The First Code

I am physically and emotionally exhausted. It's only week 4 of a 10 week rotation, and I'm dragging my feet, counting down the days, and watching the clock during the day. For me, this is worse than surgery. It's the hours, yes. Most weeks it's 70 hours, and if long call falls on the weekend (which is does for at least 5 weekends out of the 10 weeks) then it's 80 hours of work. It's the patients also, not that I blame them for being so very sick. Heart disease, kidney disease, lung disease, liver disease, blood disease....all the diseases that I have learned about in the last 2 years of lecture and self-study. I try to remind myself that the hours spent at the hospital, and with these sick patients, will help me to become a better doctor. Their suffering and diseases will help me to do better on my next board exam. I try to daily keep up with the vast array of knowledge that I am reminded I do not remember, or have never even learned. Yes, I am trying to see the cup as half full, but the truth is that I am almost completely empty.

I'm still trying to process the first code I have ever seen. Code is synonymous with some one's heart stopping, and the subsequent attempt to resuscitate the patient. It occurred 3 days ago, on our long call night, and the images still flash in my mind, right before I fall asleep at night, right at the time that I am most wanting to shut out the pain from my daytime hours.

I see her listless hand flopping up and down against the sheet, in between the ten or more doctors that surround her bed, as my senior resident does chest compressions. I glimpse her face, stark in the absence of life, and yet her eyes are open. I see one of the doctors intubate her with a breathing tube. I see yet another use a drill to put in IV access into the tibia bone of her lower leg. I hear the shouting of orders from the doctor leading the code. "How much epi has been given?" "Stop compressions! Check for pulse!" "More epi!"

Thankfully she wasn't my patient. I'm not sure that I am ready to loose a patient. She "belonged" to another student, who had seen her just an hour before, and although the patient was sick enough to be in the hospital, she certainly didn't look like some one who's heart was soon to stop. We stood in the hallway, running to get supplies if we could, otherwise feeling completely powerless, not only in our ability to help, but also in our ability to turn away. It was like watching a car accident in process. I couldn't turn away, certain that I would miss something, certain that she would definitely be gone if I walked away.

45 minutes passed. We did get some electrical activity in her heart, from the drugs given, but there wasn't enough to coordinate contractions to get the blood moving into her now floppy limbs. The lead doctor eventually decides it's time to stop. One by one, each of the doctors relinquish their duties. The anesthesiologist takes out her breathing tube. The heart monitor electrodes are peeled off her skin. The IV line that was drilled into her leg is removed. One by one they all leave the room. The nurses stay behind to continue cleaning her up, to prepare her for her family who is on the way. The same family that had just left hours before, with plans on returning in the morning to find out what we had discovered about her disease process. I waited in the hallway until the nurses closed the curtain. I was allowed to watch this heroic and seemingly barbaric attempt to bring her back, and yet was not allowed to be a part of what I hoped was a gentle apology for what we had put her body through. And that's just it. At the point of the attempted resuscitation, it was just her body, so clearly empty of life.

Her family showed up and were taken to the room. Crying could be heard from the hallway. I don't know that I could ever get used to telling someone that their loved one died. How will I keep the tears from my own eyes? We have no idea why she died, so unexpectedly, and will never find out as the family did not agree to an autopsy. We returned to our workroom at midnight, shocked, tired, and still with lots of work to do. We talked about what we could have missed. What signs did she give us that she was this close to death? What lab tests could we have ordered to give us a better sense of her sickness?

If that wasn't enough for one week, we got another very sick patient, dying of liver failure. At least with this patient, it was clear that she was going to die, it was just a matter of when. She lasted about two days in the hospital, as her organs shut down one by one. First her liver went (she was very yellow from jaundice), then her kidneys failed (no more urine production), her heart faltered (blood pressure dropped), and her lungs struggled for the last breaths of her life. We went into the room yesterday morning, to give the dismal prognosis to the family, telling them she was not a candidate for liver transplant, that her organs were shutting down one by one, that it would most likely be hours, and not days, before she passed. The tension and grief in the room was palpable. All of her children were there, as well as both of her parents, as she was a young fifty something year old woman. The only way I could keep my own tears from falling was to pretend to not be in the room. To not be present at all. Will I ever get used to this? And do I even want to? For now, I return home everyday with a heavy heart, and reluctance to get out of bed the next day and do it all over again.

