So, remind me what you're doing again?

As most of you know, I hope to become a dermatologist. I like skin. It's really cool, okay? So from 2012 to 2013, I applied to dermatology residencies (see this post for a short explanation of why I have to do a residency). Everyone in medicine goes through a process called "The Match". Basically, here's what happens:

1. You submit your application to as many programs as you want in whatever specialties you want. The more programs you want to apply to, the more expensive it is to discourage people from applying to every program in the country. Most people only apply to one specialty, but some apply to multiple specialties if they're not sure what they want to do or they're concerned that one specialty is more competitive and they want a back up. Additionally, some specialties like anesthesiology, radiology, and (you guessed it!) dermatology require you to complete an intern year (or first year of residency) in one of the big basic medical specialties before starting a residency in that field. For example, I applied to intern years in pediatrics in addition to dermatology residencies.
2. After any and all the interviews you may or may not have been invited on by various residency programs, it is time to compose something called a rank list. Every residency program creates a list of the people they want to come to their program in order of how badly they want them. Every applicant also creates a list of the programs they want to go to in the order of how much they want to go to them. There are a lot of rules surrounding this process to keep people from making false promises and intimidating applicants. These lists are submitted in mid-February.
3. Between mid-February and mid-March, *~*something*~* happens with all these lists. I'm not sure anyone is really sure of exactly what happens. But as I understand it, this national organization goes down an applicant's list and tries to "match" them at their highest choice possible. This is only possible if a particular program ranked them high enough. If no program on an applicant's list ranked them high enough, that applicant does not match.
4.  On "Match Day", everyone who matched finds out where they matched. If you matched somewhere, that's a binding contract that you can't break without some pretty severe consequences. Tears are shed, both happy and sad, and it's a giant party. The end!

Not quite what my school's Match Day looks like, but similar energy.

I can't say I wasn't nervous going into this process. Dermatology is an extremely competitive specialty, second only to plastic surgery. I wasn't at the top of my class, and there were 9 other people from my medical school class alone applying into dermatology, which is a lot! But lots of people in positions that seemed like they knew what they were talking about told me that while it was challenging, they had every expectation that I would match SOMEwhere.

I stood up in front of my classmates on Match Day and proudly announced that I had matched into a pediatrics intern year in Philadelphia. Everyone cheered, I got champagne, and congratulations were passed around, but underneath all of that was the truth that went unspoken: I did not match into dermatology. I was one of the (usually few) people each year from my medical school who failed to match. Often this would be chalked up to not following advice for ranking programs, or not applying to enough residencies. But in my case, it was simply because I wasn't good enough. I did everything I could, and it wasn't enough.

Friends and non-friends alike would come up to me and start talking about it, about how well I was handling it. They talked about how, if THEY hadn't matched, they would be a complete mess and wouldn't know how to deal with everything. How did I do it? What did I think had gone wrong? What was I going to do? I smiled and thanked them and told them it wasn't that bad. They didn't see me bursting into tears, breaking down into an ugly cry on my roommate's shoulder the night I found out I hadn't matched. They didn't know how I had sobbed a mere hour after Match Day in my Dad's hospital room across the street (more on that later) before rejoining everyone for the festivities. I didn't let them see, because I was so embarrassed to not be welcome in the field I desperately wanted to go into.

This unique combination of embarrassment and devastation was what I think made me look so put together. I gave advice to third year students on the match process with poise and fake confidence, while all the while a voice screamed in my head, "Why should they listen to you?! You didn't even match!" I still feel that way, a year later. I envy all the fourth year students who matched into residency programs, who know that at the end of a certain number of years they can practice medicine. That's security that I still don't have. But I'm also nearly done with my intern year, infinitely wiser and more capable than where I was my first time applying for residency. Maybe this time around, I'll proudly announce where I match and people can congratulate me with no unspoken truth. Maybe this time around, I'll get to be a dermatologist.

*~*~*~*~*~*~*

I've enjoyed my time in my pediatrics intern year. Due to a rather strict social media policy regarding blogging about patient care, I have been absent from this blog. While I did try for a few months to get approval for this blog from upper level management, I was also struggling to be an intern and probably didn't try as hard as I could have. Now intern year is winding down and much more time will be opening up for me starting in July. I'm renewing the effort to get official blog approval so I can share some of my stories about being a real-life physician while still protecting patient care. Wish me luck, and either way I hope to be back to the blog soon.

