Lots to learn

I've been an intern for about a month (and a half) now. I've saved about 5 people's lives so far. Now... before you think I'm

Let me clarify: all of these patients would have been totally fine without me. I am nothing special. Even though they seemed "critical", basically anyone in the ED would have been able to handle these patients. This brings up one of the most important lessons I've learned (or rather - I'm learning) since I became an intern. The critical patients aren't the ones that actually wrack my brain.

My residency director brought this up with me very early on. I was talking to him about the critical/resus beds and I said something along the lines of "I'm afraid of walking into a critical patient's room... I don't know what I would do". And he responded with "actually, the critical patients we know exactly what to do with - it's resuscitation - it's definitely tough, but you know what to do". "The tough patients, for me at least, are the ones who are undifferentiated - like the back pain patients. Is that the guy who pulled a muscle after lifting something heavy? Or is that the guy who has a leaking Aortic Aneurysm and is about to crash? That's what keeps me up at night".

And boy, was he right. And I'm realizing this just a month and a half into my intern year? Clearly wise words.

Don't get me wrong, I am by no means a master (or even a padawan) of resuscitation. I've got a ton to learn, but I feel like it's something I can learn. What is really challenging - and this is one of the cornerstones of why doctors do years (and years) of residency - is differential diagnosis. It's a process doctors go through to make a list of diagnoses that we think explains why the patient has X symptoms. Then we play detective and try to figure out what is more or less likely.

And yea, it's hard.

For some complaints, you can have a differential over 10 items long. You are forced to think laterally - to think outside the box. Take the back pain example - sure he may have lifted a heavy box and now has back pain... but what if it's actually an infection in his spinal cord that decided to get worse at about the same time as him picking up that box?

Unfortunately, doctors (just like all humans) are at risk of falling into various biases when trying to make decisions. While one part of our training is to help us figure out what should go on the list of differentials, another equally important part of our training is learning to circumvent (as best we can) all those annoying biases. These are things we've been trying to learn throughout medical school. And these are the things we will continue to learn well past our residency days (or so I'm told).

This is what I see as my greatest challenge in residency: building that differential, keeping it wide, and avoiding pitfalls. Or so I think now. Check with me in a month - maybe something else will be my "greatest challenge".

But I've got to say. Through all the doubt and disappointment (when I'm wrong, and I'm wrong pretty often at this stage) - medicine is an amazing field. I'm humbled every day that I get do this. Sure, doing 8 days of 12(ish) hour shifts back-to-back can really grate on your resilience (and social life). But where else do I get to feel like:

Image from www.explodingdog.com

And seeing that look on a patient's (and their family's) face when we are able to help them? Best feeling in the world. It's not always roses and it's definitely not always easy. But maybe that's what makes those "stand out" moments... well. Stand out.

- Karthik
#DrKarthik

The doctor is in

So. This happened.

I graduated. Now it's time for me act the part... and start residency. It would be fair to say that my reaction is equal parts excited and scared out of my mind.

It's been a long road getting here, but I'm very excited to be here. Can't imagine any place I'd rather be. But it's scary. Now, people will turn to me and ask "so what should I do about this". Or "what do you want to do for this patient." Sure, 4 years of medical school has taught me quite a bit, but it's not nearly enough. That's what residency is for... but it's one of those "here, let me push you into the pool - time to learn how to swim."

The good thing is - and in honor of father's day - it's exactly like a dad teaching you to swim by pushing you into the pool (PS - happy father's day dad!) It feels scary, but he's standing there. Making sure you don't drown. Giving you advise just when you need it, but letting you try and figure out as much as you can by yourself. And that's what my teachers / attendings / nurses / fellow residents / patients and all the support staff will be over the next 3 years of my residency training.


Well. Over the rest of my life really. You can't ever know everything in medicine. You can't ever know how to deal with every situation a patient can come in with. And in the Emergency Room, I have no idea who is going to walk in with what. It'll be scary. It'll be chaos.

And there's nowhere I'd rather be than right in the middle of it. Learning. Helping. And, hopefully, healing. I've still got a ways to go. Better get to it. Tomorrow is my first day as an intern at Cooper University Hospital.

So I end my medical student career with these words: “You’re braver than you believe, and stronger than you seem, and smarter than you think.” –A.A. Milne

And I'll start my residency career with these: "Let's do this."

- Dr. Karthik
#DrKarthik

Match 2014 Episode IV: A New Hope

The epilogue

The letters are opened, food has been eaten, dance floors have been trounced. Match day has come and gone.

