From the ICU to the ICN: The Beginning of 4th Year!

I started fourth year in the ICU -- the adult ICU. I was rounding with the pulmonary service, and it was quite a shock to the system after a year in the research setting. Our team consisted of an attending, an R1 about to become an R2, an R1, and me (RX= Resident in year x). I learned an incredible amount in a very short time. I learned about ventilators, I learned about lung-disease, I learned about a different way of assessing acid-base status (instead of Henderson-Hasselbach, my attending was a fan of the Strong Ion approach). The chief resident asked me to identify Howell-Jolly bodies on someone's peripheral blood smear -- which I kind of did! I was able to look at cells under a microscope, at least, because of my research year :) So I had a lot of fun. But it's also tough -- long hours, a lot of feeling undereducated, and just complex issues that everyone else is comfortable with. However: they fed me lunch FOR FREE every day! Every. Day.

 Last night, the night before I started my sub-internship, I dreamed I was being asked a series of questions I couldn't answer. LOL. The subconscious mind is so ridiculous. Today was the first day of my sub-internship in the intensive care nursery. Very ill children and a very different way of doing things. I already have two patients, and I'm going to try to figure out how to present them tomorrow. I don't even know what to read tonight because there is so much. However, I really like the content -- the babies are adorable (of course) and the problems are really interesting. A lot of diseases of prematurity, and a lot of congenital malformation. And a free lunch (okay, so I am a little food-centric. Food keeps me from being hangry). My resident is really smart and really nice -- I hope this will be a good working relationship. I have to not bug her -- I tend to bug people when I'm excited. I ran into one of my students from the master's program on my rotation! She's in the year below me now, I think. Or maybe in my year? I'm all mixed up at this point. After a certain point in life, what you are doing matters more than how old you are.

I have a lot of work to do, but it's the good kind. The kind where if you work really hard, you might be able to reach your goal. I have an entire month of this, so I really hope to be somewhat competent by the end of it. I am so excited to be working in a field I think I want to do for the rest of my life. And on that note: the residency application program opened on Sunday! I registered and started entering my information. There is something so fresh and summative about putting everything career-related into one online application -- it's like looking at an updated CV. It sort of gives you the perspective to handle one challenging day.

In the meantime, I am determined to find time to write up the rheumatoid arthritis paper from the research year. My mentor has already asked me how the writing is going. It is not going. It is paused. Oops. I should probably un-pause it by the end of the week. In fact, I should write them both a detailed update with a timeline.

Rica: How are you doing with your intern year? Are you excited? Stressed? Overwhelmed? Send us a message from beyond the bar!
Che: When does your program start? Oh, wait, I can stalk your blog and find out!
Mom: Come back from NC and tell Dad to stop playing the video games we downloaded for him on his birthday. My brother and B are irrepressible. You gotta love em, though.

Hugs,
Nia

How Am I Going to Learn Enough?!

I am so frustrated right now. I've spent the past few days reading about ventilator management, lung volumes, and acute respiratory distress syndrome. We've covered congestive heart failure and why the traditional way of thinking about acid-base disorders is incomplete. However, for some reason I just can't get questions right when people ask me point blank. For instance, even though I read an article my preceptor suggested a few days ago, I just couldn't summarize it when he asked me to this morning. What has happened to my recall? In high school, that wouldn't have been a problem. In fact, I think memorizing medicine in general would have been easier in high school.

I'm quite sure the British system does have something over us -- they take kids right out of high school and teach them, so they still have the ability to stay up all night and study, or memorize things as soon as they read them. I don't know if my brain is aging or rusty, but it's just maddening to know that you can't recall something that you thought you knew. Today, at the end of the day, a neurologist was quizzing me about locations of strokes in the brain. I *knew* this stuff at the end of last year -- and now it's gone -- poof -- like the wind. F*%K. A great way to end the day, looking like an idiot in front of your senior resident. Terrific. I'm being quizzed about everything except the lung on this pulmonary rotation.

And here's the twenty-four million dollar question: If I don't have this stuff memorized now, when on earth am I going to have a chance to learn it? How am I ever going to become the type of doctor I want to be -- the kind that understands physiology, biochemistry, and disease? How many times a day can I feel like a complete idiot? When will I know how to manage patients on my own? What the hell is wrong with me? Seriously, just shoot me now.

