Changes

Today, I drove home from work post-call, crying. I had a busy, largely sleepless night, with the lovely addition of the onset of a head cold. I made it through the call shift, made it through my work shift in the morning, then headed to a feedback session with one of my course directors. The course was "Empathy" and involved interns listening to comments made by patients on tape, then delivering empathic responses back.

Most of us had a hard time with this.

One intern said she felt like she couldn't respond to the happy patient because she only sees suffering or she assumes the patient is manic or borderline--she didn't know how to treat someone who was just happy. My responses felt to me like I was still using them as questions to extract more information, instead of just interjections to let the patient know I was listening and perceiving what they said.

My course director said I had done a good job, and that I had "a practical, pragmatic approach" that she felt would become less self-conscious and improve over time. I started to say something in response and instead tears welled up (I've cried in front of her before, so I doubt she was shocked).

I told her I felt like I used to be better at empathy, at understanding where patients come from and what they're going through, and trying to connect, and that I've lost something this year. That I used to enjoy trying to connect with patients, and now I find it difficult (I didn't tell her that often, I don't bother trying).

As I drove home, I started to cry again. At first, I couldn't tell what was bothering me. I assumed it was tiredness + being sick. It felt too bad to be that simple, though. When I get really upset, I feel a squeezing pressure in my chest that seems to wring tears from me (yes, I'm aware this is psychosomatic). I tried to think, what was bothering me? Then I realized I was still crying over what I'd lost this year. But why am I so burned out, empty? What have I lost?

I think a combination of forces has dried up my empathy well (maybe it wasn't very deep to begin with?). Call it soul, or humanity, or empathy, or sympathy, or "being with"--whatever--I feel like mine has shriveled a little (or a lot) under the blaze of a ferocious burn out.

(A note about burn out: when high school seniors, or college seniors moan about being "so burned out on school right now", that is not the same. This kind of burn out leaves you feeling hollow and empty. It invades your personal life, your marriage, your quiet time, and your dreams, even when not at work.)

I'll point a finger at chronic sleep deprivation. I've been working around 60-65 hours per week (which is not that much, really, by medicine standards; please, surgeons, don't hit me) and taking 5-6 calls per month for the past 6 months. I don't feel recharged between calls, and I think over time my reserves have gotten lower. I've taken some vacation time and tried to catch up, but it seems to only take one call to flatten me out again (I like my sleep, so sue me).

That's not the whole story, though. Part of it is the patient population I treat. On call, the most memorable patients are the substance-using (usually cocaine or alcohol) homeless narcissists (or antisocials) who are in it to get a free bed. I used to fight this, but I've given in to the system where I work. This system pulls these patients in and suckles them for a while. Aww, did you relapse for the 40th time? Was that placement not nice enough for you? You didn't make any of your follow up appointments (often, despite having benefits, bus passes, or special transportation) and couldn't be bothered to take your meds (given out for free), but that's okay, come here baby, I have a bed and a tray for you. I strongly feel that this system thereby encourages these patients to continue this behavior. There's no need to make choices or take responsibility when there's always a cushy safety net. Just say the magic words ("I'm thinking about hurting myself", but don't have a real plan) and you're in. I don't mean to suggest that all my patients are like this, but enough of them are (and they all seem to come in crisis at 3 am, because they know an intern is on, rather than during the day when the attending will send them to outpatient rehab) to be grating. I said in a previous post that there are few true psych emergencies at 3 am, and I still hold that to be true. There are some, and I'm happy to treat those, but most 3 am consults to the ER are for someone who's crashed off cocaine, feeling suicidal, and completely oblivious to the idea that cocaine could make them feel this bad. They want me to fix their sadness, but don't want to give up the high.

Some few of these patients can be verbally abusive, which makes it oh-so-exciting when I get to call the police or security to escort them out.

