I no longer have my "intern" excuse

For I now rank among the second year residents.

This is a bit of a mixed bag.  I don't feel completely "NO MORE INTERN YEAR!!!" because we're relatively unabused pathology residents and I've been on clinical pathology rotations for the past few months so I've been particularly unabused.

We had a couple parties today: one a path party at one of our seniors' houses to celebrate the new residents/fellows and say bye to the remaining ones, and the other was the same awesome mixer at the marina, which we showed up at the end.  We made friends with two fellow SGU grads (one med; one vet) and upon leaving they were like "You're path people!  Why are you bailing at 9 PM?" and we had to very honestly say "We have to get up early tomorrow.  We're going sailing."

Yeah.  Hard times.

Because of the ACGME (residency police) regulations set in place last year, first year pathology residents don't tend to take any call.  Essentially, they made it so that newbies would no longer work 24 hour shifts, which is critical when you're a surgery resident trying to not develop a meth habit, but less critical when your call consists of going home and maybe answering your phone a few times.  What does this mean?  It means welcome to taking call, mofo.  I drew the straw of being the first resident on Anatomic Pathology call this year, so Monday to Monday, I'm the late night frozen section and weekend/4th of July autopsy girl.  It's mildly intimidating, but we have a decent support network.  I will at this point reiterate the advice of "try to avoid going to teaching hospitals as a patient the first week of July".

I will be back on autopsy next month, which critically means getting to wear nice breezy scrubs instead of people clothes during the 100 degree month, which, hooray.

Last few weeks... hmm... due to Step 3 and my Journal Club and my CP talk melting my brain, I had forgotten that as part of my last month's rotation in molecular pathology, I had to give a talk at what they call the Big Meeting.

So about ten days before that, our attending mentions it offhand, and I'm like "Uh oh", and casually ask him to *remind* me how long this thing is supposed to be.  Apparently like 20 minutes.  The two talks a year that we spend weeks preparing for is 30 minutes.  I spend 8 hours at the hospital over 5 minutes.  So I'm like "No problem!  (AHHH)"

A short time after that, at our afternoon meeting about Extremely Difficult Things, he's like "Oh, apparently I have to go to a meeting at 5 to discuss a new machine with the heme onc docs.  Wanna come?" and I'm like "N... sure!" because I am spineless enough to barely qualify as a vertebrate.

This impromptu meeting turned out to be incredibly cool.  It was all new technology-esque with abilities to sequence hundreds of genes for the same cost as five, and then they were getting into interpretation and marketing and it was all very Future of Medicine like and I got super excited about it.  Unfortunately for me.

I expressed my enthusiasm to my attending and he thought it was great and suggested I present it as my topic at the Big Meeting since the techs would love getting a look at a machine that might be implemented over the next year or so.  I wholeheartedly agreed.  Heck, half the work had been done for me and it all seemed really cool anyway.

Holy crap.  This stuff is HARD.  The difference between briefly explaining the implications of a new technology to doctors that don't work with it and explaining how the machine that uses it works when you don't even know is just wow...

Even the company website was taunting me.  "It's simple!  It works just like any other microchip!"

OH DOES IT REALLY?  Dude, I still think my iPhone runs on elf blood.

Wikipedia took an absolute beating.  "The technology uses next generation PCR".  (sigh)  Wiki.  "next generation PCR."  (sigh)  Wiki "DNA beads".  Wiki "Emulsion PCR"  Wiki. "PCR".  Wiki "DNA Sequencing".  Wiki "DNA".

"The DNA beads are then loaded onto the chip, which is made out of a silicon boule."

(sigh)  Wiki.  "Boule".

The whole thing gradually built into this mental house of cards on which my entire understanding of this technology rested.  I was thinking so hard that I felt like I was working out.  When roommate's boyfriend came home, I was squint-glaring at my computer screen and wouldn't greet him because I was afraid the fragile base of my knowledge would crumble into dust if I deviated my glance for a second.

So the presentation comes, and I was told the meeting was very casual and no big deal, which is what is colloquially referred to as a complete lie.  Fellow resident and I actually showed up at the wrong conference room because we thought it would be our three attendings and a couple lab people and some sandwiches, and everyone would probably be eating and doze.

