Winding Down

This post has been simmering for a long time, mostly because not much has been going on in the med school world. Except for today. Two code blues, at the same time. And by my count, this would be my first code - at least where I did something. I ended up at the one that was actually kinda cool (except for the patient). Postop patient refusing DVT prophylaxis is begging for a pulmonary embolism. My money is that's what threw the poor guy into vfib. As an aspiring EM doc, I actually knew a lot of what was going on and why. I got to do chest compressions, which was kinda cool since I've never done them. It's actually a decent amount of work and ended up getting reasonably sweaty and tired - 100 compresssions/minute with each one trying to slam 1.5 inches into the guy's chest adds up. Long story short, the guy's heart freaked out since it didn't get oxygen and was functionally stopped, after about 12 minutes it actually stopped. And no exaggeration, with literally the last round of pressors, antiarrhythmics, and shocks before they were gonna call it, the guy flips back into sinus rhythm. Sixty seconds later, the guys writhing around and trying to verbalize. Pretty cool.

Anyway, I'm at the halfway point of my last rotation (internal medicine) and six weeks away from the end of third year. I don't feel as if I've studied all that much. Compared to a year ago, my former self wouldn't recognize my current self. I actually know some stuff, both book-wise and clinically. I'm somewhat comfortable on the wards, and can handle a brand new patient and managing a basic workup on an uncomplicated patient. As for the details and logistics of patient care, I'm lacking for sure. Same story if the patient is remotely complicated or requires deep differential diagnostic skill. But IMHO, I've progressed nicely over the past year and for sure over the past three years. I can actually see myself as a resident and not as a bumbling, awkward med student.

All that said, it's scary how much I don't know. Knowing limits and what one doesn't know is by far the best thing to have learned over the past year. I like the idea of being able to handle anything that's thrown at me, and don't really wanna give up anything. Fields that are typically polarizing I've enjoyed, including OB/gyne and pediatrics. As someone considering EM, I should traditionally despise the slower pace and more in-depth management of patients. Shockingly, I actually enjoy both aspects.

And it's for those reasons that my ever-evolving list of specialties includes the following: EM, EM/IM, med/peds. Part of me likes the idea of being able to handle pretty much anything. For the combined residencies, part of me likes being able to put off a true specialty decision for a little bit longer.

When I Grow Up

Nine months into my M3 year, I still don't know what I wanna be when I grow up. Put into context, I'm fourteen months away from graduating and actually getting an MD. I'm twelve months away from "the match," where I find out what specialty/residency I matched into and where I'm going for the next few years.

In making my M4 schedule, I've been forced to think about what I've truly liked. This has proven to be pretty difficult, since I've liked everything. Having done seven rotations to this point, we basically decide our careers based on these experiences and impressions of ones we've yet to do. I'm not one of those who knew exactly what I wanted to do when I came to med school. I'm jealous of them at this point. I always figured it would kinda come to me along the way. Not so much.

At this point, I can safely say that I probably won't be going into OB/gyne, neurology, psychiatry, pathology, radiology, or dermatology. I'd be pretty competitive in most of those fields, but I just don't see myself doing them. Of the six, I'd be most likely to go into OB/gyne. I'm ambivalent towards neurology and psychiatry. I have zero interest in pathology, radiology, or dermatology. A word about derm. It truly appeals to some people: that'll happen and good for them. It appeals to others because its among the most competitive specialties to match into, it's a decent lifestyle, pays well, and there's an according "prestige factor." Zero appeal on those fronts for me.

Traditionally, the first decision to make is surgical vs. medical. I really liked surgery and could see myself enjoying it. As an attending. Five years of a general surgery residency are not really to my liking though. The thought of five years of 80+ hour weeks and getting zero sleep every third or fourth night isn't all that appealing. Problem is, gen surg is pretty much the gateway to most of the subspecialties: peds surg, cardiothoracic, vascular, trauma, colorectal, transplant, surgical oncology. And for these subspecialties it's another 1-3 years in fellowship. I think not.

There are more lifestyle friendly surgical specialties: otolaryngology, urology, plastics, and ophthalmology. These have a reasonable mix of surgery and medicine and are less intense than gen surg residencies. For these very reasons, they're ridiculously competitive, on the same level as derm. My refusal to be extracurricular (research, volunteering, networking in those fields, etc) is a pretty limiting factor. More importantly, my board scores are slightly to decently below average for these fields. Ortho is another pretty competitive specialty, but it doesn't really interest me all that much, and its residency can be pretty intense.

Sadly, the above thought process puts a lot of things ahead of surgery. And my body of work realistically limits me to general surgery and it's associated fellowships. It was a realization that I had been hoping to avoid.