I hate the stigma against the mentally ill, even though I recognize some of it within myself. I recently treated a patient with delirium tremens who had a CIWA of 21 on my exam. The reason for consult was "rule out other psychiatric issues". My note politely stated that I would reassess other psych issues after pt was more alert and oriented (not A&O x none like on my exam) and that the primary team should consider increasing the lorazepam drip. Agitated patients who cannot give a clear history of alcohol or benzo use are often shuttled to psych while having withdrawal. I've seen patients not receive appropriate treatment of surgical or medical conditions with no other explanation than "due to psych diagnosis". (I also hate inappropriate medicine consults by psych because someone forgot how to look up the dose on a blood pressure med, so I'm perfectly aware that this is a two-way street).

Of course, when I went to the dentist last week and saw that my chart said (in Magic Marker on the front cover) "depression, nervousness, psych problems", I nearly cried in the dentist's office. I mentioned having a history of depression and anxiety during my intake, but I had no idea it would be proclaimed on the front cover of my chart like that, for all the office staff to see. So I understood my patient last night who told me she had lied to her psychiatrist about her previous suicide attempts because she was too ashamed, so she said she'd never done anything.

I believe a lot of my burn out is related to having been an intern for nearly a full year. Internship and residency are tough (yes, even in psych). I also believe that I would be pretty burned out no matter which specialty I'd chosen.

But a part of this burn out is psych itself. It's the overuse of meds, the overuse of diagnoses, the stigma against psych patients and psych doctors (but man, are you glad to see us when you need us!), the massive pharma scandals (Seroquel, Zyprexa, and Abilify all come to mind), the overmedication of children who need appropriate discipline (and the recent revelation that the data supporting stimulant use was oversold to us), and the overwhelming feeling that I'm not cut out for this like I thought I was. I'm not as good at psych as I thought I could be, which is tough for me, as I'm usually good at clinical work (for pete's sake, I won an award for best clinician of my med school class when I graduated!). I doubt I'd be a terribly skilled therapist, and I believe that therapists should be skilled. I have some sensitivity to what people are feeling and am able to read between their words, but I'm finding that doesn't seem to be enough. In other words, I'd probably be a competent psychiatrist, but not an excellent one, and that's not good enough for me.

So for all these reasons, and one other big one (and maybe a few I forgot), I'm switching residencies to internal medicine. The other big one, obviously, is that I like medicine and miss it. I think I'd be pretty burned out right now if I'd just finished a year of medicine internship, so I'm trying to think pretty realistically (although sometimes I'm so desperate to escape my burn out that I get "grass is greener" syndrome and wish for medicine to fix my problem). I wasn't a fan of medicine as a med student, largely due to a certain attending who tore me a new one and then said I should go into medicine (which is a dumb reason to avoid a whole field, really). I clicked with medicine as an intern, though. I was good at it. I was my usual gets-too-flustered-when-paged, OCPD-I-might-have-missed-something self on medicine just like on psych, but I was better there. I was better able to see the big picture on medicine than I remembered, and less able to see the big picture in psych than I thought.

So there, that's my big announcement. Will switching residencies solve everything, or anything at all? Maybe not. It's not that I hate psych, because I don't, despite all the mean things I just said about her. After all, you have to care about something to get angry about it. There's nothing magical about doing internal medicine now (and many of the same problems exist there as well); I still don't know exactly what my career will look like from here (which makes me nervous), but I realized at some point in the fall that I could no longer see myself as a psychiatrist, and in November I realized I could see myself as an inpatient medicine attending, or supervising residents in a clinic, giving lectures to med students--in short, similar plans to what I had for psych, only now in medicine. I'm doing psych consults this month, which is giving me some closure (which I needed). I'll miss psych, especially during the sweet 3rd and 4th years of psych residency when they work 8-5 M-F and I'll be a ward upper level on medicine. I'll miss the intern class I came in with--they're wonderful people, and it has been a pleasure to watch them learn how to be doctors. The psych department is full of people who are special to me and I will miss them.

Fortunately, I'm staying within the same medical college, so the switch is relatively painless. I'll be a PGY-1.5 for 6 months, then start PGY-2 in January. This will put me 6 months behind for medicine, but 6 months ahead for psych. I still plan on doing a fellowship, so I'll be a trainee for a long time ahead.

