Bad outcomes

Obstetrics is a weird specialty. We're always super-obsessed (often to my chagrin) with documentation and CYA-type practices. These first couple months on service (since I started on medicine/ICU this year) have had their share of moments of me saying, "But on medicine we didn't worry about this." But I also do know that when things go wrong in medicine, a 90-year-old pt might have a bad outcome, but it's inherently easier to tolerate than when things go wrong with a 20-year old woman -- or a 1-day-old infant. (That doesn't make the loss of someone's grandmother or grandfather any less important, but for the general population, we tolerate the death of a 90-year-old moreso than of a 20-year-old.)

The aftershocks of the death of our post-partum patient from H1N1 pneumonia continues to ripple through the department and hospital. As of this week, the hospital is not allowing anyone under 16 years old to enter the hospital at all (H1N1 is widespread among children). We continue to screen and test our pregnant patients for H1N1, and have a positive test result at least a couple times a week. Tamiflu is a godsend, though; we start our patients on it early and we haven't had any other bad outcomes yet. And I got my H1N1 vaccine, so I feel better that I won't get sick and 1) feel crappy myself and 2) spread infection to patients.

This morning I got to deliver a patient who I admitted the night before. She is a 33-year-old primiparous woman at 36 weeks and 3 days who came into our triage unit for rule out labor. She was contracting every 3 minutes or so for sure, but her cervix was only 1 cm dilated and not effaced. We watched her for a little while because her blood pressures were really elevated, so we wanted to check labs. And 3 hours later, her cervix was still 1 cm and not effaced, but given her high blood pressures, we kept her for more testing. Not in labor. An hour later, the third year resident saw me and asked, "Was Ms. B really 1/long/-3* when you checked her? Because she's 80% effaced for me." And for once, I was really confident in my exam, and I knew she hadn't been effaced an hour prior. Since it was 2 am and my turn to go down for an on-call nap, I went to sleep for 2 hours. And when I got up at 4, the third-year said, "Guess what! Ms. B is in labor! She's 5 cm now."

So in 3 hours, she went from 1 and long to 1 and 80% to 5 and 90%. Off to L&D she went, and got her epidural. And an hour and a half later, she was complete and +1 station, and ready to push! And I was there and able to do it! So we started pushing and she did really well, and in about 30 minutes she was ready to deliver. The head delivered nicely, and at first I didn't feel a nuchal cord. But then we saw a nuchal cord -- a tight one. Both my attending and I tried to reduce it, but couldn't get it at the first pass, and as I was trying a second time, my attending told me to stop, and grabbed the clamps, and we ordered the patient to stop pushing while we clamped and cut the nuchal at the perineum. The rest of the baby delivered fine. It gasped for breath as usual, and I suctioned the mouth and nose, and handed the baby up to mom's belly, just like normal. And then the nurse grabbed the baby and brought it over to the warmer, and while I was collecting cord bloods and cord gases, it all of a sudden hit me: I hadn't heard the baby cry yet. Gasped, yes. Cry, no. And the mom realized it, too.

So the pediatricians rushed in and did their thing (I couldn't see it; I was busy doing my thing), and while we delivered the placenta and repaired mom's tears (the shoulders busted out all at once, so she had a couple little ones), the silence in the room was overwhelming. A nurse called out the time. "Seven minutes." As in, seven minutes without a cry. I start feeling sick.

And then, finally, the baby cried. Everyone breathed a sigh of relief, myself included. But I'm anxious to go to work tomorrow to see how the baby's doing.

And while I gripe, I know why we document up the wazoo. Because when a 90-year-old woman with multiple medical comorbidities dies, chances are you won't get sued. But when a 23-year-old woman dies 1 week after delivering her baby, or a baby ends up with a bad outcome, everyone is going to be scrutinizing what you did over and over. We scrutinize it, and try to learn from it. And we hope we won't be scrutinizing it in court.

Why couldn't I have gone into a less stressful field?

Balsamic Vinegar

Yum! I used it a lot this past weekend, with great results. Here's a recap:

Saturday, dinner with my friend and bridesmaid Karen, her husband Jake, and their 2-year-old daughter, Lily:

Brushchetta as an appetizer: Tomatoes, diced onion, fresh basil, a splash of good balsamic vinegar, a drizzle of EVOO, and salt and pepper. Serve with a good loaf of bread -- we got a baguette from the Asian grocery store down the street (Vietnamese cuisine has a lot of French influence, remember).

Balsamic-glazed grilled chicken:

Make a marinade using balsamic vinegar, olive oil, some lime or lemon juice, some dried oregano, salt and pepper, and minced garlic. Mix to combine, and pour over chicken parts. Marinate for a couple or few hours. Grill, basting with the marinade.

Cut up some peaches (it's peach season!) and put on the grill. Slice some onions into thick slices (I used yellow onions because I have a bunch of them right now, but red onions or Vidalias would be even better, I'm sure!), give them a swipe of olive oil, and add those to the grill, too. While everything's grilling, mix up a balsamic vinaigrette: good balsamic vinegar, salt and pepper, dried oregano, a sprinkle of sugar, and some fresh chopped herbs (I used basil). Whisk while drizzling in extra virgin olive oil, until it reaches the right consistency. I used a bagged mixed greens salad from the grocery store, topped it with tomato wedges from my garden, the grilled peaches and grilled onions, and poured the vinaigrette over the whole thing. Serve alongside the grilled chicken.

For a few reasons, I have started to buy different versions of certain oils and vinegars. For marinating and sauteeing, I use regular olive oil. I save the EVOO for salad dressings, bruschetta, and other preparations in which we'll be eating the oil in its raw and pure form. The regular olive oil is cheaper, and I save the good stuff for when it matters. The same goes for balsamic vinegar -- I use a run-of-the-mill balsamic for marinating and reducing into sauces, and save the sweeter, better, and more expensive balsamic for pure/raw preparations like vinaigrettes and bruschetta. If you're trying to make your dollar stretch farther, this is a great way to do it while still being able to use quality ingredients when it counts.

Sunday, dinner with some friends and an excuse to use up more chicken and peaches:

Same chicken marinated in the same balsamic marinade, but this time, served with a grilled peach and corn salsa, recipe courtesy of Mark Bittman's How to Cook Everything. Cut 2-3 peaches in thirds or halves and grill. Also grill a couple ears of corn. Let cool until able to handle, and then cut off the corn kernels and dice up the peaches and put everything into a bowl. Add about 2-3 tablespoons of chopped Thai basil (regular basil or mint would also work well), and half of a jalapeno, finely diced. Squeeze some lime juice into the bowl and season with salt and pepper. Serve warm over the chicken. We've been eating it cold ever since as a salsa with chips, but it was really best warm over the grilled chicken. The spiciness of the jalapeno in the salsa is cut by the lime and Thai basil, and it all goes wonderfully well with the sweetness of the balsamic glaze on the chicken.

To use up the jalapenos and banana peppers I've been growing, we also made jalapeno poppers. To make them, slice your peppers in half lengthwise and scoop out the seeds and white rinds. Mix shredded cheddar cheese with cream cheese, and spoon into the peppers. Wrap the whole thing with half a strip of bacon and secure with a toothpick. Grill for a few minutes over semi-direct heat until the bacon is cooked through, and eat warm. Very yummy. I thought about using a more interesting cheese instead of the cheddar, like Monterey Jack or Colby, but decided the heat of the jalapeno would negate any subtle taste differences, and I think I was right. That said, if all I had was Jack cheese, I wouldn't bother going to get cheddar for this recipe. We stuffed ourselves with jalapeno poppers and then ate the chicken with the corn and peach salsa, and it was plenty of food.

One of the things I particularly loved about cooking this weekend was being able to use so many items from my own garden and from the local market. One of my own tomatoes went into the bruschetta; I used my own basil for the bruschetta and Thai basil for the corn and peach salsa. My own jalapenos and banana peppers were the basis for the jalapeno poppers -- I definitely would not normally have made them if I didn't have an abundance of peppers I didn't know what to do with.

And the Italian market is definitely my favorite place to shop. I got 3 pounds of perfectly ripe peaches for $1, which went into the salad on Saturday and the salsa on Sunday; fresh Jersey corn for the salsa; amazing slab bacon -- for much less than the grocery store charges! -- for the poppers; and great whole chicken breasts to go with the dark meat I already had in the refrigerator. The butcher offered to split the breasts for me, but I chose to do it myself; it was a good lesson in chicken anatomy, and it gave me the opportunity to save all the little extra trimmings and bones to freeze and make stock with later. The only downside to the market is that everything closes down around 5 or 5:30 so it's hard for us to get there during the week.

As exhausted as I am from working, I am really enjoying cooking this summer. I hope the weather doesn't cool down anytime soon -- we need to keep grilling!