That leaves the medical half of the equation: internal medicine, pediatrics, family medicine, and their associated subspecialties. I haven't done IM yet, but I could see myself doing any and all of the above fields. Family medicine has turned out to be surprisingly appealing, as it's generalist medicine in the truest sense. Anything can walk through the door, and you've gotta be able to at least recognize what's happening so as to either manage it or refer it out. There's a decent number of minor procedures, a chance to work in urgent care centers, and opportunities to practice obstetrics (becoming rarer with malpractice).

All that love for the medical specialties, but I'm actually in a gray zone with the surgical/medical debate. Top two specialties right now are emergency medicine and, wait for it: anesthesia.

Emergency medicine is something that's always been on my radar. A nice breadth of pathology and patients, potential for lots of procedures, shift work, and all sorts of acuity. The major downers are no continuity of care and (strangely enough) shift work. The shift work is nice as a younger attending, since it's pretty easy to work 36 hour weeks and consider that your work week. The downer is still working 7PM-7AM shifts on a regular basis as a middle aged attending. Most attendings at that age transition over to administrative work, which is something I'm not remotely interested in.

Anesthesia is probably the shocker for those who've kept tabs on me over the years. It gets me involved in the care of different types of surgical patients, it's a medical field where I getto use my brain (vs. surgery). For being in the OR and involved with surgical patients, there's a decent amount of physiology and pathophysiology that has to be applied. There's also a reasonable number of procedures and yes, it pays pretty well.

To add more confusion to the picture, I just finished my family medicine rotation. And I actually thoroughly enjoyed it. I could see myself being a family doc - good breadth of pathology, some minor procedures, continuity of care - just no acuity and the hours aren't set in stone. The other downer is that the training isn't as in-depth as I might like. Not to say that FPs aren't qualified, because they are. I just wouldn't mind having a little more in-depth training, maybe to the tune of a combined med/peds residency. I wouldn't want to lose treating kiddos by doing an internal medicine residency, so I'd be amenable to combining my training with a peds residency. The med/peds idea and whether it moves forward hinges pretty heavily on whether or not I like my internal medicine rotation - which starts tomorrow.

Basically, I there's no field that I *have* to be in. But I know what I don't want to do. And there are a few fields that have either piqued my interest or that I could see myself doing. Which brings me to the current list: emergency medicine, anesthesia, family, med/peds. And as a sign of how unsure and fluid my thoughts are, those last three fields weren't on my radar a month ago.

Tapas!

I don't actually dabble too much in Spanish cuisine. That said, my main interaction with it has been through tapas, having been a few times over the past several years. From this limited sample size, I'd have to say I had my best experience so far last weekend at a South Loop place called Tapas Valencia. I left the place stuffed, which has never happened, from either a tapas or dim sum place. And for the price of $35/head, the eight of us got stuffed with roughly twenty dishes of tapas, six plates of dessert, and two pitchers of sangria. Even the server got stuffed with a pretty reasonable tip.

The things that stuck out to me were the tuna canneloni, baked goat cheese, spanish omelette, lamb medallions, and calamari. If I had to pick one dish from each of the "entrees" and dessert, it'd have to be the bacon wrapped dates and the profiteroles.

For the price point, it was a really satisfying and delicious meal. There wasn't a dish I didn't like. The only downer is that it probably takes a bigger group to get your money's worth and while still being able to try out a lot of the different offerings.

The Beat Goes On

I closed out my peds rotation a few weeks ago and am two weeks into my family medicine rotation. Long story short, although nothing's been too mind blowing over the past four weeks, I've still enjoyed my time on the rotations.

Peds was a good rotation: good children's hospital, diverse pathology, fun med students, enthused residents, good faculty. I was/am in shock at how much I actually enjoyed everything. The best parts were well-child visits in clinic. Brief enough encounters that I don't get sick of the kid, but long enough that I get to play with them when they're healthy. Ironically enough, the worst part of the rotation was clinic. Outpatient just isn't as fun as inpatient stuff, especially when I'm seeing my fifth cold/flu/gastro of the morning. Up on the floors, my patients had things including: DiGeorge syndrome, osteosarcoma, CVID, and complex congenital heart disease.

By far the saddest patient on during my rotation was a two month old kid who came in with shaken baby syndrome. Yes, it's exactly what it sounds like. DCFS and the cops were close to making an arrest but couldn't tell us who, though we all suspected the dad. The kid had broken ribs, retinal hemorrhages, hypoxic ischemic encephalopathy, and ended up with both a tracheostomy and gastric feeding tube. At two months old. I hope the sick fucker rots in a cell.