I've thought about combining medicine and psych, and I think that's a definite possibility. I could run a primary care clinic for psych patients, for example. My psych program has offered to let me come back in the future if I want to do so; I haven't ruled this out (although I do NOT want to be a trainee for the rest of my life).

So now, on to different things. As of next Wednesday, I will no longer be a Tiny Shrink. As I've already changed the handle on this blog a couple of times, I think I'm going to close the blog out and maybe start a new one. If I do that, I'll post a link. As I struggle to find my identity as a doctor, I'm not sure it's fair to make my blog struggle with me. It's kind of like CSI picking a new lead actor when Gil Grissom's character left (or maybe not). So I think this is goodbye for now. I really appreciate anyone who has read this blog or left a comment (or indeed, made it to the bottom of this circumstantial, rambling mess of a post), and I thank you.

Vacation Part II

Taking 3 days off to go see my dad and my grandmother. Trying to catch up on my sleep before taking more calls.

Still Here

Just haven't felt much like posting lately. Back soon. In the meantime, I'll be watching "Lie to Me", my new favorite show.

He's Fantastic (As Usual)

If you have a few minutes and want to read about the history of nationalized medicine in England, France, and Switzerland, as well as the history of how the American health care system came to be, and even the American telephone system(?!), go read this article by Atul Gawande in The New Yorker. Go, now.

I found the link at Kevin, MD. Congrats on Best Medical Blog of the Year!

God-Awful

My husband was talking to a non-medical friend at a party the other night, and he referred to internship as being "god-awful." I immediately turned to him and corrected him.

I do not think internship is god-awful.

In fact, I have been fairly happy lately.

Yes, I have been really stressed out. I have cussed out loud while getting gang-paged and dropping the call pager into a cup of coffee. I have been (unintentionally) surly to nurses who have paged me for 2 am constipation. I have had months where I've been very sleep deprived and cranky. My house is filthy. I almost never cook dinner. I've put weight back on because I am often too tired or busy to go to the gym. Sometimes I snap at my husband out of stress and anxiety.

It's also true that I've been to 2 excellent rock concerts and 1 symphony concert since starting residency. I've gone to visit my sister. I've made friends with some of my neighbors, who are awesome people (and closed my garage door for me last night, since I left it open by accident). I've kept up with friends nearby and seen 2 friends who moved cross-country for residency. I've read a few non-medical books and played a lot of Rock Band (II was my birthday present!) Thus far, I've kept up my blog, and my reading of multiple blogs (thank you, Google Reader!). We put up our tiny Christmas tree and some really puny Christmas lights, which somehow makes me really happy. My husband remains incredibly supportive through all of this and still spoils me rotten.

In residency, I've almost finished 6 months at several different hospitals, some inpatient, some outpatient. I've taken some call and learned a ton. I've learned a lot about teaching med students and giving on-the-spot feedback (although I'm definitely still a beginner). I found out I really liked internal medicine as a resident, which surprised me (I really didn't like it as a student). In fact, I liked IM so much, I have concerns about how much I'll like psych when I start in January. I'm studying for Step 3 and it's astonishing how much I've learned, how much I've forgotten, and just how much there is that I've never learned about.

Now obviously, I'm not a general surgery intern, or even a medicine intern. Psych internship is relatively cush compared to what many interns endure. I could imagine that other interns are way less happy. Overall, though, when I look at my current lot in life, I'm pretty satisfied, and look forward to where this is all going. So no, residency is not god-awful.

And now, Merry Christmas (or whatever holiday you celebrate)!

Public Persona

There is a post over at Shrink Rap this week regarding an article in the Psychiatric Times, written by a psychiatry resident. The article got posted to several weblogs, and suddenly the author's email address ended up posted in the comments section. Now, you have an article that was written for an audience of psychiatrists, therapists, and other health care professionals. I really doubt that the author intended for this article to get posted to the internet for all the world to read.

