Friday, July 15, 2016

one doctor's struggle

It's been a hard week for me for a lot of reasons.  I'm going through another period of time where my work schedule and work-related stresses are ruining my relationships when I thought things were going well.

Right now I sort of wish I had a 9-5 no weekends type of job, just working hard but with time for family and loved ones.  I thought I had been doing well but I guess I was so wrapped up in adjusting to being a PGY2 that I did a bad job noticing how everyone else was truly doing.  I guess I was just viewing things through a tired, hazy lens.

Everyone and I have become tired of me saying "Things will get better."  It seems like there's always a new obstacle and things don't get better.  I've been trying  to make changes and effort but I guess it isn't enough.

Some of the work is wearing on me and I tell myself that's typical for residency, at least that's what a lot of people communicate candidly at work.

i'll have a real day off sometime this month.

I'm just going to get some rest and hope the forces in the universe help fix things for me a little.

Tuesday, July 12, 2016

Passed Step 3! Here's how you can pass too!

Kind of late, but passing Step 3 is a great feeling!  I can now focus on boards and jurisprudence and not on pediatric diarrhoea.

I recommend taking it as an intern if you're in something other than medicine so you can maximize your time studying for your specialty.  I'm not sure "who" exactly Step 3 is targeted for, but I thought of it as an exam more for the general practitioner before they go onto get their license.  

A lot of Step 3 is general medicine and you can pass doing great on general medicine.  Step 3 does cover OB and peds, but from what I hear, its usually the high points and big concepts.

There is basic sciences on Step 3.
Not a huge amount, but reviewing the mechanisms of common drugs used every day in clinic and wards will help you.  I've heard there could be some CRAZY pharmacological/enzymatic metabolism questions.

Step 3 is a different difficulty for everyone.  The way to really pass it with a good score is not just to have a superficial med school knowledge of medicine.  You need to get down into your differential diagnoses and know everything there is to know about thyroid pathology and iodine uptake, how vitamin D and PTH and calcium all interact in disease, generally a solid foundation in pathophysiology and patient management.

Prep Time
Don't listen to how long other people are preparing.  You do you.  Prepare for as long as you think you need to pass the exam in one attempt.  Some people take 2 weeks, some people take 2 months. Shore up your weaknesses until you feel confident.  That's the philosophy I took during college and med school.  Forget about those other boastful people

Prep Materials
I prepared for Step 1, Step 2 CK, and Step 3 with UWorld.  For Step 2 CS I just rented the First Aid book on Kindle from Amazon.  If you want the highest score, I'd suggest combining UWorld with First Aid Step 3 CK and

Get good at biostats!  I can't emphasize that enough.  Classic things like number needed to treat, types of study bias, and specificity and sensitivity are all over that exam in every block.

Clinical Cases
I honestly recommend practicing the clinical case scenarios because the software is terribly not intuitive and you could fail Step 3 if you don't know how to order labs, when to move patients to different treatment settings, and importantly, how to order surgical procedures and consults.

You will have to take into consideration what treatments/exams come first, the proper setting for them, and doing the appropriate follow up.  I had to shore up weaknesses on ulcerative colitis and Crohn's disease management as well as pediatric GI problems.

Expect to read a lot of films on your exam.  Make sure you know classic findings.  The patient in the question stem might not have their symptoms described or have any other information other than the chest radiograph you have to read.  Don't miss questions because you haven't reviewed deep sulcus sign or what a perforated ulcer looks on CXR.

Expect some basic EKGs as well as how they will tie into patient management.  Know what treatments actually impact mortality instead of just symptoms.

Know at least your first and second-line treatments!

If I Could Do it All Over Again

I would take any free time as a med student to study for Step 3 without interruption and take it earlier in intern year so I could open more time to study for my specialty.  I had the problem of a lot of heavy rotations early during intern year, but if I had the luxury of more time, I would've taken it earlier.

