Burn out

Cross-posted on Dose of Reality:

Between October 4 and December 14 I did fourteen residency interviews, although most of them were concentrated between October 27 and December 14, so all told I did an average of two interviews a week for seven weeks. I was home for 17 days during that period, spread out over the interview season.

Things that were wonderful about the interview trail:

• Catching up with friends in distant cities
• Enjoying cuisines that aren’t available in Ann Arbor
• Meeting so many delightful future colleagues/potential co-residents

Things that were terrible about the interview trail:

• Sleeping on floors, air mattresses, couches, and guest beds; thank you to everyone who hosted me, but the cumulative effect was rough
• Air travel
• Leaving Walter with every friend and relative I have in the greater Ann Arbor/Detroit area

I’m glad I did it, but I’m really glad I’m done. Now the excitement of making a rank list and holding my breath until March 15 when I find out where I’ll be heading for the next four years. Stay tuned!

Thanksgiving

This year, Thanksgiving was not only a time to reflect on how wonderful it is to spend time with my friends and family, but also a respite from the ridiculous interview season that has consumed most of October, November, and December. I had almost a full week at home over the holiday, and I made the most of it. This was the most delicious part of that week:

 To accommodate everyone, there are little sugar free and gluten-free versions of the pumpkin pie baking on the bottom rack. 

Yum!

Peach Cranberry Pie
adapted liberally from Mark Bittman’s How to Cook Everything

Two batches of pie crust
16 oz frozen peaches, thawed and drained
6-8 oz frozen cranberries, thawed, drained, and sliced lengthwise
3/4 cup sugar
1 tablespoon lemon juice
1/4 teaspoon ground cinnamon
1/8 teaspoon ground nutmeg
1 1/2 tablespoons cornstarch
Little bit of milk

Preheat the oven to 425F. Prebake the bottom crust (using a little more than half of your crust dough) for about 10 minutes with foil and pie weights (or dried beans, which is what I use) over it, and for another five minutes with the foil removed, or until it is very slightly brown. While this cools, mix the lemon juice with the peaches and cranberries. Increase the heat of the oven to 450F. Mix together the dry ingredients for the filling and toss the peaches and cranberries with this as well. Roll out the remaining pie dough, and cut it into strips a little less than an inch wide. Once the bottom crust is cool, pile the fruit filling into it. Lay four-five strips of crust across the top of the pie, and attach them to the bottom crust on one side. Starting at one side and working across the pie, weave the perpendicular strips across the pie, over and under the other strips. When it is all woven, press the edges of the strips into the bottom crust. It should look roughly like this when you’re done.

Brush the top crust with a little milk and sugar, and bake for 10 minutes at 450F. Reduce the heat to 350F and back for another 40-50 minutes, until the pie is golden. Let cool and serve warm or at room temperature.

In addition to eating, we also went to the parade, joined by Ash’s mom Cindy. The weather behaved so well that it was an ideal first parade year for her!

The Detroit Mounted Police

The clown fire brigade

Grover visits Detroit

Emergence of a rank list?

Cross-posted on Dose of Reality

At the beginning of the interview process, I had some sense of which programs would be at the top of my rank list*. I also had some ideas about which would be at the bottom. I'd set up a list for myself of programs likely to be in the top 5-6, and programs likely to be in the bottom 5-6, but the middle of the list was a bit of a mystery. Now that I'm through nine of my fifteen interviews, I'm getting a better sense of what I'm looking for in a program, although it's still difficult to make concrete pre-interview predictions. Some things I have learned:

• As promised by all of the residents and faculty I've talked to, interacting with current residents is really important. Not only do they have a completely unique, insider perspective on the programs, but their personalities and preferences seem to be the best indicators available of what kinds of applicants match at particular programs, and what sorts of people do well there.
• I'm really glad I'm not couples matching. Applicants who have a significant other (or anyone they want to match with, really, as there is no requirement that you be in any particular kind of relationship) who is also applying to residency this year can choose to link their match lists with that person's. The match algorithm then processes the two lists together so that if Applicant A only wanted to be at Program X if Applicant B were at Program Y, and Program Y isn't an option for that applicant, then the algorithm moves on and looks for a better match. This means that although OB/GYN isn't the most competitive specialty, those applicants who are couples matching with someone in a crazily competitive specialty have to apply and interview to many more programs. The travel is already wearing on me, and I can't imagine having to do more than I already am.
• The fit and feel of a program are much more obvious after an interview day than I'd expected. I know it sounds dubious, but you really can get a good sense of a program after an informal mixer/dinner with the residents and then an interview day. There are, I'm sure, lots of things that can't come out in that amount of time, or that are intentionally hidden away during interview days, but the personality of a program really does come out quite clearly in that brief interaction. 

I've definitely not finalized my list at this point, as there are still lots of interviews to come, but it's exciting to feel like I'm getting closer.



*For those of you confused about what a "rank list" is, I refer you to a post from May that describes a bit of the match process.

Catch up

Somehow it's been ten days since I last posted. I was home for a week over Thanksgiving, and thoroughly enjoyed the break from the travel. I'm back on the road again, and wanted to share some highlights from my interlude visiting Ruti in DC!

 She lives very, very near to the White House, and I realized that I'd never seen the front side of it. Here it is, in all it's glory!

 We tried a delicious soft-serve spot that starts with bars of frozen yogurt and actual fruits (or pumpkin, in my case) and then blends them into delicious soft-serve. I got the pumpkin spice flavor with chocolate ice cream - a perennial favorite for me, but new to the astonished gentleman behind the counter. It was amazing.

I went to the Renwick Gallery, the Smithsonian Museum of American Craft, and saw some of their permanent collection as well the 40 under 40 exhibit, which featured 40 works that had been created since the opening of the gallery 40 years ago. 