The problem is, now this article is out there. The article featured the author's name and school affiliation. While I'm sure she changed some identifying characteristics, there's still a potentially recognizable patient in this article. As someone pointed out to me, if this patient felt the urge to Google his former therapist's name (which is not uncommon--who hasn't Googled themselves? Um, I mean, not me) then he'd find this article very easily. Chances are, this patient may identify himself in this article, especially since the therapist's name is attached. It's unclear from the article whether the patient gave his permission to have his story used in this manner, but given the tone of the article it seems unlikely.

How is this better than an anonymous blog with patient identification removed and characteristics changed?

Yet, some residencies will allow, even encourage their residents to publish in magazines and journals like Psychiatric Times, yet have policies forbidding residents to write blogs or post to message boards. I feel that policies regarding internet writing should be more reasonable and take into account the level of anonymity of the blog. It's one thing to post publicly "I'm a resident at XX school and my name is YY and I worked 95 hours last week and I think this affected my patient outcomes"--which seems to be what residency programs are afraid of, and what lawyers may look for in litigation. It's entirely another to post anonymously, take careful precautions with patient identification, and be deliberately vague.

One argument I could foresee regarding the difference in regulation is that an article in a journal or industry magazine is published with the intent to educate, whereas a blog post may be more for entertainment. I disagree, however--I rely on multiple blogs to help with my every day medical education. I know much more about recent Medicare legislation, new medical studies, and interactions between drug companies and medicine because of reading blogs than I do from my standard education. I receive 3-4 journals a week at my house, and I quickly get overwhelmed trying to read them all. Reading small amounts of blog posts daily, however, is much more feasible, and usually feature links to the actual articles so I can read them for myself.

Publishing case studies is a long-honored tradition in medicine. New diseases and therapies come to attention through case studies--reports of one or a few patients with a given syndrome or receiving a specific treatment. I do not have a problem with the article in Psych Times; in fact I found it enlightening. I simply feel that blog writing should be given the same consideration, given the crossover between internet publication and traditional academic journal.

Let's Talk About Death

We were talking about code status last night, and how it's really terrible that families get forced to make decisions about life or death. I know it's not a cheerful Thanksgiving Day topic, but as usual it tied in to some patients I treated whose families made them "full code" at 90 years old with advanced dementia, diabetes, heart disease, emphysema, strokes, etc (and usually all of the above). It's too late at that point to ask the patient what they want, so we rely on the families to help us. Unfortunately, I think it's human nature for families to balk at this, or to balk at withdrawal of care discussions when the loved one got intubated and is now in a persistent vegetative state on the ventilator. Who wants to be the one who "killed" Grandma? Isn't that how we would feel, if we make the decision to pull the tube, or the patient is crashing and doctors ask "should we intubate, or let her go?" (Not in those words, but you get my drift).

How much simpler if patients told us in advance what they wanted?

Having already had this discussion last night, I was surprised to see the One Slide blog rally going on today, and decided to jump on the bandwagon. Go check out their website to learn more, and then have the discussion with someone. They call it "Engage With Grace". It's easy. We fear death so much in America that we forget that life has a 100% mortality rate. Death is not always the worst thing that could happen to us. Tell someone what you want done to you when you can no longer decide for yourself. And then listen to your family when they tell you the same thing. Then, it's no longer your decision--it's the patient's decision, which is where it belongs.

Grand Rounds

Today over at Dr. Deb's blog. Check it out!

Hot Topic

My husband has watched all the political debates, while I only watched a few (and honestly, got bored within 20 minutes and kind of zoned out). It's surprising, though, that neither of us had heard about this until now.

I'm going to try to be politically correct, but I will express my opinion here: I am pro-choice. I do not like abortion. I do not like that there are some women who have multiple abortions because they cannot be bothered with birth control.

But neither do I like that so many women are so incredibly ignorant of their options or about sex in general. And I really don't like the idea of criminalizing a procedure which can actually be performed to save a woman's life.

John McCain has an opinion on this, apparently. He said in the third presidential debate that "health for the mother" has been stretched to mean "almost anything" by the pro-abortion movement in this country.

Is this true?

