Asshole doctors: Less common, but still around

I am on a surgery rotation now and one attending I work with is a complete asshole. Now, surgeons are suppose to have a reputation of being assholes, but after a rather benign surgery experience in medical school (the worst I got was just not being acknowledged), I thought it was a thing of the past. For the most part, it is. However, there are still some physicians around who still perfectly fit the arrogant asshole stereotype.

Despite having gone through medical school, I do not know the intricacies of the types of prostheses or the indications for these types of prostheses. When an attending hears that I am not familiar with those types of equipment, they could respond in one of four ways: 1) Teach me the differences, 2) Direct me to someone who could teach me, 3) just tell me what to order, or 4) Sigh, yell at me for not understanding him, ask where I went to med school and why they didn't teach me that particular fact. Guess which one I got today.

At some point in the past, that type of response was the norm. I suppose it was somewhat of an effective way of teaching. It scarred residents enough to force them to remember it. Today, though, with the hospital working more like a system of individuals, each with their own expertise and responsibilities, rather than a boss that (thinks he) knows everything and his underlings. Today, people don't take to kindly to being treated like an underling. The nurses, physician assistants and administrative people who work with this physician just plain don't work as hard or as effectively because this guy is an asshole to everyone. To me, it doesn't really matter. I ignored most of what he said because I'll be leaving this hospital and won't be seeing him ever again. If I were to see him again though (perhaps as a radiologist), I'm not sure I'd go out of my way to make his life any easier (I just might do the opposite, as long as it doesn't harm patient care). If you're arrogant or an asshole in a hospital, it doesn't matter how experienced, educated or well-qualified you are, your co-workers that you depend on will make your life much, much harder.

Open discrimination

Another one to add to the list. This hotel freely discriminates against those that don't believe the owner's religious beliefs. Richard Dawkins' reservation was canceled once the owner saw him on The O'Reilly Factor. Actually, if I include all companies that have owners that watch The O'Reilly Factor, it would probably be a perfectly accurate list of religion-laced businesses that I would want to keep my money away from.

General medicine is generally frustrating

Not because the medical decision making is difficult or the patients are a mystery. It's more that I spend most of the day doing work that really shouldn't be part of my job description. A typical medical admission is like this:

1. The ER or outside hospital has already diagnosed the patient, my job is to put in the basic orders to get them admitted and write a summary of what brought them in. Then, whether they came in with a diagnosis or not, consult a specialist and wait for their recommendations.

2. Fix their electrolytes, heart rate and maybe start them on some broad antibiotics while waiting for the specialist to see them.

3. Specialist sees them, gives recommendations, and I put in the recommendations into the computer system.

4. Wait for the patient to get better or wait for the specialist to tell me they can be discharged.

5. Figure out where they're being discharged to. Call medical offices to make them appointments. Call nursing homes, long-term care facilities to see if they'll take them.

6. Summarize everything that happened to the patient during their hospitalization.

Every once in a while, I feel somewhat like a doctor when I am answering patient's questions.

All important things, but, as you could see, there is very little actual medical decision making. It's very rare that I am reading up on various medical conditions and thinking about what tests to perform to figure out what's wrong with my patient.

Oh well. Glad I won't be doing that for the rest of my life.

You are what you eat

Blood just drawn from a patient with pretty extreme hypertriglyceridemia with triglycerides of near 10,000. There's more fat than blood in this patient's veins.

Update on sign out

OK, now that I've got some more experience on my belt. I gotta say that sign outs really aren't that bad. First, every morning the entire team rounds on every patient on the service, so even though I'm not managing every patient, the fact that I may be responsible for the patient at some other time gives me incentive to pay close attention. The fact that I have that incentive to pay attention has the added benefit of learning about a patients condition without doing all the busy work. The second reason why sign outs aren't that bad is that we're all getting better at effectively presenting patients to each other and writing effective notes. This is a skill that takes some time, but each week it gets better and better. So, now I'm willing to say that shorter hours and more sign outs (in the long run) is better for patients and residents than an overtired resident managing patients. Numerous studies have shown that sleep deprivation severely affects cognitive performance. So, I'd rather have fresh residents who need to spend some time getting to know patients versus an overtired, cognitively impaired one that knows their patient really well.