Wrong.  We end up at our morning conference room, and it is *packed*.  We don't have that many people for the real morning conference.  I've met about half the people.  It ranges from the general techs, that do sciencey stuff all day long and work with the type of machines I'm about to try to explain to different types of techs to doctors to god knows who.  There's also some PhDs thrown in for fun.  Ya know, those people that were learning this subject specifically and writing papers on it while I was screwing up IVs and taking blood pressure.  I mentioned very recently that I don't tend to get stage fright for this stuff, and this proved a notable exception.  This was more like that dream where you have to take a calculus exam in your underpants.

I was in such a hurry to unload the giant ball of painful information in my head that I even forgot to introduce myself.  Possibly as an unconscious defense mechanism in case I screwed up.

It actually went really well.  In jamming the data into my limited capacity to understand it, I had inadvertently created a presentation that was apparently easy to follow while getting deep into the subject since it was the only way I could create a presentation on it in the first place.

I would say this taught me an important lesson about how to do this in the future and how to pick topics that I find extremely challenging, but hell no.  Brain drain.

So happy July to all of you, and congratulations to all my fellow travelers at your various stages of progress.  May your powerpoints never crash.

Another frigging USMLE, really?

So, in my program, you have to take the USMLE Step 3 by June 30th of your first year because they realize path residents are going to forget all their clinical medicine.  The plus side is we don't technically have to *pass* it until June 30th of your second year.  But since "Step 3: Electric Boogaloo: MCQs in Space" is two days of work-day length misery instead of one, I really don't want to do it twice.

Being a responsible person, I'm taking it June 8-9, which is about three weeks before when normal me would take it, but about nine months past when a reasonable person would take it.

Being a SUPER responsible person, I decided to make use of all resources that would really help me study for this exam.

Yeah, roomie and I got a boat.

How do you study?

Roomie mostly got a boat, particularly since she has a car that can tow it without invalidating the warranty and I don't, but damn.  I'm now officially a disgustingly rich boat owning doctor, except I'm poor and part-owner of a hobie cat we got off craigslist, but the potential is there!  All that's left is to stuff it full of golf clubs and caviar and butlers and such.  Posh people do that, right?

Posh people also go to Kiawah Island.  As part of my program being incredibly awesome, they sent us to attend at least one day of a conference out in rich people land.  This was my first for-real conference, and I was sufficiently blown away.  The lecturers were actually pretty damn amazing; notes came with bling and a preprogramed flash drive with the power points, and then the spread required a lot of extra treadmill/swimming/weights time particularly since it all concluded with an oyster roast/food orgy/open bar out in a beautific location.  I thought when they saw my handbag lacked either a "Coach" or "Louis Vuitton" logo on it, they'd throw me out, but security must have been lax.

So yeah, perhaps I'm in an upswing that will terminate with my telling all you fine people to run screaming from the profession (again), but life is currently making all the Step 3 UWorld pwnage worth it.  Despite the fact that palmetto bug season is starting to bloom, or "Satan Death by Aerial Insect Assault" season as it's known by those who can interpret the screaming.  For you lucky uninitiated, palmetto bugs are roaches that are pumped up on steroids, aggressive, and fly.  You're welcome.  Pleasant dreams.

Back in heme, I was required to do a five minute presentation at conference on something I'd learned that month.  Since I'd had a quasi argument/discussion/I know this topic talk with my attending on thalassemias, we jointly decided I would do that since I'm lazy and he wants to focus on a topic where there aren't a lot of cases here.

For some reason, this five minute topic on a disease my mother is carrying a trait for had me up until 2 AM.  Personally, I blame powerpoint for being a horrendously inefficient way to present information that isn't a picture of something.  So I did the thing this morning to a fading audience, but my attending had left, so I did it again at the beginning of sign out, and he approved, so I may be doing it again to all the heme onc people because I like boring diverse groups of people.