Bottom Line
All you really need to do is pass.  If you want a fellowship, find out how important your score for Step exams are early on before preparation.  Passing this exam will boost your confidence and do wonders for your morale intern year.  It feels just as good as passing Step 1 because you can feel the transition to another part of your career.  You might feel like you're deciding between 2 correct choices, and what might often be the case is just choosing the one that is the best first step rather than second step in work up/treatment.

Happy studying.  Good luck!

Monday, July 4, 2016

A typical day in anesthesiology

Anesthesiology is a pretty different field from a lot of medical specialties.  It's also a big difference being in the pilot's seat from pre-op clinic to the PACU or ICU.

Pre-Op Screening Clinic

This is where you meet some of your patients you take back to the OR.  Depending on the situation, you'll have a lot of laboratory work and imaging to review or you'll order an EKG or other tests based on guidelines and clinical judgment.  This is where a solid background in general medicine helps.

A lot of it is fast-paced but you have to be thorough.  Heart and lung disease are some of the biggest things to focus on, and I also do pre-operative counseling in the sense I explain to patients how important it is to stop smoking weeks prior to surgery and how explain to them how beneficial it will be to them to get their blood sugar and blood pressure under control prior to surgery.

Poor exercise tolerance or bad COPD can mean disasters.  Patients need to understand this.

I will go over the risks of anesthesia and get consent from my patients at this time.  I bluntly tell them how they should minimize their risks in an approachable, empowering way.  You want to do everything possible to minimize risk on elective procedures.

I tell patients I'll meet them in pre-op holding on the day of surgery and describe what pre-op holding is like as well as what will happen there.

Pre-Op Holding

This is where your patient will be wheeled back to in the morning.   Patients are often nervous so I take the time to address their concerns and explain to them what their anesthetic will be like and what they can expect perioperatively as far as their care from holding to the PACU.   Midazolam as indicated, kek.

I recommend starting your own IV instead of using a floor IV since those have usually been in a while and might not work the best.  Make sure the IV is working prior to rolling back.  Know all of the IV access available because a line can infiltrate on induction.

Pre-op holding is a place where hang ups can occur, even this close to the OR.  There needs to be good coordination between surgery and anesthesia when it comes to peripheral nerve blocks so the patient can be comfortable perioperatively.  I recommend every budding orthopedic surgeon and ortho resident to make the effort to mark their patient on time so anesthesia can do a peripheral nerve block prior to surgery because it makes a world of difference in vital sign stability.  Blocks translate largely into less tachycardia, less hypertension from pain, less narcotic use, and faster recovery time post-op and faster discharge.

MAC+regional block is a lot safer than general anesthetic alone in a frail patient.  Be an advocate for your patients.

The Operating Room/Induction of Anesthesia

We've usually pre-medicated patients with a little bit of midazolam just prior to rolling out.  We arrive in the OR and staff help us get the patient on the operating room table.  We start pre-oxygenation, finish set up, and then its time to induce with usually propofol, lidocaine, fentanyl, rocuronium, and whatever else we need while watching vitals closely and making sure we keep having good end tidal CO2.

This is where it can get scary.  You might not be able to mask ventilate.  You might go down difficult airway algorithm with a patient with a very large BMI, OSA who becomes hypoxemic between intubation attempts.  You might need to video laryngoscopy with someone else doing fiberoptic intubation.  You might need to wake the patient up.   You might need to cric in an emergency situation in a trauma.

Some patients don't tolerate much induction well with tachycardia, SVTs, hypotension, and sometimes you might even spend an entire case resuscitating aggresively with fluids and pressors, turning down the volatile anesthetic.  

Anesthesia to some might seem "easy" and "just watch the patient sleep," but I feel I've been working with sicker patients from the ICU and they generally need more support than say, the healthy 30 year old undergoing MAC for a hand injury.

Induction of anesthesia is a lot like the take-off portion of a flight: you know what to do, how to do it, and the general weather, but you might be making a lot of adjustments and changes to keep things going safe and smoothly.  Sometimes you might feel like you're flying with just one engine and need to take emergency measures like going lighter on the gas, less narcotics, etc, so the patient can survive.