Sick Doctors

I remember once during my massage years seeing one of my regulars who was an ophthalmologist (eye doctor) and asking how he had been since his last massage. He reported that he was very very sick, sicker than he had been in many years. I asked him if he took any time off work, to which he smiled and said "Doctors don't take time off when they are sick," which I figured at the time was just a representation of his generation. He was an older man, near retirement himself after a life of giving up his time to medicine, and had that "old school" mentality where it is expected for doctors to work over 100 hours a week, and work when sick, all without complaint. After just two weeks working in the hospital with internal medicine residents, I've realized that the expectation for doctors to work when they are sick is still very much alive.

Take the intern for example. Last week while giving presentations out in the hallways he would have to take a break to wipe his eyes, and the sweat off his brow. While in the rooms leaning over patients to listen to their hearts, he would tip his head way back, and deeply sniff, so that he didn't drip any of his nasal secretions on the patient. After the heart exam he would quickly go over to the sink, blow his nose, then wash his hands, and return to the work at hand, until his secretions sent him to the sink again. We watched him suffer for many days with his illness, all the while being slammed with the work of an intern (something I am NOT looking forward to). He would be sitting at the computer in the call room, with blood shot eyes from being up all night, and a sweaty brow from his fever, with runny nose and eyes, trying desperately to keep up with the relentless incoming pages from nurses about medications or symptoms of his patients. You see when on overnight call, the intern is not only responsible for the ten patients that we have on our team, but is also responsible for what is called "cross cover" - he is also responsible for all the other internal medicine patients in the hospital (because the other interns are home sleeping). My heart broke for him, and I wish that we could have helped him, but unfortunately medical students don't yet have what it takes to do intern level responsibilities.

If that wasn't enough to believe that this whole working while sick thing in medicine is utterly ridiculous, I have been fortunate enough to experience it myself, so that I can know for SURE, that it's absurd. Last week, just days after the intern's snivels started to abate, I started with the infamous sore throat, that soon led to a dry hacking cough. After several days I just started wearing a mask, because more of my time was spent coughing than not. I drank cough syrup like it was candy, and went though a whole bag of cough drops in one day. Thursday was the worst day, as it was long call day, which meant an overnight shift. Thankfully my resident sent me home to do my work, as she was probably sick of hearing me cough in the workroom. So after examining my patient, I went home to spend hours writing my history and physical exam, assessment and plan, and slept a few hours sitting upright on the couch. I returned for rounds early the next morning at 6 am, and spent the next 4 hours in uncontrolled coughing spasms in the hallways of our medicine ward. My eyes watered, I slugged another few doses of cough syrup, and prayed to at least stop coughing long enough to give my presentation to the attending. 3 hours later, after listening to the other medical students give their presentation, as well as the intern discuss the other patients, I finally got to my 10 minutes of "fame" which of course, was interrupted by racking spasms of coughs.

Now what is most disturbing to me about this whole thing, other than the obvious fact that I did NOT belong in a hospital, around patients much sicker than I, who definitely couldn't afford to get my illness on top of theirs, was the fact that we all pretended it was completely normal for me to be at work while sick. I'm looking into the resident's eyes, telling her between coughs what I think we should do for my patient, and it's like a HUGE elephant in the room, my sickness, that is completely ignored. Oh sure, I know that everyone on my team was aware of my sickness, just like we were all aware (and feeling bad about) the intern's sickness the day before. But no one can say anything about it, because like my massage client/eye surgeon told me years ago, "Doctors work when they are sick."