Signing Out

With the new work-hour rules for medical interns, the ICU is no longer a place where every 4 days an intern spends 30+ hours in the hospital. I'm glad for the rules. 12-18 hour days are bad enough. However, what it leads to is a lot of passing patients from one resident to another, which, in turn, leads to a general lack of ownership of a patient. It used to be that you admitted your patient to the ICU and for the next 20-30 hours, stabilized them and figured out what was wrong with them. You knew their history inside-out and knew how to manage them and what to look out for. Now, you may admit a patient, but 6 hours later, you've signed the patient out to the next intern. The sign-out is a five minute conversation relating the patients history, status and what to anticipate. The receiving intern know very little about the details of the patient and has to essentially start over. This leads to lots of information falling through the cracks. I recently got handed a patient that had been in the ICU for several days. He was stable enough to be transferred, which meant, I write out the discharge paperwork. Since I didn't know the patient, all of it is based on previous notes. I have to trust that those notes are completely accurate and thorough enough or something important about the patient could be missed. Unfortunately, many notes are neither completely accurate nor completely thorough.

It's a choice between having overtired residents who are prone to make mistakes or this. I'm not sure which is better.

The ICU

So, I finally get a day off from the ICU today. It's not bad, but there have been a few situations where I felt like I was biting more than I could chew. This is the place where the sickest patients go. It's pretty scary to be playing doctor with people who are just barely hanging on to life. Just a few hours ago, a patient of mine passed away. He crashed in front of my eyes and I can't help but look back at every order I made (or didn't make) to see if it could have been prevented. What's worse is that I can find things that really could have caused him to crash. I suppose this is the reason why the learning curve is so steep. If you don't pick it up quick, lives will be lost.

The fact that I, as someone who hasn't had any meaningful responsibility in a hospital, suddenly am seen by others (patients, nurses, family members) as an expert whose every wish will be carried out (if it's correctly entered in the computer) is terrifying. What's worse is that there never has to be a backup. Yes, there are other interns, residents and attendings, but there is a lot of on-the-spot decision-making that falls on me. Most of it is harmless, but there are times (especially at night) that it can irreversibly affect a patient's health. There are many orders I've put in that I am not confident of (or as a fellow intern said about an order a nurse suggested to her, "I don't know what it was, but I ordered it"). Things go very quickly, there's high patient turnover, and people die (signing your first death certificate is a pretty strange feeling).

I've only worked in the ICU for 7 days, but it's felt like a month. It's an experience where you learn a lot, but it wears you down. I'm glad I'm getting the experience, but I know it's not for me.

Lost in the ICU

Talk about getting slammed! Working in the ICU doesn't leave much time for anything else. I should have known that when a fellow intern said that I should take care of all my bills before starting the rotation. I will try to have an update sometime soon.

Frustrating Patients

My attending and I have a pretty good relationship. Good enough that we can have a back and forth about politics (typically a no-no in the world of medical education and "professionalism"). He tends to point out my leftist tendencies and I point out his right-winged nuttiness. After 3 weeks of working in his clinic, which serves a rather impoverished part of the state, I can see his point of view.

Nearly half his patients have their healthcare covered by the state. This is great, but it seems like those same patients tend to do the worst at taking care of themselves. I don't mean eating right and exercising. I could understand if they didn't have the resources to do that. I mean they ignore doctor recommendations, then get an exacerbation of their disease, get admitted and have a hospital work-up that costs tens of thousands of dollars, get better, then go back and ignore every recommendation made to them. It's frustrating for a physician when a patient who is unemployed (and has no trouble with transport or any responsibilities at home) misses important appointments repeatedly or a patient who has all their medications paid for not taking them. Yes, some patients with good insurance also fall into this pattern, but from my admittedly short experience so far, it's a nearly universal pattern with those that are under the public health plan (and my attending agrees). One assumption I could make is that they have trouble following recommendations because they have a lot of other problems in their lives, but it's hard to tell if that's the case.

