Dec 3, 2013

And now the month of Christmas can begin...

It's been quite the fight this year, and I've really had to dig in my grinchy heels because the hospital put up all their lights and decorations up a week before Thanksgiving this year; they go all out, and it really does look lovely, so when I left after dark (which, thanks to winter, is usually), was just like "nope.  Not appreciating it.  Nope, grinch!"

But then our wonderful clinical pathology coordinator took in my boyfriend and I for Thanksgiving, complete with 20 lb suspiciously moist turkey and traditional stuffings, and with the final death of Thanksgiving, I can look around and go "ahhh" and start enjoying the holidays rather than feeling assaulted by them.

The news... after nearly two wonderful years with the roommate that took me in after the fire, I took the big step with the boyfriend and am now the proud decorator and resident of a three bedroom apartment that is both closer to work *and* closer to the beach.

Ah milestones.  This is the first place that's really been mine to mess with.  My apartment in Grenada was solidly mine too, but it was pre-furnished and all that could be added to it was the 50 lbs of luggage I reserved for books and toothpaste, but this is *mine*.  I won Battle: Christmas Tree and am the proud owner of a real one, since spending an hour cursing into the pine needles shoved in your face while your arms get continually scratched up and pitch-covered as you attempt to wedge a tree trunk into the ill proportioned metal grasp of a stand whose designed hasn't changed since the pagan era just makes you appreciate the magic more when the bastard finally stands up on its own.

The boyfriend's never been one for Christmas, thus spent a great deal of this time swearing that the tree stand wasn't made for a trunk like this one and so naturally I'm like "Oh, silly boy.  No tree stand is made for a tree.  The notion is preposterous."

Of course since I owned nothing of substance for obvious reasons, and he was the spartan type, this meant that most of my post Thanksgiving holiday shopping (sans the morning of Black Friday because I have pride, dammit!) was done for me and largely spent trolling craigslist for bar stools (mission: accomplished).

This reminds me of another important point about medicine.  Milestones.  First real apartment and hosting of Christmas?  Yeah, I'm 33 years old.  Despite being beacons of the community (if you live in a small town in 1955), doctors tend to lag behind in our maturity and lifestyle because we live in a state of being perpetual students that really lasts through a great deal of residency with both the lifestyle that entails (hello roommates!) and the mindset "I can't be a dad.  I have a test to study for."  So that's fun.

Other news, I was improbably elected onto a cytopathology committee, which means January-February are going to be busy travel months for me since I'm getting sent to a meeting in San Diego (rough life) and then am burning the rest of my vacation days until July (since I'm on surgical pathology from March through the end of July and can't take time off) by going to Nicaragua!  It's been two years since I left the country so I've been feeling itchy, and going with nine people (see above) means a pretty damn cheap dream vacation.

Other other news.  I'm officially the bad patient.  Since I seem to officially be old despite my maturity level stating otherwise, my blood pressure has me grounded to ACE inhibitors until my doctor stops being angry at my deep levels of self-neglect.  Exercise and healthy eating shall commence until my pons and/or kidneys stop being in danger of imminent explosion.

The bad reading has happened a couple of times, though this is the first time medication has been attempted, but I always know it's going to be bad news when the nurse starts taking the pressure, frowns at the cuff, and then pumps it back past the diastolic again, and then looks down at me accusingly or asks if I'm stressed.  Since I'm newly employed through 2016, have a new house, and finally transitioned to a more relaxed rotation, I'm kind of like "mwa shrug?" which is what a vocal meh sounds like.

So that's obnoxious.  But hey, I need to be bathing suit ready in less than two months, so also working toward not having a catastrophic stroke ten or twenty years in the future can't hurt, right?

Nov 21, 2013

Fellowship Achieved!!!!

Huzzahs and the like.

It's strange; a fellowship is a one year commitment where you're not paid much more than a resident, and gives you no guarantee of a full-time position, and yet the overwhelming relief of being able to somewhat relax and focus on my studies and my patients since I now have employment through mid-2016 is pretty great.  I still want to build up my CV and go to conferences,  but now I'm not scrabbling to get publications in during a surgical pathology month because applications are due.

I'm really happy with where I'm going, and I'm really happy with the responses to my applications.

Essentially, I had a fairly solid bet of a cytopathology fellowship at my home program, which is groovy and kept the application process from being as stressful as it could have been (or as expensive, since it meant I only applied to programs that I thought could be a step up from mine rather than "any job"), and my attending pulled me aside to tell me that I was safe, but that I should fly out of the nest if possible to get different training.

But I didn't apply to enough medical schools, particularly for my stats, which weren't bad, but not good enough to put all my money on the California schools, which I did.  I went to SGU, as you know, which is a decision that may be pretty darn expensive, but I don't regret.

I did learn my lesson for residency.  Despite going through the hellishly expensive ERAS program, I applied to 51 programs, got mid 20s interview invites, went on 16 interviews (gah), and ranked 14.

Fellowship, I hedged more, despite it not yet being an ERAS process for most pathology fellowships (thank the gods), and applied to six, two of which I didn't expect a response from, and the four that I was hoping for all offered an interview, and the three where I went (including home), expressed a strong interest in me.