Since I'm pathologically addicted to Game of Thrones, this does allow me to make the most specific geekiest, least funny reference in history by saying "Hemoglobin Constant Spring is a deletion in the alpha gene stop codon which leads to a long alpha globin chain, contrasted to Hemoglobin Winter is Coming which causes the gene to make progressively stupider decisions until someone kills it."  [Crickets chirp, awkward silence ensues]  "Thank you!  You've been a wonderful audience!"

I get nervous about presentations until the time where I actually have to give them and then I don't care.  You'd think this not caring would carry over to the presentation effort so that it doesn't take me 7 hours to hack together a 5 minute presentation, but it doesn't.  I also never do a practice run, usually because it's 2 in the morning.  I attribute this all to being 11 years old, with my precision team, opening the Ice Capades (yes, really) and falling directly on my ass during a simple maneuver in front of at least a couple thousand people.  Given that, scrambling some medical terms to a group of thirty people who know me just doesn't matter.

That being said, if I give a presentation and you ask me to do the same presentation an hour later (today), you will get two entirely different presentations.  And despite all the care and effort I put into making a stupid powerpoint presentation, I rarely reference anything but the pictures.  "Behind me, you'll see a list of bullet points that constitute my midnight stream of consciousness and have nothing to do with what I'm talking about.  Enjoy."

I also over research and under reference.  This has been something I've literally done since high school.

"Oh, I have a paper due on Shakespeare?  Okay!"  [Read all of Shakespeare's works.  Read several biographies on Shakespeare.  Pull up lots of webpages that recount the same information.  Do this for several weeks.  Write entire paper in a single run beginning at 10 PM the night before it's due with no rough draft.  Sprinkle arbitrary references in among facts that may or not be where you got the original information, but by then it's amalgamated into your "common knowledge" and you have no idea where it came from.  Hope like hell they won't fact check you or that you've inadvertently plagiarized someone.  Swear you won't space your time like this next time.  Repeat pattern for next fifteen years.]

What else?  Oh, we did the Residents In Service Exam, which for first years, as I mentioned, has no real significance other than telling you what you need to learn.  What did I learn?  I'm good at microbiology.  I don't really know why I'm good at microbiology since we haven't rotated in it yet.  I'm not good at surgical pathology even though I spent most of my time in it and stresses related to it nearly sent me fleeing to Mexico despite an exquisitely poor command of Spanish for a native Californian.  Baby steps.

I blame the media for my current career path.  I wanted to be a virologist initially because I thought Outbreak was a good movie and I was, like, 12.  I downplayed this during my "Why did you get into pathology" interviews because I wanted to eventually get work.  I'd like to say X-Files hasn't played a role in my current course, but I'm suspicious.  Now I'm weirdly good at microbiology, and the most logical reason I can come up with is that Dustin Hoffman is remotely beaming the information into my mind.  That's reasonable, right?

Anti Powerpoint Rebellion

Though apparently I'm late on the bandwagon and there's already a group of anti-establishment Luddites that have taken this position, but I'm over PowerPoint. This hit me last night.

I'm not saying PowerPoint doesn't have its uses, like all three of them. As someone that's infatuated with pathology, you need PowerPoint (or some kind of visual projection device) to teach it. Diagrams are also useful, particularly in surgery, where they tend to do procedures that connect stuff to other stuff you wouldn't necessarily expect, and you kind of need a diagram representation of what GI anatomy looks like after you've put in Tivo and a hot tub. Or something. So yeah, if you need something that isn't "words", hooray for PowerPoint.

I was kind of indifferent to PowerPoint for a long time. I laughed when people put in the "funny" slide or the unnecessary slide effect, as you're supposed to, and the really bad PowerPoint presentations stand out as really bad PowerPoint presentations, so I hadn't really chalked them up to the program, but to people's inability to understand the concept of margins, grammar, or choosing colors that don't provoke seizures, and that's valid.

But two things happened yesterday. One, it was conference day, which pretty much means around 7 hours of PowerPoint. Some lecturers are good; some are not. But I realized that the second they dimmed the lights to put up the projections, I had a Pavlovian reaction. I pulled out my Surgical Recall to study.