After getting your airway, you have to inflate the cuff, start the ventilator, turn the volatile anesthetic gas to a safe amount, keep watching vitals, adjust your gas flows, secure your airway down, protect the eyes, start another IV or arterial line as indicated, hang antibiotics, put in your OG and esophageal temperature probe, put the surgical drapes up, address vital signs with medications/anesthetic gas/ventilator again, all the while no one is slowing down for you and continuing to demand the best surgical environment.  Surgeons will always be chomping at the bit to cut and move onto the next case.  The patient may be unstable and you don't know how long you might be managing their instability.

Maintenance of Anesthesia
It's not over yet.  Vitals will be changing in real-time and you have to keep running differential diagnoses in your head and put them in the context of the ongoing surgery while listening to what the surgeons say.  As described earlier, you might spend a case constantly resuscitating with pressors and fluids, mixed with making changes to your anesthetic during different steps in a surgery, and managing tachycardia and hypertension.

During anesthesia, there is always the possibility of MI, PE, hypoxia, pneumothorax, or other emergencies you need to be able to handle.

During the case we work quickly to give pain medicine that will cover the patient post-op while addressing issues like hypertension, hypotension, tachy/bradycardia, blood loss, equipment issues, etc.

With a good idea of where the case is going, you can start reversal of paralytics and going down on your volatiles.  Typically, emergence and extubation is pretty straight forward and then staff help you move the patient.  I don't let anyone transport a patient to the ICU without them being connected to transport monitors first, no matter how eager people might be to get out of the OR.  Be an advocate for your patient.

We reach our destination (PACU, ICU) and tell the nurses and MD about the patient, procedure, and medications administered.  We get a set of post-op vitals and reassess as needed.

It's satisfying to take a patient back from the OR to the PACU after major surgery and see them comfortable.

A lot of the stress in anesthesiology comes from not knowing how patients will respond to anesthesia or if there will be surgical complications but you learn to prepare and manage those kinds of situations.

Saturday, July 2, 2016

is this the best way to study during residency?

I ask myself that question a lot.  Lately I've been trying to speed-read because I know time is limited until my next exams and I'll be tired and overworked.

My theory is if I read quickly, I'll cover the material more and more times via repetition and it'll solidify.  So far that isn't working so I'm trying to make flash cards online.

The benefits of flash cards so far is that they're portable on whatever device you have, and you are reading the material actively as you're making your cards.  You can get as much repetition that way as you want and you actively test your recall. 

Recall was one of the biggest issues in medical school.  You're flooded with knowledge and you foolishly think you'll remember facts just because they're familiar when you're reading over them again, and then can't remember them for the exam.

It's all about what you find most "fun" and what method you excel with the most.  I have to remember so many details like half-lives, elimination, time of duration, doses, etc and I think flashcards are the best for me.  It helped me all through medical school, so I think it's worth a shot.  I'll let you know how it works

Friday, July 1, 2016

first day as a PGY2

So far a better first day than intern year's.  Then I realize a lot of residency is being yelled at for things you didn't do and getting caught in the middle of medical politics between departments.

Other than that it was the typical get in early and scramble to get things done and see all the patients in a timely manner type of day.

I'm excited to move forward in my career, I'm just pretty nervous about the new situations and being mistreated and disrespected by faculty.  So far just about everyone's made it through the program though, so I have that as source of comfort.

Well, I'm off to go read.  Wish me luck

Thursday, June 30, 2016

intern year is over!

The most difficult year of my life is about to be over.

Intern Year, Generally Speaking

A whole year of stress, anxiety, being pushed around by senior residents and attendings, being ignored and not taught while being pushed to my physical and emotional limits.

Working under intense time constraints with unstable patients, giving bad news and poor prognoses, soothing crying family members and patients, seeing some patients actually make it off pressors and out of the ICU, being thanked by patients and family during rounds, patients and their family giving me blessing after blessing for just doing my daily job.

Calling the shots to initiate pressors and call the code when I had done neither before.  Being called to bedside to get ready to pronounce someone dead soon and watching the final changes in their vital signs.  Getting cornered and pressure to make decisions without time for help because I have "MD" after my name.