It was hearsay until now, but I do feel like the Caribbean stigma decreases with each stage of training.  Though make sure all your stuff is in order because your biggest skill will need to be your unofficial degree in red-tapeology.  I had a couple of days of sweating for the program where I'm going because some of my rotations weren't greenbook according to this particular state.  For those of you heading for your fourth year clinical rotations, that means doing your rotation in a program that has a residency program *with that residency*.  In other words, orthopedic surgery needs to have ortho residents, not surgery residents.  Most states either don't care at all or allow umbrella coverage (ortho and anesthesia could be covered by a program having a surgery residency) and you should know what those states are, how many weeks are required, and what extra requirements you need.  And if you say "I'll never live in that state", you'd be surprised.

So it's going well.  Also, start all paperwork processes early.  Way earlier than you think you need them.  You need weird extra paperwork or your home state takes 8 weeks to send a birth certificate?  Apply near the deadline, and that's sweat and tears.  Apply 18 months early, and it's vaguely annoying.

Medical school feels farther away.  I'm not sure what Grenada is up to lately, or how much the resources around the school have been built up.  I remember all the residents' and attendings' names from third and fourth year and remember smiling and chatting with the in the hall five months after my rotation, and only am aware now that those residents largely had no recollection of me at all, saw the short white coat, and had the same "how are applications going for you?" conversation that is always a safe bet, because that's exactly what I do now when they wave and smile at me in the hall.  They rotate for two weeks, maybe a month, two or three at a time.  I get that difficult "Oh... um... tomorrow I have a lecture/interview/blood draw/drug test/dean meeting?" question that I remember finding so hard to ask because I was afraid my residents would think I wasn't interested in the rotation and realize now that oh my god, we don't care at all.

I still try to teach them, advise them, show them what I'm doing geared to their specialty, and not scut them too much, but I'd be lying if I said that I didn't call them "short coat" or "medical student" when I'm addressing them if their name tags aren't showing.  We tend to reference them by appearance "hey, did you have giant medical student?  He was amazingly helpful."  Or "Did you have Harry Potter med student?  He wouldn't stop checking his Pinterest app for the entire sign out".  Then I wonder if I had a designation as a medical student, or if I'm the jerk resident that every medical student hates.

I briefly contemplated tutoring the MCAT when specifically asked to, because hey, free money, and upon a rudimentary glance at the study materials, realized there is absolutely no way.  Friction on a bike tire?  Seriously?

Cytopathology is going well, despite constantly having to ditch out on my chosen specialty to fly to interviews, since I thought invites would come *way* later than they actually did.  My attending has been very understanding about it, fortunately.  I managed to complete a successful FNA without bungling it or upsetting the patient.  I'm upping my reading now.

So it's good.  Things are good.  Life is pretty good.

Oct 24, 2013

Adventures in Cytopathology

Me (to clinician): "We have adequacy.  I've got abundant follicular epithelium, macrophages, and colloid."
Patient: "And in English, that means..."

Me (in other room): "Yes, as you suspected, this is consistent with metastatic disease from her earlier lesion."
Rads tech (from other room): "Ma'am, you're hypertensive?"
Patient (cheerfully): Yup!  But on a list of two things, that's not going to be the one that kills me.

Clinician: "Whadda you see?  What do you see??"
Me: "The technician staining my slide."

Clinician (leaning on his elbows on the counter next to me about six inches from my face): "Now, don't let me make you nervous."

Clinician: "Well?  Do we have enough?"
Me:  "We have adequacy."
Clinician: "Is it cancer?"
Me:  "It's suspicious.  I haven't seen enough of the groups my attending saw to tip the scales."
Clinician: "Can you tell me what it is?"
Me: "It's suspicious."
Clinician: "If you tell me that it's cancer, we can stop the procedure.  Otherwise we're going to have to go in and get a biopsy."
Me (sweating): "I can't call it cancer at this point."
Clinician: "Well, what would your attending think?"
Me: "Sir, if I knew what my attending thought, I'd be an attending."

Aug 21, 2013

Wait, what, already?

Fellowships?  Seriously?  Already?

If I haven't mentioned it before, pathologists are pretty much required to do a fellowship to get a real job in reality land and start paying off those monster loans.

I'm sure I've mentioned *that*.  What I should have mentioned, and been thinking of, is that you have to start applying for fellowships like... uh... now.  Yes, 18 months prior.  And I'm already out one fellowship because you have to start cranking out the paperwork even earlier than that (A program that rhymes with Who Be Ann Sancisco).  So now I'm in the eternal dilemma of whether I stay nestled in the safe bosom of a program that already has done well by me and where I know I like the cytopathology person, or whether I fly out, try to get an in back in my home state, or at least my home coast, and rack up some new experiences.

The fortunate thing is that fellowship applications don't cost money until you book a flight.  This contrasts to residency applications through our match monopoly which cost me 1800 dollars before I left my apartment.  The unfortunate thing is pathology fellowships are far less vetted, since there aren't all that many of us, so I'm throwing my applications into the abyss and hoping they want to grow me into a decent community pathologist, rather than using me for scutwork or ignoring me entirely.

Then the job hunt after that.  Then maybe, I can settle into being an adult with a job and a house and a place that's home rather than living the life of a perpetual student.  Not that I can really complain much other than the six figure debt leavings.