So essentially, I don't mind PowerPoint because it offers me the opportunity for self-directed study unmolested without the distraction of an engaging or novel lecture. And books tend to be more significantly higher yield, probably because they're not in PowerPoint format. And they're in normal English because the authors presumably have not been doing language gymnastics to avoid direct plagiarism. And I realized the only way to actually pull me OUT of reading my book is to have a lecturer that is either distractingly good or distractingly bad. But most fall under the "okay" line of droning information that is already on their slides with topics they know well, but are no longer capable of presenting in an interesting fashion.

Then I watched one of the really good, extremely knowledgeable residents get the crap pimped out of her on topics that were already later addressed in her presentation, which in fairness, wasn't bad. But you have no flexibility in the direction you're going with PowerPoint because it's already on the slides. And then if the attendings toss you in another direction by ripping you apart with questions, you're still left having to come back to your presentation and plod through slides they may have just explained to make a point, at which point you just kind of stare blankly at the screen, glance at the audience, say "uhhh" and then flip quickly past an hour's work, most of which probably consisted of spacing out the bullets and changing the fonts. Your audience is bored, you've lost your mojo, and more importantly, an hour of your life you will never ever get back.

Everyone thinks about the bad PowerPoint lectures because they're hilarious. But then I thought long and hard about the last GOOD lectures I've had. I've had plenty of perfectly functional decent lectures, including by other students, even when I was forced to pay attention, because text on screen is still text with information, even if it's a wildly inefficient way to get it.

But even this rotation, the GOOD lectures? Half of them were rounding with attendings. The SICU chief who kept vividly maiming our patients when we strayed in the wrong direction: "After spending four hours convincing Anesthesia to actually let you do this procedure, the patient codes on the table. They're resuscitated AGAIN. Systolic pressure is 50". "Uhhh... well, I'd order..." "40." "I'd explore the..." "30." "AHHHHHHH!!!" "Patient begins pouring feces out of the incision site." "AHHHHH!!! Is that a real thing???? Yes?? AHHHHHHHHH!!!"

The lectures with our attending that tells dirty jokes and pimps us... the impromptu question reviews, even when I think they aren't going to be relevant because they're surgical resident question reviews and I haven't studied adrenal anatomy in 8 months. Almost none have used PowerPoint. The ones that do have either been almost exclusively image-oriented or the speaker has barely referenced them and flips through them in the middle of an interesting lecture because a PowerPoint presentation was required or he doesn't have a pen that writes well on the back of his hand. (I'd make one of many easy cracks at Sarah Palin here, but since I totally do that too, I can't.)

And why do the funny effects or that humorous cartoon, or the serene picture of the beach entertain us? Because PowerPoint lectures are so mindnumbing that we need the emotional break from wanting to kill ourselves.

Which finally brings me to my second point. I had to present an excruciating article for surgery today and was up late doing it (because I was late in a lecture and spent a good part of the day listening to an attending bitch and moan about medical students not 'being around' because we're unreasonably 'post 24 hour weekend call' or 'in mandatory conference'). The article was almost exclusively statistical analysis on other statistical values about a topic that wasn't really easy when you stripped it to the original condition, and because I'm not a statistician (nor am I good at arithmetic), I had to Wiki half the terms in the freaking thing.

So I *finally* was able to understand the article, its point, and the original topic it addressed, and interpret the numbers.

But THEN I *still* had the task of taking all the information I had in my head AND the organization and logical follow through, and then turn it into a deadpan samey boring ass PowerPoint presentation despite having no idea which way the attendings would direct it. Plus doing PowerPoints gives me complete mental constipation while I struggle to elaborate on bullet points without reading text off the slide like the listeners are illiterate children rather than board certified freaking surgeons. In addition, the article was virtually incapable of being made interesting by anyone nor to anyone, and the only way you can make it less interesting is by taking all those statistics and copying them onto a PowerPoint slide.

So I kind of rebelled. I put together like 5 slides with the main points on them (particularly since the entire point of the article is summarized neatly in the title and the entire paper is merely justifying why they aren't full of crap) and just talked about it, summarizing the key findings without blasting numbers on a screen at 7 in the morning, and pretty much ignored my own slides. I think I was stuttering a bit because I'd gotten four hours of sleep and was presenting to a group of attendings without the mental crutch, but no one seemed pissed, so who knows.