Less depressing stuff

Last week we had a patient who came into the ER with chest pain. 33 years old, otherwise previously healthy, though with a significant family history of cardiac disease. Chest pain, and in the ER, he went into V-fib, and was shocked back. It doesn't happen all that often, but what made it even more exciting was that because he had no other comorbidities, he was a candidate for our hypothermia protocol. I had never heard of it before, but lo and behold, a day after we dropped his body temperature to 33 degrees Celsius, I saw this article on CNN.com: Cooling is catching on for cardiac arrest patients. (No, I do not generally get my medical news from CNN; however, I was post-call and just doing some fluff reading on the Internet.)

Our patient did great! He was cooled for 24 hours, then rewarmed slowly. He slowly came to and did well neurologically, and we transferred him from the ICU out to a regular floor bed later that day. The other night I was walking through the floor units and saw him -- sitting in a chair outside his room reading a book. Totally normal. He's definitely shaken by what happened -- imagine waking up in a hospital having no idea why you were there, and being told that not only did you die for a minute, but that your body was then frozen (OK, not really frozen Austin Powers style, but you know...) and rewarmed. Crazy! He'll do fine physically, but I hope he follows through with his emotional/psychological counselling, because boy, will he need it. In any case, I thought you'd enjoy a slightly more happy story from the ICU.

And here's a Can You Believe It story: I have an 87-year-old woman who is on a ventilator because she developed respiratory distress the other night. She's a sick woman, and when it came time to think about intubating her, we needed consent from someone, and since she was unable to give consent due to her respiratory distress, we called her son, who consented over the phone, saying she would want to be intubated. So she was intubated. The next morning, another son contacted us and said he was her healthcare power of attorney and she did NOT want to be intubated. Uh oh! The first son, when approached with that information, maintained that there was a newer document in which HE was named power of attorney, and she DID want to be intubated. And when we told him to go home and get the papers, he came back and said he couldn't find them. Hmmmm. And of course, it turns out the two brothers don't talk to each other. So we scheduled a family meeting and waited. And in the meantime, one of the nurses found out the scoop: The first brother, the one who initially consented to the intubation, is apparently $1.5 MILLION in the hole from gambling debts. And he continues to gamble. He has multiple sclerosis and lives with his mother, and he uses her social security money to continue to gamble! So of COURSE he wants to keep her alive and on the ventilator -- he wants her money! Juicy, juicy.

In the end, papers were found at the lawyer's office, in which the patient had checked off that she did want to be resuscitated and did want to be intubated, so we will continue to treat her. But I can't look at the son the same way anymore. The gall!

And finally, I walked home today via the Italian Market and stopped to pick up a couple lemons and some bread. Dinner plans tonight are for chicken scallopini and bruschetta (home grown tomatoes ripened yesterday!). Sarcone's was sold out as usual (they sell out first thing every morning!), so I walked down to Talluto's, where I've also gotten bread before, about 10 minutes before they closed. Alas, the bread bin was empty, but the woman behind the counter said there was some at the register. I peered into the large brown bag full of rolls and as I asked for a couple short rolls, the woman shoved the whole paper bag into a plastic grocery bag and pushed it toward me. "Oh," I said, a little confused. "How much for the whole bag?" "Have a good day," she replied. And when I looked even more confused, she explained, "We don't sell day-old bread so we won't sell them tomorrow, so you can have them." Wow! What luck! Yay for the Italian Market.

More life and death. Or just death.

I was going to update you yesterday on the status of my patient with relapsing lymphoma, and then yesterday HAPPENED, and it almost seems silly, and I almost didn't blog at all. You'll understand why in a minute. But I can already tell that if I don't write this down, I'll never remember it.

So last week was my last week on general medicine floors, and I took care of Ms. Jones, the 42-year-old with relapsing non-Hodgkin's lymphoma, who came in for abdominal distention and some difficulty breathing. As I recounted already, her heme/onc physician was sure there was nothing more that could be done along the lines of curative treatment, but she had not yet formally made the decision to become DNR, or enter hospice the program. She came in on Monday evening, and on Tuesday got a therapeutic thoracentesis (drain fluid out of the chest using a needle -- the fluid can be from a variety of causes, but in her cases, it was cancerous) and paracentesis (draining fluid out of the abdomen using a needle -- again, cancerous in her case). On Wednesday we let her recover a little bit and made arrangements to have a family meeting. On Thursday at noon, we met with her family -- her fiance, a tall, big, strong guy who had quit his job to take care of her and was incredibly caring; her mother, a larger woman who had been rather pushy with some of the other people on the medical team and whose motives may have been slightly suspect; her aunt, a thin, sharp woman who had her Bluetooth in her ear for the entire family meeting, which looked so ridiculous to me -- at one point, when she stepped out of the room for a minute, I really couldn't decide if she was overcome with emotion or was answering a call; her father; her brother; her sister; and the second of her three children, her oldest daughter, age 18. The heme/onc attending was there, along with his nurse practitioner, and the social worker from his practice, and then there was me, the primary doctor for her hospital stay, and my third year medical student. It was a packed room. Even though Ms. Jones was doing so poorly, she wanted to look presentable for the meeting, and so the start was delayed while she tried to get out of bed to use the bathroom, wash her face, comb her hair, and put on a fresh hospital gown, with her fiance's help.

The nurse practitioner, Nancy, did most of the talking. She re-capped the situation for everyone: the patient had had multiple rounds of chemo, and the cancer kept coming back. There were no more options for treatment in which the potential rate of cure would outweigh the definite risks of side effects. And so, the physicians felt that she should focus on going home and spending time with her family. She explained hospice, and explained that it could be done at home. In the end, everyone agreed. The social workers started getting things organized. Ms. Jones would go home the next day, Friday. Overall, the meeting was sad, but I was more of an observer than a participant, and I kept myself mostly detached.

On Friday, the medical transport team was going to pick my patient up at 3 pm. By late morning, her fiance called to say everything had been set up at home (hospital-type bed, oxygen machine, etc), and could she come home sooner, because she wasn't feeling that well? So we moved up the discharge to 1 pm. I had to hurry to get all the discharge paperwork in order. And then a kink popped up and discharge was again reset for 3 pm. I saw her off, loaded in the stretcher, and she wasn't looking good. Discharge was delayed even further because when the ambulance team realized she was DNR, they had to call me to get me to fill out more paperwork certifying her code status. I noticed that the ambulance form specifically asked for an attending's signature, and I'm not one, but for things like that, it doesn't really matter. That was Friday afternoon. I found out on Monday that she died at home on Saturday. I'm OK with everything that happened, but I wish she had gone home sooner -- wish that she had become DNR and chosen to enter hospice sooner. But it's hard for doctors to give up, even when you're in the cancer business and it happens often. And it's hard to talk about those things -- if I had even been more willing to discuss everything with the patient, the meeting could have gotten scheduled sooner and she could have gone home on Thursday, instead of Friday.

I wanted to write down what happened with her, because I know I'll forget. I had the day off on Saturday, and was on call Sunday, with a fairly rough night that ended with me switching services post-call and starting in the ICU on Monday morning. And that's where Nancy the nurse practitioner ran into me, with my post-call addled brain, and told me Ms. Jones had died. I actually didn't even remember the conversation had taken place until Tuesday evening; that's how much damage being on call does to your mental function. You remember only what's completely necessary, and everything else gets pushed aside.

So that's that. I was on call again last night, and it was truly one of the roughest nights I can imagine -- definitely the worst I've had so far. The largest event of the night was a bad one, so bad that I don't even really want to talk about it, out of respect for the patient and in acknowledgement that I don't think I'm going to forget about this one any time soon. But here are some small thoughts from my first call night in the ICU:

-The 23-year-old died. Asthma, obesity, and pregnancy are not a good mix when it comes to swine flu. Her lungs were just shot, and in the end, there was no way to oxygenate her. Unfortunately, her family refused to "give up" and insisted in a family meeting a couple days earlier that we "do everything." When the time came, though, and they saw what "do everything" means -- chest compressions, with people, including me, taking turns bouncing her whole body around on the bed with the force of our compressions; sticking needles into every vein and artery we could find to try to draw blood or give fluids; bodily fluids coming out of every orifice she had -- a result of natural events, the medicines we were giving, or her impending death, I don't know; and the general chaos in the room, with us shooing them out of the room continuously while we tried to work on her and save them from seeing all these horrible things -- they reconsidered and asked us to stop. They spent a last few peaceful minutes with her instead, which was the right thing to do. Her family was a mess. I can't blame them. Her husband almost threw a chair at my resident -- he later apologized, and no one blames him for being so angry, but that's how much emotion there was. Now, a couple days later, the memory of it is at once completely fresh yet also blunted enough that I don't know how to put it into words. In a weird circle of care, it turns out that the whole rest of the OB/Gyn department worked with her in the beginning of her stay, when she delivered her baby and then got sick, and I, the only OB resident who hadn't met her during her obstetrical care, was the person who took care of her in the end.

-I got to put in a central line on a woman that night, too. First stick, and success!

-I found out the next day that a paper I worked on a few years ago will be published. It took this long because I didn't have ownership of the data, and so the work wasn't mine to publish. But the people who do own it decided to resurrect it, so it will be published later this summer in a big journal. Quite exciting!