No, fear not dear readers (both of you), I'm not becoming a Republican (though my attending keeps on telling me that it's a matter of time). Rather, I think that there needs to be a shift in healthcare resources. Covering expensive medications and procedures is great, but I'd rather give those up for increased education of patients and more access to social workers. Preventative care looks great on paper, but in the real world, it only goes as far as patients know to take it.

Refill on the Vics

So two weeks into a non-academic community setting, I've learned what the real world is like. I'm not so surprised by fact that there are a lot of patients who are addicted to narcotics. I'm more surprised by how there are so many doctors that are feeding their addiction. It's so easy for a patient to find a doctor that will prescribe them some heavy-duty narcotics without too many questions that things that I learned in med school like counseling, pain contracts and limiting refills just plain doesn't work. If legitimate doctors to try to manage their patients' chronic pain without overly relying on narcotics they risk losing the patient and likely the patient's other chronic medical conditions won't be taken care of. Or, they can just write the refill to bring them back and make sure that they have their diabetes, high cholesterol, heart disease, asthma, etc. under control. It's a hard decision to make, but many of the patients in this area just won't see a doctor unless they need their pain meds refilled.

Slow Start

So, I'm officially a doctor. July 1st was supposed to be a mind-numbing experience where I get thrown into the medical system, overwhelmed with things to do and actually get to feel like I'm making a difference in people's lives. Unfortunately, I feel like I've gone back a few years. I start with a primary care rotation. Primary care is not my thing, but I can appreciate the value of health maintenance and getting to know patients and I was looking forward to actually acting like a primary care doctor. To my surprise, I find out that all I do is shadow a physician while he sees his patients. It's worse than 3rd year. At least then I got to see patients beforehand. The clinic I'm at doesn't have electronic records, so I can't even read about the patients. I go in not knowing what's going on and about 30 seconds later come out not knowing what happened. The physician knows his patients and doesn't really need to go into the details that I would have needed in order to diagnose and treat (actually, I'm a little wary of how quickly he goes through patients). It's a complete waste of time. All I can say is that at least I get paid for it.

Last day of vacation

After nearly 3 months off, I'll finally be getting back to the medicine mindset with the start of intern year tomorrow (actually, it's just orientation tomorrow, the real intern year won't start for another week or so). I'm a little worried (ok, terrified might be a more accurate description). I've been calming myself down with the thought that lots of people have been through the same thing and have done fine, but with a 3-month break, I'm sure I'll be a little rusty. I suppose I took a 4-year break from medicine during graduate school and did ok when I got back into things, but med school is not the same as being an actual doctor who's orders actually get carried out. I was thinking of spending some time studying medicine, but there's little motivation to pick up a book and I figure that anything I could have learned on my own during the break would be minimal compared to the vast amount of information I'm about to get forced down my throat.

My mindset right now consists of many conflicts: I'm looking forward to actually starting work (I'm getting tired of being home all day), but at the same time, I know I won't have much of a chance for a break for a long time. I'm excited to see patients, apply my knowledge, try to help people and maybe have some fun along the way, but I'm also terrified I might make a mistake and hurt someone. I'm looking forward to meeting new people, but I'm afraid that they actually might know medicine. I'm terrified that I won't be able to handle the workload, but I'm calm because life at the community-hospital based intern year that I'll be going through won't be anything close to that of the academic-hospital based interns that I got to vicariously live through during my recent sub-I. I'm hoping for starting with something light so that I can get my bearings before getting slammed, but at the same time, I want to get the tough months over with before I get burnt out.

