Rising from the Ashes

Last weekend I spent the last weekend of my vacation in New York City, a place that I've visited several times since moving to Philly but never really in its entirety. Prior to residency, I had only been to New York once, during my junior year of high school. At that time, the World Trade Center was still standing, though I only saw it from the windows of a harbor cruise ship. My next visit to the city was in 2009, during my intern year, because my college roommate was working in NY at the time and invited me for the weekend. Since then, I have tried to make a day trip to New York at least every 2 months, each time going somewhere/doing something different to check off my NY bucket list. In my visits to NY, I've been to the Empire State Building, watched "Spiderman: Turn off the Dark" on Broadway (twice!), ridden a water taxi to the Statue of Liberty (when my parents came to visit), ate ramen at Ippudo, and been to both the Metropolitan Museum of Art and the Museum of Modern Art (MoMA). One place I had never visited up close, however, was Ground Zero.

The first time I laid eyes on Ground Zero was from a plane in 2009, when I flew from Rochester to La Guardia Airport en route to Philly. I'd always been fascinated about the events of September 11, 2001, particularly the stories of survivors who escaped the carnage and the firefighters/policemen/civilians who gave their lives in the end to help others escape. I rarely ever went to Lower Manhattan (where Ground Zero was), as most of my time in NY was spent in Midtown, but on the rare occasions I did go to Lower Manhattan, I captured pictures of work in progress.

This was taken in summer of 2011. And nearly one year later, it has reached its full height.

The 9-11 museum hasn't opened yet (will likely open on September 11, 2012), but the Memorial was open to visitors. Admission was free but passes must be reserved in advance, so I booked my ticket online and joined the huge throng of visitors from all around the world to view the memorial.

The layout of the  Memorial had two pools in the footprints of the Twin Towers (the South Tower waterfall and the unfinished Museum in the background are seen above). I tried to imagine what the towers must have looked like up close in 2001, but could not. There were so many names inscribed along the wall surrounding the pools, with several reading "____ and her unborn child" for the women who had been pregnant when they died. All those names were a grim reminder of all that was lost. Amazingly, at the North Pool I spotted a rainbow hidden in the water.

Then there was the "Survivor Tree," a pear tree that once stood outside the Twin Towers and was reduced to a stump after the attacks. Miraculously, it survived and was taken to a nursery where it grew new branches and eventually grew more than 30 feet tall. Recently it was moved back to the Memorial, where it is held in place with support wires. Up close, you can see the original stump pulled from the rubble of the towers and the newer branches that grew from that stump after it was rescued. Truly a survivor.

I feel fortunate to have been able to visit the Memorial and pay my respects to the ones who died on September 11, 2001. Someday when the museum opens, I will definitely be back again.

Killing Me Slowly

These past four weeks have been some of the most painful I've ever experienced in residency. My attending admits patients from her office like there's no tomorrow (one day we got eight new patients in 24 hrs), completely disregarding our team cap (14), then becoming frustrated when we don't know what's going on with the patients that overflowed to other teams. The general medicine teams don't appreciate our overflows either (just like I dislike having general medicine overflows to my team), and the worst part is, it is extremely hard to discharge patients on this service. My attending is very good with her patients and they love her, but she gives in to them too much. We have a patient on our service with C. Diff who could have gone home days ago, but can't because her insurance won't pay for her antibiotics so she's just getting them here. Another guy could have gone home today, but we're babysitting him just in case his WBC drops (after chemo). Seriously? His WBC went from 4 to 16 after getting neupogen! Today we had 8 possible discharges; by the end of the day, NONE of them went home. A big reason for this was that we rounded with a more junior attending who was afraid to do ANYTHING without my attending's consent; his response to the patients was, "We'll see what Dr ____ says tomorrow." Does he not understand I am trying to get these patients OUT?!