I not only believe that there are situations when abortion is clinically advised, but I have witnessed situations where a surgical abortion had to be performed for the health of the mother. I am making no statement about how often this occurs, and it is totally possible that this gets exaggerated by some in the pro-choice crowd. McCain may not be totally wrong there.

However, to just write off "health of the mother" as simply a "pro-abortion" tactic is to deny that this procedure exists for a reason.

I watched a woman have to undergo a surgical abortion because she had anhydramnios and a fever at 19 weeks gestation. It was a baby she and her husband really wanted, and she was devastated. To protect her health, wait, to protect her life, she needed the procedure. She had chorioamnionitis and the pregnancy was no longer viable without amniotic fluid. At 16 weeks, there was no way to try to save the fetus (which was not yet deceased), and she could not wait 2 months to viability. A horrible situation with a horrible solution, unfortunately.

Of course, being truly "pro-choice" means that had she chosen to refuse the procedure, we would have had to respect her wishes, even if it meant potential death from sepsis and hemorrhage. Some women would make this choice, and though I don't agree with it I understand why they would make it.

Am I exaggerating this case? No. I didn't make it up for the sake of making a point. Is this a rare case? I certainly hope so--I only saw this one. There are other scenarios where the mother's health would be placed in jeopardy by becoming pregnant, of course; renal failure is one, heart failure another, diabetes, etc. These cases all must be judged on a one-by-one basis between the woman and her doctor (and her partner, ideally). To make a sweeping statement that "all of these cases require abortion" is (to me) as ridiculous as saying "none of these cases could ever require abortion."

Of course, the best way to prevent abortion is to prevent unwanted pregnancy, or to prevent pregnancy in a woman who is at such high risk from becoming pregnant. Still, even wanted, planned pregnancies can have a terrible outcome. To mandate across the board that "health of the mother" doesn't matter (as by leaving it out of the partial-birth abortion ban) is to mandate at a legal level the choice some women are forced to make. Even if this is an extremely rare condition (and I think it is, although I do not have stats on this), it seems to me grossly unfair to have a law which makes the decision that a woman whose health is jeopardized and whose life may be in danger must not terminate her pregnancy.

And if Senator McCain thinks so little of the "health of the mother" then I think I know what side he will ultimately choose to vote for.

No comments on this post, please.

Comment About Comments

I have rejected a few comments recently because they seemed like they were drug ads, or linked directly to drug company websites. Sorry if I rejected a legitimate comment, but I don't want ads (of any sort, drug or not) on this site, including in the comments.

Carry on.

Healthcare Is Not a Right

Forgive me for just posting a link, but Shadowfax at Movin' Meat has written an amazing blog post which essentially summarizes my thoughts on universal healthcare, only MUCH better written and with a LOT more thought put into it than I usually do. Go check it out.

Oh, and I'll spoil the conclusion he makes: healthcare isn't a right, as we define rights, but an entitlement, and one we should probably extend to all citizens. It's okay if you disagree with this, but it's still a damn fine essay.

Busy, Sorry

Inpatient rotation with q4 call = busy TS. Sorry for the lack of posts. It will probably be next week sometime before I can start posting with regularity (sounds like something you take Dulcolax for, doesn't it?) Anyhow, I'll be back soon!

Grand Rounds

Go check out this week's medical Grand Rounds at sixuntilme, a blog about all things diabetes from a sufferer of type I. She's organized the posts into a form of the Dewey Decimal system on the advice of an evil card catalog in her nightmare. Just because I find that hilarious does NOT make me a huge nerd. Really.

Shrink Rap Grand Rounds

I think everyone should go to Shrink Rap and read their amazing Grand Rounds right now. Or at least, go over there and look at their awesome rendition of the new iPhone 3G. They even put my icon on there!

My Grand Rounds post is here.

The image above is from the Apple website and is their property.

Blog Work

I've been reading a ton of medical blogs lately. It's one way of getting me ready for what's coming to me in 14 days (or 13 days, 5 hours, and 50 minutes, according to my handy counter on Facebook). I've added some blogs to the drop-down menu on the right, in addition to changing my template. I may keep it, I may not--who knows? Does anyone have an opinion as to whether the drop down menu is better, or should I just list out all my blogs down the page? These are tough questions here, people!