I figure it's no use worrying too much about it. It's not like I can change anything.

Setting up shop in a parking lot

So, after a crazy month, I officially have my MD and have moved to where I will spend my intern year. I'm excited (and scared) for it to start. Orientation is next week, I'm sure you'll hear about it.

In the meanwhile, Mrs. mxh has started her job as a pharmacist. She works one day a week at a pharmacy in a sketchy part of town and it turns out that the doctors there are more sketchy than the patients. There are a few doctors in that part of town that are notorious for prescribing large amount of narcotics, a lot of the times without even seeing the patients. The only thing that comes out of their primary care clinics is narcotics prescriptions and their patients have a suspicious pattern of getting new prescriptions too soon. What really makes it bad, though, is that one of the doctors has a habit of just hanging out at the pharmacy and writing prescriptions for narcotics in the parking lot! Yikes! This isn't something new either, it's well known among pharmacists in the area. Why do these people still have jobs? Why isn't the state medical board stripping their licenses from them? Why aren't they arrested?

Part of the problem is that not too many people report them. But, I think, a major problem is that medical boards are notorious for not punishing their own. Medical schools emphasize fitting in and keeping the status quo. If you bring up a problem, it's better that it is discussed quietly. I think this attitude carries on to medical boards. If they punish a doctor, it'll make the news and that type of attention is something that medical boards don't like. If they ignore a problem, then everything will go an as it has. So far, it's been working, but some day, the narcotic ring that these two physicians are running will make front page news and the state medical board will wish that they have dealt with it sooner.

More bad journals

Synthese - Apparently criticism of intelligent design is frowned upon.

Psychology Today - Racism dressed up as science in the form of an essay by a regular contributor to their website called "Why are black women rated less physically attractive than other women?" Yes, it was quickly removed, but the fact that it was written in the first place is disturbing. How can this guy have evidence that "black women are objectively less physically attractive than other women"? Has he seen Halle Berry?

Both are added to the list.

Torture still doesn't work

I expected the right to give all the credit of Bin Laden's death to Bush (even though he said he doesn't care about finding Bin Laden), but I'm pretty upset that they would try to rewrite history by saying the information leading to it was because of "enhanced" interrogation techniques. Torture is inhuman and the fact that half the country supports it is the most worrying sign about our future. This analysis shows how Cheney and the rest of the criminals in the Bush administration are completely wrong about torture helping the US get Bin Laden.

If your doctor is praying to heal you...

... you haven't got long to live (or you should find another doctor). Time to add to the list of science journals that have little regard for science. Here's a presidential address published in the American Journal of Surgery entitled "Can prayer help surgery." Unfortunately, the answer is "yes" (or more like, "No, but I'll say yes anyway"). Despite the fact that the author acknowledges that there is no scientific evidence that prayer works, he decides to add the old religious line of "What if those results are the will of God?" Really? Hell, I should have just responded to all the tough questions I got from reviewers by saying "It's the will of God. Who are you to question it?" This presidential address makes a mockery of science. The field of surgery is already decades behind the rest of medicine and Dr. Schroeder of St. John Hospital in Detroit (along with the American Journal of Surgery) just sent it back a couple of centuries. (uggh, I'll be working in a Catholic hospital next year, hopefully I don't run into these types)

Once again, I have to say that if any physician claims that their successfully treating a patient was God's doing, they should give up their salary.

Gotta bring back the Jesus surgeon picture. It makes me wonder why a surgery residency is 5 years. It must take that long to not get creeped out by Jesus giving you a shoulder message while helping you with surgery.

(PZ Myers has a better evisceration of the address and Orac discusses how ethically and scientifically inappropriate it is).