It's a Bird! It's a Plane! No, it's...Super Medical Student!

Over the past four months or so, my friends and I have been jetsetting and roadtripping across the country. Lest you think we're traveling for fun, we're actually desperate to convince various training programs that they would be PERFECT for us, and we would be PERFECT for them. It's a rough process.

Part of the reason it's rough is that you have to get to know your interviewer and they have to get to know you in a very short amount of time, sometimes as little as seven minutes. Therefore, their questions and your answers become extremely (and stressfully) important. Some questions are pretty straightforward, and some really throw you for a loop. The next few blog posts will be a series on some of the questions I was asked during interviews and how I responded to them (or should have responded to them).

Today's question: "Tell me about a time you went above and beyond for a patient."

Source

I felt like this was a pretty tricky question. As a medical student, it's hard to determine from rotation to rotation what level of performance is expected. On one rotation, the perception may be that if you're not following five patients, why are you even here. On another rotation, that same number of patients may be seen as exceptional work, and wow this student is really together to manage so many patients! This can even vary on the same service, depending on who your attending, or head doctor, is.

So what would this interviewer consider "above and beyond"? At first I thought about when I had spent hours of my own time researching what could possibly be wrong with a confusing patient. But what amount of time would have met the criteria of going above and beyond without making it seem like I was inefficient at developing a differential diagnosis? I quickly scrapped that idea. The time I called three different hospitals to obtain medical records on one of our patients? Or would he think that is simply the medical student's job, and view me as a complainer for thinking that was a big deal?

Ultimately I settled on the time that I wrote out every single one of my patient's 22 medications, what they were for, and common side effects or pitfalls to watch for when taking those medications. I then spent an hour going through the list with her and just talking about what she had been going through. My interviewer seemed satisfied with that (though is it really possible to know?) and we moved on.

But it got me thinking. All these examples that I thought of were only possible because I was the medical student. I had the time to spend hours reading outside of the hospital because I wasn't stuck doing paperwork. I had the time to call three different hospitals because I wasn't trying to schedule two CT scans and an MRI. I had the time to write out my patient's medications because I didn't have six other patients to take care of.

If I ever end up in the hospital, I totally want a medical student involved in my care. They are the ones with the time to read up on what's wrong with you, they are the ones who are taking care of fewer patients and can give more time to each of them, they are the ones who aren't yet jaded by years in medicine and might care a little more about the humanity of their patients. It's something I hope I'll never lose, but at the same time I know next year that can't be me spending hours to go through a patient's medications with them. I simply won't have the time.

There are plenty of things I will not miss about being a medical student: all of my work being completely redundant, arbitrary grading processes, impromptu evidence-based medicine presentations, waiting for someone to sign my order for IV fluids, twiddling your thumbs for three hours at the hospital because there's nothing to do but no one has let you go. But I will miss having so much time to spend with my patients. I've learned a lot about building patient relationships during my time as a student. Now all I have to do is learn how to build that same relationship in a tenth of the time.

For those medical students out there, what will you miss (or not!) about being a student? For non-medical students, what would you consider "going above and beyond" for your care if you were in the hospital? For everyone, would you want a medical student involved in your care?

Does this index make me look fat?

Weight is a funny thing. It seems that experts can never agree on what constitutes the "right" weight. Should we eat a low calorie diet and be a little underweight? Should we be a little overweight? Who decides what is overweight or underweight anyway? One of the sticking points in these conversations is the Body Mass Index, more commonly known as BMI.

I recently told a friend that I was trying to reach a healthy BMI. He immediately went off on how BMI is a scheme concocted by capitalism and physicians to scare the American populace into losing weight, and how I should not even try to reach a healthy BMI because I might kill myself in the process. Now, I don't put much stock in such an extreme reaction, especially since this same person told me I couldn't be "serious" about losing weight without restricting my exercise to only cardio and cutting out certain "bad" foods. I'm certainly trying to exercise and eat healthier for better reasons than to reach a number on a scale. But it did get me wondering: how good of a goal is a healthy BMI?

BMI is a measurement calculated by taking a weight (in kilograms) and dividing it by a height (in meters) squared. It was originally designed in the mid-1800s, and first started to be used as a proxy for body fat percentage in the 1970s. Despite warning that BMI should only be used on a population level and not to determine any one individual's health, it is currently used by insurance companies and physicians as a diagnostic tool for personal obesity. In the average person, BMI can aid physicians in determining who may be at increased risk. Anything below 18.5 is considered underweight, while 18.5 to 24.9 is considered normal. 25 to 29.9 makes you overweight, and anything over 30 enters you into the "obese" categories.