Peds is actually a surprisingly diverse field, once you get outside of clinic and all its colds and stomach bugs. There's a pretty extensive set of pathologies that are peds specific and even common pathologies which present atypically in the peds population. Long story short: I liked the rotation and it's still on my radar.

Transitioning from one primary care field to another, I'm now two weeks into my family medicine rotation. As is becoming a common theme for my M3 year, I'm surprisngly into the rotation so far. As a student, I'm given a lot of autonomy: see the patient, workup an assessment/plan and present to the resident/attending I'm working with that day. Kinda makes me feel like a doctor :)

As a career, it's a diverse enough field for my liking, as pretty much anything of any age can walk through the door. Pathology-wise, I see whatever most people go to the doctor for, as family docs are most people's interaction with the health care system. Lots of colds, back pain, headaches, dizziness, belly pain, asthma, COPD, GERD, etc. Since a lot of this stuff is less acute and complicated, it's a lot more amenable to student level assessment and management. That right there might be why I like the rotation so much. This lower pathology complexity affords me more opportunities for patient education and counseling, which I actually enjoy. Since a lot of these conditions are also chronic, there's lots of continuity of care (which ER is lacking by nature). It's somewhat nice to see the same patients again, but also educational as a student to see how things progress, both for better and worse.

Some things I'm not a fan of are the lack of acute, diversified pathology (e.g. heart attacks, collapsed lungs, etc.), lack of inpatient experience (family med's by nature an outpatient practice), and patient noncompliance. All of the above things can be brought back to family being an outpatient specialty. If you're being seen in clinic, you aren't that terribly sick, which can secondarily lead to noncompliance. In the hospital, odds are you're reasonably sick and as such more amenable to treatment compliance. Compounding noncompliance is lying about it. I'm open to noncompliance if I'm told about it. Bonus points if it's reasonable: insurance, treatment timing, etc. But as long as I'm not lied to, then it's something we can work on.

The biggest thing I'm not a fan of is the compressed timeframe of family med visits. Sure, some things are bread and butter, like a slam dunk otitis. Grabbing the HPI (history of presenting illness), doing a quick exam, getting the azithro written, and giving followup instructions should take under ten minutes. Fifteen at a residency program where we present to attendings. But that's for a simple case of otitis.

If anyone ends up being a psychosocial visit (e.g. depression, bipolar, anxiety disorder), it's probably at least fifteen minutes just for the HPI. As a student, I haven't figured out how to diplomatically and also feel bad about cutting patients off. Especially if they're in for or bring up the aformentioned. And probably at least a third of my patients so far have had some flavor of psychosocial problem in their visit. As someone who wants to address everything that's brought up, I have a hard time condensing the visit into an appropriate timeframe. It's a bit frustrating and unfulfilling, since I don't want to diminish what's been brought up. Maybe it gets easier as I get more experience. But even as a resident, I then get slowed down by all the paperwork, presenting/discussing, and more paperwork.

Overall, family's been pretty good: great residents/attendings, decent autonomy, reasonable hours (including no call or weekends), and that "being a doctor" feeling. Downers include lack of time crunches, lack of acuity, and noncompliance. Thus far in my mind, the pros outweigh the cons though.

Pediatrics

I'm four weeks into my six week peds rotation. At my site (Hope Children's Hospital), I spend three weeks on a general floor, one week in the nursery, one week in outpatient clinic, and one week in a subspecialty (just finished up my peds GI week).

Taking a further step back, this half of my M3 year is more medically oriented (vs. surgical - e.g. ob/gyn, surgery). As such, I have had dust off my thinking cap and throw it on in the morning. And there was quite a bit of dust on my hat.

At this stage in our careers, I'm realizing it's not all about nailing the correct diagnosis. Yes, it's nice when your residents and attendings agree with your assessment But it's all about thinking about what something could be and what else it could be.

Take appendicitis for example. Classically, it will present in 10-15 year olds beginning with diffuse abdominal pain and cramping that localizes a few hours later to the right lower quadrant, 2/3 the distance from the navel to a hip landmark. Pain should precede any vomiting or anorexia (vice versa in gastroenteritis). On exam, the patient'll probably be febrile, hopefully without any peritoneal signs, and hopefully positive one of a few classic signs: psoas, obturator, Rovsing. It's said that 80%+ of diagnosis is based on history and physical and they guide appropriate workup. A story convincing for an appy will buy you a CBC to confirm infection and probably imaging to confirm that you've actually got an appy.

The story I just gave is pretty straightforward for an appendicitis. In thinking of right lower quadrant pain, one's also gotta consider adnexal cysts/torsion, ectopic pregnancy, PID, mittelschmerz, mesenteric lymphadenitis, Crohn's, volvulus, intussusception, pyelonephritis, urolithiasis, Yersinia enterocolitica. In entertaining thoughts of appendicitis-mimics, the vice versa also has to be considered - appendicitis mimicking other conditions. That is, appendicitis presenting in an atypical fashion.