That is one of just many things in the medical profession that is totally insane, from so many points of view. First, there's the possibility of infecting the patients; then there's the idea that when a doctor is sick, they are probably not thinking very clearly (not to mention when combined with the drugs taken to help control the symptoms);and how about being a part of a profession that takes the oath "first do no harm?" Could one argue that going to work sick is not only harmful to one's self (should be at home healing), but also possibly harming a patient?

These are all things that I have thought a lot about this past weekend, as I laid on the couch, coughing up my lungs. As I coughed like crazy this morning, I thought about calling in sick, as I knew that I really need more time to heal (2 days just isn't enough). But here's the thing: I realized that to miss a day of work means that I have to make up this day, and when would I make this day up? I only have one day off a week anyway, and I certainly don't want to come in on a weekend day to make it up. And I imagine the reason doctors go to work sick is the same - when will they make up the work? If they have a whole day of patients, or several surgeries scheduled, when will there be time to fit all those people in? Sure, maybe you would be lucky enough to have another physician pick up your patients for you, but most likely, they are also overworked and have no immediate openings in their schedule. So imagine that a patient has waited three months for an office visit to see their doctor to follow up on some lab results, and the doctor has to cancel because they are sick, and you have to wait another three months. Wouldn't you rather just listen to him or her cough behind a mask, rather than wait? Most of us would probably admit that we wouldn't want to wait, and alas, that is why doctors go to work sick. While I don't have any patients that wouldn't be taken care of in my absence as a medical student, I certainly don't want to spend any more days in this hospital than I have to. So here I am at work, cough, cough, cough.

Short Coats

I just finished a 12 day stretch of work with no days off, that included three 28 hour shifts, on my internal medicine rotation, a ten week rotation that it the core of all medicine. The concepts reviewed in this rotation are the basic building blocks that hold up all other aspects or specialities in medicine. This rotation takes care of very sick patients who are put in the hospital because there is disease or illness in their internal organs - the heart, lungs, kidneys, gastrointestional tract, or blood, to name just a few. I've had patients with pneumonia, angioedema (swelling of tissues due to leaky blood vessels - in the case of my patient, his throat swelled up), AIDS (and the subsequent fungal infection in his brain), acute kidney failure, heart failure after a myocardial infarction (heart attack), endocarditis (bacterial infection of the heart valves), and blood loss due to a tumor in the stomach. As a medical student we are fortunate to only be responsible for one or two patients at a time, while the resident and intern have to know everything about all ten patients that our team takes care of (which I will have to do in only a year and a half).

Having only one patient to be responsible for at a time allows us ample time to talk to the patient, to practice our history taking and physical exam skills, and most importantly, to review the mechanisms and treatment of the diseases so that we can sound competent when we present our patient at the daily rounds. Rounding compromises walking around the floor to each patient's room, and discussing the "case" out in the hallway. There is a very strict order of how information about a patient is given to the rest of the team, and this is standardized across all medical schools and residency programs in the US. You start with a brief one liner that describes who a patient is, and why they were admitted. For example, "Mr. J is a 50 year old man with longstanding hypertension and coronary artery disease admitted for chest pain." You then go into what's called the HPI - history of present illness, which is a chronological account of how the current illness presented itself, a description of the symptoms, onset, duration, therapies previously tried, and any pertinent information that can help the listeners start to whittle down the potential list of what could be the problem for this patient.

After the HPI, you then launch into any other medical conditions the patient has, and what the status of that disease is, or how it is managed. Then it's onto family history of diseases (for example, it would be important to know with Mr. J that his father had his first heart attack at age 45). Then it's social history, where the person lives, what they do for a living, married, children, etc... plus their habits with tobacco, alcohol, and drugs. Then it's a list of their allergies, and medications.

