PGY-3

It's been six weeks since the start of PGY-3 year. It still feels weird to be a "senior" resident and have interns look up to my classmates and me as the source of all medical info when in reality I still feel like I don't know anything. My upper-level residents have either become fellows or moved on to become attendings/moonlighters at other hospitals, and I miss having them around whenever I have questions. Fortunately my classmates are (for the most part) great about helping each other out, and I know I'll miss them terribly once we finish residency.

Since I didn't match into fellowship, I now have to start looking for a job. I've pretty much decided to go back to Texas to be closer to family; the question is, where. I've pretty much narrowed my job search to DFW, Austin, or Houston areas (preferably within 30 minutes of these cities), and there's no shortage of phone calls or emails from recruiters. The question is, which city do I want to be in most? I know Austin and DFW the best, so they're taking precedence over Houston right now (not to mention jobs in Houston are probably more competitive) I've gotten emails from Baylor Health systems, so I know I could always apply there. Just have to get my CV in order.

And yet, despite my plans to return to Texas to practice medicine (might be easier said than done, who knows? Maybe I'll fail the medical jurisprudence test and not be able to practice in Texas), I'll definitely miss the East Coast. For all its humid summers and icy winters (snow is beautiful when its falling, not when I have to shovel my car free to get to work), I've grown a bit fond of living in Philly. I'll definitely miss the tax-free shopping and weekend trips to New York, Baltimore, or DC (only 2-2.5 hrs away!), and this year I plan to make the most of my time here and enjoy it to the fullest. My friends are already asking if they can visit me in Texas and go out for some "real" BBQ, which I'd be all too happy to do.

But first...gotta find a job.

End of One Road

Today was a pretty long-awaited day, the day I would find out whether or not I got accepted at a heme/onc fellowship program. The results would be posted at noon. I was in clinic at the time and logged into NRMP around 11:55 am. When I had a chance between presenting patients to my preceptor, I quickly refreshed the NRMP page and saw this:

"We are sorry, you did not match to any position."

Ouch.

To say I was shocked was an understatement. I had 9 interviews and gotten pretty good vibes from at least 2-3 programs. When I interviewed at my home program, I was told that the program director (who wrote my letter of recommendation) had thought very highly of me and would rank me high. Based on those words, I had (mistakenly) assumed that I had a spot here no matter where I ranked it, and I had high hopes I wouldn't have to go that far down my list to match. My friends thought I was guaranteed a spot here, but we were all wrong.

Surprisingly, I took the news better than I thought I would. I'd had misgivings about applying for fellowship from the start, since I liked both heme-onc and internal medicine, but thought I'd at least give it a try to see if I'd match. When I saw that I didn't match, there was a brief second or two of surprise and disappointment, but I was never truly unhappy. After all, there are so many opportunities available within internal medicine, whether it be a job as a hospitalist or as a primary care provider (again, I can see myself doing either). In fact, after I told my parents the news, I was already thinking of cities in Texas where I'd want to practice (i.e. Austin!), and suddenly not matching for fellowship wasn't such a terrible thing.

Most of my friends did match at their fellowship of choice, and I was genuinely happy for them. A whole bunch of us went to a sports bar for drinks after work, and it was fun to find out where people matched and share in their joy. Several of my friends came up to me and said things like, "I'm sorry." "What happened?" "I thought for sure you'd match somewhere" or my favorite, "You okay?" Yes, I am okay. If I wasn't okay, I probably would have gone straight home from work, curled up in a ball, and cried my eyes out. If I wasn't okay, I wouldn't have gone out with my friends to celebrate their achievements. Please do not feel bad for me. I did my best and have no regrets about how things have turned out.

Some people have already assumed that I will reapply for fellowship in another year or so. "Don't give up, you'll match next time." That's still up in the air. At this time, I have no plans to reapply for fellowship. Since I know I'll be practicing internal medicine in another year or so, I'm going to focus on that for now. And of course, I'll be making a six-digit salary while my friends are still on a PGY-4 salary =P