Long story short, it's interesting having to actually think through a patient's story. And I'm pretty sure I like the process. Even though I'm realizing how much I don't know at this point. At the same time, I still have an itch to do procedures. Sooo, I still haven't made any progress in the surgical vs. medical debate.

That said, I'm actually enjoying my peds rotation a lot more than I thought I would. The floor patients are pretty interesting - if a kiddo's in the hospital, there's got more going on than the stereotypical sore throat or ear infection. Patients I've had include: congenital heart defects (mostly tetralogy of Fallot), foreign bodies, ovarian cysts, nephrolithiasis, pill ingestions, hydrocephalus, diabetic ketoacidosis, Crohn's, supraventricular tachycardia, common variable immunodeficiency, and seizures. More typical peds admissions include RSV bronchiolitis (shittons) and appendicitis.

On a sadder note, some kids ended up having with serious shit. I.e. hepatocellular carcinoma, leukemia (ALL), and osteosarcoma. The osteosarcoma was particularly sad - a 17 y/o girl whose presentation was a lumbar vertebral fracture leading to paraplegia. It was on her workup that a femoral osteosarcoma was found with metastases to her abdomen and spine.

Those sad stories aside, probably the only interesting case to nonmedical folk would be an incidental finding of pinworm in a girl getting scoped for Crohn's. Note: the upcoming in parentheses might be a bit disgusting.

(Classically, its presenting symptom is perianal itching. If having worms in your colon isn't offensive enough, the reason for the itching is because they come out of your GI tract at night and lay eggs perianally - it's these guys that cause the itching. The traditional diagnostic test is the scotch tape test. Double side some tape around that area before bed, let them do their thing, have a look at the tape in the morning.)

Now that I've gotten sad and disgusting stories aside, there's not much to write home about. I'm shocked at how much I'm enjoying the rotation. I can appreciate the diversity in pathology, patient age, and the fact that kids' problems aren't self induced (alcoholic cirrhosis, noncompliance, etc). In all honesty, it's playing with the little ones that's the best part of my day. Especially the 3-15 month olds in clinic - good age group and if they're in clinic they're reasonably healthy and amenable to playing. This week I'm in the nursery and the NICU. Not gonna lie, the kiddos are pretty cute.

Call Rooms

Being POD 1 from getting my wisdom teeth out, I've been doing a decent amount of sleeping. Some of that's probably due to the vicodin. Overall, there's pretty minimal pain and swelling - which I'm pretty happy about. I figured I'd try out the vicodin or an equivalent narcotic combo since I've given it to scores of postop patients. I feel it's good practice to experience what patients go through, if feasible.

Wisdom teeth aside, all the sleep got me to thinking about how much I like sleeping in a bed I call my own. Then that reminded me of how some were unaware that on-call rooms existed in hospitals outside of TV. Well, here's a rundown of the one's I've been in.

Christ Medical Center, Oak Lawn, IL
Did eight weeks of surgery and was on-call an average of every fourth night. The surgery call rooms are actually a set of four rooms. Two single-bed rooms for the trauma and gen surg chief residents. Then two bunked rooms in the back for the trauma and gen surg junior resident and med student. The rooms are the length of a twin bed and the width of 2.5 twins. The beds were reasonable enough, it was just cold in the call rooms. And I usually like it cold. I didn't mind sharing the room, because it's not like we were ever there anyway.

The food was better than expected. Even better, I never paid for a meal. That's a perk of being in tight with the coordinator for meal tickets. A cool cafeteria lady who charges only $1 for your lunch also helps. And so does grabbing lunch in the OR suites' doctors lounge - both time and cost-efficient.

By far the best part about Christ's food was their hours. And by hours I mean that they were open from 130A-430A for the on call and night staff. Hell yeah. No other hospital's had the common sense (or more likely money) to do that.

Jesse Brown VAMC, Chicago
Did six weeks of psychiatry at the VA and took three nights of call. There's actually a wing in a newer part of the hospital dedicated to on call staff. That said, the rooms were even nicer than I expected. Especially from a federal institution. The rooms were basically converted patient rooms, each with their own bathroom, desk, bed, TV, and window! Oh and the rooms were ridiculously spacious.

Unfortunately, the food at the VA is exceptionally subpar. The chicken strips were okay at best. Between UIH and the VA it's quite the competition for my lowest rating. Making it worse, I had to pay for lunch each day I was on psych. At least my nights on call, meals were free.