Stupider than I thought

I already mentioned how Arizona sucks... but this new bill (that was just passed) that requires presidential hopefuls to "prove" their US Citizenship to get on the state ballot is incredibly stupid. Accepted forms of proof includes a "long-form" birth certificate (because Hawaii only releases the short-form to the millions of nuts that have been asking for it) or, get this, at least two other forms of accepted proof such as early baptismal certificate or circumcision certificate. Are you serious? Some shady religious nut can forge those in a second. I keep on thinking this country can't sink any lower, but I get proven wrong over and over again. Let's hope that the next piece of legislation doesn't do away with the whole birth certificate thing and instead require a baptismal certificate.

Translation: A black man with a funny-sounding name couldn't possibly be an American.

House of God

With my time off, I recently started rereading Samuel Shem's House of God (must read for any medical type that hasn't read it yet). A novel about an intern learning the truth about how things work in the hospital. It has a lot of dark humor in it, but there's a lot that (even as a med student), I could tell is based on a grain of truth. For example, the type of patients you see at the hospital. You'd think that they'd be a cross-section of the population, but they aren't. I assume it's because those with repeat hospitalizations aren't exactly your average Joes. Upon meeting the patient who hides under the covers whenever his discharge is discussed or the patient that wants to keep his rectal tube in because he's too lazy to get out of bed to go to the bathroom, I was immediately reminded of the characters in the book. I wouldn't like to get to the point where I think about my patients as GOMERS or follow the Fat Man's Laws, but at least some of my experiences with medicine so far say that I may have to face days where it'll get close.

Here are the Fat Man's Laws (courtesy of Wikipedia):

1. GOMERS DON’T DIE.
2. GOMERS GO TO GROUND.
3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
4. THE PATIENT IS THE ONE WITH THE DISEASE.
5. PLACEMENT COMES FIRST.
6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM.
7. AGE + BUN = LASIX DOSE.
8. THEY CAN ALWAYS HURT YOU MORE.
9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
10. IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
11. SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
12. IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
13. THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

I would really like to think that #12 isn't true.

The Scramble

So, luckily, on Monday, March 14th, I got a one-liner email (with the ridiculous subject of "Did I match?") that said "Congratulations! You have matched." But not everyone was as fortunate. The people who don't match, if they want to find a position for the next year, have to go through "the scramble", and it really is a scramble. I helped out someone with the scramble and thought I'd share (or more like remember it for myself by putting it here). Here's the timeline:

March 14th 6:30 PM - meeting with the dean of students. Very somber mood in the room. Some are near tears, others are angry, others are happy that they only have to worry about a prelim year and others (like me, who have matched and were there only to help) are trying not to look people in the eye. The dean goes through the process. Seems like a very involved procedure that depends on timing. Hard to know what'll happen at 10 AM the next day.

March 15th 9:30 AM - the dean hands out the list of residencies that had open spots after the match. The number of spots range from 1 in very competitive fields to hundreds for the preliminary surgery year. They're separated by specialty and by state. Everyone had 30 minutes to plan where they will call first. I helped my friend indicate which programs she is interested in on the centralized match website.

March 15th 10 AM - The scramble officially begins. We hit submit on the computer and simultaneously call places that aren't participating in the computer system. The computer system was very slow, so in about 5 minutes, gave up the computer and went to calling everyone. Calls went one of three ways: 1) Busy signal, 2) Answering machine or 3) actual person responds. If a person responds, we rattled off a prepared one-liner about who we are and what we want and asked what they need to consider us. The response was either to take our phone number and say they'll get back to us or (a few times) actually start a mini-interview.

March 15th 11:30ish AM - All the states my colleague wanted to match to were contacted, one promising phone interview was done, but no response yet. We started calling the less desirable locations (while redialing places that hadn't gotten back to us - and accidentally calling some places that already took our name down).

March 15th 12:00 PM - Got a phone interview (5 min) at a decent program in a not-so-great location. They want information faxed... quickly faxed over something like 15 pages.

March 15th 12:45 PM - Decent program gives my colleague an offer! Quickly look over the curriculum and location (seems like a decent part of the not-so-great city and the curriculum is actually pretty nice).