The child upstairs is singing 'Colors of the Wind.' The most relevant line from that song:

You'll learn things you never knew you never knew.

It's clearly a song about med school.

Anyway, there has been another milestone in the process of becoming a doctor: I have my basic lifesaving skills card, and I actually performed my first real CPR during a Code Blue in the ICU on Friday. It's physically more demanding than I realized. He was in shock, of a type that has a very high mortality, so the prognosis was unfortunately grim from the start. Then I had to call the family to let them know that the patient had passed away. I was grateful that my resident trusted me to make the phone call myself.

You know, what they don't tell you about medicine is that it's not the long hours, the terrible things that happen, or the yuck factor that makes it difficult. For me, the long hours are fine as long as I have enough food; the patients are the brightest part of my day, even if things are taking a turn for the worse, because you can't just abandon people if things go to pot; and the yuck factor is negligent because I was fortunately given a strong stomach. It's the doctors. The residents sometimes, and the senior doctors often. Some of them have a gift for teaching students, but most do not. They personally resent the extra work teaching requires, no matter that they chose to remain in academics. A few seem to particularly enjoy humiliating medical students, especially if there's an audience or a competitive aspect involved (like grades).  I guess it does make them look smarter, but how are they going to feel when one of those junior doctors is the one taking care of them when they grow old? The Hippocratic oath involves promising to teach the next generation of doctors as though they are your own lineage, not as though you are shooting fish in a barrel, and I hope I remember that if/when I get to that stage in my career. Hazing went out with the baby boomers.

For this reason, I am dreading my presentation tomorrow. What should be an opportunity to present and learn something will instead become a who-can-take-turns-outshining-the-dumb-med-student session. Am I the only one surprised that many doctors are, to put it mildly, not very nice people?

Okay, done venting. Mom and Dad, it's still worth it. Make change from the inside, and all that.

I'm So Terrified.

Medicine is terrifying. On Monday, I officially begin the first rotation of my fourth year. I will be expected to know more than I did last year, to care for patients more fully, to have memorized a larger percentage of relevant facts. That is scary enough; but at least the damage I can do to my patients will be limited by the supervision of those above me. One thing that really scares me, though, is being expected to teach third years. I do not know enough to teach third years! I've been off the wards for an entire year. I have no idea what I'm going to do or how I'm going to learn the material I need to learn. This afternoon I am having a little attack of nerves that makes it hard to breathe, let alone study. I'm going to go home to my nice B and spread my books out on the dining room table and try to get some work done. It's just difficult to read and process information as though you have all the time in the world when you have a Clock O' Doom ticking in the back of your mind.

Change is Good. Change is Good. Change is Good.

"The old order changeth, yielding place to new

And God fulfills himself in many ways 

Lest one good custom should corrupt the world."

-- Lord Alfred Tennyson, The Passing of Arthur

Here I am, just before another corner. Friday was my last day in lab. On Thursday, my lab took me out to lunch at Pacific Catch at the corner of Lincoln and 9th, which was amazing. They gave me parting gifts -- a pediatric rheumatology textbook from my boss, a cute cardigan from our senior technician, and yummy hand lotion and tea infuser from my junior mentor. I brought them thank-you gifts, but was touched to receive things from them. I think the art of gift-giving is dying. It's sad. But that's another blog post. Anyway, with the lab folks, I really felt as though we had managed the true spirit of giving something you think the other person will like because you appreciate them and were thinking about them. One way to achieve this is to limit spending. Small consumables are more likely to make it into the "how thoughtful, I'll definitely use this," category.

Lab bench, all cleaned up before I leave for good.

The last few months of the research year are over. It's been fun. One highlight was a student conference at the Mayo Clinic -- technically it was free, but I have yet to be reimbursed :(. I roomed with a Pharmacy student, and we even went running by the river in Rochester.  We saw goslings! Rochester is a really cute little town. They are trying to encourage diversity, which means our waitress didn't know how to pronounce the eight very non-Christian names at our table, but actually cared about how to say them. The conference was interesting, but the food was unfortunately better than the content. You know there's something wrong when a poster you stumble across on your way to lunch is better than any of the day's speakers, keynote included. That said, there was some *amazing* student work presented. Out of three keynotes, the last was actually mind-blowing (pun intended) -- a neurosurgeon who has been part of a team that is inventing an implantable chip to measure neurotransmitter levels (like dopamine) in the brain, and then transmit the information to a computer. Amazing!! There will be so many applications for the technology.