Then you present what you found on physical exam, what the heart, lungs, abdomen was like, paying appropriate attention to those physical exam findings that will having a bearing on what the person was admitted for (you don't need to know Mr. J had clear tymphanic membranes in his ear, but you definitely need to mention what his heart sounds were like - regular rate and rhythm, and murmurs, rubs, or gallops?). Then it's on to the lab findings, where you list out the chemistries and blood cell counts, all the data that internal medicine doctors rely on to give them clues to what's happening with the internal organs. And if you've gotten an x-ray or a CT scan, you need to talk about the results as well.

After all this information is given, the most important part comes, the part where med students sweat the most. The assessment and plan. The "so what do you think about all this information, and what do you want to do for the patient?" You have to list each problem the patient had, whether in terms of their presenting symptoms (Mr. J's chest pain), or their past medical history (his hypertension), and any physical exam findings (say a heart murmur), and any lab abnormalities (say he has hyperkalemia - that's too much potassium in his blood).

No problem right? Well the first week the attending that we worked under wanted this presentation in 5-7 minutes. To make matters worse, while I am speeding through my presentation trying to decide what information is most crucial and cannot be left out, the attending is looking at the computer, most likely looking at the lab results I am trying to relay to him. By the way, the attendings and residents already know everything about the patient, and don't really need the medical student's presentation to make any decisions about care for the patient. This whole process is for the benefit of the student, which is hard to imagine given that most of the time the residents aren't paying attention, and are clearly just wanting you to hurry up so they can get their work done. At the end of my first presentation, the resident looked at his watch and said, "that was 9 minutes."

The second week was totally different in that the new attending gives us 15 minutes for our presentations, which feels so wonderful to have the time, and she actually listens to everything we say, to the point that we have to comment on every single abnormality, ones that the previous attending just blew off. I can say while the new attending means much more work, I prefer her thorough style because it forces me to look up reasons for any abnormalities, to understand the patient completely. It does of course mean that I have to get to work early, so that I don't make the mistake of not knowing why. As I've said before, I think most of the stress of this third year comes not just from the long hours, but from the constant evaluation that is occurring by the residents and attendings - those that will give you your grade, and have a say in your future. It's like constantly being on guard, hackles up, in preparation not for a discussion between equals, but for interactions that question your knowledge and skill as a doctor. I can't tell if the stress of this comes from the high expectations I have of myself (my inherent perfectionism) or from the unreasonable expectation that doctor's should know it all. All I know is that each day that goes by is one day closer to that MD next to my name, that day when I can no longer hide behind the short coat of a medical student.

Oh...Dr. Brooke?

There's something that happens once you start medical school and you go home to visit your family for the holidays. Every family member asks you about their health, no matter that you usually have no idea what they are suffering from. No matter when you explain you are just a student, only in your third year, and that you really won't learn anything until you finish residency, and at that point, you will only know what you specialize in. No matter, you still get barraged with questions. One family member launched his questions just as I stepped into the door with the statement, "Dr. Brooke what's this thing growing on my upper lip." So I peer in between the gray hairs of the mustache, looking intently like I am trying to decide from a long list of possibilities what this little growth may be, and have to admit, "I don't know what it is, you need to go see you doctor." Then I get an incredulous look, with the underlying and implied response being, "God don't you know anything?", and "What are you paying all that money for?" and "Are you sure you're in medical school?"

And in fact, I am constantly being reminded at how little I know. Sure I knew at one point, right before I took a 4 hour exam, and right after which it all disappeared from my short term memory in preparation for the next cram session. The things that have stored themselves in my long term memory at this point are only the diseases that are associated with actual patients that I have seen and taken care of in the last 6 months. And because I have just started the third year of clinical rotations, there are not a lot of patients and their stories in my head quite yet. There is really something to be said for apprenticeship however, it works! Too bad I can't just start an apprenticeship in physical medicine and rehabilitation. Nope, have to continue learning all about all aspects of medicine, and if I did a rotation in dermatology, then I may be able to answer my family member's question about that little growth on his upper lip.