Scary though.  The last two years have flown by, and I by no means feel ready for the next step.  I'm just happy I don't cry during readouts anymore.

I'm at a weird stage though.  I don't feel ready to be independent but I feel far removed from it.  I was attempting to remember who wrote a poem quoted by my attending from a "college English class" and realized I was in college ten years ago.  The antics of the medical students seem immature and their questions weird, despite the fact that I needed to be shuttled home from a bowling alley as recently as two hours ago.  Yet I feel comfortable giving attendings from other specialties update reports.

I'm removed from a lot though.  No one really knows much outside of their own very limited experience so it's hard to know where to go for advice.  Within the hospital, you get "The job market is fine in this academic setting where I've been working".  The other residents are "I have a fellowship in 'x' secured and that's where I'm going, but I'm not an IMG or from California".  People at my level are in the same boat.  The advice on the internet is "JUMP SHIP!! PATHOLOGY IS DOOMED!!  OBAMACARE WILL HAVE US IN POVERTY!  DO ANOTHER SPECIALTY", which is disheartening, but unhelpful.

So I feel a little trepidation.  On the other hand, I think I have a good chance at securing a fellowship if I merely stay put (something not an option in medical school), good friends, a great boyfriend, and hey, kayaks.  So we'll see what happens.

Aug 12, 2013

Recreational activities, dead people, and blood

No, not *those* kind of recreational activities.

This year in Charleston has been... let's say meterologically bipolar, so my celebration of "summer is here!!" after finishing surgical pathology in June was met by about a month of solid rain.  This isn't really notable since it's pretty much been raining since February, but then I wanted to *do* stuff.

This led to my roommate, boyfriend, and I finally saying f- it and sailing in the middle of a storm.  It went shockingly well.  Even saw some dolphins.

At a certain point, I think the endless weather got to my roommate as well.  She's a persuasive sort too, so in the last month I've encountered "Let's join a bowling league" (note: I have scored a Zero while bowling, granted, while very very drunk.  I have also bowled a 50 while completely sober) and "Let's buy kayaks!!!" (my kayaking experience consists of about four trips out in sit-on-tops and the ownership of an inflatable diveyak whose sole purpose was carting gear).  Since I'm a follower, I'm now in a bowling league and own a kayak.  Since my boyfriend is apparently even more suggestible than I am, he now owns an SUV.

Yeah, it's a good thing this girl isn't into drugs or something.

Yesterday was the maiden voyage of the kayaks out of Wappoo Cut, which went shockingly well for me.  Saw egrets and jumping fish and the boaters were nice to us.

And the bowling league is going well.  But that's all fun stuff.  I've been continuing my lengthy training for the bridge run (while injuring my calf and being grounded to swimming a week), and periodically attempt to surf over at Folly Beach.  I've also been catching up Breaking Bad (god I hate Walter) and the Walking Dead (god I hate Andrea).  There's a reunion trip to NYC in a couple weeks to catch up with the medical school crowd and all is well.

So the work stuff.  Staffing continues to be an issue, but now that I'm off surgical pathology, it isn't really my problem until next month.

July, I was on autopsy with one of my best friends, who also wants to go into forensics.  Despite having one of the most death-spectacular months on record, I'd think, I can't call it anything but insanely fun given the dynamic.  Which, I know sounds weird.  The combination of our working well together and our general experience now that she has three months of autopsy and I have four absolutely thrilled the attendings, and they know they hooked her before she started, so now they've started working on me.

A forensic pathologist that thinks she can sway you into the field is a bit like a Baptist who thinks you have an interest in Jesus.  They are *relentless*.  Highlights were "You're gonna push glass!  You're gonna be miserable!!"  And I'm like "No!  I want to go into cytopathology!  I want to be a general pathologist!  You're not my real mom!"

But still fun.  There's also a thing that goes down in autopsy where you get really sick of having dead people with no relevant findings so you have no good answer as to why they're dead, and this happens more than you'd think.  Usually toxicology clears it up (sorry CSI fans, but that takes 3-6 weeks), but it's less satisfying.  So when your gross examination reveals a smoking gun of a cause of death (ruptured berry aneurysm, saddle embolus, aortic dissection), you get really excited about it, but you can't express that if the surgeon happens to be in the suite with you, which happens occasionally.  So you have to wait for him to leave, which usually provokes a dance.

Yeah... it is neat.  I'd be more tempted, but as you can probably glean from my previous fire experiences, I *hate* court, and that's part of the job.  I will do virtually anything before I spend an hour in court.  The entire process just makes me rage like the Hulk.  I'm wondering if I can use it to get out of jury duty.  "Hi, yeah.  I have no opinion on this case, but I'd just like to say, judge, that I hate you, I hate both lawyers, and I hate everyone in this courtroom.  Can I go?"

Now it's hemeland, with it's chaotic leukemianess.  And we've had a ton of people rotating through so seating is always an issue, but so it goes. That used to be my chosen specialty before I got led away from the fold by cytopathology.

That's the update for now.  Next month will be back to surgical pathology.  Next few weeks, we'll see if the heme team slows it up a bit.  Oh, and fellowship applications need to be consolidated around September 1st.  Eek!

Jul 2, 2013

Time flies when you have no time

So, as of yesterday morning, I'm a third year resident.  If I were a family medicine or IM resident or many varieties of emergency medicine resident, that would make this my last year.