I can't come up with a good way to end this post. I don't have any wise words or thoughts to bring things to a close. It is what it is -- the events and my feelings. I have to get them out of my head, though, both to document them and to start the forgetting/remodeling/healing process.

Death

One of my patients might die tonight. I think the chances are greater than not that she'll survive the night, but there's a real chance she might die. She has relapsing Burkitt's lymphoma and HIV, both diagnosed in September, and she has failed all of her chemo. She has only a short time to live (like, weeks), and I'm OK with that. What I'm not OK with is that I left this evening without being sure of what her wishes are. When she was admitted last night, she was a "full code" -- wanted everything done. As of an hour ago, she's a "DNR-A" -- "do everything except CPR." The attending signed the DNR order after talking to her. But I don't know if he actually talked to her about it. And I wouldn't even have thought to question it except for something the nurse said to me. (And in his defense, he had talked to the patient about it before, in the office, but the papers had never been signed. And I'm not saying that I think the patient actually wants CPR; she knows the extent of her disease as well and is very realistic about it.) But I didn't have the guts to go back into the patient's room and confirm with her in person that these were her wishes. Because she's already been crying all day, and I didn't want to see or hear her cry again. And that's what's bothering me about it. From a technical standpoint, if she dies tonight, it's not really my business, because the papers are signed and the orders are in, and I'm not there tonight to have to deal with it as it unfolds. From a guts standpoint, it IS my business, because I am one of her doctors now, too, now that she's in the hospital, and it's my job to talk about code status with patients, and I hate doing it, and this is a near-worst-case scenario of what happens when I try to ignore it. So if she dies tonight, I'm going to keep wondering if she really really truly didn't want CPR (even though I know this is objectively the best decision). And if she's alive tomorrow, am I going to be able to make myself talk about it with her?

Another woman might die tonight, too. She's in the ICU. She delivered her baby 6 days ago. She has swine flu. She's the third H1N1 case in our hospital this month; the first two died. All the cases have been obese, and all have had a history of asthma. But the first two I didn't know the name of, and no part of their care. This woman I found out about because everyone in the OB/Gyn department got an emergency page yesterday to go to employee health to get Tamiflu. Since I'm on medicine right now and not OB/Gyn and I wasn't exposed to her, I'm not at risk. But since I'm on medicine right now, I was around when the infectious disease team pulled her chest x-ray up on the computer this afternoon and I saw it. It's one of the worst chest x-rays I've ever seen. And then I asked the ICU team (which I'll be joining in one week), and they said she was intubated today and could seriously die tonight. I don't know why it's bothering me so much; all I've seen of her is a chest x-ray. But since she's post-partum, she could be one of my patients. And since she's in the ICU, she'll be my patient in a week, if she's still alive. I don't even know that it's her baby I'm thinking of (the first time I can truly say that I'm acting like a "mommy doctor" instead of a "baby doctor," as most people like to characterize the profession. I'm thinking about her -- the "sickest person in the hospital," according to one attending. And me.

Oh, hello

It's hard to pick back up when you haven't blogged in so long. I want to do a huge recap and tell all the crazy stories from the last two months -- TWO MONTHS! -- but that would be a novel in itself. And I have very little free time these days. So maybe it's better to just start back as though I never left. Even though that would be weird, too. So here are a few references to some of the things I would tell you about if I had all the time in the world, and maybe someday I'll come back and tell you about them for real.

• My graduation speech was awesome, thank you very much. I got the DVD in the mail last week, but haven't watched it yet.
• The two weeks between graduation and the wedding were crazy. Crazy fun, but still crazy.
• The wedding was amazing. I love looking at our pictures. I need to share the Flickr link with everyone.
• The honeymoon was amazing. We need to write it all down before we forget all about it.
• Moving to Philadelphia was not much fun. We were tired -- no, exhausted -- and packed everything up in 36 hours. Then drove 12 hours to Pennsylvania. The moving truck got damaged mysteriously, and of course, we had declined the damage insurance. We just got the estimate this week. It's bad, but we were imagining numbers in the 4 or 5 figures, so it's really not that bad at all, by comparison. I drove through the night, slept at various roadside stops, arrived at my mother-in-law's house at something like 6:30 in the morning, and slept for two hours before we had to wake up to go to our mortgage closing. We pushed through it, said hi to our new house, and went back to Downingtown to sleep all afternoon. We saw Up that evening, and I cried and cried and cried. There were a surprising number of touching moments, and I was just so emotionally drained that the tears kept flowing. "This is what residency will feel like," I thought.
• And now I'm a doctor! My white coat is ridiculously too big and I haven't had a chance to get it tailored. I took care of a former Eagle for a week, and I told him he needed to finish college. I've felt maybe 3 cervices, and have had no idea how dilated any of them were. I'm an expert in hypertension and diabetes -- which will be useful in OB/Gyn, no doubt -- but I know even less OB/Gyn than I did as a med student, because I'm spending my first two months on medicine/ICU. I've had three overnight calls so far, and a "good night" consists of an hour of uninterrupted sleep. I have not had to do CPR on a real person yet, and I have not delivered any babies. I haven't cried at work once (there was one almost time), and I haven't come home and cried since the first week. I've had two golden weekends (this is #2) and no black weekends, and I've come very close three separate times this week to discharging all of my patients, which would mean I wouldn't have to come in the next day. Each time, though, the patients foil me at the last minute. Oh well.
• Our house is 85% set up, which means it's very functional. It's not completely put together, though. We have lots of little projects, and some big projects. In some ways, we have less space than we did in Louisville, and in some ways, we have more. The net effect is that we will still need to get rid of some stuff, so that's happening slowly.

And I think that's it for the updates. If, next week, I all of a sudden tell you a good medical story (I know you like them, after all, and I've got some good ones!), I'll consider it fair, since I've now updated you, and you know I'm an intern in Philadelphia, and no longer a med student in Louisville.

Oh, hello.

You probably thought I had forgotten about you, right? Of course I didn't. Things have just been really... busy. And un-busy.

I spent 4 weeks in NJ, and it was devoted almost 100% to looking for a house in Philadelphia. Of course, looking for a house consists of a few days of looking at a ton of houses (we saw 15+ each day!), and then tons of inactive time looking around the internet at MLS listings, Craigslist listings, and learning about the finances associated with buying a house.

I got really bored and unhappy and mopey on the inactive days. Eric commented that I'm really bad at being unemployed, and it's true.

I've been back in Louisville for two weeks, and the boredom is over. It's been non-stop action for the last 10 days. First there was Senior Week -- a trip along the Bourbon Trail, a trip to a winery, Senior Skits, a Bats game, a class cookout, Doctors Ball (aka Med School Prom), our awards banquet, and finally, graduation itself. As class president, I gave a speech -- in front of probably close to 2,000 people! -- and it went really well.

So I'm a doctor now! Yay! Finally! So far, it doesn't feel any different, other than using it in arguments with my mom: "I KNOW about the potential dangers of lead paint; I'm a doctor!" Haha.

This week has been split between wedding stuff and house stuff. On the house front, we had inspection on Monday, and submitted our request for repairs/price adjustment today. Let's hope the seller does everything we've asked; some of them are non-negotiable on our part, which means we'll walk away if they aren't done. That would suck, since we're moving in less than 3 weeks and need a place to live.

Lots of people have complained that we haven't posted any pictures of the house, but I'm a little bit wary of doing that too soon. I was definitely nervous doing so before the inspection; even now, I'd rather wait until we know the seller has agreed to our terms. And even after that, there's still the final approval of the mortgage to wait for (a friend of ours had problems with that, through no fault of her own; we've been following the saga via her Facebook feed). So you'll get pictures when I know for sure we can call the house ours :)

On the wedding front, I've been buying lots and lots of things, making final calculations to see if our money is going to cover everything we need it to (it's going to be close, but we'll make it!), organizing all the wedding crap we've accumulated as nicely as possible in the office, and cleaning the rest of the apartment. A good pre-wedding workout is to move 10 boxes of wine from your car to your building lobby, then from the lobby down the hall to the elevator, then from the elevator to your apartment at the end of the hall, and then from the door to the office. Repeat with 10 cases of beer, and again with 20 bottles of bar mixers, as well as all the other wedding stuff you've brought home. I'll get toned triceps by the end of the week, no problem!

I may not post again for a while, but at least this time I'm giving you warning.

-Dr. HWong14

In New Jersey!

Yesterday I drove east, through rain (pretty much the whole way) and snow -- yes, snow! -- in western Maryland. I'm in NJ/PA for the rest of the month, and have a lot planned.

First, we need to find a place to live. This Friday we're meeting with three or four real estate agents and hope to narrow it down to just one. Tied up in this process is getting our mortgage figured out -- after lots of leads for a doctors loan, we only have one good lender option, so we're in the pre-approval process right now. The doctors loan is absolutely awesome -- 100% financing, no PMI, and your student loans aren't counted against you in the debt-to-income ratio calculations. Of course, you need to be a doctor (!!).