So sometimes I have no idea what my family member is suffering from, and at other times, I hear my family talking about medical things that are way off from the actual truth, and then I have to figure out how to explain it in a way that is not condescending. Take something another family member said to me, "You know there are cancer cells in mother's milk." I just took a deep breath, and thought about correcting her, and then thought about how I would go about explaining what cancer really is...and gave up before I even tried. So many times I have heard people in my family say that medicine will never cure cancer because "they" make too much money off of cancer! That's one statement that I have no interest in even taking a bite of, so I just nod my head, and say something lame like, "You know cancer is not one disease. It depends on which type of cancer you have, and each one is so different, and it depends on the cell type...." all the while watching the eyes glaze over, and my family member moves on to their next attack on the health care system.

Today I heard about how ridiculous it is for a blood test for testosterone to cost $600. Of course I do think that's an insane amount of money, but I couldn't come up with a good reason why it would even have to cost that much. Must be a very specific test, one that has to be sent out to some special lab. I just bought my husband a book called "Money Driven Medicine, Why US Health care Costs So Much," and I'm hoping to read it myself, and maybe I will be able to answer the question about a testosterone test costing $600, maybe not.

I think what I am realizing is that I thought that once I started learning medicine I would start to KNOW things, you know, like what is that growth on the upper lip, or what cancer is, or why a hormone test is so expensive. Instead I am constantly feeling like a visitor in a foreign country. The language sounds familiar, and I've heard the words before, but my short time in the medical world means I still don't know the answers. And even if I did, maybe when I am here visiting family on vacation, I would choose to not know the answers, just so I could have a break, and be the person I used to be.

PM and what?

So I'm here in Bend OR for a rotation, but this time I get to help others heal not their minds (did a psych rotation back in Sept), but their bodies.....Vague, yes, because that is the problem I am having when it comes to telling others what kind of medicine I would like to pursue. It's unfortunate that I can't just roll off one word from the tip of my tongue, like surgeon, or pediatrician, with the subsequent complete understanding of the receiver. Everyone knows what a surgeon is and what they do, and the same applies to pediatricians, OB/GYNs, family docs, cancer docs. I'm sorry to say that I can't so easily just roll one word off the top of my head to describe the very very very specialized type of doctor I would like to become.

If you have been following this blog for awhile (not sure if any of you are still out there), then you probably know or at least have heard before about physical medicine and rehabilitation, or physiatry, or PM & R. Now, I am fortunate that most doctors know what I'm talking about when I say that is my chosen field of practice. But a lot of my fellow students don't know about it, most likely because my medical school does not have a residency in this area of medicine, which translates to there being ZERO exposure to the field. There are two advisers at my school that are physiatrists, twin brothers in fact, and they have been my tenuous link to this field in the past two years. I did find out about another doc in this field over at the VA, but after I had already been at OHSU for almost 2 years. I met with him once for 15 minutes, but was unable to continue the connection (he never returned my emails, so I gave up).

I'm very happy to say that I have been working for the past 3 weeks in Bend with a group of (get this) 6 physiatrists, and they have been fantastic. Each one has gone to a different residency program, so they have been a wealth of information about the training programs, as well as about the field in general. I haven't seen anything yet to turn me away from the speciality - in fact, I so enjoy going to work everyday with them that I can't imagine myself doing anything else.

So what do they do exactly? The PM&R Association website states "rehabilitation physicians are medical doctors who restore maximal function lost through injury, illness, or disabling conditions, and are experts in diagnosing and treating pain." That about sums it up, and there is a long list of conditions that physiatrist treat including stroke, spinal cord injury, traumatic brain injury, amputations, arthritis, work injuries, back and neck pain, to name just a few. So the question is, how can I easily describe what I want to be to those that are not in the medical field? I tried to tell my husband's cousins once, and after using way too many words, one of them replied, so you're going to be a physical therapist? Oh ya, and if I cut it way down and say I'm going to be a rehab doctor, most lay people think I mean drug or alcohol rehab. Sigh....