Pathology residency, as I've explained, is four years, plus a relatively mandatory fellowship, but it means I'm in the last half.  There's an end on the horizon.  I get the little pay bump every year.  I'm now in senior ville.  I have a new office downstairs, that I share with two of my closest friends.  I start to feel a little more like a grown up.

It's been a little hit and miss lately.  I tackled my first month back in surgical pathology at the main hospital in over a year with quite a bit of trepidation.  For those taking note, any month of surgical pathology tends to have me tearful and bipolar by the end of that month, and coupling that with the hardest of the surgical pathology months, and being rusty, seemed like evidence for disaster.

I handled it.  We've been having an endless supply of administrative and staffing issues lately, which culminated at the end of last month.  Three weeks in, I have to say, I was grimly doing well.  Usually I go in with a "this time things will be different!!" attitude and melt down around day 9.  This time I held a really good pace until things exploded at the end, and even then, I got my cases done, researched them well, and only had one day where I was like "Seriously, no one f-ing talk to me.  I can get my work done today and I can do it well, but I cannot do that while being a nice human being, so you can pick one and then get out of my face".

One of my attendings, and I love him, is the warm fuzzy type, kids of his own, grandkids, but he's a "Smile" guy.

I can be smiley.  Which is surprising, I know.  I'm generally absolutely silly, and my conduct around is largely like my conduct online in that I make a ton of sarcastic jokes and say things that border on inappropriate and periodically dance around when a song I like comes on.  When I'm happy, I smile.

I'm also an only child.  If I'm not happy, I don't smile.  If I want to be alone, I don't smile.  I go to my room to cool off and deal with it myself.  Telling me to smile when I'm already irritable and pissed off is going to go poorly.  I can pretty much manage "dead face" when I'm that angry and irritated, and it's my way of telling you to please be elsewhere unless you have immediate business with me that needs handling.  If I were a rattlesnake, this is when you'd hear the rattle.

But otherwise, ever since I got my schedule at the beginning of last year, I thought "June is going to suck.  You know what you're going to be doing in June?  Nothing, that's what." so with that acceptance, the days I made it home by 8 PM or the weekends I was able to attend old roommate's wedding or awesome attending's wedding were good days.  And the weather has obliged my awful on call then surg path schedule by raining since February.

And now it's my summer.  And I'm a senior.  And tomorrow I fly out to somewhere in Texas that incidentally has rattlesnakes so I can spend the 4th of July with my mom.  And there's that.

I'm also dealing with the "grown up resident" stuff now.  I'm beginning to compile a list of fellowship institutions to which I plan to apply.  I'm working on multiple projects and papers.

Oh, speaking of the latter, I got another CAP abstract accepted so I get a free trip to Orlando and networking opportunities in October, so that's pretty groovy.  And speaking of *not* being mature, in September I get to go up to Ashville for something called "Brewgrass" which involves microbreweries and all day bluegrass music at a time of year that's gorgeous.  So things are going up.  Boyfriend and I are still holding strong, despite my periodically being a terrible person.

So July is an autopsy month, home again of cool stuff that I can't tell you.  I can say I'm now 8 autopsies away from our mandatory 50 though.  This is required for licensing.  And since I'm on my fourth month down there *and* on with one of my favorite people, it's honestly just fun, which probably sounds callous and mean, but there it is.  I like the staff, they're not having the issues we're dealing with upstairs, things are pretty relaxed and I know the score of how it runs so I feel confident *and* competent, a rare combo.  I'm used to the attendings down there enough to know when to joke with them, even if they're micromanaging my heart dissection.

That's the update.  I still advise here and there on going to the Caribbean, though my knowledge feels somewhat more dated, but keep in mind, people going through it, you come out on the other side, and then you deal with all residency stuff.  It's hard to picture doing anything else.

May 21, 2013

I'm gonna go ahead and ask you to not put that over my face

Ah Micro.

The return to the very origins of my interest in medicine.  Outbreak, with Dustin Hoffman... a little sprinkling of Hot Zone.  And overly ambitious 12 year old.

And I've arrived.  I'm currently doing exactly what I wanted to do when I was 12 with the exception of chasing monkey around.

Mornings are on the bench.  Today was the urine bench, it was not as awful as you'd think.
Sometimes genital-rectal.  Sometimes wound exudates.  Sometimes respiratory.  They teach, I learn.

Then rounds.  Rounds consists of wandering around without a real idea of what's going on, poking you head in to see what's interesting.  Then you start the smell game. "Hey, smell this plate!"  "No.. I don't wan... yeah, it does smell like rancid juicy fruit.  Am I about to die?  I feel like I shouldn't be holding this near my face."

I'm not OCD.  I feel like I'm going to become OCD.

I've learned about the devious nature of these creatures.  They're oxidase positive until they aren't.  They behave differently.  But clean.  Where ever you are, clean.  They're under your nails  On the faucet handle.  You have to watch them.

In between this, the calls.  My attending is gone until Thursday so all the spooky day calls fall on me.  Can we get more extensive cultures?  Can we get susceptibilities?  Things I can initiate, but haltingly so.

This is on top of about 6 working days of micro.  Sherry, Justin, the Wrestler, and I hit Mexico Beach and had a horrendously good time.  I mean...