I imagine my fellow, my intern, and med students probably think I'm becoming more and more callous because I keep trying to get my patients out of the hospital. And with good reason: for the past 48 hours I have been caring for 15 patients, which is one above our cap. And some of these guys are sick. One of my sickest patients is a ticking time bomb; his pancreatic tumor has invaded into his stomach, causing a massive GI bleed several days ago. GI and IR have said there is nothing they can do and recommended palliative care. The bigger shock was when the surgeon told the patient how extensive his cancer was and his caretaker tried to stop him from saying too much. As it turned out, the patient had absolutely no idea that his cancer was so extensive. He knew he had a "tumor" in his abdomen and that he was getting treatment for it with chemoradiation, but no one in his family told him that the tumor had taken over his liver or that he could possibly bleed to death at any time. I don't know if it was done to protect him or what, but at any rate, he knows now that his cancer is much more serious than he thought. It's a shame that the cat was let out of the bag the way it was, but I think it's better this way.

With an average census of 14+ patients for the past two weeks, I feel like I'm being torn apart. I'm trying to do my job and be the best resident I can be for these patients, but between social placement issues and my attending endlessly admitting/never discharging her patients, things are getting out of control. I tried to dictate a patient's discharge summary today, and when I played back my dictation, my voice sounded completely defeated and tired, almost like I was on drugs. This service is sucking my soul away, and I'm beginning to lose myself. Even an impromptu trip to New York the other day to watch the Spiderman musical (which I thought was exciting and well done) did nothing to boost my spirit. My only consolation is that I have only 3 days left on this godforsaken service, and after that, three friends and I are going to watch the Philly orch perform Debussy's "La Mer." Let's hope I'll make it 'til then.

Choosing Death Over Life

One of my more unusual admissions was a 57-year-old man named Dan who was sent to the hospital from his oncologist's office for, of all things, "suicidal ideation." Three years ago he was a healthy gym teacher who did everything right in life. Then he was diagnosed with nasopharyngeal cancer, and radiation treatments worsened his ability to swallow, causing him to require a feeding tube and depriving him of the joy of eating what he liked (at best, he could eat soft foods). Then, he was recently diagnosed with a second cancer (lung), and even worse, it had spread to his bones. He became both depressed and discouraged to the point where he threatened to stop eating at home, saying that he wanted to die. It took my attending an hour to convince him to come to the hospital for treatment of dehydration.

When I first met him, he looked absolutely miserable, barely making eye contact with me or the nursing aide watching him (to make sure he didn't try to kill himself), and when I asked if he knew why he was in the hospital, he said, "Yeah, I want to die." He was tired of living with the knowledge that his cancer was no longer curable, and would eventually disable and kill him (the RNs said he used to do pushups in the hospital room when he was first diagnosed). We consulted psych and started him on Zyprexa to see if it would help his mood (it didn't). He also complained of intractable hiccups, so we gave him thorazine. He was also neutropenic and spiked fevers almost daily (though we had no obvious source of infection, as his CXR looked clear). The nurses who knew him gave him pep talks to keep his spirits up, and even my attending told him that since the cancer had only spread to his bones, he could continue to receive radiation and live a relatively normal life (since the cancer had yet to spread to his liver or other organs). I thought he was starting to believe him, but then he developed a bad case of rigors (presumably neutropenic fever) that knocked him down. That was the beginning of the end.

The following day was my day off, but I still came to work in the afternoon to prewrite my notes. My intern was nowhere to be found, and I later learned that he was with Dan, who had a rapid response called on him for rigors and hypoxia. His CXR, to our horror, showed new pulmonary edema that was NOT present just two days ago; his lungs had a lot of "fluff" that looked like ARDS. A MICU eval was called, and the MICU team wanted to intubate him. Dan refused. He made it very clear to the MICU team that he did not want to be intubated, even if it would save his life, and he didn't even want to wear a BiPAP. He just wanted to be comfortable. Normally the advance directive forms in our hospital don't allow patients a place to sign (the attending usually signs it); Dan, however, was so insistent that he wanted no life-saving measures that he signed his name on the side of the paper, at least until the attending signed it the following the day, to make it as official as possible. His older brother, who was also visiting, disagreed with Dan's choice and started arguing with him in the room while he was struggling to breathe; security had to get involved and they ended up banning the brother from entering the hospital "under any circumstance." I felt bad for the brother, as none of us were truly comfortable with Dan's decision to withhold care and felt that if he gave intubation a chance, he could potentially make it through this. But in end-of-life care, the patient has the final say.