Making A Rank List

So it's May 30th, and the deadline for submitting my rank list is tomorrow. Although I certified a preliminary rank list weeks ago, I haven't actually sat down to really think about what order to rank my programs in until now. Back when I submitted my rank list for residency, I knew what my top 3 were. It was just a matter of ranking them in an order I was happy with. I was very happy to match at DUCOM for residency, but there was a time when I had UIC ranked higher than DUCOM because I just wasn't sure which city I preferred to live in. Philly or Chicago? A few friends thought I should have ranked UIC higher because it had the "better name" and for some, better location. In the end I ranked DUCOM higher than UIC because Philly was 1) not as cold as Chicago 2) Cheaper cost of living 3) Free parking in Center City Philly 4) Better Chinese food 5) Close proximity to cities like New York and DC (which I've visited several times since moving here)

Regarding fellowship, I have no idea what my top 3 choices are. There's not even a clear cut number 1 choice. Almost all my interviews are in the Northeast, with the lone exception in Florida. And while I really liked the program in Florida, I don't know if I'd like the city (it's pretty much a small college town), and an intern who went to undergrad there said that there's little to do there if you're not a student. Some of my friends are encouraging me to go to New York. If my ultimate goal was to live in New York City, then the choice would be obvious, but I just don't have that urge to live in the city. Some of the programs I like are in smaller cities, and yet, I feel like I need to be close to a large city so that when I'm not working, I will have lots of things to do to occupy my free time. New York would be perfect for that.

Then I need to ask myself, how much do I want to stay in Philly? When I first moved here I didn't think too much of Philly, but now that I've spent more time here, I've come to really like it. It's within driving distance to New York and DC, there's lots of places to shop (and eat), and there's a great orchestra downtown that I've gone to listen to several times. I'd miss that if I had to move. Three of the places I interviewed at are in/around Philly, so if I really wanted to stay in Philly, it's an easy choice. But just because I want to go to a program doesn't mean I'll get in.

*sigh* Decisions decisions. I just hope it'll all work out in the end.

May 1, 2011 at 11 pm...where were you?

Everyone remembers what they were doing on Tuesday, September 11, 2011, and when they found out about Al Qaida's attack on the World Trade Center and DC. I was a freshman at UT, just coming out of my 8 a.m. calculus class when I saw people gathered around a TV that screamed, "BOMBING ON CAPITOL HILL." That was an early mistake of the press when American Flight 77 crashed into the Pentagon. I remembered sitting in front of the TV with my roommate watching footage of the planes crashing into the WTC and the towers falling afterwards. I remember the deathly quiet that fell upon campus in the following days, as no one knew which city would be targeted next. Austin was an attractive city to attack if one really wanted to target President Bush. He had been the governor of Texas for years, and his daughter attended UT.

Last night I checked my Facebook while working (it was my last night working the 7pm -7am shift) when one friend's status caught my eye: "Security sources say that Osama Bin Laden is dead!" Disbelieving, I checked CNN.com and saw nothing about such a story. Then my fellow nighttime resident got a text from the Associated Press, and she said, "Hey, you're right! Bin Laden is dead!" We then recalled hearing earlier that President Obama was planning to address the nation; fortunately we had finished our admissions at the time and hurried down to the resident lounge to watch the president speak. We were joined by several other residents, and when Obama finished speaking, all we could think was, "Wow."

The following footage of the people cheering in DC, New York, and the Phillies game (yes, fans there were chanting, "USA!" despite the game already dragging into the 12th inning) was uplifting. Most of the revelers on the streets were college students, who were only in elementary school ten years ago. It was encouraging to see that the September 11 attacks made such a huge impact on them so that they were the loudest among all those celebrating. Although I'm not really one to celebrate the death of another person, I was sure that the families of those who had lost loved ones to September 11 could find some closure in Bin Laden's death. And if that's the case, then the cause was a good one.

Lankenau Hospital

First Impressions: Lankenau Hospital is located in Wynnewood, a suburb just outside of Philly; I've driven past it on several occasions to go to shop at the nearby farmer's market. It was a community hospital; one of my upper levels said he'd interviewed there for residency but hadn't been impressed when the intern kept answering pages and was too busy to really tell him about the program during the tour. I hoped the fellowship program was different.
Interview Day: What is going on with the weather here? I thought it was some sort of April Fool's joke when I saw huge snowflakes falling outside, but fortunately it didn't stick. There were three applicants total; the program director welcomed us and took us to Grand Rounds. The topic was rheumatology, and the speaker was a UTSW-trained rheumatologist from Baylor in Dallas, which was a pleasant surprise. Afterwards the program director told us a little about the program for about 1 hr, and then the 3rd year fellow took us on a tour around the hospital. The hospital itself was nowhere as large as HUH, but more spacious and well-lit. Amusingly enough, I was most impressed with the variety of food in the cafeteria; fresh sushi daily! =P Prior to interviews we attended tumor board at noon conference, where I noted that the camaraderie among the residents and fellows was really good. I had two interviews, one with the PD, one with another attending. I appreciated that the first attending had prepared a list of questions to ask me based on my CV; he even asked me questions about my dean's letter, which was a big surprise. The PD asked me a list of questions that she asks everyone. Among the tough ones were "Tell me something about yourself that's not on your CV" and "Tell me something your patients taught you." Not sure I answered the second question well, and the 1st one took me a while, but I said I had perfect pitch.
Overall Impression: Pros:
Cons:

Thomas Jefferson University Hospital

First Impressions: I got a voicemail from the program coordinator one week ago saying that they had an opening in their interview schedule and asked if I'd be able to make it. I originally said no because I was on call that day, but after thinking about it I called them back and said I'd find a way to be there. Fortunately since my interview was in Philly and would end at 1 pm, the chiefs gave me permission to miss half a day of MICU and then return to complete my call. I hadn't heard too much about Jeff except that its fellows worked very hard and that the program liked to takes its own residents into their fellowship.
Interview Day: I thought seeing snow in Stony Brook in late March was unusual, but as I walked to my interview there were big fat snowflakes falling from the sky. There were only 3 applicants at the interview (one of whom I'd met at Montefiore), and the program coordinator was quick to tell us about the program and, more importantly, how we were graded on our interviews. We got a copy of the "grade sheet" every interviewer gets; basically, the ideal applicant would have board scores in the top 10%, have rec letters from prominent leaders in heme/onc, excellent personal statement, strong interest in research and academics, etc. If I had to grade myself, I'd rank smack-dab in the middle, and wondered how they even selected me for an interview in the first place. I think the only thing I had going for me was my personal statement. There were four interviews total. The first was with a hematologist who was infamous for cutting interviews short if he didn't find you worth his time. Fortunately we were able to talk for the full 20 min, though I could tell he was very hard to please. The second interview was with the program director, who was a HUH grad and commented that HUH grads usually do well in the heme/onc program at Jeff. The other two interviews passed by in a blur. Afterwards we had a tour of the hospital (which was well lit and nice) and infusion centers, then had lunch while a fellow spoke with us. We were done by 1:15 pm and I was able to get back to work before 2 pm. The resident who covered my morning shift said it was the easiest call ever for him.
Overall Impression: Pros: Diverse pathology, 5 fellows a year. Located in Philly, associated with Kimmel Cancer Center. Very strong in hematology.
Cons: Weaker in solid tumors, emphasis on research, likes to take their own residents, no free parking in Center City (which my own program offers)

Stony Brook University

First Impressions: I met a guy from Stony Brook at my RWJMS interview and had asked him back then what the program was like. He said there was more emphasis on clinical practice, less on research, but that it was a great program. I drove to Stony Brook the night before my interview accompanied by a classmate's fiancee, who was a PGY2 at Stony Brook and needed a ride back home. She was able to tell me where to go since my GPS was not working, and let me tell you, the night sight of NYC from the Verrazano Bridge was amazing.

Interview Day: It was snowing/raining as I drove to Stony Brook University Cancer Center, which seemed a bit bizarre for March. Incidentally I ran into the guy from RWJMS outside the entrance, and he said, "Welcome to Stony Brook." There were 5 of us total interviewing that day; two of which were from Stony Brook. The other two applicants I'd met at the Drexel interview just last week; both of them had interviewed at Jefferson (my next interview) just two days. We had a brief overview of the program from the PD before one of the fellows took us on a tour of the hospital. The hospital consisted of two round towers connected by a walkway; all the floors had a circular pattern. I immediately made note of the Starbucks on the ground floor ;) There was also a VA located about 30 min away where fellows do their continuity clinic (and have plenty of autonomy while doing so), but we didn't go there.

We had two interviews each today, and I think I got extremely lucky with my interviewers. The first was a breast cancer specialist not too far out of fellowship, so he was extremely easy to talk to. We chatted about breast cancer, non-fiction books dealing with medicine (i.e. the infamous House of God), medical TV shows, and more. My next interview was with an attending from the VA who also happened to be Taiwanese, so we talked briefly about places in Taiwan worth visiting. He made it clear that he wanted to know who I was as a person, not about how much reseach I've done (thank goodness), and asked questions about my life and my family. He took lots of notes about me, and when I told him why I wanted to specialize in heme onc (my mother was a breast cancer survivor), he looked impressed and said he would like to see me here next year. O.O That is the most positive feedback I have ever received at any interview.