March 15th 12:50 PM - Accept the offer.

March 15th 1:00 PM - Still calling places while waiting for the contract to get faxed over.

March 15th 1:30 PM - Contract is in, it's signed and faxed back. It's official!

March 17th 11:00 AM - Go through the match and pretend to be surprised when you open the envelope.

Whew! It's a rush, but it's a mess. Students at our school was lucky because the dean had paper printouts of the open spots. Apparently, the centralized computer program was down, so many students across the country did not have access to the list until hours later. Some in this situation just cold called every program. Eventually, people were able to get a list emailed to them from the matching program. By then many of the more desirable open spots were taken.
It's a terrible system, but luckily, from what I've heard, it'll be more civilized next year. I believe they'll have mini-matches where, in a calm manner, students can research and take their time applying to programs and, just like the normal match, rank the programs they're interested in and the programs do the same. Later in the day another "match algorithm" is run and students get matched. Any that are left over go through a second round of it.

Matched

Match day came in went. Having it in the middle of the internal medicine sub-internship (where I get to pretend to be an intern) makes it hard to digest. I matched into a pretty decent prelim year. The only reason why it wasn't ranked first was because I didn't want to move twice. I matched into my first choice for radiology. Very excited to be stepping out into the real world.
On a side note, I got a chance to help out with "the scramble," where students who didn't match frantically call programs that didn't fill their spots in order to find a job. It's a bit chaotic and this year it was a disaster to many across the country. I'll go into it (and the sub-I) in future posts when I catch up on some sleep (5 hours in the last 65 is just not enough).

Another fake journal

Journal of Cosmology. Another fake science journal to make the list. As the title of the article reviewing it says "Aliens riding meteorites." Need I say more? OK, I will. Here's a description of the field of cosmology according to the journal's website:

Cosmology is the study and understanding of existence in its totality, encompassing the infinite and eternal, and the origins and evolution of the cosmos, galaxies, stars, planets, earth, life, woman and man.

Hey, I study something that fits in there, so I'm a cosmologist! Clearly everyone would be interested in this journal.

Not so:

The interdisciplinary Journal of Cosmology is devoted to the study of "cosmology" and is dedicated to those men and women of rare genius and curiosity who wish to understand more and more about more and more: The study of existence in its totality.

Man, now I kind of feel bad about putting PLoS One on my list.

Glad we're vaccinated

Passenger on flight from Baltimore to San Diego had infectious measles, officials warn

With all the recent flying, I'm glad my one-year-old is fully up to date with his vaccines. As the San Diego County health officer said, "Measles is so contagious that if one person has it, 90% of the people close to that person who are not immune will also become infected."

By the way, I had an interesting discussion with an autism expert recently and he concluded that with more and more evidence that signs of autism are detectable well before the age of one (and the likely development of techniques to detect autism in infants in the near future), the anti-vacciners will have to come up with another excuse for putting their kids at risk of getting terrible communicable diseases.

Computer overlords

Oh, no. NPR, you did it again. I've said before that journalists make terrible science reporters, but this is just bad. A computer beat two Jeopardy champions pretty easily. It was an interesting game to watch and an amazing feat of technology, but Martin Ford, a computer programmer and writer decided that winning at a game show is enough evidence to show that computers can take over medicine, emphasizing on radiology. He said, "Radiologists basically focus on looking at visual images from medical devices — things like X-rays or CAT scans, that type of thing. Now, machines are getting much better at analyzing that type of visual information."

Arrgh! Radiology is not just looking at images. It isn't even just pattern recognition. It's putting together information from a vast number of sources (patient history, previous scans, pathology, physical properties of the imaging technique, variances in image acquisition, positioning of patient, etc.) To be an effective radiologist, you can't just look at every image with the same formula (if you can, who needs a radiologist?). That's a start, but personal experience at interpreting images and intuition about what the image and patient history points to adds a lot. It's that intuition that looks more closely at an image or orders a different view that makes the diagnosis.