It was an amazing experience. There was just so much excitement in the air, it was crazy! It was interesting to see how a few hours later... all of us were beat. Maybe it's because we are older now, but more likely it's because of how exciting match day was. I think our adrenal glands were completely done after pumping out gallons of adrenaline to keep up with the match day.

The sheer excitement was amazing and humbling at the same time. I can't believe I spent the last 4 years with these amazing people. Penn Med's match list for 2014 (as it is every year) is amazing. It was also so nice to see so many friends and families come out to support us. I know everyone things graduation is a big deal, but for medical students - it's all about match day. This is what we've worked very hard for over the last 4 years. Actually for many of us, this is something we've worked towards for almost 2 decades. So definitely the bigger deal.

It takes a while for the truth to sink in: I have my first job as a doctor. That's crazy. Personally, it's a bit disappointing that my first job as a doctor pays me less than my first job out of college (almost a decade ago). And I have way more loans. But that's just how medicine works (initially anyway). Besides - life isn't just about money. And medicine is so much more than just dollar signs.

Match day is a happy day. But it's not equally happy for everyone. Most students from Penn match in their top 3. Almost everyone matches in their top 5. Then there are those who do not. Now - matching itself is a great accomplishment. But it's easy to forget that when you have your hopes set high it's easy to get them (seemingly) "dashed". Much of life is about expectation management. Most of us didn't get here by aiming low. We aim high. Very high.

Unfortunately, when you aim that high and miss, the fall is pretty painful. Some people matched "not as well". At their 14th spot out of 14 programs on their list. On the other side of the country from their family and friends. In frigid temperatures. There is no doubt that they will still get amazing training and become amazing doctors. But it fell short of some personal, subjective criteria. And thus, some people are sad on match day. A sadness that is heightened because it stands next to the sheer, unconditional joy that the rest of the medical school feels (i.e. the ones that matched to their top choice). It isn't personal, but it's hard to not take it personally.

Personally? I wasn't very happy at match. I wasn't sad, but I wasn't jumping for joy either. Based on my match results, everyone around me was happy for me... except me.

I will start training at Cooper University for Emergency Medicine in Camden, NJ. Regardless of where you are in the US, you've heard of Camden. And that's the exact reason why it is an amazing place to train for Emergency Medicine. If you try to conjure an image of an emergency medicine doc, you are probably picturing the kind of doctor produced by Cooper (or from any place in the US that has quite a bit of trauma and violence - like Harlem, Baltimore, St. Louis, etc). Camden also has a surprisingly high amount of medically complex patients - again, great training for residents. Camden, in general, has a big focus on medical education and their residents do exceedingly well when they get jobs after residency. I also have a strong interest in higher level management of hospital systems - and Cooper has a specific track devoted to teaching this.

And it's in Jersey (across the river from Philadelphia). So it's obvious why my family (they live in Jersey) and my friends (who are mostly in Philly / Jersey / New York) are happy about this. My fiancee loves Philadelphia so she's happy about it.

So why wasn't I happy? Because of mismatched expectations. And focusing on the things that don't actually matter.

I hate cold weather. Always have. But I ended up living in Canada for a year. I went to Cornell for undergrad. I was in Philly for medical school and went through the polar vortex. I've tried to go to California every step of my life: undergrad (didn't get in), work (did get placed there, but got moved to Jersey soon after), med school (didn't get any interviews) and now residency. So when I said I wasn't as jump-for-joy happy about the rest of my classmates, it was for one reason only: I missed out on the California weather. Yes California is more expensive. Yes California's on the other side of the country from my family and friends. BUT OMG WEATHER!

This single-minded focus meant I shut out all other possibilities from my head. Even though my rank list was pretty split between California and Philly / Jersey, I only thought about California. I dreamed of getting up and walking outside without having to put on 3 layers of clothing. I had blinders on. I wasn't even thinking about "hey, what do I need to do to be a great doctor?" (now, this doesn't mean that California training programs are not awesome, I'm just saying I didn't think about that aspect as much). I wasn't thinking about "hey, what about all the other stuff that matters for the next three years, apart form the awesome weather?"

So, when I opened my letter and saw I wouldn't be in California... I didn't know how to handle that. I have to be in cold weather for another 3 years!? I have every intention of starting a family and putting down roots over the next few years... which meant this was it. I probably would never get to move to California again. And that made me very sad.

Did it matter that when I start a family I'd probably want to be close to my parents in Jersey? Nope!