 I mean seriously, add 200$ in hooch to that and you're here

It was amazing.  Tons of us, everyone happy and having a good time, and utterly relaxing.  Now to this weekend in Vegas where we do the exact opposite of that.  Woot!

Apr 9, 2013

Beat them again!!!

I'm on Clinical Pathology call this week.  This is the one that can drag you in on the weekends, but usually doesn't require coming in on weeknights, but rather answering complicated questions at 2 in the morning.  I'd say I'm getting a much better hang of it, but that will ensure I have a terrible shrill screaming pager night, so I'll say nothing of the sort.

I've had one call so far tonight and the day the attendings of my hospital collectively get together and realize that when they get paged by a Dr. (Generic Half of Last Name) to a cell phone number (I got tired of hanging around the hospital phone like a jilted date), they're getting duped by an aggravated resident will be a much rougher one for me.  Apparently the lab had been paging this guy since the mid afternoon with no answer despite increasingly urgent messages, which put me on the case.  I used my "get surgeons to call me" trick and my phone lit up within three minutes.  Mwa ha ha ha ha.

If you are speaking with a patient or actively cutting things inside them, I am absolutely happy understanding a wait.  But ignoring the lab all day because you deem their results unimportant?  Considering that the last time I had a full call week, I stripped down during an autopsy *five times* because my pager was going off, I'm not hearing it.  When I do get nailed at 3 AM, I jolt out of bed, take long enough to flip my computer open and find a good reception spot, and call back.  Because chances are the person calling me doesn't really want to wait up for me to call back at 3 AM either.

Things to know about call... hmm...

1.  If you're at a hospital that uses a pager system, there *will* be one specific pager alarm that is awful, shrill, and will wake up anyone, which is why you will use it when you're on call, opposed to your normal "chirp and vibrate" for your waking workday.  After a couple of times on call, you will have a visceral awful reaction anytime you hear it.  If you're in a conference room and that alarm goes off, *everyone* will reflexively twitch, shudder, and snap for you to change it.  If you have a significant other, that individual will similarly be negatively conditioned.

2.  Pagers hate showers.  You can have three hours of absolutely nothing and the minute you get shampoo in your hair, ring!!!

3.  Pagers like reckless driving.  Fast moving but heavy traffic between freeway exits is prime pager territory.

4.  Pagers LOVE the hour before you were due to get up.  This way they can ensure you are short slept while depriving you of any opportunity to go to sleep *or* the potential to try to sleep in since "you're already up".

5.  Pages love company.  If you get ten pages on a Saturday, they will absolutely all be within a half hour of each other, and the sudden flux will make you so paranoid, you won't leave your desk for the rest of what will no doubt be a dead silent rest of your day.

6.  Pagers give off psychic energy.  If they cannot psychically compel other people to call and wake you up, they will merely falsely broadcast dreams of them going off.  If you don't wake up in a suitable panic, they will up the ante by broadcasting dreams of missing critical pages.

7.  Pagers loathe patients.  Pagers enjoy afflicting patients with whatever ailment will require the most satellite resources at times when those resources cannot possibly be mobilized, requiring stop-gap measures.  Pager favorites are HLA matched platelets on Fridays after the Red Cross has closed and organ donations.  I can help, but I can't fix until three different labs in two different cities have opened for business at 9 AM on Monday morning.  The pagers of surgeons, I'm told, enjoy introducing simultaneous critical patients that require the same specialist.

8.  Pagers are offended by blog posts condemning them.  Mine just went off.

These should help guide you all in your own experiences.

Apr 7, 2013

Never let your guard down

Not in any kind of dire horrible way, don't get me wrong.  I'll explain.

I feel like medicine is full of the general sensation of feeling like you're done, but you really aren't.  Got into medical school?  Whew!  Smooth sailing!  Nope.  Class rank.  Step 1.  Step 2.  Surgery hours.  Trying to scrape in a publication, schmooze with residents, schmooze with attendings, pick a discipline, hope you get a residency in it.  And then, you're a resident!  Wahoo!!!  It's all paid off!  Well, hold on a minute there sunshine.  Do you want to be chief resident? (No)  Do you want to do a competitive fellowship?  Is your field a little difficult on hiring?

You're not done taking tests.  You're not done studying.  You're not done with having projects hanging over you.  These aren't necessarily bad things; you have to stay on top of material just to be a good doctor, but that feeling I had in medical school that any time I was recreating I felt guilty still exists.

So the current sequence of events.  Pathology has a notoriously difficult job market that really requires a fellowship.  You begin applying for fellowships at the beginning of your third year, which seems really far away when you're just starting and now you're like "What do you mean I have to decide what kind of pathologist I wanna be???  I just decided on "pathologist" not that long ago!"

A friend of mine wants forensics, which requires an even greater jump ahead.  Fortunately, all forensics people seem to be born knowing they're forensics people.  So friend is freaking out because she needs to get in her fellowship applications like.. now.  Naturally, as is the way of medicine, this triggers an avalanche of freakouts in her colleagues.

Now, when you're in surgical pathology, you're in surgical pathology.  Nothing much else is expected of you other than reining in the urge to kill surgeons if they stand behind you and make snarky comments.