Take a look at this handy-dandy chart!

The problem with BMI is that it cannot distinguish between fat and lean body mass. This means that it fails to mark some people as obese who have excess body fat, while it marks some people (like athletes) as obese who clearly do not have excess body fat. It also fails to adjust for the extremes of height, which gives taller people a deceptively high BMI and shorter people a deceptively low BMI. At least one physician has altered the formula to correct for this, and you can view the comparison between the two here.

So if BMI is so flawed, how can we use it? A study conducted in 2007 looked at the relationship between BMI and body fat percentage in college students: males and females, athletes and nonathletes. They suggested altering the cutoffs for what should be "overweight" and "obese" based on the population being examined. For example, if you're a female athlete, your cutoff for overweight should be 27.7, but if you're a female nonathlete your cutoff should be 24.0. Linebackers shouldn't be considered overweight until they reach above 34.1. Clearly, there's a lot of wiggle room.

Why not just measure body fat? Measuring body fat percentage directly is a real chore, requiring an individual to wear special clothing and be submerged in a water or gas chamber with trained personnel at special sites. Slightly more intensive than hopping on a scale and backing up against a wall. Even the body fat percentage calculated by electrical currents or measurements with skin calipers can be way off if performed by inexperienced people or on someone with significant obesity.

The BOD POD method of measuring body fat

But there are other measures that can add good information to BMI. For example, waist-to-hip ratio is a good indicator of how much fat a person stores in the belly. Where you store your fat is just as important as how much of it you have. More fat around the abdomen (i.e., a higher waist-to-hip ratio) is associated with poorer health outcomes than more fat around the hips or thighs. Your level of cardiovascular fitness is also important, like the fastest possible speed you can run on a treadmill.

So my original question: how good of a goal is a healthy BMI? I think no one would argue that I am an athlete, and I'm smack dab in the middle of the curve as far as height. So none of the pitfalls of using BMI apply to me, and I can trust that my BMI correlates with my body fat percentage fairly well. If anything I should aim a little lower than the upper end of "normal" given the 2007 study. For me, at least, BMI is a good measure of progress in my attempt to get healthier, in addition to waist-to-hip ratio and cardiovascular fitness.

What do you think about using BMI? Is it fair for physicians to calculate BMI and potentially base treatment decisions on it? Should we be required to obtain other complementary information to get a more complete picture of a patient's obesity status?

Fancy seeing you again!

I've been away from the blog for a while. First there were away rotations to make a good impression on, then a giant test to study for, then applications to submit, then interviews to attend. The thing about medicine is there's always something that makes you "really busy", something coming up that you can use as an excuse not to do something. The trick is going to be finding a way to do the things that are important to me anyway. And, despite my small number of posts, this blog is important to me.

I mentioned that I'm going on interviews. For those of you unfamiliar with the process, during the fourth and final year of medical school, students must decide what specialty they are going to train in. When we graduate from medical school in May, we will receive our diploma, become doctors, and have the much-worked-for M.D. placed after our names. However, we can't just go out and hang up our shingle and start practicing medicine on patients. No no, first we have to complete a residency. While we do finally get paid during this period (hooray!), we are still under constant supervision and continuing to learn, albeit less than a medical student. We will be known as "residents", and this process could take anywhere from 3 to 7+ years depending on the specialty.

So I'm traveling around the country, interviewing at different residency programs, trying to convince people of why I would make a good doctor and a valuable addition to their institution. It's rather intimidating and exhausting, not to mention I've now developed a surprisingly passionate hatred of people who place both of their carry-on items in the overhead compartments on airline flights. However, it has brought about a great deal of introspection regarding my life and what's important to me. One of the things I find myself talking about time and time again is communication, and my interest in writing naturally comes up as an example of practicing my communication skills.

I do want to be a writer as part of my career. The best way to do that is to write as much as I can and read what other people have written. I need to make it a priority. While interviews may be nerve-wracking, the questions I've been asked have helped me remember experiences during medical school that affected me in different ways. I plan to write about these experiences and other random thoughts in the near future. So, stay tuned! I promise I'm not going anywhere this time.