This weekend we're heading down to DC for an engagement photo shoot we won last fall. I'm really excited to meet Carmen, our photographer, and to get a face-on, eyes-on-the-same-level photo to support our New York Times wedding announcement submission!

This month Eric is having his bachelor party (Phillies game and other debauchery), I'm having my bachelorette party (no idea what that entails), and we're running a 5K together. It will be my first race, and the first time I've ever run that far in my life (I was a swimmer!). Today is supposed to be my first workout on my training schedule, but right now there's a cat asleep on my lap and it's chilly outside, so I'm still trying to work up some motivation.

Also on the to-do list in the next few weeks: do my taxes, figure out what to do about my student loans next year (public health services deferment vs. forbearance vs. income-based repayment), and create my own personal electronic medical record (I'm going to scan in all my old lab, vaccination, and procedure reports and put everything on its own thumb drive).

I also have lots of small wedding projects to take care of, like programs and assorted other printing projects. Speaking of wedding projects, our invitations got out ahead of schedule and we've started receiving RSVPs back. The only flaw in my plan? The RSVPs are being sent to Louisville, with a due date of May 1, and I will be on the east coast through May 3. The post office is holding my mail, so at least I don't have to rely on my never-home roommate to pick it up for me. I won't be able to keep tabs on the RSVPs as they come back, but I'll make it my first project as soon as I get home!

On the school front, we are planning for Senior Week, and lots of fun activities, like a trip down the Bourbon Trail, a group outing to a baseball game, and, of course, Senior Skits. I'm supposed to be working on a couple skits/videos while I'm here. Graduation is May 9, and I have to give a speech, and I have no idea what to talk about, so that's causing some anxiety. I'll just put my speech writer on it -- that would be Eric, not Sam Seaborn.

OK, time to get this cat off my lap, go for a run/walk, and look through MLS listings!

Last. Day. Of. Med. School. Ever.

The end.


Haha, just kidding. Like I could ever leave anything that short. Today was my last day! My preceptor doesn't work Fridays, so I've had every Friday in March off, and this month was my last rotation, because, smart person that I am, I decided to save four weeks of my vacation for the last four weeks of school.

I AM DONE!

Now it's just full-time sleeping, reading for fun, wedding planning, and buying-a-house-and-moving preparations.

(I do have one silly multiple choice "test" on Monday and a 5-page, double-spaced paper on a historical medicine figure of my choice due next Wednesday, but those aren't that painful.)

Gardens

Every spring for the last four years, I've planted an herb garden inside the apartment. The first year, I was really ambitious and had two large window boxes, but through trial and error and figuring out which herbs I liked to use, I decreased to one window box plus some larger pots. Last year, I had a major planting project, setting out to grow 100 3" pots of Kentucky Colonel mint, for wedding favors. I don't think I ever documented the end of that project, but at its peak I had about 20 individual plants rooted, but then things quickly took a turn for the worse when I had to do my away rotation in Philly last August. Needless to say, our wedding guests are not receiving mint plants.

My must-grows are basil, flat-leaf parsley, and cilantro. I've also grown oregano, thyme, and chives, but the first year I tried it, I didn't thin the seedlings enough, so they never really flourished (I didn't really believe in thinning before that, but now I see the benefit). Mint does not grow well from seed, so I buy it already started -- and actually, the mother KY Col. plant I bought last spring has survived the winter and is sprouting like crazy again. Same with rosemary -- buy it started, and as long as you keep it watered through the dry, hot (indoors) winter, it will survive. Unfortunately, I was traveling so much this December for interviews that mine died. I love to have rosemary for my Thanksgiving turkey, though, so I'll likely buy another small potted one this spring.

Cilantro is a funny plant because it grows really quickly, then quickly goes to seed (the seeds are coriander) and dies. You can harvest the coriander, of course, but what I really want is the cilantro, so if you want a continuous supply, you have to continuously re-plant it, probably every month or so. It definitely takes constant attention.

But basil and flat-leaf parsley are great, grow wonderfully, and pretty much survive as long as you keep it watered. They add such a wonderful fresh taste to all of your dishes, and that's why I love to grow them.

A few weeks ago, I was itching to start my seeds -- I use peat pellets then transfer the seedlings to pots or window boxes -- and then I came to a realization.

I'm driving to New Jersey in two weeks, to spend the month of April on the east coast. It's difficult to bring all those seedlings with me (I did it last year with the mint, and it was a huge pain), and they'll definitely die if I leave them here. Then, while I'll be back home for the month of May, we go on our honeymoon in early June, and then pack up the apartment to move to Philadelphia in mid-June.

So for the entire spring growing season, things are going to be very much in transition, which means it's a smarter idea if I just don't bother with planting this year. That makes me sad.

But the good thing about growing indoors is that you can pretty much start seeds at any time of the year, so there's always a chance that I can start those little seeds in mid-June, after we move.

And if we end up with a place with one of the top things on our "Nice to Have" list -- a deck or patio -- then I can transfer my pots outdoors and probably even give composting a try. Plus, if I had a little more room outdoors, I could do potted vegetables, like tomatoes and peppers. I have to admit, that deck is really high up on my "Nice to Have" list and the only reason it's not a "Must Have" is because I have to be realistic. Let the house hunting begin!

A day late, no dollars short

I got my first choice, Pennsylvania Hospital!

It was really exciting to open the envelope and see those two words. I looked twice, gave a muted shriek, showed it to Eric, and gave him a big hug. Then I may have shrieked again, this time a little louder :)

Today has been a whirlwind of house shopping on Craigslist (Do we have a loan or broker yet? No...) and getting wedding crap done. After collecting and tasting samples from four -- count 'em! FOUR! -- bakeries this afternoon, we've made our final choice. And all evening, we've been going through music playlists from our DJ, various places on the web, and our iTuneses to pick wedding music. Whew! All while massively hungover, I must add, because the celebrating yesterday was hardcore.

Unfortunately, Eric leaves in the morning, and then I'm left to the neverending task of trying to straighten up this apartment, finish the invitations, and get a tiny bit of work done before the tiny bit of motivation I have left disappears in the next week. Because I only have ONE WEEK of school left! Smart me, I took the month of April off, which is among the best decisions I've ever made.

Yay!

Short and sweet

From:	"NRMP Staff"
To:
Date:	Monday - March 16, 2009 11:51 AM
Subject:	Did I Match?
Congratulations! You have matched. Check the Match Site at https://services.nrmp.org/R3/ on Thursday, March 19, 2009, at 1:00 PM eastern time to find out where you matched. Because you are matched, you will not have access to any information about unfilled programs.

Now I just need to wait until Thursday!

Scramble Day approaches...

I've been trying not to think about the impending Match Day, and for the most part, I'm doing quite well. OTHER people, on the other hand, keep mentioning it, and then I get this awful feeling in the pit of my stomach. Actually, it's more like the top of my stomach, because I think my ulcer is back, and I haven't restarted medicine for it yet. So with every mention of Match Day, a little more acid is released, and I feel a little more nauseated.

Tomorrow -- TODAY -- at noon, I'll get an email telling me which way I've gone. Matched or scrambled. If it's scrambled, Student Affairs will page me to get my ass into the office for some counseling and planning of the scramble attack. Like I said, I'm doing pretty well not thinking about it, but other people keep bringing it up.

This morning, I had a dream -- make that a nightmare -- in which I opened my letter on Match Day to find out that I hadn't matched. The process was clearly out of order, since you're supposed to find out on Monday, not Thursday, if you haven't matched, but that's the way nightmares go. I was crying in my nightmare (don't think I won't be crying in real life if this happens!), and I woke up with real tears on my cheeks. I immediately dozed back off, and the nightmare started all over again! This time, I opened my letter to find the name of my #4 program. I was instantly upset, not because it's a bad program (I actually really like it), but because (in my nightmare), I knew Eric would be upset, because it's not in Philadelphia. I woke up from that nightmare with palpitations, too.

To assuage my fears, Eric today looked up the Match statistics from 2008. I've looked at them before, but I always take away the bad message: 6% of people don't match at all (not even via Scramble). There were 7 open Ob/Gyn spots in the country this year after the match. Eric called me to talk about the positives -- 60% of applicants get their first choice, 80% get one of their top three choices, and 90% get one of their top four choices. 94% match anywhere. I countered with my negative statistics, and made him all depressed, also. Oops.

Ulcer's acting up again; time to go to sleep. In 12 hours I'll know IF, but not WHERE. IF is all I'm asking for at this point. Here's hoping for no more nightmares. It's disconcerting to wake up with real tears on your face.

You think YOU'RE unhealthy?

Just imagine if you were a 33 year old woman who just had a heart attack and two stents placed. That's what I saw in the office yesterday. That's what uncontrolled diabetes, hypertension, and hyperlipidemia will get you. Even worse, she knew she had all of those things and just didn't take any of her medicines, for months at a time. NOW she's going to be on top of all of her meds, but that's akin to, as my preceptor likes to relate, the person who quits smoking after he is diagnosed with end-stage lung cancer.