MacNeal Hospital, Berwyn, IL
Did six weeks of ob/gyne at MacNeal with a week of night float on OB and took two Friday nights on gyne, for a total of seven nights. There are actually two call rooms for me to use. One is about five seconds from the labor/delivery floor. The other is about five minutes or a block away. The closer one is definitely nicer, newer, better lit, and better furnished. But this room was usually unavailable to me, since there's typically a family practice resident on call with the OB team.

The further one is older, in an empty part of the hospital, less comfortable, poorly lit, and cold. All that said, it's quieter. But it's also apparently for gen surg med students. I only discovered this my last night on call after getting paged to basically move my shit out. Meaning I had no place to sleep. Hell no to that. After talking to the nurses, I ended up sleeping in a patient room on the L&D floor. It was ideal: right in the middle of the action, quiet, comfortable, with a bathroom right there.

The food was reasonable at MacNeal. Paid only for a handful of meals, thanks to meal tickets and the doctor's lounge usually being stocked. Unfortunately, they didn't have late night hours. They do have a bank of vending machines though, from which I've gotten: hard boiled eggs, tuna sandwiches, White Castle burgers, and other assorted fare. Be jealous.

In Queue
I've got three more core rotations my M3 year: pediatrics x 6wks (at Christ again), family medicine x 6wks (Hinsdale, all outpatient), and internal medicine x12wks (Lutheran General). If I remember, or get this bored again, I'll update you on the bed situation for Christ's peds and Lutheran's IM med students.

OB/Gyne & More

Having just taken the shelf exam on Friday, I've closed out my ob/gyne rotation. All jokes aside, I actually enjoyed the rotation. Enough that it's still on my list of possibilities. Along with most other things, as I'll touch on.

Except for the demographic restrictions, the pathologies and scope of practice are pretty diverse. Ob/gyns function as a lot of women's only interaction with the health care system. As such, this provides for a decent amount of primary care and outpatient experience. Outside of usual primary care stuff, there's obstetrics, which encompasses its own breadth of experience including prenatal care, normal births, instrument deliveries, C-sections, and conception/infertility treatment. Entwined in all of those are maternal and fetal conditions and morbidities of pregnancy with appropriate management.

Then there's the gynecological aspect, including birth control, dysfunctional uterine bleeding, cancer screening/biopsies, pelvic organ prolapse, and urinary/fetal incontinence. Gyne is a lot more surgically oriented, e.g. D&Cs, hysterectomies, LEEPs, tubal ligations, and prolapse repairs.

As a specialty, ob/gyn encompasses a lot: decent amount of clinic/primary care, inpatient medicine, and getting to operate. Not many specialties offer that combination. Of course the downers include being on call (though not as bad as gen surg), malpractice insurance (highest risk specialty), and regional litgation (Illinois is one of the worst states). Overall, I was pleasantly surprised by the specialty - especially since I was expecting to hate it and immediately rule it out. I might even say that I'm giving it some consideration.

On the "when I grow up" note, I now officially have no idea what I want to do. The first decision people traditionally make is between surgical or medical fields. I can't even decide between the two and want to do both. I know I want to be in the OR. I thought EM would quell my desire to do procedures. But it's just not the same as being in the OR and getting to operate. That said, I don't want the majority of my medical practice to be based on surgical anatomy - I also enjoy thinking and working through medical problems.

So, I've basically got a few months to realistically decide on a specialty - and I've regressed on that front since M3 year started. Score.

Rotation Highlights

Clinically Sweet Procedures
Translation: things that may not sound so hot to you, but are actually big deals to med students.
1.) D&C: dilation and curettage. Basically an ablation procedure, most commonly applicable to the uterine wall in the context of dysfunctional bleeding. As a lower end operation, why is it a big deal? Because my resident and attending let me do one of them :)

2.) Fascial closure. If you were watching an operation, closing would be the most boring part. That's because it is. Unless you're new to operating and actually get to partake. Closing fascia is basically what keeps your insides inside you. Nobody likes herniating through their incisions. The most suturing action we get is usually closing skin. So closing fascia, fat, and skin was pretty sweet. Especially getting to do it more than once :)

2b.) Digression. My other operative things were from gen surg and have a bit of a better "cool factor."
-Taking a rake out of a foot.
-Washing out a compound comminuted distal tib/fib fracture. Why is it cool? Because you could see the fractured bones outside the skin, and it was basically my hand and some soft tissue keeping the foot attached to the leg.
-Laparoscopically taking out two gall bladders, with an endocatch and a grasper. Basically like playing one of those "claw" stuffed animal games, except with a camera, a lot smaller instruments, and a gall bladder. Harder than the residents make it look, and a pretty sweet opportunity for me.