Another random, cool event was my old high school best friend, Div, coming in from Dubai! She was visiting her brother on the peninsula and they all came up to the city for dinner, so B & I joined them. We ate at Udupi Palace, a South Indian restaurant. Delicious but precarious -- the dinner plates were literally too big for the tables, so the edges were hanging off the sides over our laps! Div is doing well, and unofficially planning a wedding! She's in banking, not a bio teacher as she originally planned, and I'm going to be a pediatrician, not a lawyer like I was thinking about in high school.

High school friends, 10 years later!

I'm trying to write a personal statement for residency. Meaning that I'm thinking about trying to write a personal statement about residency. It's much, much harder than I anticipated because I'm switching fields. All my research and volunteer work has been in aging/rheumatology up until now, and now I'm shifting gears entirely and working with kids and embryology. Somehow, I have to articulate my trajectory, the 'ah-ha' moments, and why I want to work with kids. I feel like there is an entire category of things -- exams, personal statements, impressing my supervisors -- that I'm no longer rocking. Nia needs her groove back. Ah, well. If you can't beat 'em, just keep plodding forward.

B is home from DC. People keep asking how married life is. It's awesome, because I'm rooming with my life partner. It's so worth it. It's something I'm grateful for every day. We celebrated our one year anniversary by running Bay to Breakers, which is a 12K (7.5 mile) race that starts down by the San Francisco Embarcadero and winds its way through the city and Golden Gate Park to end at Ocean Beach. It was on my bucket list, and B kindly agreed to run it with me. I was the 6202nd runner to cross the finish out of 23, 072, and the 1853/11,793 woman, at a pace of 10:22 minutes/mile (1 hour 17 minutes overall). Not too shabby. B was my coach and ran with me, instead of jetting on ahead. Nice B! Che and Rica did B2B as well, walking in costume (thousands of people dress up), and we all met up at the end for tacos!! Yum. Che was a naked lady and Rica was a superhero. My favorite costume was the guy who dressed up like he was riding an ostrich, with feet dangling on either side of the bird, so it looked like the ostrich was running the race. My least favorite costume was The Silver Surfer -- running behind his reflective outfit was like having a glaring mirror in my face for three sunny miles. I also enjoyed seeing the Salmon, who always run the race as a 'school,' backward from Ocean Beach to the Embarcadero (going upriver to spawn). I almost got a salmon high-five. The most popular costume was a pair, running as the Lorax and The Tree -- the tree was nearly 8 feet high!

I am going on vacation.

The next two weeks will be packed: Open House party this weekend with our friends & my parents' friends, etc, and then a week of very intense review/getting things done before my pulmonary rotation. The Open House will be a nice break from reality. We are sending the cat on vacation to my parents' for the party, because my mom wants to attend and she's allergic to the cat. My dad saw our place last week, took one look around at the mess, and said, "Well, since our friends (meaning real adults) are coming, you can host the party at our house if you want." Thanks, Dad. Thanks a lot. But then, he has many strengths beyond tact. I hope the weather is nice so we can go outside. I don't remember much clinical medicine, so I need to study like crazy. I bought and borrowed the books for my rotations, and they all weigh a ton. I really hope 4th year works. I am excited to study more focused areas of medicine than I did with my longitudinal clerkship. Also, wouldn't it be nice to have an MD?

Here's the To-Do:

Open House!
Study pulmonary medicine
Study neonatology
Study child neurology
Write personal statement for residency
Research rheumatoid arthritis paper
Write rheumatoid arthritis paper
Meet with pediatrics department chair/advisor
Come up with list of residencies to apply to
Get photo taken for residency
Ask research mentor for a recommendation letter

Busy = Happy.