Yeah, time to get my cholesterol checked again...

Roses and pot pie

Check out what I scored at Kroger on Monday:

Valentine's Day leftovers for 75% off! First I saw the "Valentine's Day"-specific rose bouquets, and was going to buy 3 roses with some filler for $3.25 (originally $12.99), but then I saw, over by the regular flower display area, that ALL the roses were 75% off, so I got these beautiful terracotta-colored ones for $3.75 for a DOZEN, no filler (originally $14.99). Sweet!

They were kind of cruddy looking, but that's where working at a florist in college comes in handy. With some love, some lukewarm water, sharp scissors, and some floralife, they perked up immediately, and bloomed beautifully. The fact that they were already "past their prime" when I brought them home was OK, because they're all maximally open right now, and I'm leaving tomorrow morning for a long weekend, so I was able to enjoy them to their fullest potential.

And then, check out what I made on my (unexpected) day off yesterday:

Chicken pot pie, inspired by this Real Simple recipe:


The only thing that could have made it better (other than a little more salt; I didn't season it enough) would have been a cute casserole dish like the one in the magazine. I need more pretty baking dishes. NEED. On Sunday when I was cleaning out the refrigerator, I salvaged some almost-bad chicken breasts by poaching them in water, then stuck the cooked chicken back in the fridge (I intended to cook this recipe on Monday after I got the pie crusts, but things got put off...). I wasn't able to salvage the already-bad chicken thighs, so those got tossed. I hate wasting money like that.

Here are some action shots for you:
First step: Sauteeing the mirepoix (the celery was my addition, since I had some; but why would you write a recipe with just onions and carrots and not make it the full mirepoix?).


Last step: Eating! It's a store-bought frozen pie crust (the package came with two and I used them both) and I also added frozen peas, as per the recipe. We discussed pot pie today at work and decided potatoes would also be good in it (although I hardly ever buy white potatoes any more; what do you think of sweet potatoes in a pot pie?). If you added bell peppers you'd have a mirepoix AND a trinity!

As I was cooking it, I realized I was making a "lite" version of a regular white sauce, and I was annoyed I hadn't read the instructions a little more closely before starting to figure out what their method was. No butter?! Give me a break. I have to admit, though, that the pot pie was very good, aside from my too-little-salt error, and WAS very rich-tasting. And then I looked back at the recipe and saw the butter omission was on purpose. They meant for it to be a "lite" pot pie. Oh well. At least now I know that I know the method of making a pot pie sauce the right way -- BUTTER and flour, then some wine and stock and milk :)

Now I have a confession: A mere 24 hours later, that entire 9x13 pan of chicken pot pie is gone. I had it for lunch yesterday immediately after it was cooked, as a snack a little while later because it smelled so good and I'm a pig, for dinner last night while watching Lost (OMG, what happened to Aaron?!?), for lunch today, AND for dinner tonight. If I weren't leaving for 5 days tomorrow morning I might have let it last longer, but really, it was THAT GOOD and I didn't at all mind eating it so many meals in a row. I already said I was a pig, so we're covered there.

And with that, I'm off to Snowmass, for one final year of skiing -- I mean, learning how to be a better student leader. My goal: black diamonds without shaking in my boots! And since I'm a lazy fourth-year medical student with growing senioritis, I hope I DO get snowed in on Tuesday morning and have to stay an extra day... or two!

Rank List in!

Last night Eric and I finalized my residency rank list, and I stayed up late to submit it. It's in! It's done! The final deadline is Feb. 25 at 9 pm, but I'm not going to open the list back up before then. First of all, I'm going to be gone Friday-Tuesday, leaving me just Wednesday to play around with it, and second of all, word on the street is that people who make changes or submit close to the deadline have an increased frequency of 1) having computer malfunctions screw with their ability to submit and 2) having regret about last-minute changes. So that's it, I'm done.

What comes next? Between Feb. 25 and March 16, a computer program runs The Match and produces the results. On March 16, if you have not matched anywhere, you receive an email and start to cry. On March 17, you get to see the list of unfilled spots in the country and participate in The Scramble, in which you scramble to contact programs with unfilled spots and beg for acceptance. If you have matched somewhere as of March 16, you just breathe a sigh of relief that you don't have to scramble, and you continue to squirm until March 19.

On March 19 at noon, every graduating medical student across the country gets to open an envelope that contains the name of the program they have matched into. Most schools have a Match Day ceremony of some sort that involves some pomp and circumstance, food, anxiety, and alcohol. At noon, everyone opens their envelopes, everyone cries either happy or sad tears, and then the drinking continues. Whew! I get nervous just thinking about it. Oh, who am I kidding; I've BEEN nervous for months now!

So how exactly does the program match everyone up? Well, the basic tenet is that the match favors the student, not the program. That is, it will try to put each student in the highest possible program from his or her list, rather than filling a program's spots with the program's highest ranking members. Here's an article that appeared in JAMA describing the history of the match, why it was implemented, and how it has changed over the years.*

And here's a really good explanation of the matching algorithm courtesy of NRMP, the National Resident Matching Program, the body that runs the match. Here's a personalized example:

I create my rank list, with 3 programs. We'll call them Program A, B, and C. Each of those 5 programs has 5 spots to fill, each interviewed 50 applicants this year, and each program ranks its 50 applicants from most desirable to least desirable.

So say Program A, my #1 choice, ranks me as its 6th choice. Program B, my 2nd choice, ranks me as its 2nd choice. And Program C, my 3rd choice, ranks me as its 10th choice.

The computer first looks at my list, and sees that I ranked Program A first. At that moment, at the beginning of the algorithm, Program A has all 5 of its spots open, so I get put into one of them. I have tentatively matched. Then the computer moves on to the rest of the applicants in the pool. If 5 other applicants all ranked Program A as their #1 choice as well, and those 5 applicants are higher on Program A's list than I am (at #6), then the computer would bump me out of Program A and fill Program A with Program A's #1-5 applicants, since those applicants also chose Program A as their #1.

So now I'm unmatched again. Now the computer considers it impossible for me to match at my #1 choice, and moves on to my #2 choice, which is Program B. If Program B is already tentatively full, I will bump the lowest ranking applicant out, because I am Program B's 2nd choice. I think at this point it would be nearly impossible for me to not match at Program B and match anywhere else, so I should be all set.

But how could it be possible for me to match at Program A, if I'm Program A's 6th choice and they have 5 spots? Well, if Program A's top 5 applicants don't all choose Program A as their first choice, I have a window of opportunity. For instance, if Program A's top choice (we'll call him John) hated Program A when he went to interview and decided he would never in a million years want to go there, then he wouldn't rank it at all. So even though Program A really wants John, John absolutely does not want to go to Program A, and it is therefore impossible for that match to be made (see, this is where the match "favors the applicant's desires, not the program's."

So if John is out of the running, then I would become Program A's #5 choice, instead of its 6th, and I should get in.

Stressed out yet? Yeah, me too. Now multiply that until you reach reality, in which there were 3,475 programs with 22,240 available spots for 44,598 applicants (U.S. seniors, foreign medical grads, people who delayed entering residency for a variety of reasons, etc), and 20,940 matches last year. (Data and charts here.) Eek! Thank goodness computers are so fast and powerful these days!

Someone told me that this matching algorithm was originally designed for some sort of dating match-making, and I found another article that confirms this (from the Society for Industrial and Applied Mathematics). Another tenet of the match, aside from favoring the applicant's desires over the program, is to create a situation in which no applicant-program pairing prefers swapping with another applicant-program after the match is done. In other words, say I end up at my #2 and John ends up at his #2. If I ranked his program as my #1 and the program ranked me as its #1, but John ended up there; and at the same time, John ranked my program as #1 and it ranked him higher than it did me, then my program, John's program, John, and I would all prefer to switch around. This would be disastrous if it happened to multiple pairings, because then the match would not have worked as well as possible, and you'd have people switching around afterward. A logistical nightmare!

And yes, when I signed up for the residency application process this fall, when I registered with NRMP a few months ago, and when I submitted my rank list last night on NRMP, I agreed over and over again to adhere to the match results I am given. If I match somewhere on my list, I can not pull out completely, or approach other programs to try to switch. It's binding. I don't know what legal action might be taken, but you can bet I would never match anywhere next year if I tried to reapply. I'm sure I'd be blacklisted.

So what makes a successful rank list? Essentially, a longer list is better (especially if you're applying to something really competitive), because it gives you more options. If I only rank only one or two programs, there's a higher chance the computer can't stick me anywhere that works, so I might have to scramble. In order to rank a program, you have to have interviewed there. Then, you have to decide whether you want to rank it. The litmus test is to say, "Would I rather learn [my chosen specialty] at [Program X] or would I rather learn [my chosen specialty] in somewhere completely random (like Alaska, Alabama, Maine, insert random middle-of-nowhere place of your choice)?" A stricter litmus test is to ask, "Would I rather learn [my chosen specialty] at [Program X] or would I rather learn something completely different somewhere completely random?" (I often say, "psychiatry in North Dakota".) If that's your choice, you're likely to decide to rank Program X after all.