3.) LMA placement: laryngeal mask airway placement. One of the anesthesiologists and I got along pretty well, so she eventually had me place a few of these airways. I thought it was pretty cool, her letting me place airways. Especially since I'm only a third year, wasn't on an anesthesia rotation, and wasn't an anesthesia resident or CRNA student. The head is suprisingly mobile and taut at the same time when under sedation. As such, I'm a bit tentative to shove things down people's throats. Apparently that's poor technique. Regardless, it was a good learning experience :)

30 y/o G6P2032 sAB @ 16 wks
Translation: 30 y/o with six prior pregnancies, two full term births, three abortions/miscarriages, and two living children. This lady was by far the saddest patient of my six weeks on the service. This lady comes into the ER and we get called because she miscarried her 16 week fetus at home and was still bleeding. The bleeding was secondary to not having delivered the placenta and uterine atony, both of which resolved after she spontaneously delivered the placenta on the bed.

Messed up: she brought the fetus in. We ended up examining it and it was ridiculously disheartening to me. It was a lifeless miniature baby at only a few inches long. Even more fucked up is the fact that this was her fourth miscarriage. I can't imagine the pain and suffering this family has gone through over the past few years. With this many miscarriages, she's long overdue for a workup, i.e. for antiphospholipid syndrome, lupus, or something else systemic. Her lack of insurance keeps her from doing this and four miscarriages is the end result. Poverty's also keeping her from a proper burial for this fetus. She wanted to take the fetus home with her and bury it, but the hospital wouldn't allow it.

Long story short: this patient's story was immensely sad and emotionally draining. Even for someone who's grown somewhat numb to morbidity and mortality. We didn't even speak the same language, but our faces told each other what we were feeling. It was a legitimate downer to that night on call.

NSVD
Translation: normal spontaneous vaginal delivery. As opposed to complicated labor such as failure to progress, asynclitism, breech presentation, or any myriad of indications for C-section. Getting to deliver a baby is considered a rite of passage in med school, and I'd agree with that sentiment. It's not the prettiest thing, but it isn't as disgusting as I'd been led to believe either. That aside, I think it's pretty damn cool to deliver a baby and be part of bringing someone into the world. I only delivered a few babies, but it was legitimately one of the highlights of my clinical career so far.

Lost in Translation
In medicine, there can be a disconnect in communication between providers and patients. Especially when talking gynecological history in younger patients.

"Are you sexually active? Because your pregnancy test came back positive."
-asked of a teen patient with a belly bump complaining of weight gain, nausea, vomiting. And yes, belly bump is the medical term.

"No."

"..."
"How'd you get pregnant then?"

"Oh, I'm not active."
"I just lay there."

Just so not all my anecdotes from my rotation are depressing downers or med student geeky.

Ortho & OB

It's been awhile since I've been on here. In that time frame, I've finished up neurology, had a friend tie the knot, watched the Rams and Illini win games, done two weeks of orthopedic surgery, and started six weeks of OB/gyne. Clearly only one of those is of any real life significance - congrats buddy. Other than that, not a whole lot of excitement from the clinical front.

Ortho
Orthopedic surgery deals with management of musculoskeletal problems. Some of the more common surgeries are shoulder and knee arthroscopies and some of the more common repairs are bone fractures and ligament/tendon tears (ACL, Tommy John, rotator cuff). And then there's the always popular hemi/total hip or knee replacement.

As for the nuts and bolt of the specialty, that metaphor describes the field pretty well. There's a lot of hardware involved: screws, pins, drills, mallets, metal plates, etc. It reminds me a bit of carpentry, as these tools are used a lot in conjunction with measuring angles, range of motion, and approximating fractures. It's a bit mechanical, maybe too much for my liking. It's a moot point anyway, since ortho is one of more competitive fields to get into.

OB/Gyn
I've been on OB for three weeks and dealing with pretty much anything birth related. By far, my most common patient is the high risk mother in for prenatal care and fetal screening. After that, there's a lot of women who come into triage for rule out pre-term/term labor. There's also some higher risk pregnancies at term coming in for labor induction and/or augmentation. And of course, there are deliveries and C-sections.

Overall, it's actually a better field than I thought. And I'm surprised at the number of people who have no problem answering pretty intimate questions and having a random med student involved in a lot of their care, including deliveries. I consider it a privilege to be involved in families' happiest moments. I'll admit, it legitimately puts a smile on my face - even if it's 330 in the morning. That said, the attendings have a pretty pervasive obsession for perfect prenatal care and deliveries. This mostly comes from the litigious nature of the specialty, which is especially exacerbated by practicing in Illinois (and Chicagoland). That said, I'm pretty grateful for the amount of stuff the attendings and residents let me do.