Understand that it's important for me to figure out how to describe what I will be doing for the rest of my life because I already feel such a great divide between myself and those in my life that are not in the medical field. With each new medical concept I stuff into my brain, I find it harder and harder to talk about everyday things. It's like my husband and other spouses of my fellow medical students notice about our medical school parties - we all get together and talk about medicine.

So I would like to take a vote for all those who are still reading this blog. Here are some ideas about short succinct ways to describe a physiatrist. Let me know what you think!

I'm going to be:

1. A doctor of physical disability

2. A doctor of muscle and nerve injuries

3. A doctor of physical medicine and rehabilitation (this hasn't worked so far)

4. A pain doctor

5. A doctor in between a neurologist and a orthopedic surgeon

6. A doctor of physical function

7. A doctor of injury

8. A doctor of musculoskeletal medicine

Any other ideas, just shoot them my way! Cheers!

Money

A friend of mine in med school recently said to me that "you need to be rich to go to medical school," in response to the financial struggles she has had in the last few years. While I don't think you do have to be rich, there is an element of truth to her statement. Either you have money, or are able to borrow as much money that is needed for this long process. And the payback for this grand investment is not so great these days, as physician salaries have not keep up with the increasing cost of being educated. The American Medical Association reports that public medical school tuition went up 133% since 1984, and up 50% for private medical schools, preventing low income/minority students from entering medical school, and therefore decreasing the diversity of our physicians.

A patient of mine last week asked me if I was going to be a doctor so that I could be rich, and I had to chuckle.....the days of being rich as a doctor are way over, unless you 1. are incredibly bright and want to spend 10 more years after medical school learning how to cut into people's brains (neurosurgeons make the most, averaging $541,000 per year), 2. you create some durable medical device that can make money on the side, 3. you get paid by pharmaceutical companies to market their product (which is going by the wayside due to an "anti-pharm" movement from within the profession).

But before I get into physicians salaries, let's talk about what it costs to go to medical school. For OHSU, yearly tuition runs about $36,000, and most students take an additional $14,000 per year for living expenses. So that's $50,000 per year, for four years, leaving one with a balance of $200,000 for just medical school. If you have any undergraduate loans already accumulated, that is just added onto the top. According to the American Medical Association, in 2008, the average medical student in the US graduates with $154,000 of debt, and 80% of graduates have debt over $100,000.

There are a few issues that come up in the process of even getting the student loans. First, there is a minimum of amount that the government will guarantee to loan a student that does not have the money to pay. This is determined yearly by filling out a form, where you list how much money you made (if any), and if you are still supported by your parents, how much money they made in the previous year as well. This allows the government to determine who should get the loans, which have a pretty decent interest rate of about 6%. These government loans however, do not cover up to the $50,000 needed for a year of medical school. I'm not sure of the exact amount, but at least $15,000 has to come from private lenders, and for this you have to have good credit. If you happen to have bad credit, too much debt, or don't have anyone else to cosign for you to get the additional funds, too bad....no med school for you. Or you could always give up four years of freedom after residency by joining the armed forces, which two of my classmates did do, just so that they could pay for medical school.

So once you have secured the $50,000 you might think you are in the clear, that all will be just fine financially for the next four years. Not so. There are many other expenses that come up during medical school that are not accounted for in the financial aid packages. First, the cost of books. Yes there is some money in the student "budget" to allocate for books, but this amount definitely does not cover the cost of getting the long list of new edition books that are either required or recommended for each class. For this reason, many students either 1. don't get any books at all, and just use the syllabus to study from, 2. buy older used editions from upper classmates that are full of highlighting, 3. use their grocery money to buy books.