However, I interviewed at 16 programs, and have only ranked 13. The last three were just too horrible. Well, two were horrible and one I decided would be a big blow to my ego. And yes, I fully believe that I would rather become a surgeon or internist at some random middle-tier program (for one year, anyway, then reapply) than to learn Ob/Gyn at those three programs. They were that horrible. I think this is safe; 13 is a pretty long list, so I should be OK.

And finally, why the long wait between the ranking deadline of Feb. 25 and the results starting March 16? According to NRMP, they say that in those three weeks they take :

"a number of major steps to assure the accuracy of both the Match and the subsequent release of Match information. Those steps include:

• Checking the integrity and completeness of the data.
• Transferring the data to the algorithm module, checking it again, and running the Match.
• Verifying the results of the Match and transferring the data into the NRMP databases.
• Creating more than 60,000 individual reports for applicants, programs, and schools, and assuring confidentiality of the information. The reports are then posted to the Web in accordance with the Match Results schedule.
• In addition, time is allotted for unmatched applicants and unfilled programs to make decisions before Match Day." [ie, the Scramble]

I guess that sounds fair. You might also be interested to know that almost every year, someone tries to sue NRMP on anti-trust grounds. I have to admit, the whole matching concept is rather weird. But objectively, it is a fair and orderly way to evaluate programs, to have programs evaluate applicants, and to try to make everyone happy. If things were the way they used to be, in which I might get a telegram offer during my second year and have to reply in a matter of hours (well, it would be via email nowadays), that would be MUCH more stressful. You might agree to accept a position and never know if that's truly the best you could have done with yourself. Decisions would be made based on first- and second-year grades, which, while important, aren't necessarily good predictors of becoming a good physician. I can't even imagine the insanity. Yet somehow, lawyers, dentists, pharmacists, and a number of other professional students manage to find jobs without using a match. Who knows.

In any case, now it's just a waiting game. Twenty-six days until March 16, when I found out IF I've matched, and 29 days until March 19, when I find out WHERE.



*Subscription may be necessary to access the full article, but just comment if you want the pdf and I'll send it you. The citation is JAMA. 2003;289:909-912.

Abstinence is "not realistic at all"

I just read this CNN story on the interview Bristol Palin did with Fox News. She says that abstinence is the best option, but also believes that abstinence is not a realistic expectation for teenagers.

I fully agree. However, I connect those two thoughts with an acknowledgment that contraception is very important to prevent disease transmission and pregnancy. I don't know how Bristol reconciles her two beliefs, but she has a baby now, so you can draw your own conclusions.

Our society is fighting biology. We tell our 16-year-olds in the clinic that if we were living 200 years ago, they would be married and have kids by now. But instead, because we want them to grow up and continue their education, they need to put off having sex. They need to control their hormones. And if they can, that's wonderful (and believe me, I hand out the "101 Ways to Say No to Sex" brochure left and right); but if they can't, they need to know how to protect themselves from STDs and pregnancy. And no, the oral contraceptive pills most of them are on for out of control periods do not count.

So when that 16-year-old the other day (the one I had to clandestinely sneak instructions for emergency contraception to) told me she had had sex, and she said, "We talked about it a lot and decided we wanted to do this. I mean, we're both religious and we believe in waiting until marriage, but we also love each other and talked about this for a long time before making our decision," I couldn't laugh at her or point out the idiocy of her two opposing statements. That's how teenagers are. They know, at least to some degree, that they should wait, but it's also an unrealistic expectation for some people. Thank goodness she and her boyfriend have the heads on their shoulders to recognize that they don't want a baby anytime soon. That's all we can ask for, really.

So I will happily give out condoms and dental dams with explicit instructions on how to use them and why, and I will continue to put fear into teenagers' minds about what STDs are and what they look like and how they are transmitted. And how to use their OCPs as emergency contraception if they have them, or how to get Plan B if they need it. Because while no one wants 16-year-olds to have sex, when they decide to have sex, they're going to do it. Better prepared than not, right?

Pediatric and Adolescent Gynecology

Remember how I love, love, love pediatric surgery? And I like pediatrics in general pretty well, too. But I'm going into OB/GYN, right? Well, it probably wouldn't be much of stretch to imagine, therefore, that I am liking pediatric and adolescent gynecology a lot. A LOT.

There is such a wide variety of patients, which is always fun. And they are anywhere from young children, 3-4 years old, to young adults, 21-22 years old (my preceptor will see her patients until they graduate from college before she kicks them out to an adult gynecologist). Here is just a sampling of the patients I have seen in the last week and a half:

-Tons of girls with bleeding disorders. von Willebrand's disease is more common than I realized (even though I knew it is the most common inherited bleeding disorder). I can't imagine starting out my period for the first time and having it last 12 days and being so heavy I had to change my pad every hour. It's so nice to be able to help these girls, although in some in can be tricky to find
the right medicine combination.

-Lots of ethical gray-zone issues. Like the 10-year-old girl with special needs with heavy periods. "She has autism spectrum disorder," her mother informed me, "she was vaccine-injured as a child." At that point, it took all my strength not to just walk out the door or lecture her on why that was highly unlikely. (Have you seen the latest news on this, by the way? News #1, News #2). So anyway, her mother wanted to not only make her daughter's periods manageable, but wanted to get rid of them completely. And yes, doing this with oral contraceptive pills is perfectly fine, but the mother wanted to discuss permanent solutions. "Like what I had done," she told me, in reference to the hysterectomy she had in her 40s. 40s, not 10, thank you very much. "She has special needs, so she can't take care of herself, and I'm concerned about hygiene issues," the mom said. And while that's a valid concern for severely mentally limited girls, I ended up spending about 20 minutes alone with the patient because the mother wanted to talk in private with the nurse pracitioner. And in those 20 minutes, not only did I not see any evidence of this girl having ASD, I also got confirmatory (verbal) evidence from her that although she thought having a period sucked (which any 10-year-old would think), she in fact did bathe herself. And when I mean this girl didn't have ASD, I mean I would still have to see some intelligence/personality testing, but she was conversing with me like any other totally normal 10-year-old. Not so much mentally or socially withdrawn from what I could tell. No judge would ever allow that child to undergo a hysterectomy.

-A fair amount of sexual abuse, unfortunately. One girl that we saw today was being molested by her father before he was incarcerated for illegal drug issues (and her mom is incarcerated for robbery and grandma just got custody of the patient and her five siblings). Her older sister was also being molested and had the courage to tell someone. Both girls have genital warts now. Another girl was in the custody of her grandmother because her mother was the perpetrator of a neighborhood playacting fantasy, in which she would drug her daughter and the neighborhood kids with "something blue" and have them act out sexual activities with each other. It's very sad. One of the residents who works with us occasionally can't handle it, and becomes very emotional when she hears these stories. She has a 13-month-old and a 7-year-old, and I think it affects her a lot. I'm still as emotionally closed off as I've ever been when it comes to medicine, so it hasn't penetrated my emotional barrier yet, thank goodness.

-Lots of teenagers having lots of unprotected sex, starting at a very early age. When you start having sex at 13 and have had multiple sexual partners, you're just not mentally prepared to deal with the realities of STDs, let alone pregnancy. The nice patients I've seen are the ones like that who have decreased their sexual activity as they've gotten older, seeing the error of their ways. But all you can do is support their decision, try to make sure that they're making actual decisions and not just being pressured into sex by someone else, and give them the tools to prevent diseases and pregnancy. And screen them for STDs every time they come in. I like to reinforce that their romantic relationships need to be emotionally healthy, not just safe from physical abuse.

-A few older adolescents who are sexually active, but more in the realm of "reasonable" sexual activity, like a 20-year-old who has been dating her boyfriend for a couple years and is on the pill for period-control reasons but who has the fear of pregnancy and STDs stuck in her head and so still uses condoms (the best thing to do). These are patients I enjoy counseling on emergency contraception and period manipulation techniques. They're old enough and smart enough to have an intelligent conversation with, and they deserve to know all about how their bodies and medicines work so they can take control of their own health care.

-Sometimes it can be very tricky to work with adolescents. We have all our patients fill out a questionnaire every time they come in that assesses risky behaviors (tobacco, alcohol, drugs, sex, etc), and we discuss worrisome answers with them. Without their parents present. Yesterday, my 16-year-old patient wrote on her form that she wanted to discuss sex without her mother in the room. I got nervous, because I haven't had enough practice making that transition happen, and I'm not confident in being able to make it happen smoothly, so I knew I was going to have to deal with it. While we were discussing the patient's periods, her mom's cell phone rang, and she stepped out of the room. All of a sudden, I took advantage of the opportunity and switched gears: "I know you said you wanted to discuss some things without your mom. Let's talk about those now and when she comes back, we'll pick up with this menstrual calendar." So the girl told me how she and her boyfriend had decided to have sex for the first time, but they were using condoms, and she wanted to learn about her pills from a birth-control standpoint (she was on them for period-control), as well as about emergency contraception options if she ever needed it. As soon as mom walked back in, we picked up where we had left off ("So, how many pads are you using on your heaviest flow day?"), and when the phone rang again and mom stepped out for a second time, we went back to sex. In the end, I needed to write down some information for her, so when I went out to present to my preceptor, I wrote her two notes: one on ibuprofen dosing information, and another about emergency contraception. At the end of the visit, mom walked out the door first, and there was a moment when the patient and I were face to face. "Here's that information about ibuprofen I promised you," I said out loud, and then whispered as I showed her the second post-it behind it, "and here's a secret note for you." She nodded, smiled in thanks, and stuck the second note in her pocket. And mom didn't see a thing. Whew! What an adrenaline rush! It's like a spy operation sometimes.