I have to reboot my computer now, which is why I only made a few small changes to the olde blog here. It seems that "Windows Explorer is not responding" and quit doing so at 7:50 PM (that's the time still showing on the laptop as of now--it's now after midnight). Fortunately, Firefox kept working, so I was able to indulge in medical blogs all night (tasty), but I couldn't maneuver between windows. This is a brand-new laptop, good brand, purchased towards the end of May, and already I think I've crashed Windows Vista 3 times. I'm averaging around 1 crash per week. I don't do anything very exciting--mostly play around on Firefox, use Outlook, or play Spider Solitaire. I'm not sure why this is just too much to handle for this new super-duper fancy OS. I've never really considered going Mac because they're just so friggin' expensive, not to mention I'm used to Windows, but with all the changes they put into Vista to make it look more like OS X I'm not as familiar with it as I was, and with all these crashes god forbid I try to do something important on this computer! (Otherwise, it's a lovely computer, very shiny; I just wish it had come with XP). GRRRR!

While I'm soliciting advice here, does anyone use a particular feed reader to read blogs? I've never used one before, because I always just click the links from my bookmarks or from my own blog. However, I think that if I contain them within a reader, it will make catching up easier from the hospital. I've put stuff into Google Reader, but is this a good one? Any tips for using it?

I really will try to post more. I realize I'm not a prolific blogger (just wordy when I do write), and I probably won't become one, but surely I can do better than this. At least until July 1, when all bets are off. GAH, I just got that cold feeling in my guts and my heart rate just accelerated like 40 bpm JUST THINKING ABOUT IT! It's a good thing I haven't had a real medical rotation since my AI in January on pedi, and I haven't done neuro since the January before that one, so I'll be just super prepared. It'll be great!

Merry Christmas!

We are having a truly white Christmas here on the Western slopes of the Rocky Mountains and San Juan Mountains in western Colorado. It has snowed 11 inches here at my mom's house and it is AWESOME! I have taken tons of pictures, but I don't have the connectors here for my new camera, so I'll have to post them when I get home. Suffice to say, it is totally gorgeous, and we are quite happy to see a white Christmas. I'm sure it's 80 degrees back home, and for right now I don't miss it.

Merry Christmas (or whatever holiday you celebrate)!

An Excellent Question

"TS - are you only interviewing at 5 schools? Do you think that's going to limit your match? ... is it worthwhile to interview at other schools as well, as "safe" backups? (or is that too undergrad application process-y?)"

Thanks for the question, Rach. I chose to answer it here because other people might have a similar question later. The short answer is that it varies widely from specialty to specialty and from person to person.

I am interviewing at 6 schools total. I applied to 10 and canceled/didn't schedule 4 interviews. I'm taking advantage of the fact that psychiatry is a non-competitive specialty. In psychiatry, 6 is kind of an intermediate number. I've had residents tell me they interviewed at only 3 schools, but I met an applicant yesterday who had scheduled 15+ interviews. Since I am "geographically limited", I limited the number of applications and interviews. Also, I need to go where my husband can get a job, so I'm only applying in one state.

I have friends entering psychiatry who wish to move to the East or West Coast, which would require many more applications and interviews (and often an away rotation to seal the deal). They may apply to around 20-30 programs.

I have a friend entering neurology (a low to intermediate-ly competitive specialty) who applied to 30+ programs because she wishes to escape the Gulf Coast and go to the East Coast. Another friend is applying to anesthesia and is applying wherever she can; she applied to 40-50 programs, ranging from state public to East Coast Ivy League.

If you are entering a very competitive specialty, you will be advised by most people to apply widely. When I was entering urology, the AUA said the average candidate applied to ~40 programs. Derm Guy applied to 75 derm programs. Also, many programs require a transitional or preliminary year in medicine or surgery, which often have to be applied to separately (Derm Guy applied to 10+ prelim programs).