I never claimed I was the smartest person in the room. And over the last few days, the objective parts of my brain have kicked in and said "Dude. Seriously?" To the point where I feel ashamed that I wasn't happier than I was on match day.

But that's the thing about being human: we aren't objective 100% of the time. We don't approach everything rationally. It's very easy to take for granted the things we have in life.

It takes a long time to realize that we were given what we need, not what we want.

How does that Rolling Stones song go? "You can't always get what you want. But if you try sometimes, you might find, you get what you need!"

The unofficial mantra of the match process is "trust the match."

I'm a believer.

Congratulations again to everyone at Penn Med and everyone throughout the US / world that matched. I truly hope that you matched where you needed to. And I cross my fingers that it lined up with what you wanted.

Match 2014 Episode 3: It's about time

This will be a short blog post.

Between finding out that I did match on Monday to 11:30 am today (Friday), it's been mostly excitement. less anxiety. I think my fiancee is more anxious than I am. My family still doesn't understand the idea that I only match to one place (unlikely how medical school / undergrad admissions work).

So I went to bed at 2 am so I'd sleep in till 10:30. Unfortunately my fiancee woke me up with a call at 8am because she was super excited for me. No other way I'd rather wake up in the morning - it was cute to see how excited she was.

These are the times you realize how much love and support surrounds you - when everyone around you is way more excited than you are.

And man, this has been a long time coming. 4 years of hard work. A couple of decades of hard work before that. Making sure to dot my i's and cross my t's throughout my education career. Following the long road to my dream. And today - I get to hear about my first job as a doctor.

Let's do this. I have no idea where I want to be or what school I want to go to. Partly because I am shielding myself from disappointment.. but also because I would truly be happy to go to all the schools I listed on my rank list.

So, here goes everything!

Edit: The graduating class decided to give a gift certificate to Barb and Helene - two awesome rock starts at Suite 100 (our administration office) to thank them for all their help over the last 4 years. You guys definitely deserve it! And the standing ovation!

Edit 2: They've started calling names now. It's like a lightning round. Name after name - people run down, grab their envelopes and hurriedly open it. We are all screaming "whoo"s and "yeaaa"s. I don't think my voice will survive this day. Also, I don't think I can keep track of all of my friends who've gone up while still listening for my name. Man... the atmosphere is electric!!

Edit 3: I forgot to mention this. Each person who matched today brought in $1 to put into a pot. This would go to the person who's name got called last (people's names are pulled out randomly). A nice gesture!

Match 2014 Episode 2: The middle chapter

11:58 am, Monday morning. I'm walking across the South Street Bridge onto campus. Officially, I'm walking to the administration office to pick up some paperwork for the VA (I'm planning to do a rotation there in April). Unofficially, I'm walking over as a backup: today is the day we find out if we matched or not. If we didn't match, we have to go through the "scramble" process (now called SOAP - see my previous post for more details) to find residencies with an open slot. To do that, it's recommended we be on campus between noon and 2 pm to meet with our advisors to help with the scramble process.

As I mentioned last time, this is the anxious phase for me: if I match, then the excitement will build. My plan last night was to play video games and watch TV till about 2 am so my body would sleep till 10:30 am. So I wouldn't have to nervously pace for too long before the NRMP emails went out. So I wouldn't have to look like this:

Back to the bridge: my phone decides to play "I got a feelin'" by the Black Eyed Peas, from their album The END (Energy never dies)

It's an oddly calm day on the bridge. It's also snowing pretty heavily given that it's mid/late March. It was like a scene out of a movie. And, out of nowhere, a large gust of wind hits me and swirls around. At this point I thought to myself "hmm, maybe this is a sign."

So I pull out  my phone and there it was: a new email. In the little preview line you get with the notification I see this:

From: NRMP
Subject: Did I match?
Body: Congratulations! You have mat...

It's 12:01 pm and all I want to do is a happy dance on the bridge. Unfortunately it's icy and I'll probably break my neck if I tried. So I settle for a "YES" with a windmill of my arms and ended up in the following Rocky pose:

Complete with snow and hat and everything!

I am very happy and very excited to have made it this far. I cannot wait to see what happens on Friday. The last few days have been a roller-coaster ride, and I'm sure the next few days won't be any different. But I do like roller-coasters - and now all I have to do is enjoy the fun. 

Friday can't come soon enough. I could end up here or, literally, on the other side of the continent.

4 days to go.

I predict there will be two more posts: the moments before the match - blogged "live" from Dunlop. And then a blog of the aftermath / the epilogue.

PS who is the first person I see in suite 100 as I get in? Helene of course. It was epic.