-It's really heartwarming to see my preceptor do a pelvic exam on a pubertal girl, because she's so gentle and caring. "I'm a special doctor who specializes in dealing with girls' bottoms," she says. She gently gets them set up in the stirrups and sets up a mirror so the girl (and her mom, if the girl wants, which in this young girls, they all do) can see from up above (when I'm in the room, my job is to be the mirror holder). Then she points out all the anatomy. "The first thing I look at is your hair growth. This is normal hair growth, because it is in such-and-such a pattern. These are called your labia majora, which means 'big lips.' These are your labia minora, which means 'small lips.' This is where your pee comes out, and this is the opening to your vagina. Everything looks normal from the outside, and that's all we need to do today. As you get older, it will become necessary to do an internal exam to make sure all your girl parts inside are OK." That's so much better than having your first exam be in the emergency room, or even in an adult gynecologist's office. I wish mine had been like that! (And if they do need an internal exam, everything is just as gentle and informative along the way.)

-One of the funniest things I saw was a little 4-year-old who was having some itching down there (very common, just a little nonspecific vaginitis), and we set her up for a similar visual pelvic exam. In pre-pubertal girls, the hymen can be imperforate, and can set you up for an infection because urine can't flow out properly if blocked by the hymen. So we were examining her hymen, and she could see it in the mirror. She somehow figured out that if she tightened her rectum, it tightened her vaginal muscles, and made her hymenal opening squeeze shut. And if she relaxed, it opened back up. So all of a sudden she starts contracting and relaxing her butt to watch her hymen open and close. And finds it hilarious. It was pretty funny to see, but all I could think was, "Oh dear, now she knows a new trick that's she's going to want to duplicate at home..." Little kids are hilarious sometimes.

-We give the HPV vaccine to everyone. And I love it. I've been able to address every single patient's and parent's concern about it. "Well, I've heard about some of the controversy and I'm just not sure," a mom will say. And I respond with, "What concerns you about it?" and we address every concern as it comes. And they always understand by the end, that this is a good thing to do. I'm finding that I really like counselling patients a lot. Safe sex, emergency contraception, vaccination, you name it.

I had no idea pediatric gynecology even existed before a year and a half ago. Now I know that even if I don't go into it, I will definitely refer patients to a pediatric GYN without hesitation, because they provide such great child-oriented care in some very sensitive issues. And I highly recommend anyone who knows a child or teenager who need the services of a GYN to seek a pediatric specialist out. There's only one in Kentucky, and I'm working with her.

Also, here's a tip on a great book for pre-pubertal girls to get them ready for the transition to adolescence. It's called The Care and Keeping of You: The Body Book for Girls, by the American Girl company. Every 9-year-old should get it, and read it.

Snow Days

OK, so I was wrong and the weather people were right. We got about three inches Monday night, and another 3+ (I didn't really measure it) last night.

I've never seen snow like this in Louisville:



(It's kind of hard to see, but the falling stuff is real snowflakes, not rain. Video taken from my bedroom window.)

So I was going to drive to work today (when it's this yucky out, I deserve to drive and not walk), but this is what my car looked like, and I couldn't get into it:
The handle is completely frozen shut. I managed to chip the ice off of the lock itself, but I couldn't open the door to save my life. So I walked. I still have to go back out there and try to clean the car off this afternoon. Snow days were so much more fun when I was a kid.

Oh and guess what else was wrong about my last post: I wasn't an amazing medical student who went into the hospital to care for her patient on her day off yesterday. I slept in, and it was as divine as I thought it would be. I felt a little bit guilty upon waking, though, so I had my friend David look up the pathology results for me, and guess what -- they STILL weren't back! Guilt gone. They ended up coming back yesterday afternoon, but that would have been after I would have left, anyway, so no harm done. So I saw him this morning and it turns out that the guy does have cancer (not surprising), and it's probably not good, but he still needs a PET scan to look for mets, which will tell us how bad it is.

His lung cancer is almost 100% due to smoking, based on the kind of cancer it is and his smoking history -- 90 pack-years. Yikes! (A pack-year is the equivalent of smoking 1 pack per day for 1 year. So this guy could have smoked 1 pack/day for 90 years, but he's only 74, or 2 packs/day for 45 years, or 3 packs/day for 30 years, etc. In other words, he's a heavy, heavy smoker.)

So don't smoke, kids. Seriously. He's a really nice man, and his 5-year survival prognosis, depending on what this PET scan shows, is 1-30%. There is a 70-99% chance he will be dead within 5 years. That's really sad. Did I mention how nice he is? I don't like days like this.

To end on a slightly less depressing note, here are some snow day pictures from my commute.

In between the two rounds of snow, we had ice. The trees can't handle it, and all over the city, they're falling over and taking out power lines. I still have my power, thank goodness.


I like the icicles hanging off of the traffic light pole. I was walking in the middle of the street because the sidewalks weren't cleared and there were hardly any cars. Look at all those big, fat snowflakes that are falling!


I like how frozen trees look.


I can't remember what this tree used to look like, that is, whether it's a weeping willow normally or not. I love the look of weeping willows, so it's too bad I can't ever have one; it's bad feng shui.

And since that's another depressing thought, here's what Eric just bought me for my birthday:

source

With liners, so they can be used in the rain or snow. Versatility AND purpleness! (And no more walking to work in the snow/rain in my Danskos.)

Snow night?

It's supposed to snow tonight. Anywhere from 1-6", I've heard. I'll believe it when I see it.

Tomorrow is supposed to be my day off from work (1 day off each week, averaged over 4 weeks, remember?). I would LOVE LOVE LOVE to be able to sleep in, just this once. I mean, I normally don't work very long days this month -- if my team isn't on call, I'm usually in around 7, and out by 2 or so (today it was 1), and I'm not working very strenuously while I'm there. Actually, I take that back; we THINK a lot on medicine, as opposed to surgery, where we are doing things a lot. I prefer doing, which is why I chose Ob/Gyn, but both are tiring in long doses. Anyway, like I was saying, I don't work very long or very hard, but I still have to wake up early, and that's the part I don't like. So a morning off tomorrow would be divine. Small problem: my one and only patient is a 74-year-old guy who has a big thing in his lung. The top differential is tuberculosis vs. malignancy. Unfortunately, we've ruled out tuberculosis. They took a biopsy of the mass on Friday, and the pathology was supposed to be back today, but it wasn't. It will be back tomorrow. I've been taking care of this guy for almost a whole week now, and when I say I've been taking care of him, I mean it; I'm being a true acting intern for this case. He is my patient, really and truly. So I really want to be there tomorrow morning to find out the biopsy results and tell him and his family. I think they'll appreciate that it's coming from me. And that means no sleeping in. ARGH. On the bright side, I guess I'm really dedicated to my profession...?

I took part in a brain wave study this afternoon, for a professor in the Birth Defects department for a study about the origins of dyslexia. They took an EEG of me while I read different words, some jumbled and some not. I got $10, but the real reason I did the study is because they're going to give me a copy of my EEG. My very own! Yes, I'm a dork.

Happy Chinese New Year! Here's my ox-related story for the day: During one part of the EEG study, I was supposed to push a button if the word I saw was an animal. So, don't push the button if the screen says, "ftea," don't push the button if the screen says, "couch," do push the button if the screen says, "cats". What did I push the button for? "Beef." Yikes. I hope they don't ding me for that one, but believe me, I'm totally ready to defend it!

Lost!

Of course, you must watch it.

But then you should read these two articles. I found them interesting. Probably not earth-shattering, but interesting.

Secrets of Lost Revealed!
I Know What Happens on Lost This Season

OK, maybe one semi-earth-rumbling thing. Charlotte as the baby in the opening scene?!!?!? It might explain why she's getting all nosebleedy and the others aren't, if she's been doing the time travel thing her whole life... I have to go watch that scene again and analyze the ethnicity of that baby. Thank goodness for DVR.

The start of a new era

Today marks not only the start of a new presidential administration for the country, but the start of a new presidential administration for Eric and I. Believe it or not, even though it seems like we've been together forever and a day, we didn't start dating until the first year of Bush's first term. So wow, we'll see what it's like to live life with a new president.