Seeing way too many people die uncomfortably and unresponsive on a ventilator on pressors and seeing far too few people take the option of comfort care.

I hardly saw my friends, even the ones I started residency together with.  A year further in my training, a year spent becoming more separated from the people I love.

It took me 3 months to renew my driver's license because I had no time to do it.  I've seen hundreds of patients over the course of this year but I haven't been to a doctor myself.

I've seen a lot of the people I started residency with gain 20 pounds or more.  I've seen one person quit and two people switch residencies.

This year's been a blur for me, but when I really look at it, it felt like a long march, often stressful and joyless.  I call it joyless because after a while, the amount of clerical things you need to do and time spent at the computer wears away at you.  So does having to study for your specialty while trying to pass Step 3 in one go (which I did!  that was awesome!).

Clerical Woes
Medicine reconciliation is one thing and absolutely good for the patient, but having to constantly tell administration why this central line is indicated is ridiculous and sends the message to us that doctors aren't to be trusted.   Yes the patient is in the ICU and they are unstable and/or need central TPN, why do you need me to tick these boxes?

The Burn Out
Being a doctor is something you're excited about since childhood, often times.  Then there comes the classic intern burn out you hear about all the time.  For most, it happens in January.  For me, it didn't hit until this June.  I didn't feel the same satisfaction I had at the beginning.  Mostly because so much of medicine is done through a computer clicking this box, and typing in this order, being rushed and gradually eroded by volleys of non-critical calls from nursing.  Often you're trying to stabilize a patient and then you get hammer get paged/called about the decision to start diet orders or maintenance IV fluids on someone.  Day in, day out.

Also, being made to do some activities like consent patients for things while your superiors play on facebook or do nothing wears on you because on top of that, you have to do all your internly duties of H&Ps, progress notes, and fielding all kinds of calls your superiors don't have to do.  You're taking care of something every minute of the day until sign out is over.

Futile care is something that you'll learn about and will erode you.  I've been so direct and compassionate with families and patients who end up not choosing comfort care and see their family member die unresponsive on a ventilator instead of choosing comfort care.  I know they're not doctors and they don't get how medicine works, but I'm constantly pushed to "do everything possible" even though I explain they're going to die unresponsive on a vent.

Hospice or comfort care is viewed too much as a defeat..but when you're not going to win the battle regardless, why not die comfortably surrounded by your loved ones instead of the middle of the night after undergoing a dozen procedures we recommend against including surgically placed equipment/devices?  I think aggressive family-led care in the moribund uses up a lot of resources, but most importantly, means less time a patient spends comfortable with their family before they die.

Break Time
A year of driving to work at 530AM or in the middle of the night to work 10-14 days in a row without a day off.  Telling myself my weekend was "6 hours long" so I could convince myself I actually did have some semblance of time for relaxation.

I've become more aggressive about my time off.   I'm disappointed I have to make a timetable for all my activities, but it helps me get to everything fun I want to do.  The earliest I've started drinking and enjoying my time off is 0841, lol.  Whisky in particular is my drink of choice.

The Comrades

I've been able to make friends from different specialties.  The good part is I have so many friends going into surgery and surgical subspecialties that the OR environment as an anesthesiologist will be somewhat more familiar and less stressful.  I've become closer with the medicine interns most of all, but had the deepest bonds formed with the pediatrics interns.  A lot of off-service interns/prelims like ophtho, derm, and neurology bonded with me, mostly over the trying times we shared together and how badly we wanted to move onto our specialized training.

Monday, June 27, 2016

Thank you for helping my readership grow!

Hey readers, just wanted to thank all of you who are sharing my blog and telling others about it.  I feel like my blog has grown from a small whisper to an audible voice.  I'll keep writing about my adventures and trials in medicine and help make this blog a place where we can all get together and share our experiences.

So far I've been working 10 days straight without a day off and I'm so ready for my upcoming day off that will happen in just a few more'll be a great break.

cheers and thank you