You see, the additional $14,000 per year is not a lot of money to live off of....because with that you have to pay for rent, car expenses, utilities, groceries, not too mention the balances of medical expenses you may have. Yes, there is a health care plan that comes with the tuition, but it is a deductible plan, where the student/patient has to pay out of pocket....all from that just over $1,000 per month that is left over after tuition is paid. Fortunately for me, I have a husband with a job that can support me while in medical school. And for anyone who happens to be a non-traditional student with children, you have to support your family on that measly monthly amount, leading again to a lack of diversity amongst our physicians.

In addition to books, there are A LOT of expense associated with the licensing process in becoming a doctor. You have to register for the board exams you are required to take during medical school (step one costs $480, step 2 costs $1,500, plus a plane ticket to fly to LA to take the practical board exam). Then in order to even pass the exams, you need to buy practice test question banks (step one costs $350 for 3000 questions, step 2 costs $500 for 3300 questions),not to mention the high yield exam books that are needed for review, because no student has the time to use the books we had to buy for our individual classes. You need the more succinct bullet type review books, a condensation of all we learned in the first two years.

Then there is the expense of applying to residency. Just like the expenses associated with applying to medical school, there is a flat fee for the first 10 programs that you apply to, with an addition amount added for each program above 10. The baseline cost for the online application is only $65 (phew!) with an additional $8 or $15 or $25 per program depending on how high you go. I heard of a current 4th year student that applied to 127 programs.....that comes to about $2,700!! Of course most students don't apply to that many programs....I think the average is around 15 - 20.

In addition to books, exams, and application expenses there is the HUGE expense of flying all over the country for residency interviews. If you are fortunate enough to go to medical school on the east coast, your expenses will be less because you can drive to many places that you need to interview. For us here in OR, we are not so lucky, as most places are far enough away that a plane flight is necessary, as well as a hotel stay. Now, you might think, people fly across the country all the time for job interviews, what's the big deal? It's the number that matters. Just like applying to medical school, you have to anticipate a certain amount of attrition at each level of the process.

It is recommended that you "rank" at least 10 residency programs. That means that you have interviewed at those ten places and liked what you learned about their programs. But each place only has a certain number of positions open for interviews, and not every interested student gets to interview. So, you have to apply to many many more than you will even get an invite to, in order to make sure that you can rank at least 10 programs in the end. So, that usually means you should apply to 20-30 programs, hope to get invited to at least 20 interviews, and actually attend about 15, in order to eventually put down your list of top ten.

So that means flying to 15 different programs, each of which will give you the limited months and days with openings. Fortunately, many programs will try to accommodate you if you know that you will be in the Chicago area for one interview for example, by interviewing you when you are in town. I don't know yet how much this process will cost, but I have heard estimates around $5,000 depending on how many programs you interview at, and how spread apart the programs are. I have heard that you can take out an additional loan for these expenses, but that the interest rates are high. Go figure.

I am not complaining about all the expenses involved....only trying to clarify it for those who are not aware of what it costs for a student to go to medical school these days. I will finish with around $250,000 in debt, and that's debt that used to be put off until after residency, with no accruing interest. Recently this has changed, in that the loans have to be paid during residency.

So what's the big deal when physicians make so much money right? It's true that doctors do make a very good living, but certainly nothing in comparison to corporate CEOs - the real money is in business. The top doctors (neurosurgeons) can make up to $800,000 or more, but there are very few of those. Most family practice doctors make between $128,000 and $200,000, so no wonder why many students are staying away from primary care because they are wondering how they are going to pay off their debt, have a family, buy a home and dependable car, and live the American dream. I wish that I could have given that patient that asked me if I was going to be rich all this information. Maybe then she would know that going into medicine these days is not about the money, it can't be. It's about doing what you love, taking care of others, and making those darn student loan monthly payments. Cheers!