Let's be absolutely clear about this

I would like to open this particular post by stating the following very clearly. This is not a post about politics. This is not a post about abortion. This is not a pro-life or pro-choice post, and to use it as such is to misrepresent what I am about to say. This is long, but I ask that you read all of it.

As most of you probably are aware by this point, Rep. Todd Akin (R-MO) made some comments on Sunday (August 19, 2012) that have caused a great deal of controversy. Rep. Akin possesses a college degree in management engineering and a Masters degree in divinity. He worked as an engineer for IBM. He is currently a member of the U.S. House of Representatives (has been for 12 years) and is currently a candidate in the race to be the next U.S. Senator from Missouri. In the House, he serves as a member of the Committee on Science, Space, and Technology.

In short, Todd Akin is an educated and accomplished man. And that is why these remarks concern me so much:

"Jaco: So if abortion could be considered in the case of a tubal pregnancy or something like that, what about in the case of rape? Should it be legal or not?

Akin: Well you know, people always want to try and make that as one of those things, 'well how do you slice this particularly tough ethical question?'. It seems to me first of all, from what I understand from doctors, that's really rare. If it's a legitimate rape, the female body has ways to try to shut that whole thing down. But let's assume that maybe that didn't work or something. I think there should be some punishment, but the punishment should be on the rapist and not attacking the child."

While Rep. Akin has apologized for his remarks, saying he "misspoke" and that what he said was "ill-conceived" and "wrong," it does show an underlying and recurring assumption that may be more prevalent than I realized: that somehow, women's bodies can recognize a rape and prevent resultant pregnancy. What bothered me is that several commentaries I saw refused to comment on the FACTUAL ACCURACY of what Rep. Akin said. For example, Philip DeFranco, who is known for speaking his mind, stated "I am not a doctor or a scientist, so I cannot say if the female body automatically prevents pregnancies during rapes."

This is ridiculous! You should not have to be a doctor to know that Rep. Akin's statement is totally 100% false, anymore than you should have to be a doctor to know that smoking is bad for your lungs. I find it extremely unnerving that so many people were not totally sure whether or not his remarks had some basis in reality.

And I'm not the only one. The American Congress of Obstetricians and Gynecologists (ACOG), a group of licensed physicians who care for women, released a special statement the following day attempting to dispel this myth that the female body can prevent pregnancy following rape. It's fantastic and awesome and blunt and you all need to read it. I'll wait while you go do that. Back? Okay, moving on.

According to one paper from 1996, an estimated 32,000 pregnancies result from rape, but as ACOG's statement shows the actual number is impossible to discern. One paper even found that the rate of pregnancy after rape may actually be higher than pregnancy following consensual sex. Can psychological trauma or stress affect a woman's menstrual cycle? Yes. Is there any evidence, any evidence at all, to suggest that this idea can be extrapolated to a single stressful incident immediately prior to sperm exposure preventing ovulation/fertilization of an already released egg? No. I could go into the science of why this is literally impossible, but this post is already very long.

To suggest that the extreme emotional trauma of a rape will make a pregnancy impossible says one of two things to these women. Either there is something physically wrong with your body and you were unable to prevent your pregnancy like a normal rape victim, or you couldn't have been that emotionally traumatized by your rape (i.e. it is not "legitimate") because it clearly wasn't enough to kick your body into Prevent Pregnancy Mode.

Abortion in this country is a hotly debated issue. But when lawmakers and the lay public do not have an understanding of the basic, fundamental facts surrounding said issue, it limits our ability to have productive discourse. It devolves into people yelling at each other over the inaccuracies and lies being passed around as truth. I believe it is our responsibility as physicians to provide clear information on topics like this, and I'm proud of ACOG for doing so.

But what's WRONG with her?

I've been on a pediatrics rotation for three weeks now. I've encountered several frustrations on this rotation, but one that I've found rather surprising is our inability to always answer the question that every parent wants to know when their child is sick: what is wrong with them? WHY does he have a fever? WHAT is causing her rash? HOW did he get sick? Often the answer is something no one wants to hear: We don't know.

One case that sticks with me is a patient we sent home recently after she was admitted for a "rule-out sepsis workup". We do this in little babies for several reasons. One is that they really can't tell us what's bothering them, so we have to check everything. But another is that babies can get some scary infections from birth despite the best precautions, like HSV encephalitis or Group B Strep sepsis, and they require a spinal tap or blood cultures to diagnose these life-threatening illnesses, not to mention inpatient treatment at a hospital. Not all babies who are 4 weeks old who get a fever will have one of these scary infections. Many will just have viruses. But we can't sort out the not-scary ones from the scary ones, so they all get the workup.