Overall Impression:
Pros: Good balance in both heme and onc, diverse pathology throughout Long Island, 3 fellows a year. Autonomy in decision making and patient care at the VA. Emphasis on clinical training. Friendly fellows and attendings. Located 1 hr away from NYC and JFK International Airport. Long Island known to have famous beaches and diverse outdoor life.
Cons: Stony Brook seems a bit isolated, surrounded by small suburbs. Still, there are Starbucks, Barnes and Noble, and even a Cheesecake Factory nearby, so it can't be too bad.

Trying to Die

In residency I've been a relatively white cloud, and so far my MICU calls have never been overwhelmingly busy. That's not to say, however, that the patients on my census are well. My GI bleed from two calls ago was still on 4 pressors and officially in multi-organ failure, so finally his family withdrew care and allowed him to pass on. I was sad about that; this man came into the ED one week ago for a lower GI bleed which was fixed, but for some unknown reason he went into vasodilatory shock afterwards. He himself had given consent to be intubated after he coughed up bright red blood, believing that after the EGD he'd be extubated. Sadly he didn't make it.

Last night I was able to sleep for about 45 minutes before midnight before my fellow called and said there was a multi-drug overdose in the ED. The patient was a young man close to my age who attempted suicide by swallowing TCAs, an entire bottle of aspirin, and some Tylenol. When I got downstairs, he was undergoing gastric lavage and the ER was trying to get ahold of nephrology for immediate dialysis. The reason being was that despite taking tons of TCAs (which would make him dry), he was diaphoretic, indicating aspirin toxicity. His initial labs, however, showed normal levels of the drug and no signs of lactic acidosis, and the nephrology fellow argued that based on the current labs she had no reason to emergently dialyze this patient. Both the ER attending and toxicologist insisted that this was a life threatening overdose and that the patient would die without HD. This was the first time I ever perceived relations between the emergency department and medicine department to be hostile (though the attending was more welcoming toward me and my fellow, since we'd be taking the patient to the ICU), but I could see where the ED people were coming from.

Just a few months ago, a patient died from a metformin overdose because his labs on admission were "normal" and he was sent to a step-down unit instead of the ICU. By the time he made it to the ICU until his pH was already 7.1 and his bicarb was in the single digits. Almost every department in the hospital attended the M&M that followed his death, and the conclusions we came to was that presenting labs can be deceiving, and that we need to anticipate the progression of the toxicity of any drug overdose. If "Metformin Man" had received bicarb and emergent dialysis on admission, he probably would have lived. And now looking at this TCA/ASA overdose, I couldn't help but remember what had happened to the Metformin Man, and I hoped that we would be able to save this patient.

Fortunately repeat labs showed that the aspirin level had tripled, providing the nephrology fellow with a reason to start HD. HD was started 3 hrs after admission, and he was put on IV Mucomyst and a bicarb drip. I got my first truly successful A-line in him. By mid morning his drug levels were trending down and his labs remained stable, so I'm hoping he does all right. What saddened us was the reason behind his drug overdose: he didn't match for residency last week =/

Drexel University College of Medicine/Hahnemann University Hospital

First Impressions: Ahh...good old HUH. A common question I've gotten on the interview trail is why I came all the way to Philly to do my residency instead of staying in TX. I'd had my best interview here, and the camaraderie among the residents and faculty really appealed to me, so I ranked the program high on my list. I have no regrets about my decision to go out of state for residency, as I've made many friends here and have grown to love living on the East Coast.

Knowing from day 1 that I wanted to apply to heme-onc, I immediately went about making myself known. I did inpatient heme-onc floors at both HUH and the "Bing," selected heme-onc electives, and started doing a secondary clinic this year at the outpatient heme-onc office. All the attendings knew me and, for the most part, knew my work ethic and personality. I was told that HUH likes to takes its own applicants for heme-onc, and hopefully that's still the case.

