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.