DNR doesn't mean Do Not Treat, so we started him on a heparin drip (in case of PE) and gave him a huge dose of Lasix in hopes it would clear the fluid that was building up in his lungs. Dan spent the remainder of the night with his wife at his side, and they made small talk about friends and family. He desat again in the early hours of the morning and finally had no choice but to wear the BiPAP to help him breathe. Sometime around 7:30 a.m., he told his wife that he was thirsty, and she left the room briefly to go to the cafeteria.

I entered the room around 7:50 a.m., and I immediately noticed that the BiPAP was off and in Dan's hand, which was resting at his side. Slumped to one side, his breathing was agonal now, one breath every 20-30 seconds, and he didn't respond when I called his name or shook his shoulder. I immediately knew that the end was approaching, and with the help of a nurse we repositioned him to help him be more comfortable. I saw several more patients before returning to the room and saw his wife waiting outside while techs took a chest Xray (which had been ordered previously but I knew was now futile). I told her that he was now unresponsive, which was a huge shock to her. "I was just talking to him! We talked all night!" she said. As soon as the X-ray tech left the room, both of us went inside and found the patient lying still in bed. He was so thin that previously I could see his carotid pulsating in his neck; now everything was still. With a sinking feeling, I realized that he had died during the X-ray, or even before.

"Dan? Dan, wake up!" his wife said as she shook his shoulder. I quickly ran into the hall and asked the nurses for a flashlight to confirm that Dan had died. No breath sounds, no heart sounds, pupils fixed and dilated. Time of death 8:30 a.m. His wife burst into tears, unable to believe that he was gone after he was just talking to her two short hours ago. I felt extremely sad, too, but in a strange way, I felt that Dan would not have wanted it any other way. I had heard that he didn't want to prolong his illness because he didn't want his wife (whose first husband had also died of cancer) to go through the pain of watching another husband slowly die. I think that he waited until after she left his room to let go, so that she wouldn't have to watch him take his last breath. Afterwards, we left him in his room for several hours while his family and former students came to say goodbye, and his wife thanked us for being so understanding.

Dan came to the hospital saying that he wanted to die, that he was tired of getting treatments to delay the inevitable, and he finally got his wish. He never had a choice when he was diagnosed with not one, but two cancers, or when he needed a feeding tube to sustain him when he could no longer swallow properly, but in his final hours, he was able to choose how he wanted to die. Not in the ICU, not intubated and hooked to monitors, but in a quiet room after spending the night with his wife at his side. It's some consolation to know that Dan died on his own terms, in the way he wanted. That was one thing not even cancer could take away from him.

When the Young (and Old) Have Cancer

This month I'm doing an oncology inpatient service (originally requested when I dared to dream that I would one day become an oncologist), and after working for seven days straight, I already feel burnt out. There was one day where my census was 7; after that it exploded to 14 and has stayed above 10. And these patients are sick. My attending is a very nice woman, but she also has the mindset to treat patients until the very end, giving people chemo at the cost of quality of life, and refusing to make her patients DNR/DNI as she believes residents take less care of them once they're labeled with a DNR (not true). She has a tendency to make promises to her patients that everything will be all right, and it frustrates my fellow and me to no end when the promise is being made to a stage IV cancer patient who has weeks or months at best.

Sadly, my service this week was full of young people with deadly disease. One was a 34 year old guy with metastatic CA who initially was seeking treatment at Cancer Treatment Centers of America, but came to us when even CTCA deemed there was nothing more they could do. (We half-joke that when patients from CTCA are transferred to our hospital, they come to die, because it happens like that all the time). He developed a bacteremia sensitive to everything but colistin (a last line antibiotic that eventually causes kidney damage to all who receive it), and while we continue to give him chemo, his kidneys are taking a huge hit. So what's the better option, go on dialysis or die of sepsis? His family and young children came to see him over the weekend, and it was sad to hear them ask nurses if he was going to get better. And we all know the answer is no. When I see him, I think of Bryan and Heather, and wonder how they are doing now that Bryan is home on hospice.

Two other patients have rhabdomyosarcoma (rare and deadly), and both are younger than me. One was 18 weeks pregnant when she was diagnosed and had to have a therapeutic abortion to give her a chance to receive chemoradiation and live, not just for herself, but her other children. The other noticed something was wrong but was unable to see a doctor because he had no insurance; now the sarcoma has spread to his lungs. But both are optimistic and hopeful, and hopefully their youth will act in their favor. But it still saddens me to see them in this position; when I was 26, my biggest worry was where I would go for residency, not how long I'd live.