So, why did I only apply to 6? I really need to go to a place where my husband can work. I will probably only rank 3 programs, which are all geographically equivalent for me. Yes, that leaves me the chance of going unmatched, but if that happens I will try to scramble for a prelim medicine spot in that area; if THAT doesn't happen, I'll try to get a research position or work at McDonald's for a year. In my situation, my first priority is to go there, and my next priority is to get into psychiatry. Other people's priorities are different.

In other words, I took 3 interviews that were "safe backups", if you will. If I chose to rank those programs, it would be as a backup to protect against going unmatched.

There is nothing wrong with applying widely and whittling down your list as the interviews roll in. Do keep in mind, however, that it will start costing you a great deal of money. My 10 programs cost me $110 for the application ($60 for the programs and $50 to release my USMLE transcript). From the ERAS website:

ERAS processing fees are based on the number of programs to which you apply. ERAS fees are: $60 initial application fee (includes up to 10 programs); $8 each for 11-20 programs; $15 each for 21-30 programs; and $25 each for program(s) over 30.

In other words, applying to 20 programs costs $140, 30 programs costs $290, and 75 programs costs $1415 (I think I did that right). Every interview may require all of the following: flight, hotel, rental car, parking, suit dry cleaning, etc. Some derm applicants can spend around $10,000 applying and interviewing; this cost is NOT included in your student loans for fourth year. Fortunately, you get a break when you rank programs (NRMP website):

There is no charge to programs or applicants for entering their rank order lists for the specialty matches. The registration fee covers registration, submission of rank order lists, and access to Match Results.

The NRMP registration fee is $40 so long as you get it paid on time; late is a $50 fee plus $40 to register. There is no extra fee for ranking a zillion programs (but you can only rank those you have applied with).

So, risks of not applying widely enough: going unmatched, or missing out on a great program you never knew about. Risks of applying too widely: $$$$$$$, interview burnout, time away from electives, family, friends, etc.

After this novella of an answer, it still comes down to this: it varies widely from specialty to specialty and from person to person. Hope this helps.

While I'm Not Studying

In case you read her blog and missed it, Michelle over at the underwear drawer was offered a book deal. I am so excited for her!!!! Her blog was the first I ever read. If you don't read her blog, you should. She's also responsible for the 12 Types of Med Students, the 12 Medical Specialty Stereotypes, and several other cute comics over at Scutmonkey. I will definitely be buying her book when it comes out--and so should you!

Comment Moderation

I turned on comment moderation a while ago, after the prairie dog incident. Since turning it on, I think I've deleted 3 comments--two related to the prairie dog thing, and one that was racially vitriolic. This is my blog, and I reserve the right to delete comments, but I prefer to do it only when the comment is particularly vicious, especially when the commenter feels the need to hide behind the "Anonymous" title.

So why did I just allow this comment, on an old post, to be posted? So I could make fun of it.

"If this ding bat that is typing this blog wants to go into psychiatry she has better get used to seeing the same TEN DSM IV’s and I hope she does not wet her pants when she has to consult with a psycologist."

This is priceless entertainment; many thanks to Anonymous. I have copied it in, errors and all. Let's examine this, shall we?

"ding bat that is typing this blog"--how dumb IS a ding bat, actually? Can bats type? If ding bats are ordinarily stupid, and I'm smart enough to learn how to type, then I must actually be ahead of the pack.

"she has better get used"--I'm sure it's a typo, but it still gives this comment that whole "Your base are belong to us" feel which makes it even funnier.

"seeing the same TEN DSM IV's"--As in, I'll see the same TEN books of the DSM IV? Or the same TEN DSM IV diagnoses (which is probably what Anon meant)? I'm sure there is an element of repetition to psychiatry, just as there is with family practice (which is what the post was about), but I personally prefer the repetition of psych to FP. It doesn't offend me if you want to deal with hypertension, diabetes, and dyslipidemia forever, but I choose not to do so, as I find it stifling.