Match 2014 Episode I (the prequel)

Hiyo!

Depending on where you're seeing this, you will likely see a mirrored copy of this blog post on either Penn Medicine's Match Day series, or on my personal blog site. A special thank you to Penn Med's dept of communications for helping me organize my thoughts into a three part series.

I have heard nothing back yet about where I stand in the match, and it's pretty nerve wracking. To bring you up to speed, here's the sequence of events in Match 2014 (I took this directly from the National Residency Match Program website).

It's hard to believe that just a few weeks ago I was looking through long spreadsheets with complex calculations trying to figure out how to rank the programs I was interested in. I had multiple categories: location, cost of living, "feel" of the program, future opportunities, future "settle down" potential, etc. I designed an awkward weighting for each of the categories. Then I plugged in hard values based on my interview day (and research from here for cost of living). All of this culminated in a final rank list. I compared this against a more subjective rank list I'd come up with (which had significant input from my fiancee). Funny enough, they were very similar (which probably means my subjective selection took into account all the objective categories in the excel calculator).

Finally, with my fiancee on the line, I clicked "Certify my rank order list" one final time. All of this happened a few days ahead of the Feb 26th deadline.

What now?  ...We sit on our hands till Match day rolls around. In a way - this is good. There's nothing more (within reason) we can do to affect the outcome of the match process. So, every time I start dreaming (or nightmare-ing) about match day / week, it's easy enough to tell myself: "Well, I can't do anything about it, so I might as well just sit on my hands and watch some TV."

Problem is - how many people in the medical field do you know who are ok with sitting on their hands? In many cases (many more than medicine would like to accept) - doing less is better. But doctors have historically been horrible at doing less. Discussing whether or not doing less is more is a topic for another day - but suffice it to say that doctors, as a whole, prefer to do rather than not do. This makes it very hard for us as fledgling doctors to sit on our hands while a magical computer in the sky crunches numbers and decides our fates.

The best we can do is keep ourselves busy. On a personal level - I have a lot riding on this (as does everyone). This is my third career. I put quite a bit on the line by leaving the corporate pharmaceutical world after 5 years and entering medical school. It may be an oversimplification - but all your efforts over your 4(+) years in medical school boils down to this: the Match. It will determine where you'll end up for the next 3 or more years of your life. In some cases, it also determines what path you walk down - what kind of doctor you'll become. No pressure.

I'm lucky in a way: I was doing some clinical rotations for the past few weeks. I'm also directing, acting, dancing, collecting funds for and making ads for the medical school play we do every year. All of this keeps me busy by default. And there's all these TV shows I have to catch up on!

But patience has never been my strong suit. And limbo sucks.

NRMP hasn't been too helpful either. You find out on Monday if you matched, then on Friday you find out where you matched. The reason for this separation is the the back-up process built into the match called SOAP (Supplementary Offer and Acceptance Program). SOAP kicks in if you do not match in the first round of matching. Mind you, this is significantly better than the previous back-up process (affectionately referred to as "The Scramble") because SOAP is more computer-based. So, why is NRMP not being very helpful during our wait? They send us emails telling us about our eligibility for SOAP. When you open their emails, it takes a second or two for you two realize that NRMP is telling you nothing about whether you matched or not - they are just saying "hey, you have everything ready to participate in SOAP... just in case". Which is definitely nice of them to do! But for neurotic medical students, those few seconds of panic is quite painful.

So here I sit, waiting for Monday (2 days away) to find out if I matched. I am secretly happy that I'm eligible for SOAP (most people who go through the match process are) - just in case. I've thought through possible Plan Bs, Cs and Ds. I'm not sure what's worse - waiting till I find out if I matched, or waiting between Monday and Friday to find out where I matched. I'll report back on that.

The oddest thing? I'm not excited. I'm just nervous and anxious to get this over with. I'm hoping this changes after Monday - when I find out if I matched. After everything we've been through to get here, this should be a very exciting time for us. Here's hoping the excitement mounts soon and overshadows all this anxiety and nervousness.

I will end with one of my favorite images on the net:

- Karthik the-not-so-patient.
#PSOMMatch

What gets under your skin?

Oh hello there!

Looks my last post was in June 2013. That's about 7 months ago. Yowza. Even for me... that's pretty bad. Oddly, compared to my first 3 years in medical school, I've been the most "free" over the last 7 months. Starting my fourth year has been an interesting transition. I don't go to class and I'm not going to the hospital for clinic work either. But it's odd. Because of the two research projects I'm working on, plus applying for residency programs, plus flying around for interviews... I still don't get why I didn't have time to write more on my blog.