One of the more interesting things about taking care of cancer patients is seeing how family dynamics work in light of a fatal diagnosis. Today was my post-call day, so I could have left at 1 pm at the earliest; instead, I stayed until 5 pm as though it was a regular day, because two of my patients were actively dying. Both of them are longtime patients of my attending, and a part of me is afraid that when she comes back tomorrow, she'll accuse me of being a black cloud since they got so sick. One was a woman with stage IV colon CA with huge liver mets who's biggest problem was her recurrent ascites. When I first met her, she was completely awake and oriented with a sweet personality. This morning I found her staring at the wall, barely responsive to voice and not following commands. Her ammonia had risen from 186 to 460 overnight. The attending on call immediately called the daughter and said that her mother was dying and needs to be on hospice, and palliative care was immediately contacted. The family accepted the situation and all gathered around her room to talk to her and keep her comfortable.

This was a complete contrast to the other family, whose 86-year-old father was dying of metastatic pancreatic cancer. He was on our service last week for hematuria, and at that time he was able to have a lucid conversation, follow commands, and eat small amounts of food. His family brought him back after he stopped eating, and now his speech is garbled and he keeps moaning. His wife and daughter were notorious throughout the cancer floor for stalking nurses and being demanding, keeping him full code despite his poor prognosis. Their biggest concern was that he was not eating, and wondering why he no longer recognized them and why his mental status has gone down the toilet. My attending explained that the patient was actively dying, and that not eating and hallucinations were part of the dying process. We then tried to bring up the idea of DNR, which the wife (and primary decision maker) seems to agree with. Her children were another story; a son I had never met until today pretty much said that doing nothing went against what the Torah stated (they're a Jewish family). The wife seems to be the most reasonable of the bunch right now, so I hope the whole family will come around soon. I'd hate to be the resident to code this poor man.

It's days like these where I'm glad that I'm not specializing in oncology after all.


Edit: The pancreatic cancer patient died two days after this post; by then, the family had made him DNR/DNI and comfort care, and he died surrounded by family.

The One Who Survived

Back in when I did my MICU rotation in August 2011, I had the same three patients throughout the entire month. One was a cirrhotic guy who had a massive GI bleed my second day of MICU but survived and had the best mental status I'd ever seen in any ESLD patient. Another was an alcoholic who literally drank up until she had a massive variceal bleed and ended up in the MICU with end stage liver failure. We ended up making her condition worse by getting her a G-tube (the ascites kept leaking around it) and putting her on colistin when she had a resistent bug growing in her blood (killed her kidneys and put her on CVVHD) The third was a large 400 lb guy who initially presented with a fall, developed a COPD exacerbation and refused BiPAP, ended up getting intubated and developing a buttload of complications like MRSA bacteremia, necrotic bowel s/p exp lap (which, given his girth, did not heal well). The three of them were like seesaws throughout my entire month of MICU. One day, the cirrhotic guy would crump while the others seemed to be headed in the right direction. One day, the alcoholic woman felt well enough to flip everyone off and tolerate trach collar; the following day she had to go back on the vent due to new sepsis. One night my COPD guy accidentally fell out of bed despite being on a vent and hooked up to numerous IVs (we still aren't sure how that happened), dislodging his Hickman and bleeding all over the ground (heparin drip). I had high hopes that one of them would make it out of the MICU before I did, but they were still there on my last day.

My two ESLD patients ended up dying, though the alcoholic woman was at least able to make it out of the hospital to hospice. The COPD guy walked into my clinic today, and to see him awake, walking, and talking was amazing. When I think back to how he was in the MICU, how he required monster doses of sedation (until we discovered Risperdal) to keep him from bucking the vent and reopening the barely-healing wound from his ex lap, how he developed ARF and needed CVVHD (which was, fortunately, temporary), how his abdomen grew a highly resistant bug that later became septic, there were times when we thought he wouldn't make it. He told me himself that he had no memory of those 2-3 months he'd spent in the ICU (probably a good thing), and that he was extremely grateful to be able to walk and talk again (he'd required a trach and PEG). His abdomen has healed, though the granulation tissue still looked a bit friable. I was surprised he hadn't followed up with surgery and told him to call them for an appointment. One of my friends who had him on the floors (when he drank the water used to swab his mouth while still NPO on a PEG tube) called him a giant POS, but I was just happy he survived. Considering all the people I've seen die in the MICU, he was one of the lucky ones.
There