Procedural Competency

I walked into the exam room with my preceptor and greeted Mrs. and Mr. M warmly, already familiar with their faces as this was the third visit in three weeks for Mrs. M to get bilateral injections of Orthovisc (a substance called hyaluron shown to maintain joint fluid and support cartilage), into her knee joints. She had been diagnosed with severe degenerative joint disease of both of her knees, and was hoping this series of injections would eventually decrease her pain and increase her activity. She hopped up onto the table, and instinctively grabbed her husband's hand, as she had the previous two weeks. My preceptor asked her which knee she wanted done first, after which she glanced in my direction, and asked if I could do one of the injections. The previous two weeks the sports medicine fellow had been present in the room, and had done the other knee simultaneously so that she didn't have to suffer through the procedure twice. On this third visit she wanted the same as the previous two: the shortest and least painful procedure possible. My heart immediately began to beat fast, both from excitement at the opportunity, and total fear of incompetence at the same time. My preceptor reminded her that I was a third year student, and she asked me whether I had ever done an injection before. I replied I had not, but had watched several. She then asked if I would like to do one knee, to which I replied, "Yes I would love to," smart enough to not turn down a gift when it was offered. Her husband was visibly upset with the thought of someone new like me doing this, but she reassured him by saying that I needed to learn, and in order to learn I needed to practice. Talk about the perfect patient!

The next five minutes was a blur as I struggled to hide my rapidly beating heart and mildly shaky hands. I had seen this injection done, on this very patient, two times prior, and was confident that the needle would go right where it was supposed to. I marked the spot where the needle would insert, confirmed it with the "real" doctor, sterilized the skin, shakily opened up the syringe of Orthovisc, and attached the needle. One, two, three, and we both inserted our needles into this woman's knee joints. Fortunately for me, although not so for the patient, the knee that my preceptor was injecting was full of osteophytes (bony overgrowths that crowd the joint space). Subsequently he had to maneuver his needle all around, all the while she's blurting out "ow, ow, ow, ow," blowing out her breath like she was in labor, and squeezing her husband's hand white. My needle entered her other knee joint effortlessly, and the injection was over quickly. We placed band-aids over the little pin pricks, and off she limped out of the clinic.

My heart took some time to calm down, and as I wrote up the procedural note, many different thoughts struggled for center stage in my mind. Initially I was incredibly excited at having had this opportunity to perform such an "invasive" procedure, particularly as a third year medical student. In addition, I thought about what would have happened if my needle had also gotten stuck on osteophytes. This was not a pretty picture in my mind, as I imagined myself turning white, heart doubling in cardiac output, followed by a desperate glance over to my preceptor with the signal HELP screaming from my eyes. While I did have the confidence to slide the needle into a joint free of complications, I definitely was not trained at how to handle bumps in the road. How many injections into a knee joint would it take for me to not have shaky hands, and also, to know how to confidently handle potential complications?

Finally, I wondered what it was about the patient that allowed her to let me "practice" on her, and whether or not it was just a matter of her wanting to avoid the pain of a second injection. Was it something I had done in my previous two interactions with her? Was it the unspoken confidence my preceptor had in my abilities? Was it that she was aware of my previous career as a massage therapist, or my future intentions to be a physical medicine doctor? Why did she trust me, not yet a "real" doctor? In short, what does it take to have procedural competency from the point of view of the patient, as well as from a deep internal sense of confidence from within the physician?

This patient encounter occurred several weeks ago, and I continue to think about procedural competency as I do a rotation in Bend in physical medicine and rehabilitation, the specialty I plan on going into. I have seen tons of injections here, and I've only worked for 6 days so far. I've seen injections of knees, shoulders, hips, muscle trigger points, and spinal joints. At first it looks complicated, especially the spinal injections which take place with the guidance of xray. Every day it looks easier although, as I learn the bony landmarks that are palpated prior to an injection of a shoulder or knee joint, or as I learn to decipher the shades of gray shadows on the xrays. I realize that it's a numbers game. The more you do, the better you get, and the more confident you become. I am happy to say that I can imagine myself, someday, injecting joints of the human body, with confidence and a sense of satisfaction with helping my patients in pain. I look forward to a future filled with learning how to perform these procedures competently, and I thank in advance all the patients that will help me become a proficient physician. Cheers!