This was my patient's second workup. She'd had one earlier in her little life with no obvious source of infection and she recovered well. Even though she was older than our usual cutoff she was very sick when she came to the emergency department, so she was actually admitted to the intensive care unit for a few hours until she was stable enough to come to a less closely monitored floor. Mom was very frustrated with her stay, since her blood, urine, and spinal fluid cultures weren't growing any bacteria and her viral swab was negative.

Just two of the many tubes used in a rule-out sepsis workup.

"It's most likely a virus," my attending (aka head doctor) told her. "There are hundreds of viruses out there. We can only test for a few of them, and all of those have come back negative. But we've ruled out the scary stuff."

"But is it my fault?" Mom asked. "Is it something I'm doing? We're very careful with her, we don't let her around many people, we boil her bottles, we wash her clothes separately. What else can I do? Don't tell me it's just another virus, I want to know why she keeps ending up in here!"

I wish I had an answer. Going into medicine, I thought that if I studied hard enough I would learn about all the diseases it was possible to have, and would be able to diagnose any patient. I think a lot of patients have this perception, too. If you don't know what's wrong with them, you're simply not smart enough. Shows like House perpetuate this myth each week with the brilliant doctor who figures out what everyone else missed. There's always an answer.

What was hard for me to learn in medical school is that in real life, it doesn't matter how smart you are or how much you know. The fact is that we never find an answer for many patients. It's extremely unsatisfying, both for the patients that recovered on their own and for the patients that are still sick with no obvious cause. For many, not having an answer is worse than a terrible diagnosis.

I'm still coming to terms with the uncertainty of medicine. As one physician I know put it, "I used to think medicine was like simple math. You plug in all the variables for the equation, all of their symptoms, and you end up with the answer." If only it were that simple.

Have you or someone you know ever been the subject of a medical work-up without an answer? Have you ever taken care of a patient who never received a diagnosis? How do you deal with uncertainty in medicine?

Just Do It

A few months ago, I attended a talk given by the famous surgeon and author Atul Gawande (if you don’t know who he is please immediately educate yourself). After he spoke, some of us stuck around for a book signing. I stood in line for thirty minutes, laughing and joking with friends, but secretly trying to keep my nervousness in check. Because as he was signing the three books of his that I owned and had read cover-to-cover, I was going to ask Atul Gawande how I could do what he had done. How could I, as a medical student with very little writing experience, become someone who writes about medicine as part of my job?

I actually chickened out of asking him as he signed my books. The organizers were making a big deal of getting people through the line as quickly as possible, and asked us please not to take up too much of Mr. Gawande’s time, especially if we had multiple books for him to sign. So I stood there and just told him my name and waited awkwardly for him to finish signing, each second becoming more and more convinced that I had missed my chance. But as I stepped away from the table, I thought to myself, “No. No, I drove all the way over here like an ADULT. And I am going to ask him this question like an ADULT. And then I will get an answer and follow through like an ADULT. Yeah. ADULT.”

I allowed the adrenaline rush of temporarily feeling like a grown-up to steer me back into line at the very end. I stepped back up to the table. I asked him my question. And I received both a wonderfully simple and infuriatingly broad answer: start blogging. “Really, that’s how I got started,” he told me. “Everyone calls it a ‘column’, but really back in 1996? It was a blog.”

This sort of advice is on par with other vague writing-related advice I have received.  Just write a little bit every day. Write what you know.  But somehow hearing it from Atul Gawande made it seem more legit. Like I actually had to DO it this time, and I didn’t have the excuse that it seemed too vague. It's scary, putting yourself out there on the internet for everyone to judge you. Or for no one to judge you, since most of the blogs on the internet don't get read. There’s no secret that accomplished writers or bloggers or YouTube personalities know about how to “make it big”. They just did it. And for them, it worked out.

So this is where I’ll be blogging and learning to be a better writer. This is where I’ll be writing about what I know. I’ll write about some of my experiences as a medical student. I’ll write about common questions that my patients ask me. I’ll write about how I feel regarding current topics in health or medicine. And I’ll write about what you guys want me to write about.