Looking Ahead

Wow...it's been a long time since I've written on this blog. Kind of sad, considering how from age 11 to 22 I wrote (yes, WROTE, not typed) journal entries almost every day detailing life from elementary school through college. In med school I switched from writing to blogging, but my entries throughout residency have been minimal at best. Years from now, I'm going to go through my old journal entries and lament that I barely have any entries documenting my residency years. Part of it was that I was afraid that anything I put on here would become a HIPAA violation, especially now that I was a practicing physician. I may try to write a bit more later on.

The biggest thing I had to deal with last summer was not matching into heme-onc fellowship and wondering what my next path would be. The question I had to ask myself was, "How much do I want to be an oncologist?" I had always been interested in oncology even as an undergrad (cell/molecular bio major learning about carcinogenesis, targeted gene therapies, etc.), but my reasons became more personal in med school. My mother was diagnosed with breast cancer during my first year of med school (few people knew outside of my family, as we wanted to keep it private, but she has now been in remission for 5+ years) I also remembered telling my orchestra director several days before she died of colon cancer that someday I hoped to be an oncologist and help people like her. I had high hopes for myself, thinking that my background and personal experiences would help me get into a heme/onc fellowship. Finding out I didn't match was a huge slap in the face (or, as I told my friends later on, a big fat "F*** you."), and I wondered what went wrong. My reaction on Match Day was not normal either; the ones who didn't match pretty much sulked all day; I smiled and looked on the bright side: at least I can move back to Texas! That got me thinking: maybe the people at the programs could tell I didn't want to be on the East Coast bad enough. Maybe my real goal all this time was to come back to Texas. One door closed, but another one opened.

My chief residents still sent me emails whenever they heard of any heme-onc fellowship openings, but by then I'd already decided that I no longer wanted to pursue a fellowship. I'd never been a huge fan of research, and the idea of spending time and money to reapply was something I no longer wanted. And while I personally feel I'm more suited for clinic, I liked the acute care setting better and decided to apply for hospitalist positions in Texas. I worked on my CV, looked up job opportunities on PracticeMatch.com (and browsed through those endless emails from recruiters for opportunities to practice in Texas), then applied to positions that sounded interesting. I ended up getting 3 interviews, 1 in Dallas, 1 in Austin, 1 in Round Rock.

I went to those interviews in early February and immediately noticed how different applying for a position is than applying for residency for fellowship. I didn't have to do anything to sell myself. My first interview in Dallas didn't feel like an interview at all. One of the attendings showed me around the hospital (1000+ beds!), and then we had lunch with the other partners. I asked a lot of questions, but not once did the interviewers (it was very informal) ask me anything about myself. I was prepared to list my strengths and weaknesses, say why I was applying to their program, but instead, they did all the talking. Clearly they needed me more than I needed them. I knew if I went to this program, I'd be expected to work hard.

My interviews in Austin went pretty well. I had a brief info session with the president of the company, then drove to the hospital where they needed to hire more physicians. The schedule here was Monday through Friday with every 3rd weekend on call, but work hours were flexible (you can leave once all your work is done). I also found that I had a good rapport with the attendings there; there was a good vibe amongst us that was reminiscent to what I felt at my Drexel interview 3 years ago (and helped me decide to rank them high on my list). It was in the 60s and beautiful in Austin that day. After my interview I dropped my luggage off at the hotel and then walked around Town Lake (now called Lady Bird Lake). I also got to meet up with Dina for dinner; we went to Uchi, which was AMAZING.

My Round Rock interview also went well. The doctors here have a 12-on 9-off schedule where they only rounded on the first 5 days, did rounds/admissions the weekend, and then only admitted the remaining 5 days. It was an ideal schedule for someone who needed a lot of free time (i.e. family with kids), and I found myself really liking this program as well. It was, however, a smaller program (6 physicians working per day), and I didn't have that same rapport with the attendings that I did in Austin. I liked all three of the programs pretty well, and I dreaded having to make a decision between them if I should get multiple offers (which, of course, was better than having no offer at all!)