So I got out of surgical pathology... into lighter rotations *and*, just by coincidence, a slew of extremely unfortunate weirdly presenting publishable patients.  So I went from having one publication since starting residency, to having a bunch waiting in line for me to try to make heads or tails of them.

In the middle of this, I had been somewhat poorly scheduled for a Journal Club (thirty minute talk), a GME (thirty minute talk), a "Big Meeting presentation" (20 minute talk) and a CP talk (five minute talk).  Over the course of three weeks, which also included the RISE exam, which is a way to determine whether you're going to fail boards in two years.

Since this wasn't enough busywork and stress for my procrastination addicted brain, I realized the new deadline for submission of the CAP meeting was in the middle of all that, and I had a doozy of a weird microbiology case, so... I added that workload onto myself.

I also got last minute selected as a delegate, which is actually pretty groovy, am turning in an application for a committee membership in cytopathology, and speaking of cytopathology, finally put on my big girl pants, approached the cytopathologist and begged for case series.  So... yeah.

You spend your first year trying to stay afloat and most of your second year finally feeling good about "getting it" and then realize that it's time to boost your CV like NOW.

Speaking of cytopathology, it's still battling hematopathology in my heart, but I think I'm falling into the cyto camp.  This also looks like it's going to have me scrounging for jobs in (gulp) Houston, since that's where a few of the good programs are.

So the last three weeks have been me hammering away at various projects and forgoing exercise and other necessities.

Oh!  Adding to the fun was that at the beginning of this venture, two things happened: One, I decided to undergo a minor elective procedure which generally has no complications, and two, I had a weekend catch up trip to NYC planned, all of which I had scheduled my crushing paperwork around.

Much to my surprise, said minor procedure led to a week of crippling horrifying, attending-pissing-off pain and the discovery (via emergency room) that all my pelvic organs are in the wrong place and I have an extra bone in my spine.  While discovering I'm an awful patient (though really tolerant of any blood draw procedures), once I was past the "AHHHHH" stage of the week, the various workups punched straight through concern and into fascination.  I creeped my parents out by thinking they'd think it was cool to have a spinning 3D image of my renal vasculature and sending it to them on my iPhone.  I mean, they're my jacked up kidneys; if anyone's freaked out by what is obviously INSANELY cool science, it should be me.

Oh yes, on the attending pissing off... She and I are cool now, but my first week with a new attending was spent not paying attention, unable to focus on work, and periodically passing out while she was actively talking to me.  In my 4 am ED email stating I would be missing yet *more* work, I promised her a complete explanation, but I think she put the pieces together and greeted me with "I don't need to know your business", so we're cool now.  And I got more out of the rotation that I probably would have initially because I spent the last 3 weeks overcompensating like a mofo.

What else.  I ran a 5K that benefits children's hospitals and primarily gets attention by the additional feature that the people organizing it throw colored corn starch at you while you're running and occasionally hit you with super soakers full of paint, which does make it difficult to run.  Fortunately, despite being a 5K, absolutely none of it was timed, and instead of a clock, the finish line consists of people holding out more chalk bags so you can hurl them at people.  It was groovy.  I really underestimated how awesome South Carolina could be when I was considering moving here.

Speaking of things Charlestonian, we just had the Cooper Bridge run (which spawned the "Ridiculously photogenic guy" meme last year).  Since I am way too painfully out of shape currently to run a 10K up that ridiculously angled bridge, a bunch of us instead got dressed up in clothes somewhere between old Charleston and the Kentucky Derby and went bar hopping.  I finally got a ridiculously floppy hat and a mullet sundress, so I feel proper.

So that's the update.  I'm also on CP call starting tomorrow, which I'm cautiously optimistic about and will likely have an apocalyptic breakdown somewhere around Wednesday after I get called about amylase at 4 in the morning for the 5th time.  But Game of Thrones is back on, so that will make me happy just about always.

Happy Spring!  FINALLY!

Mar 6, 2013

Breaks between surgical pathology

Hmm, what can I say to you lovely people that won't be boring and predictable?  More about life in a pathology residency?  Or more about life in a pathology residency if you're me?

My schedule since December has pretty much been to be on call every three weeks.  This overlaid February, which was one of the worst surg path months I've had to date, which also led to getting piled on by people nitpicking my after-hours work.

Don't be that guy, people.  If you know your colleague has been at the hospital for over 70 hours, don't be the jerk in the morning that goes "You didn't get my protaste marginnnns!!!' and certainly don't be the one that whines to the chief about it.

This kind of covers a spectrum too.  If you see anything that's clearly a result of a fatigued oversight (so long as it doesn't hurt the patient), like a lid not closed, or a sticker placed on the wrong thing, or an uncleaned scalpel where all the other instruments are clean, put on your big girl panties and just move on with your life.  If you find something particularly offensive, talk to the person who did it directly.  If they throw you tude and refuse to stop, THEN run and find someone to tattle to, but otherwise, just be a grown up.

Anyway, so the month of February generally sucked.  I also still find myself reading out late into the night where I feel like I should be getting better at all this, but on the plus side, my reports have been improving markedly, so I do have that.  The last week of read out, I was actually doing better, and I'm feeling at home with the ART specimens, since I've dealt with them three months so far this year.  Breast, bowels, lungs, got it.