Oh well.

Also a shout out to my new found readers: hello MS1s (for posterity sake: class of 2018)! I'm very happy and honored you guys stop by to read my blog! Sorry it's not nearly as posh as a blog should be.

So, what's up for today's topic? Empathy!

A popular question asked on the interview trail (for residency) is "What kind of patients get under your skin?" Now of course, this question actually has nothing to do with the question itself. The actual question they are asking is "Do you have insight into what bothers you, and what actions have you taken to deal with it?". I mean, it would be great if they actually asked the question they intend rather than beating around the bush. But maybe that's also part of the "test" - can you read between the lines. But I digress (as always). I strongly believe that all questions are best answered honestly. Even when others are trying to play games - such as interviewers are (I'm not blaming them - that's a topic for another day).

So I thought about. What kind of patients bother me.

That's an easy answer for me: the patients who don't take responsibility for themselves. Take (a completely hypothetical, but not unrealistic, example): a very obese patient, with type 2 diabetes, comes in with uncontrolled sugar levels. Maybe even HHNK! For those interested in medicine: most patients with type 2 diabetes don't actually go into DKA. They tend to go into HHNK because, unlikely patients with type 1 diabetes - an autoimmune destruction of insulin secreting cells in the pancreas (at least, that's what we think it is) - type 2 diabetics tend to secrete just enough insulin to prevent florid DKA.

Anyway. So there's this hypothetical patient sitting on his/her bed... with a box of fried chicken wings (that's right, right? I'm vegetarian so I may have gotten the description wrong). And they say "I'm really good about taking my medications and eating right! This isn't my fault."

With the picture I painted, there are multiple issues in play: socioeconomic factors that may limit food options available, or if they can actually fill their prescriptions. Literacy issues or education issues which may prevent them from properly following doctor's orders. It's never one thing that causes health problems (or any real problems in our world) - if it was, problems would be significantly easier to fix. But let's focus on the point at hand: "It's not my fault".

That gets under my skin. I don't expect people to be perfect. On the flip side, I also don't expect people to beat themselves over their heads for not being perfect. I think the issue is with me: I come from an immigrant family and the common denominator for many immigrant families is the idea of pulling yourself up by your bootstraps. No excuses.

No excuses.

Coming from a "take responsibility" environment means when I see patients, who have the power to help themselves (and thus have a much larger impact in their own health than any pill ever could), say "this isn't my fault" - the primitive parts of my brain get slightly fired up.

Now, will any of this actually affect my care for patients? I hope not!

Why? Because I realize when this happens (thank you frontal lobe!) that I'm making this about me. And it's not about me. It's not about how I was raised. It's about the patient who's in front of me. It doesn't matter what my opinion is on their statement "it's not my fault." It is my job to tell them "you can help us make you better - here's how." And you better believe I'm going to try having that conversation with my patient - because it's the right thing to do. For them. Not because of how I feel about their "it's not my fault." I'll also get to work on hanging some saline bags to combat their HHNK while slowly getting their sugar levels down (again med people: recall that you can't just hit them with insulin to reduce their glucose levels! They'll become hypo-osmolar when the glucose disappears!).

But it still irks me. So, I say my serenity prayer:

"God, grant me the serenity to accept the things I cannot change,

The courage to change the things I can,

And wisdom to know the difference."
I'm not Christian, but it definitely helps me quite a bit. Whether you want to interpret it as me thinking I cannot change the patient's view of their perceived helplessness, or that I cannot change how my brain reacts to the patient's statement - that's up to you.

If you've read my older posts, you'll know my post about why "blaming" people is a bad idea. That's very different from the view I present here (or so I tell myself). This isn't about me "blaming" these patients. This is about me getting irked that so many people do not take responsibility for their actions. Which, unfortunately, builds a divide. You may think me callous or "not as awesome as a doctor". Which is fine, I know I'm not perfect. But I'm trying to better. Everyone has their buttons, and I know this is mine. Hopefully I'll grow and be better about this issue.

Ok. Wall of text done. I didn't even have any pictures this time around. Sigh. I'll do better next time! For now, I leave you with these closing thoughts:

Although I live by the saying "Forgive many things in others; nothing in yourself" - Ausonius,

PS - I start classes tomorrow! Actually class! In a lecture hall and everything! I haven't done this in... years. And this month of February might be the last structured set of classes I take (unless I decide to do an MBA or a JD or something down the line). 

- Karthik out.