Love,
Nia

Death on our Floor

Our lab is under quarantine. Someone in another lab on our floor died, so the whole floor has been cordoned off and we all have to take antibiotic prophylaxis. The poor guy. My boss called me at home to let me know. So I guess I work from home/library on Monday, until this is resolved. Good thing I didn't leave my workout clothes at work. And glad that all the medical students are required to have vaccinations. I'm afraid all my transfected cells will die, and that's a year's work. But that is nothing compared to what the guy's family must be feeling. Oh, I hope he didn't have any children. Or parents. Or a spouse. Or siblings. Anyway, my job now is go pick up my prescription and then text or e-mail my boss to let her know she can check me off the prophylaxis list.

P.S. I have edited this to remove any identifying details, and am not authorized to discuss them publicly, but I will update family in a private email.

Change is in the Air Again!

Okay, although I am totally overwhelmed, I need to write. So much has happened this month. Much of it has been very, very good and exciting. A lot of it is scary. And no, I'm not pregnant.

Basically, next month is the culmination of the research year. Some of you have already heard that my molecular biology project was going really slowly. However, the fellowship I'm on expects us to have a finished, completed project that we did ourselves at the end of the year. So around December/January, I panicked a little bit and tried to think of something I could do that piqued my interests, aligned with my abilities, and was feasible in a condensed time frame if I worked hard. The project I came up with looked at predictors of refractory disease in rheumatoid arthritis patients, which I was totally psyched about because it was clinical, had statistics, and dealt with both medicine and health disparities/epidemiology.

I've basically been working every day for a long time on this project, and I finally have results! I love my data. But they are alarming, showing differences in outcomes based on level of education when adjusted for medication use and other factors. I am beyond excited that it looks like we have some interesting data. I just sent the dataset to my mentor, so I'm just crossing my fingers that she doesn't run my numbers and get something totally different. That would be a minor tragedy. My big boss I think was a little skeptical at first, but she seemed pleased at my lab meeting today and had some great ideas for what to do next.

So next week I have to somehow do the following: Finish and practice my talk, actually do the 10-minute talk for a symposium, present my poster, finish my resume and personal summary form for the Dean's office to kickstart the residency application process, go to a 2-hour evening journal club (which curtails my ability to speak with my husband on the East Coast, sadness), finish additional data analysis for my presentation, work on a different poster for a different project I've been doing on the side, and pack for a 3-day conference the week after that. Oh, and remember to give my little boss a birthday present. Actually, when I write it all down it doesn't feel so bad anymore. Thank you, therapeutic blogging. I was sad to miss meeting up with my Auntie from India, who was only in town tonight, due to a confluence of work-related and traffic-related factors. But she got to hang out with my dad (she's dad's brother's wife).

In the next month, I have to finish all my research because then I'm back on the wards! Here's my 4th year clinical schedule:

2 weeks of adult pulmonary medicine
4 weeks of neonatal intensive care nursery
4 weeks of child neurology
4 weeks of pediatric genetics
4 weeks of child rheumatology
4 weeks of adult internal medicine
4 weeks for residency interviews + some vacation time (or time to mourn lack of interviews!)
4 weeks of To Be Determined + some vacation time
4 weeks pediatric infectious disease
4 weeks of end of year required curriculum

I am so excited about this. If I do apply in child neurology, I'd like to fit in some adult neurology somewhere. So little time, so much to learn. Many of my old classmates are graduating soon. I'm a little sad when I think of it, but I'm very, very glad that I took a research year. Although I've been in medical school so long (6 years next year!) that when I graduate, it will be quite a shock to my system. If I had gone straight through, which is a big if, I could have been a 2nd-year resident by now. Then again, hopefully the added maturity will be a good thing when I have an MD behind my hybrid name. I should blog about changing my name. Anyhow, I am also nervous/excited because I finally was able to arrange a meeting with the child neurology department chair, whom everyone literally raves about (Pediatric department chair: "I'd trust her with my life...in fact, I have").

In fun news, I'm also doing Bay to Breakers! So are three people from my lab, one of my old friends who is coming in from out of town, and B. I'm so pleased B agreed to be my running buddy. He usually tries to do shorter distances because he needs to be able to sprint for Ultimate, but he was really nice about the 12K. I'm told the entire first half of the race is uphill. Ick. But then, I was also told that it's so crowded that you are forced to walk at points.

For those who asked, B is doing well. He and the other employees got to take a big group photo with The Boss of the House that Shall Not Be Named. Pretty snazzy.

And, just in case you were wondering about my political views, you heard it here first:
Keep your MITTens off my kittens. No more drama. Vote Obama.