Interview Day: All interviews are held on a Saturday, which was good and bad (good being that I didn't have to take a day off from work to interview, bad in that you don't see as much on the weekends). There were about 12 of us, and of those 12 only I was from HUH. That was a mistake on the program's part; usually they interview all HUH applicants early in the season but somehow my file got overlooked and they had to squeeze me in at a later date. The program director gave a very straightforward powerpoint presentation describing the fellowship in detail, and then three attendings took turns interviewing us. They saved me for last since they knew me already, but in the meantime two fellows came to chat with us about the program. One of the fellows I knew well, since I was helping him on a Phase II project earlier in the year, and the other was surprised to see me since he didn't know I was applying heme-onc. My interviews were extremely laid back; the first one was with an attending I knew well and we talked about patients I was currently seeing in the ICU. She also asked me what games I had on my iPhone, so I gave a brief demonstration of how to play "Angry Birds." It was fun at the time, but after I left her office I thought, "What just happened?" Not your everyday interview. They told me I didn't have to meet with the program director b/c he wrote my rec letter, but I sat down with him anyway for about 10 minutes to update him on what has been happening with me.

This program has a university name but runs more like a community program. There are no specialists in any particular organ system; all the attendings here are "general oncologists" who see all types of malignancies. The clinics, also, are combined so there is no "breast clinic" or "lung clinic;" you see all types on any given day.

Overall Impression:
Pros: Good balance in both heme and onc, diverse pathology, 3 fellows a year. Having been here for the past 20 months, I am very familiar with the archaic computer system and how the inpatient, outpatient, and consult services work. Philly is a pretty good place to live (2 hrs from NY, 2.5 hrs from DC), most rotations done at HUH except electives at other hospitals. Good relationship with the attendings, very hopeful that I'll be ranked high.
Cons: No subspecialists within hematology/oncology; this program tends to produce general oncologists going into private practice.

Futile

I am currently doing my ICU month, which I have been dreading for ages. To put it bluntly, I do not like critical care. I have never been good at thinking on my feet and dealing with stress. The ICU attendings, thank goodness, are all good people who aim to teach and not criticize. Even when I forgot to lavage a guy bleeding from his rectum (it turned out he had bleeding duodenal ulcers as well), the attending just said that I didn't work up the patient well enough. No blame, no yelling. I still felt awful afterwards and blamed myself for not being thorough (even though my fellow residents thought I was making too much out of it), but it felt better knowing that despite my poor intensive care skills, I still had the support of my friends and attendings.

Currently there are about 24 patients in the ICU, and 4 of my 5 patients were complete trainwrecks. First is the GI bleeder mentioned above; he was scoped from both ends with no evidence of bleeding (just a few superficial orders), and then he had another giant maroon BM and needed another emergent endoscopy that revealed vessels in 2 ulcers that were clipped. Hopefully that'll be the end of that. Another is a man with ESLD, partial SBO, and the worst respiratory drive I've ever seen. Sometimes he became hypoxic, othertimes he was tachypneic in the 30s, and we couldn't change the vent fast enough to keep up with him. His ABGs were slightly on the acidotic side but uncorrectable with vent settings; getting good ABGs on him was a nightmare. Another ESRD guy practically looks like a skeleton and has self-extubated himself twice since I've been on this service (each time needing to reintubated again), and his wife won't make him DNR despite his poor prognosis.

Then there's my lone female patient, a woman in her 50s who presented with a 6-month history of intractable cough and ended up requiring intubation (and later trach) due to hypoxia. She had multiple lung nodules on CT and a pleural fluid biopsy revealed lung adenocarcinoma. There was a time where she was completely obtunded and people feared she'd never wake up. She started stirring when I started the service, and now she's wide awake. Despite our best efforts, however, we have never been able to wean her off the vent. She has continued to have coughing fits while trached, and this comes out in loud gasping cries that can be heard throughout the center part of the ICU. Sometimes she's able to speak through the vent and say, "Help me." We can all hear her, and it's absolutely heartbreaking. It seems that if she can speak, she should be able to make it off the vent, but she gets so agitated all the time that she becomes tachypneic and weaning becomes impossible. I don't know how to help her. She's allergic to codeine and can't take Tessalon through her Dobbhoff, and the Robitussen isn't touching her gag reflex at all. I know that it's impossible to cure everyone in the ICU, but I feel like we're prolonging her suffering.

Sometimes I wonder how people can go into pulm/crit without being completely drained. I've been on service for 9 days straight (black weekend), and I'm already tired and frustrated that I can't help my patients get better. Sad thing is, with the exception of my GI bleeder, the other three are going to be with me until they either die or go to hospice. There is no getting better. And that's the worst part of this job.