Both Austin and Round Rock offered me contracts within a week of my interviews. I was shocked by the fast turnaround; how was it that I failed to impress anyone during my heme-onc interviews, yet with medicine they actually wanted me to work with them? It felt good to be sought after, for once. Deciding between the two programs was a huge challenge because they were so different from each other in terms of workload, salary, and call schedule. In the end, I decided on the program in Austin. They are a well established hospitalist group in Austin and provide care to different hospitals and rehab centers throughout the city. They are looking to hire a total of 5 new doctors this fall; I would be the 4th. And assuming the other new hires are MDs, I would be the first DO in the practice. And for me, that would be a huge accomplishment, showing that DOs can (and should) be able to practice wherever they want, and how they want.

Looking back for the past seven years, I can hardly believe it's finally come to this. My parents had tried their hardest to talk me out of medical school (and TCOM, once they found out it was a DO school and were fed lies about how DOs face great discrimination in the medical field), fearing that I would someday be doomed to practice medicine in a small town because no one would want to hire me. Fortunately I've proved them wrong, and now they couldn't be more proud =) I'm proud to be where I am =)

Earthquakes and Medical Emergencies

I started my MICU rotation yesterday, and while it's my second time being in the unit as a resident, I still get nervous in the MICU. One of my more "stable" patients was a 54 year old man with end stage liver disease with peritonitis who is still on the liver transplant list despite all his current comorbidities. My attending even asked if we could call him out to the PCU today, but the fellow disagreed, saying that every time he was called down to the PCU, he always returned quickly due to hypotension.

Thank goodness he stayed, because shortly before 10 a.m. I got a call from another resident saying that he was coughing up "lots of blood." I broke from rounds to see what was going on, and there was my patient, his gown and sheets drenched with bright red blood, and there was more coming out of his mouth and trach. My first thoughts: "Holy $#&!" Even worse, he recently had all his central lines removed due to fungemia, and all he had was one peripheral. This was the worst thing that could ever happen to this guy, and I was in fear for his life.

Fortunately one of the MICU attendings was already in the room, yelling for the fellow to get a central line kit and at us to order octreotide drip, Nexium drip, and above all, blood products. Rounds were completely forgotten in light of this emergency. While the fellow put in a central line and the attendings put in a Blakemore tube (which I'd never even HEARD of until today), the rest of us tried to handle everything else from running to the blood bank for blood products, putting in orders, making phone calls, etc. The first year GI fellow was nervous about doing her first scope for a variceal bleed (the patient had known varices and had bled in the past), and the GI attending tried to make it all sound exciting. In the first two hours we transfused 8 units of RBCs and who knows how much FFP and platelets (remember, end stage liver), and through it all the patient remained conscious. He knew very well what was happening, and that, I thought, was the scariest thing of all. Knowing that he was in trouble, and that he could die.

The GI attendings couldn't find an obvious source of bleed, but went ahead and banded what varices they did see just to be safe. Once he was stabilized, it was nearly lunch time, so several of us went to the lounge to eat. Suddenly, the floor started moving up and down, almost like we were on a ship, and a closet door started swinging. "What is that?" someone asked. "You guys feel it too, right?" "Is that an earthquake?" It certainly FELT like one (I'd experienced earthquakes in Asia before), but whoever heard of earthquakes on the East Coast? "I love how we're all just sitting here," one girl half-joked, but it was surprising how calm we all were. The earthquake only lasted about 20-30 seconds, and after it ended another girl (who happened to be from Cali) ran into the lounge and said, "Did you guys feel that?!" Yup, sure did.

For a lot of people this was their first earthquake (my college roommate was in DC and told me that she immediately ran out of her building when she felt the first tremors), so it was pretty frightening for them. One of my friends initially laughed when her ER patients told her that the ground had shook and thought they were just high on crack; only later did she realize that there was an earthquake and she hadn't felt it. Our lounge was on the 12th floor of the hospital; I'd always experienced earthquakes while in a high rise so I have no idea whether it's safer to evacuate the building or just stay put. At any rate, an earthquake on the East Coast was certainly bizarre. And now there's a hurricane on the way? What the heck...

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.