April Showers, a 12K, & The Match!

It has been raining a lot. My research facility is located on a hill, which means that you get pretty wet from rivulets and waterfalls as you climb up to work. I think we're getting all the downpour we missed out on this winter. I am lucky enough to own two beautiful umbrellas and good shoes, so I can actually enjoy the torrents. Usually with a hot cup of tea. I'm drinking way more tea than will be sustainable on the wards. Yes, it's almost that time -- the moment I go back to the clinical life! Yikes (Which end of the patient is up, again?). It seemed so far away all year, but now I'm only two months away.

Warming up before the race

On the Sunday after St. Patrick's Day, we ran a 12K (~7.5 miles) to benefit the Edgewood Children's Foundation called Emerald 12K Across the Bay. It was a beautiful run, staring at Fort Baker and climbing up the (steep!) hill to the Golden Gate Bridge, crossing the bridge, and then winding down past Chrissy Field and ending near Ghirardelli square. My dad walked the whole 7.5 miles!

Beautiful views of the bay the whole 7.5 miles

Post-race party with live band at Ghirardelli square

Free chocolate milk from the Nesquik rabbit

The weather was breezy, sunshiny, and cold in the morning but perfect for running. As I crossed the bridge, I saw huge, graceful pelicans fishing at the mouth of the bay. I could see Alcatraz like a jewel in the water. It was amazing. I've never run that far before. My time was 1:20:38, for a pace of 10:49/mile. Just for perspective, the winning female runner did it at 5:32/mile. She's a year older than I am!

Speaking of clinical life, the Match happened two weeks ago. The Match is a huge, nationwide event that occurs the third week of March. Medical school seniors crowd into a room, open tiny white envelopes, and find out which residency program they'll be working at for the next three (or four, or ten) years. My friends all matched! Most of them seemed very happy. E is doing internal medicine. CL is doing pediatrics, and had some great advice for me. Dee is doing internal medicine. T is going to LA to do psychiatry, which is great because his wife, K, was offered a teaching position down there (congrats you guys)! Maybe they'll go all Hollywood on me and start doctoring/teaching the stars? Mimi won her coveted dermatology spot, for those of you who were biting their fingernails. Many, many people are staying in or around the SF Bay Area, which means I might see them once every six months during their training...

The evening of Match Day, there was a class party at a cafe near the beach. I went even though I am no longer in their class, just to say congratulations. Unluckily, it was pouring rain (again). Luckily, it was indoors and we had seats by the fire. Butters brewed an awesome, hoppy beer and brought it! Dee baked a pie (her first! With homemade crust! It was delicious). There was wine and excitement and congratulations. I couldn't believe how grown-up everyone looked. I am so very proud of them and all the hard work they've invested. The matched folks graduate this May with MDs. Dear Lord, they are going to be doctors. Our 2013 graduation will be so lonely without them. Can you believe how time flies? And the handful of us that added a year are left to plunge into the breach.

A beautiful gel for Western blot, loaded and ready

Research is going...strangely. After working on a basic science project all year, I'm not sure if it's going to manifest itself or fall through. However, I've also just started a clinical project that might save my behind when the NIH people come after me for Results with a capital R. Crossed fingers. It's interesting work, looking at what types of people don't respond to treatment for rheumatoid arthritis and how their bones erode. It's actually great stuff. We'll see how it goes; the deadline is a conference coming up in May (and prior to that, an abstract due next week).  I can't believe how much molecular biology and statistics I've learned this year. I hope all the clinical info regarding patients is still in my head somewhere. Unfortunately, I've had no time at all to work on my master's thesis, and I'd love to edit it and submit it. My brain is going to explode one day, wait and see. It'll be interesting. Anyhow, this week I get to teach a high schooler volunteering at the lab. She's a bubbly senior, five foot nothing, long dark hair, wants to major in chemistry. Rock on, my little friend.

B continues to work at the pale house in a certain capital city that shall not be named on a public blog. He's coming home weekend after next, though. Yay! Maybe it'll stop raining enough for us to go hiking. It has occurred to me that it's very late and I should go to bed (this is laughable: by hospital standards it's not even the end of the day). But I am so very happy to get a chance to sleep that I should carpe noctem. Bonne nuit.