Breasts are nebulous pathological creatures.  You can rarely call a "benign breast" because there's always something going on in them even if it isn't a scary something.  So you get good at recognizing all the little halmarks of proliferative fibrocystic change diseases, biopsy site reactions.  Your apocrine metaplasia, columnar cell change, florid ductal hyperplasia, usual ductal hyperplasia, etc ad infinitum.

Lungs are more simple.  The complication comes with how much the surgeon mangles it, and how many extra structures (heart, ribs, bowel wall) you unexpectedly get.

While dealing with this, we've also been dealing with our new system.  This was put in place in October in time for Halloween, because the best "trick" in "Trick or treat" is the one that never goes away.  Communications with the new system finally reached a new low when I was on a Friday call with things going on simultaneously at two hospitals, requiring me to pack up my remaining work and bring it over to the main hospital.  It was about this time that the new system quit and refused to print anything I needed.  I had started this week on Monday going "I'm not going to let call get to me this time.  I'm going to really try a positive attitude and remember that I love my job" and ended with my sobbing in front of this uncaring machine, begging for it to let me go home.

In other news, I'm off all that now, and get to spend three months pulling my self esteem back together before breaking it all over my June surgical pathology month at the main.  Right now is immunopathology, which means playing with electron micrograph images, actually learning to read flow cytometry, and playing with the immunostains that light everything up.  Kidneys are weird business, and a lot of immuno-relevant stuff happens to them.  The process of their transplant and removal is somewhat fascinating as well.  Jam them into the abdomen, leave the old ones in place, the whole nine yards.

What else... I traded call so I could go to Brewvival on a wet and miserable Saturday following the Friday where I broke down, so got to try a number of exquisitely well made (if overly barrel aged) beers while watching shirtless men mud wrestle.

This weekend, I get to go back (and freeze) in NYC to show a new friend how to correctly negotiate the hedonistic trends of the city.  I'm excited about it, though it'd be difficult to compete with my last trip there.  May will be Vegas and Mexico Beach, the first with new Boyfriend, the second as a re-crash course into sailing once the season begins.  Roommate and I are trying to learn to turn faster, though the weather is currently not cooperating with our attempts to do *anything*.

I'm learning the surgeons I like, the surgeons I don't like, and the surgeons I wouldn't let operate on a cat.  One who did not belong in the latter category came down one lovely call night as I was attempting to leave the hospital and said "If you get the right answer, we all get to go home", and damn did I like those odds.

I saw Skyfall in the way back (hooray James Bond!) and Django Unchained in the more recent.  I'd recommend the first to anyone.  I'd recommend the second to any Tarantino fans because it's a Tarantino movie.  It's like he signed every scene.

Now that the crushing holiday season and its fall out are over, I can get back to exercising.  Surgical pathology plus crappy weather plus call plus stress equals horrendous weight gain and fatigue.

I'm getting my doctor's appointments in (never do anything that relates to your own hospital; I am dealing with absolutely jaw dropping lack of concerns for HIPAA from hospital administration which has required me to run around my own department asking for favors), trust me.  Hoping for dentistry next month, since it has been an embarrassingly long time.

So everything's kind of in a holding pattern.  I'm leaning toward cytopathology now more for fellowship but time will tell, my second year is starting to wind down in a way that's terrifying since I don't feel smart enough to be an upper level in July, and I wonder if there's ever going to be a time where I don't feel afraid of my own finances or of my own knowledge.

To those of you entering the final countdown of the Match, I wish you good luck.  It will seem awful at times, and then hopefully, you'll have those moments when you regret nothing.

Jan 14, 2013

Remember remember the month of December?

Because I certainly don't.  November... clinical chemistry.  The day after November.  Work.  8 AM on December 31.  No longer work.  Party downtown for NYE and then burn rubber for New Orleans before anyone else can page me.

I'll back up.  As I've mentioned previously, now that I'm a high and mighty second year (though since it's a four year residency, still a junior resident), I can take call.

I probably explained this in a previous post, but I'm too lazy to look back, so quick recap.  Most pathology residencies have people take call a week at a time.  You are on call starting at 5 PM on Monday night until 8 AM the next morning and that's the pattern.  You then take call from Friday at 5 PM straight through until Monday at 8 AM.  If there's a holiday during the week (like Christmas), it's like the weekend, you're on for that entire time.

There are two types of pathology call: AP (anatomic pathology) and CP (clinical pathology).  AP is the headache that frequently requires you to come into the hospital.  Surgery is running late or got scheduled on the weekend and they need tumor margins?  AP.  LifePoint has a potential donor kidney but needs to evaluate whether it's viable for transplant at 2 AM?  AP.  Medical autopsy between Friday afternoon and Sunday afternoon?  AP.  Patient is immunocompromised and may have a necrotizing fungus in their lungs?  AP.

CP is all the lab stuff.  Authorize nonstandard or nonindicated blood transfusion?  CP.  Transfusion reaction?  CP.  Stool cultures?  CP.  Oops, someone forgot to label a specimen may I pretty please oh please I swear I know it's the right patient, PLEASE let me come down and relabel it?  CP.  CP is far more likely to roust you from sleep at 3 in the morning, but typically requires a series of exhausted phone calls rather than rushing out the door with wet hair pulling your sneakers on.