The next three weeks I'm on the gyn service, which is a lot more surgically oriented - scheduled C-sections, hysterectomies, tubal ligations, D&Cs, fibroidectomies, etc. It'll for sure be interesting and a nice reintroduction to the OR. That said, I'll actually miss OB and L&D, which I never would've thought possible a month ago.

The major downside of this rotation are the hours, at 11-13 hour days. Similar to surgery, but not as intense or busy. Patient volume is definitely site dependent though. The thing that was particularly rough working a week of 13 hour nights, from 6P-7A. It takes a little getting used to and once you finally do, it's back to working days. Overall though, I'm actually liking the rotation. Which is shocking, since I was pretty sure I was going to hate it.

Third Year Thus Far

Four months into third year at this point, with 2/6 core clerkships down: surgery and psychiatry. I've even knocked off a fourth year specialty (neurology), with another in the queue (orthopedics) - in the interests of more personal/interview time for myself next year.

I'm not gonna revisit the specifics of each rotation I've been through. Instead, I'm going to touch on their similarities.

Studying
Yes, I've harped on and on about how third year's a stark contrast to the first two, in that we aren't buried in books all the time. Key phrase: all the time. Yes, it's still med school and we accordingly still have to study. After all, I couldn't have learned surgery or psychiatry magically. Granted, you learn to some extent in the hospital. But in my experience, the hospital is more of a platform to apply what's been read, reinforce your learning with real patients, and a chance to show attendings and residents what you know. It also lets them get to know you as a person, which I'll touch on later.

At the end of each rotation, there's a "shelf exam." Why the term shelf? No idea. But that clerkship final is referred to as the "shelf." It's national exam of 100 questions given over 130 minutes, with a bajillion answer choices at times. Seriously, the bubble sheets go A-K for some parts. Akin to Step I, it's not just straight up recall. The questions are clinical vignettes reading a paragraph long in which have you integrate a lot of information together and whatever experiences you have. Then, question style can be tricky: secondary or tertiary in nature and/or patient management related. The last option is particularly hard at this point in our careers. Oh and the time crunch is very real and pretty severe, even for the psychiatry shelf. At the halfway point of both shelves so far, I was disconcertingly behind halfway pace.

Bottom of the Pole
As med students, we're at the bottom of the medical hierarchy. Even M4s are senior to us. At this point, we don't even have the luxury of having gone through the core rotations like fourth years have. As such, we're there for purely learning purposes - much like anyone who's not an attending: chief residents, residents, interns, M4s. Unlike those people, our base of knowledge and clinical utility is pretty limited, making us remarkably well suited for scut work - grabbing paperwork, transporting patients, food delivery, etc. Also, since we're new to the scene and rotating through different styles of services, M3s are remarkably awkward for the first few days on service. It's like being a high school freshman again, but having to pay for that experience.

Evals
I already mentioned the shelf exam and what that entails. Of note, it's worth 1/3 of our grade for the rotation. The other 2/3 comes from the attendings, fellows, and senior residents on service with us. Quick summary of what goes into those evals: interpersonal skills, knowledge base, work ethic, professionalism, intellectual curiosity, communication skills, technical skills, etc.

Also of note, comments made in our clerkship evals show up in our med school records. Along with board scores, these third year comments and clerkship scores carry pretty significant weight in residency apps. With all this in mind, being constantly evaluated changes everyone's behavior, to varying degress among different people. Most people don't ask if/when they can leave - even if all our work is finished. Instead, we wait on seniors to give us the ok. Most of my interns and chiefs have been pretty good about letting me go within reason. Others, not so much.

On the other end of the spectrum, there are the ass-kissers. I.e. always volunteering to give a presentation, bringing in journal articles, and just brown-nosing it up. Best thing to do is to not get too annoyed and stay out of their way. Even more annoying and malignant are those who do the above, while also trying to actively outdo/outshine other med students even if it means intentionally making them look bad. There's an understanding among med students that we won't steal others' thunder or try to one up each other in the interests of getting a good eval. Some people obviously don't believe in that mantra.

Work
As I mentioned, M3's primary purpose on the team is to learn. I also touched on how there's some scut work. Outside of that, our work consists of a few basic things we can contribute to the team.
Pre-rounding:
This is basically work that happens before rounding on your service's patients with the team. It'll consist of checking up on overnight changes from nursing and other services. I'll also see if yesterday's orders were followed through on and note any changes in patient conditions. There's follow-up on any biopsies, imaging, and consults that were placed. I'll also see my patients, see how they're doing, and do a brief exam in followup.