I just heard a cute story on NPR. Neal Conan was taking calls from people to share what they were doing during the inauguration, and a man named Thomas -- from Louisville -- called in to say that while he and his wife were listening to the inaugural speech, they were at their doctor's office getting their first ultrasound, hearing their baby's heartbeat for the first time. And on top of that, they dated the fetus to 11 weeks, with a date of conception of -- get this -- Election Day! How coincidental!

And, by the way, I can never get over how Neal Conan says "bye bye" to all his callers. It's odd.

Done with interviews! Part 3

If you've actually read parts 1 and 2 of this series, congratulations; you're more of a glutton for punishment than I would have thought. But never fear, we're almost to the end!

Date: January 7, 2009
Program: Temple
Social Event: Happy hour at Penang, a Malaysian restaurant in Chinatown. When I was younger and we lived in Princeton, we would go to Edison, NJ, to the original Penang. It's a great restaurant, and I've never been to the Philly one, which opened about 5 or so years ago. But wait! Some quick Googling just now turned up the fact that they are different restaurants, but with very similar logos. This is the one I used to go to in Edison, which also has a location in Princeton and Bethesda. And this is the one in Philly. Regardless, what I actually need to tell you is that I didn't make it to the dinner, because the bad weather in Philly prevented my flight from leaving Chicago on time. I was actually pretty happy, as you might remember, although I was sad to miss out on the Malaysian food.
Breakfast: More pastries, including muffins and donuts.
Lunch: Wraps, potato chips, soda, and delicious brownies. This lunch was notable for the fact that as I was surveying the wraps, the vegetarian one all of a sudden looked extremely delicious, and I chose it. This is notable because, although I love vegetables, I am first and foremost a meat eater, and I always always always reach for meat when I'm out of the house. In the case of sandwiches, I first lean to roast beef, then to turkey. But this time, those grilled zucchini were calling my name, and they were really good. Afterward, I had a turkey wrap to top it off.
Where I stayed: Marjorie's apartment, for the last time of the season. She and her roommate were both gone.
How I got there: Southwest to Philly. I haven't flown Southwest to Philly too much, because from Louisville you have to stop in Chicago (whereas US Air and Continental both go nonstop from Louisville to Philly); I usually save Southwest for flying nonstop to BWI from Louisville. However, this time it was cheaper, and I decided I didn't care that it was going to take me an entire day to get from one city to the next, and it ended up working out for me, since I got stuck in Chicago and missed the social event.
Other notable events: I ran into Matthew, from the Drexel and Sinai interviews, again, and he gave me a ride back to Marjorie's apartment at the end of the day so I wouldn't have to ride the subway and walk in the rain; also, we discovered that we would be interviewing at GW together in two days! I had dinner with Duc at St. Stephen's Green and I had a really good chicken quesadilla that had great spicy poblano peppers in them. That night was notable because I had nothing to do -- no social events or pre-interview dinners -- and got to watch Top Chef and relax. At the end of the night, I got ready to take a shower, and a series of events unfolded that involved my legs suddenly breaking out in crazy hives. I popped some Benadryl, hopped quickly into the shower, and started freaking out because the hives were spreading up and down my legs (but not anywhere else on my body). I couldn't figure out what had caused it, but dug around Marjorie's medicine closet for some Benadryl cream, went to bed still slightly itchy, and woke up totally normal. The pattern made it seem like it was a contact dermatitis, but the only thing that had contacted my legs were my pantyhose from earlier in the day and my jeans, which I had been wearing for hours already by the time the rash started. Two days later, when rehashing it all to Eric yet again, it finally hit me: When I was getting ready to take the shower, I took off my jeans, then started absentmindedly scratching my legs while gathering up my toiletries from around the apartment. I still had poblano residue under my fingernails, so in the five minutes I was scratching, I deposited all that pepper oil onto my skin. The funny thing was, when I finally figured it out, I suddenly flashed back to a memory of me sniffing my fingers before taking a shower, and thinking that they still smelled (in a good way) of quesadilla. So there's a lesson for you: wash your hands before you scratch anything, and always after eating spicy peppers.
Cost of interview: $189, for the flight to Philly, WiFi in Midway Airport (hey, I was bored), and a couple of cab rides.

Date: January 9, 2009
Program: George Washington
Social Event: TGI Friday's by GW. Potato skins, crudite, and wings -- the usual. Of note, the program director was at the social, and was very social! I don't think that happened at any other interview dinner.
Breakfast: I grabbed breakfast from the hotel (banana, yogurt, coffee), and grabbed a croissant from the platter of pastries at the interview. Later in the morning, while we were waiting around for our actual interviews, there was another spread put out, including cheese (which I sat right next to), crackers, brownies, cookies, and more crudite. I ate more cheese that morning than I have in a while. But how could I resist -- they had babybels and laughing cow cheese in addition to the usual cheddar and swiss.
Lunch: They bussed us out to INOVA Fairfax hospital, where the residents do a significant number of rotations, and fed us lunch there. Lunch was weird: salad (fine), some sort of mystery meat that looked like stir-fried beef, but nothing else that resembled Chinese food, like rice; then there were some roasted potatoes. It was an odd combo. However, they did have fruit salad and really good cheesecake. On the downside, though: diet sodas only. Seriously, what is up with offering only diet sodas!?!!?? Are you assuming that's the only thing people drink (obviously not true)? Or are you insinuating that I should be drinking it (in which case, I take offense and get huffy!)? I hate hate hate diet soda. Yes, I fully realize that regular soda is full of empty calories, but I don't drink a lot of it, I only drink Coke for the caffeine, and I make up for it by limiting my calories in other ways (not that I've given you any evidence of this...). So that's my gripe about programs that only serve diet soda. Given how good breakfast and the snacks were, it was disappointing that lunch was so bad.
Where I stayed: Residence Inn on Vermont Avenue, just north of the White House. Driving around DC made me remember how much I love DC. Yeah, Philly's nice, but I really really love DC. Sigh. The Residence Inn was nice, although they only had wired, not wireless internet, but they did provide ethernet cords, thank goodness. The bed was really comfortable, but the towels were thin, scratchy, and small. There were tons of choices for breakfast, but I was rushing out and could only grab a banana and yogurt. Of course, the whole point of the Residence Inn is that it's for extended stay guests, so there's a kitchen and all that in the room, but I didn't need any of that. I got a good price for it on Priceline, though!
How I got there: Rented a car from Philly, and drove back to NJ for the night after the interview was over.
Other notable events: This interview was memorable because I didn't know I was going to have it until the last minute. I was supposed to interview at Abington on this day, and for a variety of reasons, I really didn't want to go, but was forcing myself to. GW was the only program I had heard nothing from (at least Hopkins and Pitt were nice enough to let me know I was rejected), and I assumed they were just too rude to inform me of my status. However, two days before Christmas, I got an email from GW inviting me for an interview on January 9! I accepted without hesitation and in the next breath sent an email to Abington to cancel. It was good, because I still had my crappy Temple interview to go to, but I was re-energized for January. (And don't worry, I wrote on my anoymous feedback form that they should tell people who are on the wait list that they are on the wait list so they don't wonder.) At the interview I saw Matthew again, as I knew I would. Saw another girl from Penn State who I had met before at Christiana. Saw another girl from Wayne State who I had met before at Christiana. And saw another girl from a Carribean med school who I had met before at Einstein. And so ended my six degrees of Kevin Bacon interview season experiment. I interviewed with Matthew 4 times, which was the most of anyone. I interviewed with Beth from Jefferson three weeks in a row, which was a lot of fun. I interviewed with Lisa from Penn State three times as well, and with a bunch of people twice. And a lot of people were concentrating in the same area as I did -- a lot of east coasters, and a lot of Philly and DC people. I didn't interview in NY at all, or I would have intersected with another whole set of applicants, I'm sure. I'm really sure I'm going to end up with co-interns who I met on the interview trail, and I'm excited to see who they turn out to be! Everyone I met was, for the most part, really nice and cool and smart. There was only one person I can identify who I would dread working with -- he goes to Johns Hopkins and I ran into him at both Maryland and Pennsy. He's an ass, for sure, but he's the only bad apple I met all season.
Cost of interview: $292, for a rental car to DC, Pricelining the Residence Inn on Vermont Avenue for $80, and the flight back to Louisville.


So there you have it. Ob/Gyn interview season 2008-2009, completed. I can't share my favorites with you yet, because it would be really embarrassing if I didn't match at any of them, but I hope you've enjoyed reading what I can share with you at this point. I'm the first person I know (who's not doing the military match, at least, which already had its match) to be done with interviews -- as of Friday, most people had 1 or 2 more to go. On the down side, I started in mid-October, whereas most people start in mid-November. On the up side, I am now DONE, whereas internal medicine goes well through the rest of January, and ER goes through February.

Now I just need to make my rank list, reconcile it with Eric's rank list, and submit at the end of February. Pretty soon I'll go over the rank algorithm with you -- it's pretty interesting, and mind-boggling to think of a computer running through the algorithm for every residency applicant in the country! For now, it's relaxation time and working -- but not too hard -- on internal medicine.