For our first year of call, we are supposed to take AP and CP weeks separately so we don't get overwhelmed.  The thing is... you can have a call week with virtually nothing... maybe three phone calls for the entire week and one frozen section that keeps you at the hospital until 6 PM.  OR you can have your pager go off constantly, fill your weekend with complicated autopsies that you're forced to pause to deal with other calls.

For December, I was on my old friend surgical pathology, which really heats up at the end of the year as everyone attempts to get in their surgeries before they have to pay a new insurance deductible.  People also may also have a week off around Thanksgiving or Christmas or have it easier to arrange so they can put their surgeries then (making a depressing holiday, I'm sure).  So December was beating me to death in general.  Just to get to our own office Christmas party required two other residents tag teaming to get all my specimens handled by 6:30 P.M., which was a job that otherwise would have taken me until 10.  Boyfriend was cooking for me a great deal of the time.

But then Christmas week... that was my call week, as the second years tend to get the holidays.  We lost a resident to family stuff who was my co-call person, which meant either take both calls or cost someone their Christmas.  I figured how hard could it be, and had several reassurances that Christmas is a slow week which turns out to not be entirely true.

Here's the thing... the most junior people are the ones stuck on Christmas, present company included, which means the hospital runs at half staff with the lowest people on the totem pole, who are the most likely ones to be calling me with weird questions, a lack of justification for why they're calling me, and reasons for procedures like "My chief wants the values to be X".

So during the week of Christmas, my pager went off 41 times.  I had autopsies and frozen sections and SO many mislabeled specimens and bizarre requests.  As the week progressed and my grinchitude grew dire, I was pretty much saying no to anything that couldn't be considered irretrievable (like lumbar puncture specimens or brain biopsies).  I did the longest autopsy in the history of autopsies just because the darn pager kept going off.  I took to referring to it as "the wife" because it kept frigging nagging me.

My mom also got to be in town for Christmas, which unfortunately didn't leave me much time with her due to the above.  Unfortunately she got to see the absolutely least exciting/sciencey part of my job "What do you mean you didn't label a random urine catch?  No, you can't relabel it.  Yes, you do have to call the patient back." and not the good stuff.  She also saw me swear at my computer a lot since the apps you need to access really like to bug up when you're on a deadline.

During this time, keep in mind that except for the actual holiday, when you're taking call from home, you're still doing your normal duty hours, and except for Christmas Eve, it was kind of a nasty week.

So when I got off call at 8 AM on New Year's Eve and did the official hand off of my cases, I actually said "If anyone has any difficulty with anything I did last week, I don't want to hear it.  My first week of dual call... I am officially above criticism."  And to everyone's credit, I haven't heard a word about it.

But I handled it.  Gone is all the panicky nonsense from last year, replaced by an aggravation by heavy workloads and unrelenting paging, but I overall like my job and feel like I'm getting better at it, which is awesome.

NYE was pretty fun.  Ended up going to a party at a bowling alley/bar/arcade/silent disco (?), had a hotel downtown, and avoided getting completely ridiculous like I did last year (though in my defense, that was a few days after the house went).  But I knew I needed to be unhungover for the drive to Nola via Jacksonville because hooray.  Replaced my hurricane glasses that got torched last year, got some great cajun food up in Baton Rouge, where it's 15 dollars cheaper, and bummed around Frenchmen street listening to great live music that involved songs that were not hacked up covers of Play that Funky Music.

Came back to cytopathology, which I'm loving far more than I expected.  So in surgical pathology, they deal with larger specimens, at least biopsies, so you are not just getting a cell that may look cancerous, but it is in the context of the surrounding tissue architecture.  For instance, your body frequently gets violently pissed off about getting invaded by cancer, so even when you don't initially see the actual tumor cell, you see the surrounding reaction to it.

Cytopathology deals with single cells, either from aspirates from suspicious tissue so that if it's nothing, the patient is only subjected to a deep needle stick and not a full surgery, or fluids that aren't blood (hematopathology's territory).  For instance, urine is supposed to be relatively cell-free.  People with bladder cancer; however, may shed those cells into the urine where we see them and go "AHH  Bad Nucleus!".  Any fluid that's accumulating around the lungs or in the abdomen, we check for cancer or bacteria.

It's teaching me about problems at a cellular level so I'm getting to know the features to look for, which will help me for surgical pathology particularly for sneaky cancers like melanomas, which the surrounding tissue may ignore.

We also see patients when we go on aspirates.  Granted, we barely speak to them and we *definitely* don't tell them what we see other than "this specimen is adequate" since the last thing a patient wants to hear is a positive cancer diagnosis by way of a complete stranger looking into a microscope near your feet and going "Holy crap".  Rapport fail.  The process is important though.  We literally influence the number of times a clinical has to stick a needle into someone's neck.  And they get frustrated with us for it.

What else.. we had a sudden warm snap, which was awesome.  It coincided with a visiting Jersey friend, which led to a beach day, a failed surfing attempt (on my part; not on her part; that crap is harder than it looks), so she finished off the surfing day while I drank beach juice (tm) with Boyfriend and Friends.

So that's what I've been up to.  Another call week is heading up on me, so I'm throwing myself into restaurant week to go out with a bang.  Unfortunately, holiday baking + stressful month + no exercise due to workload + New Orleans + Restaurant Week = the next three months of broccoli and treadmills.