Rounding:
We see the service's patients together as a team, usually with the attending. Updates are presented by the med students, residents (who carry more patients, including ours) fill in any gaps we miss, and the attending talks about the patient and elaborates on any teaching points. We see the patient together and then discuss the patient's assessment and plan.

Consults/Admits:
Throughout the rest of the day, we finish up and followup on orders, imaging, and testing ordered on our patients. While all this is happening, your service will get called throughout the day for patient admissions to your service (e.g. recent stroke patient to neurology) or consults from your service (e.g. new onset numbness/weakness in a heart failure patient on the medicine service).

Avg. work day so far: surgery (5AM~6PM), psychiatry (8AM~4PM), neurology (730AM~4PM)
Avg. work week: surgery (75-100 hours), psychiatry/neurology (40-50)

Caveats:
This is the basic framework of a workday. Each service at each hospital with different housestaff will have their variations. The biggest variation comes with the surgical specialties. Prerounding takes place earlier in the day, rounding takes place throughout the day between cases, and consults/admits/floor work are handled between cases or after the operating day is over. OR time makes the work day that much longer, because we still have to medically manage and followup on our patients. That unfortunately makes morning (pre)rounds particularly abrupt and impersonal - there's only so much time that each patient can get in the morning if you have 40-50 patients to see in an hour. Not mentioned are lectures we have to attend and presentations we have to give. These are usually either around lunchtime or during the afternoon. Also not included in the workday are the hours spent studying, prepping for presentations, and reading up on upcoming cases. On last caveat: this all describes a typical inpatient/hospital day. I've yet to be out in the clinics.

So that's basically what a third year rotation looks like. There'll be different flavors depending on if it's medical/surgical, where you're at, and who you work with - but it's all variations on the same theme.

Rebuilding Years

I'd consider myself a fan of most sports. That said, my teams are the Rams, Bulls, and Illini. And I'd consider myself a peripheral Blackhawks, Cubs, and Bears fan. Not a whole lot to be excited about right now.

Rams
I haven't gotten the chance to watch any of their games, but I think I'm probably better off that way. Seriously, we're not just losing. We're getting demolished to the tune of 24-108 over four weeks. In years past we could at least put up some points. Not so much anymore. I just glanced over the schedule and there's no game that made me think "Yeah, we should win that one." Maybe the Lions, but they're actually decent this year. Maybe we'll tie their record and put up an oh-for season too.

Illini football
I have watched most of their games. It's just straight up frustrating to watch their games. Aside from the Illinois State game, it's been a clinic in how to get in your own way. Big play? Well done, let's make sure it was run in an illegal formation. Or that somebody got caught for tripping. Or if we do gain momentum, let's kill the drive by throwing a pick or racking up penalties. Much like the Rams, the offense was the stronger unit of the two. You would think that after three years of Juice and Benn and a year with Dufrene that we'd have a pretty good offense. Apparently not so much.

Bulls
I'm actually excited about their season to start. Last year's series with the Celtic was a damn good one and isn't a bad thing to build from. I'm one of those that was happy to see BenGo leave. Yes, it's a huge scoring void and yes, we lost some "clutch shooting." Regarding the latter though, if you jack up enough shots on your own whenever the hell you want, you're going to hit some of them. Double-pump fadeaways from the corner shouldn't be a go to move.

Illini basketball
Like the Bulls, I'm pretty excited about this season. The first round exit to Western Kentucky was pretty disappointing, but apparently we couldn't stop Mendez-Valdez. Either way, I'm actually a fan of McCamey - hopefully he's more consistent this year and doesn't disappear for stretches in (or of) games. Our freshman class is pretty highly regarded too with Richardson, Bertrand, and Paul. That said our team is pretty young, having lost Brock and Meacham and with McCamey and Tisdale being juniors. Regardless, I have pretty high hopes for the season.

Chicago Olympic Bid
Ousted in the first round and it wasn't even close, since we were supposed to be one of the frontrunners. We got 18 votes in the first round, Tokyo 22, Rio 26, and Madrid 28. It was fun while it lasted. I think it would've been pretty cool to have the Olympics in Chicago. It also would've forced a pretty massive infrastructure upgrade and infused a lot of cash into the city. That said, Daley eventually signed over the city to be responsible for cost overruns. Overruns which would have happened and may have run into the billions. (In contrast to other cities being backed by their governments.) But I see that as the price of being able to get federal and state funding for infrastructure including the CTA, Metra, and highways while also fast-tracking said projects. The Olympics would've also stimulated the development of economically depressed parts of the city: around certain venues and especially in the proposed Olympic village area.

As for the sports that are happening now, the Illini and Rams are a combined 1-7. At least my fantasy team is at 2-2. Yay.