"and I hope she does not wet her pants when she has to consult with a psycologist."--This is my favorite part, not least of which is due to the misspelling of "psychologist", especially as this person appears to be defending the psychologist. Have I ever disparaged psychologists on this blog? If I have, I apologize, and I will correct that post with an apology. I have a bachelor's degree in psychology, and I recognize that practicing psychologists have to have at least a master's degree, if not a PhD. They have a graduate-level education, and then do an internship, before they go into practice. Their training is not so different from mine, then, at least in length. They may be better at things like neuropsychiatric testing, psychotherapy, etc., but I will (hopefully) be better trained in psychopharmacology, neurology, and somatic medicine. I see nothing wrong with MD's and PhD's working together for the benefit of their patients. If I've ever said otherwise, you have my most sincere apologies.

But other than that, why bring this up? If you're poking fun at the potential repetitiveness of psychiatry (compared to FP, like the post), why bring up the idea of me being offended at consulting with a "psycologist?" Where did that come from? This is a brilliant example of a loose association--the first idea has nothing to do with the second. Perhaps our friend Anonymous was trying to demonstrate a formal thought disorder for us, in which case I should thank him or her.

So, I left this comment up. I'm not sure why a post written in February has suddenly drawn such ire, but that's the way it is. I dislike deleting comments, and I will do so with care, but I will continue to do so, if I find them offensive. I might, however, mock them before I delete them. To all the anonymous commenters out there, trolling away, you've been forewarned.

Shout Out to All the First Year Med Students

Inspired by comments to this post at TruMed, I felt the need to drag out some advice to any first year med students who might need a little reassurance right about now:

Take some time out and BREATHE, now. Stat.

Hear me out: What you do in your first two years of medical school will not necessarily determine the rest of your life. Your job is to survive, and pass your exams. That's it.

But, TS, the speaker at the surgery interest group said I should make the best grades possible in order to be a surgeon! And my buddy is a super ultra gunner who told me that we'll never get into residency with any high pass grades! Help!

Seriously, breathe, and think logically.

1) If you are a med student in the US who plans to practice in the US, you are automatically ahead of the thousands of people who graduated from programs outside the US who are applying here. I'm not saying FMG's are stupid, or poorly educated, but the reality is that most US programs will accept a US grad over an FMG who is similarly qualified. Therefore, you already have an advantage.

2) If you are able to achieve passing grades in your classes, you are ahead of those people who don't. This sounds lame, but there are always people who fail classes for various reasons. Guess what? There are residency spots available for people who failed first year biochemistry, or for people who needed extra time for basic sciences.

3) The majority of med students have "average" grades. It's a simple bell curve, right? So the majority of the class falls somewhere in the middle. If there were no residency spots for people with average grades, then med school classes would be a hell of a lot smaller. In other words, most of your attendings made "average" grades, and now they're attendings. Conversely, the majority of your attendings did not make AOA, and they're still attendings.

4) Check out this article at Student Doctor Network. Residency directors care FAR more about your clinical rotation grades than about basic science grades (or USMLE scores). It's more important to show them you can think and act like a doctor than like a college student. This even applied to residency directors in ophthalmology, a highly competitive specialty.

5) Whether you know exactly what specialty you'd like to pursue, or have no idea, don't worry about it. Many people change their minds, even if they were sure at the beginning. So long as you are passing your basic science courses, you have a shot at most specialties.

6) There are ways to bolster a CV, even if your grades aren't as high as you'd like them. Want to do dermatology, but can't quite honor gross anatomy? Think about doing some research in the department. Kick ass on the Step 1. Can't handle standardized tests? Rock your clinical rotations. Do some volunteer work. It's not all about the grades, after all.

7) Lastly, whether you are a super ultra gunner type, and insist on making honors in everything, or a "P=MD" type, you should also insist on having a life. Sure, you're studying a LOT, and your apartment is filthy for a month before exams, but that doesn't mean you shouldn't take some time for yourself somewhere. Work out, or go out with your friends, or spend time with your significant other--whatever it is, take some time for yourself outside of medical school.

Remember, those two years will eventually be over, just like mine were (and I really didn't think they'd ever end), and you can get on with the rest of your life.

Thank goodness I'm not a first year anymore!