I don't doubt that computers will eventually able to do this, but just because one won at Jeopardy, doesn't mean that it can start replacing radiologists. In reality, if computers get good enough to accurately interpret all types of images (at least with the same accuracy of radiologists), then they'll be good enough to take an effective history, perform a physical exam, order and interpret appropriate lab tests, perform procedures or even surgery and prescribe medications. The only medical specialty that would be safe is psychiatry (that is, until it starts using real science also). I don't see that happening in my lifetime, and if it does, we'll be living in a pretty different world.

Looking back at the match process

It is not necessary to read this book.

OK, so we're finally getting towards the end of this crazy "match" process to get into a residency program. I think I've got my rank list down and I'll find out where I end up in March. Now that I've got about a month to wait, I could reflect back on the process. Here are some general thoughts:


1. Interviews
Interviews were a lot of fun and, at least in radiology, almost completely stress free. Those interview preparation questions that the school provided us with were pretty much useless. The conversation-like interviews I had with faculty really helped me get to know a program and helped me let them know the kind of person I am. The few "standard" interviews I had were very awkward for both parties and probably not very helpful for either (especially, the one where one faculty member was interviewing two applicants at once). Some quick points: At first I started reading about the faculty at the institution, but I gave up on it pretty quickly. I never had to bring it up and the casual conversations we were having were much better. Buying and carrying a leather portfolio was useless. I never had to pull out a CV or research paper. I lost it half-way through the interview process and never bothered getting another one. There will be "illegal" questions (especially, "where else are you applying?"). I also once got asked what religion I was ("none" was the response, in case you were wondering).

2. Traveling
Holy crap this is expensive. I went to 10 radiology interviews and 9 intern year interviews. Some I drove to, some I flew to. A few places provided a hotel room, most didn't. I kept track of the total cost and I just hit $3000. Add to that the application fees and it gets close to $4000. That's why most people take a loan. A couple of tips: Southwest is awesome (cheap, free bags, can cancel/change without a penalty; it doesn't get better). Renting a car is often cheaper than taking cabs everywhere and it gives you a chance to explore the town. Signing up for frequent flyer and hotel loyalty programs pays off, even if you end up not using the points. I got nice hotel upgrades and free perks (drinks, snacks, higher floor) just because I attached a number to my name. Trying to cluster all the interviews in one region together is nice, but will probably end up to be impossible. TSA sucks, though, I found out that if you freeze your liquids, you can take more than 3 ounces.

3. Research experience
With 10 years of research under my belt, I thought I'd get most questions about my work. Unfortunately, most radiology programs don't care about it (some even see it as a liability in residents). They just want you to check off that box. For example, a top-tier program that has amazing research claimed that all their residents complete a research project during their stay. When I asked how much research time they get, the answer was "7 days a year" (really? It takes me 7 days just to pick a background for my computer station). Something like 75 to 80% of radiology residents go into private practice, so it doesn't matter to them. However, it really hurts the field. With procedures and image interpretation being constantly taken away from radiologists by other fields (cardiologists read echos, vascular surgeons do interventional procedures, ER physicians perform and interpret their own ultrasounds), the future of radiology as a field depends on innovation. When research is shunned by training programs, the innovation will be taken by other departments also.

4. Intern year
So useless. From every radiologist I've heard that it has had no impact on their ability to be an effective radiologist. I applied to lots of intern year programs (some easy, some tough) so that I could live in the same city for both intern year and the radiology years, but it's unlikely that I'll be able to pull it off. That's OK, though. A brilliant comment I heard from a resident was "It's better to lose a weekend moving than to lose every weekend because you chose a tough intern year so that you could stay in the same city." I got some great intern year interviews, but if I could do it again, I wouldn't take location into consideration.

