thinking so far, given that I am mostly interested in emergency medicine but may apply for a family medicine residency so that I can have a variety of options when I finish (ie. spend my time delivering babies, working as a hospitalist, or doing surgical assisting):

  • Places - I'm thinking of doing my electives mostly in Alberta, BC and Ontario, because that's where I'm thinking of doing my residency, they're most familiar to me, and I know more students who have done electives in these places and therefore can get the scoop on them

  • Basics - I'm interested in spending time in ER and obstetrics, so I'll likely do at least 1 elective in each of those

  • Helpful add-ons - For someone interested in ER, I would probably benefit from spending some time in pediatric emergency, trauma surgery, and/or anaesthesia

  • Just for fun / interest - If I have time, I might as well do some shorter electives in things I don't know much about, that intimidate me, or that I have simply never seen - such as rheumatology, or neurology

There are a few deadlines for choosing coming up, so now, the question is to decide where I want to do each of these electives, and if there's anything I'm missing. If you can think of anything, by all means, let me know!

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Thursday, February 05, 2009

Trauma Team vs. Delirium team?

My Internal Medicine attending made an interesting point today, brought up at a lecture by Dr Rivers (famous for his work on treatment of shock/sepsis in the emergency department, published in the NEJM):

  • Number of hospital staff who work on a trauma patient who just arrived at a large hospital: usually ~10-20

  • Your chance of dying from an auto accident if you make it to the hospital alive: ~10%

  • Number of hospital staff who work on a patient with delirium who just arrived at a large hospital: perhaps the medical student at first, then the doctor when s/he gets around to it

  • Your chance of dying from delirium: ~50%

A bit of a disconnect, perhaps?

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Internal Medicine so far

I'm well into my Internal Medicine rotation. Fortunately, I have been well-warned that internal medicine attendings are notorius for demanding perfection, immense detail, and will respond to any lack of the aforementioned with insults substantial in volume and quantity, so it wasn't too much of a surprise.

Here are a few choice events so far:

  • doing CPR for the second time (second time for real, that is) in a code blue

  • one time feeling like I had learned something about medicine

  • most times feeling like I have not learned anything

  • being schooled by nurses who know critical care medicine much better than I do

  • being asked by my attending doctor, "I was wondering when your brain would turn on" (don't worry, he was joking...I think)

  • developing near-delirium after losing my cell phone in a call room (the first time I have ever lost my phone in about 5 years)

  • smelling fetor hepaticus - the "sweet, feculent odour" on the breath of a patient with end-stage liver failure

I haven't cried yet, so I think that means I'm doing well.

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