5. Rank lists
People really talk as if there's a strategy to it. There is none, just put the programs in order of your preference. It makes no difference if your number one is a long shot.

6. It's a big game.
By that, I mean that there are specific things that you should do to get an interview or to be considered for a position. These things have no relation to your strength as an applicant, but if you don't do it, your chances at matching may be hurt. For example, there are letters of interest, sending thank-you notes, sending "love letters". Towards the end of November or early December comes a point when you start getting worried about the number of interviews you've gotten and you haven't heard from some of your favorite places. At this point, sending a letter of interest can get you an interview. It really makes no sense (I mean, you applied there, so you're interested, right?), but it makes a big difference to some people. I've heard of a program where they won't interview anyone who doesn't send a letter of interest. I suppose it's to separate people who really want to go to the program from those that are applying to every program in the country (it happens), but if there's an unspoken rule that you must send a letter of interest (after actually applying) to be considered by a program, you might as well make it part of the application process. "Love letters" can go either way. Applicants can tell a program that they will be ranking that program first and programs can tell applicants they are raking them high. What either party says, however, from what I've heard, means absolutely nothing. Programs want to tell lots of applicants that they're ranking them high to get applicants to rank them high, so they can brag about getting their first choices. ... I could go on and on about this, but suffice it to say that the whole process leaves me with a bad taste in my mouth.

7. Med school
It falls to the background. There is no way I'd be able to go to all these interviews and still be on a clerkship. I'm glad I set up my schedule to maximize my time off during 4th year. Speaking of 4th year, the great thing about it is that pretty much everything is self-run. Your grade doesn't matter anymore, so it's all for fun and interest. The bad thing is that, unless you want to have a horrific 3rd year-like schedule, it consists of an awful lot of shadowing. It makes you burn out pretty quickly. Oh well, only a few more months.

Revolution fever

A lot of people are excited about the overthrowing of dictators in the middle east. Tunisia did it and Egypt is in the process. Some (idiots) are crediting the U.S.'s policy of trying to "spread democracy" in the middle east (starting with Iraq). A called on NPR wanted to credit Bush for Tunisia's revolution, but luckily, the guest shot him down quickly. The guest said that it actually proves the opposite of what Bush was trying to do. You get effective regime change when you don't interfere (Tunisia) and you get failed regime change when an outside force is interfering (Iraq). Whatever the cause, these revolutions are exciting. Although, I fear that something very similar to Iran in the late 1970's will happen. A popular, largely secular uprising will pave the way for an Islamic Theocracy. Let's hope it doesn't.

Not another "miracle"!

Crazy interview season has kept this blog quiet. Well, I'm done with radiology interviews and only one more intern year interview left. I'll have an update soon. I'm sure no one is left to read the blog, but whatever... I'll vent about the latest "miracle" I heard about. This is from NPR:

BRADY: At times during today's briefing, Drs. Rhee and Lemole were almost giddy. And in undoctor-like fashion, Lemole said Giffords' progress may be partially attributable to outside forces.

Dr. LEMOLE: Miracles happen every day. And in medicine, we like to very much attribute them to either what we do or others do around us. But a lot of medicine is outside of our control, and we're wise to acknowledge miracles.

Dr. Lemole, sir, you are an idiot. A lot of medicine may be outside our control (especially when it comes to recovery from brain injury), but there is no such thing as a miracle. Just because you don't know how something works, doesn't make it a miracle. This is an even less appropriate thing to say when you have no idea what her long-term condition will be. I move that any doctor who attributes the recovery of any of their patients to a "miracle" should not receive any monetary compensation for taking care of that patient. Clearly, they admitted that they didn't do anything.

It's bad enough that an imaginary deity gets all the credit when the hard work of a physician saves someone's life, but it really upsets me when physicians go around accepting that.

(A real miracle would be if the right wing nuts who have been spitting out violent rhetoric for the last few years actually admitted that what they say can affect what another nut does.)