There were no pictures allowed in the special exhibition, but upstairs in the permanent collection I was particularly taken with this "Bureau of Beaurocracy."

On my way to the museum I stopped at the food trucks (below) just a block or so from Ruti's house. I did not get the most exotic tacos, but they were delicious (above).

We also went to an aerial yoga class, but mercifully there were no photos of that experience. Unlike the class we did last year, it was not explicitly directed toward producing impressive photos. Instead, it was focused on destroying one's triceps, and it did an admirable job of that. Thanks Ruti, for an amazing visit!!!

"I have always depended on the kindness of strangers"

Cross-posted on Dose of Reality

While I'm optimistic that the end of my interview trail will not parallel the end of Blanche from Streetcar Named Desire, I nonetheless feel that, at least right now, I am wholly dependent on the kindness of friends, family, and even some strangers. I'm writing this post from dearest Ruti's living room, having stayed with my sister last night and a gracious UM alum the night before*. In Boston I stayed with a med school classmate, and an old friend in Seattle. I've got friends lined up for many of the rest of my interviews as well, and I feel incredibly grateful at their willingness to pull out their air mattresses, unfold their couches, and make up their guest rooms for me. I'll be working to balance my karmic withdrawals by hosting some applicants interviewing at UM back in Ann Arbor. I can't say thank-you enough to all of these folks who have made the first half of the interview trail that much more hospitable. Don't hesitate to call if you find yourselves in Ann Arbor. Thanks!

*The Office of Alumni Relations runs an impressive hosting program that connects interviewing fourth years with UMMS alumni across the country. I've only used it once so far, but was thrilled with it. Yay for having a gigantic alumni network!

End of the CSA

My CSA this year caused more anxiety than last year. I think I was working so much last year that I got into the habit of cooking massive amounts of food on my limited days off, and eating salads at every possible juncture. This year felt much less organized, with rotations that were really radically different each month, and somewhat unpredictable. I wasn’t nearly as diligent about cooking regularly, and so I frequently had panicky moments until I figured out what to do with the massive lot of greens in my fridge. When I finally had some time at home a few weeks ago, I cleaned up my refrigerator and finally used the last of the CSA. (I will note that since it's very, very fresh when it comes to me, it's actually just fine to sit in the fridge for a week or two. Not ideal, but fine.) Some of it, okay, truthfully, massive volumes of it, became sautéed greens with a fried egg on top. But another large portion became this:

Eggplant + final tomatoes of summer + chick peas = delicious

There’s not much "recipe" to share, as I just roasted the eggplant in the oven and then warmed it on the burner with the tomatoes and chickpeas. I seasoned it with zahtar, which is a mixture of sesame seeds, coriander, sumac, thyme, cumin, and black pepper. The sumac adds a citrusy deliciousness to the whole thing, and I highly recommend it!

Time I got up to get to the airport in Boston: 3:15AM

Number of empty rows on each leg of my flight to Seattle: 10+

Number of screaming children traveling with me from Philadelphia to Seattle: 1

Cost of earplugs that I try to keep in my carry-on: $0.50

Value of laying down across three seats and sleeping for another four hours: Priceless

I have now forgiven US Airways for any past injustices, as I was on two very empty flights this morning, and I got to sleep for almost the entire flight from Boston to Philly, and then another few hours en route to Seattle. It was so incredibly nice to sleep a bit more since I needed to catch up after Boston evenings filled with a pre-interview mixer and a fabulous dinner with the most amazing out-of-town friends a girl could want, and mornings filled with interviews (starting at 6:45AM!) and flights (departing at 3:50AM!). My gracious host (a friend from med school) couldn’t have been kinder, but I didn’t spend nearly enough time in the bed she provided!

More voting!

That’s right folks, vote early, and vote often…

I wanted to share a few more links for those of  you looking for more information about local elections than I’d provided here. I did a lot of my own research during the primaries, and so didn’t have to do as much this time around, but here are a few organizations/news items that helped me out.

If you’re voting in person, print out a sample ballot to make notes to take with you! You’re allowed to take whatever notes you like into the polls with you, as long as they don’t look suspiciously like campaign materials – leave the buttons and yard signs in your car.

American Federation of Teachers (AFT) Michigan endorsements

AFT Michigan includes a link to local AFL-CIO endorsements

Ann Arbor News article about the school board candidates

Ann Arbor News article about the library bond proposal

Ann Arbor Journal article about the library board candidates

Have fun with your absentee ballot, or making notes to take with you in person on Tuesday, and remember to vote all the way to the end of your ballot!

And the interview season marches on…

Cross-posted on Dose of Reality

I’d had a bit of a break since my first residency interview, but this weekend I was on the road again for interview number two. This really marks the beginning of the craziness that will be my interview season. Looking at my calendar for November, there are a total of about 10 days (including the week of Thanksgiving) when I’m not traveling somewhere. Here is how Walter feels about the prospect of my being away so much:

I'll note that these photos were taken on two different occasions. The dog has taken to smooshing his face into small spaces that look ridiculous. And adorable.

Despite having similar feelings about so many flights, rental cars, trains, and hotels, I’m pretty excited. [For the record, I’m not sharing here the full list of places I’ll be interviewing, out of courtesy for the match process and my friends and colleagues, so if you know them, please don't share!]

The following are some highlights from my trip this weekend:

• I ended up in the airport Friday waiting for a rebooked flight for about four hours after my original flight was delayed enough to miss my connection and thus cause me to miss my interview dinner. [Insert diatribe about what air travel has become.] But I was calm.
• I ate the following (delicious?) airport food while waiting: a hummus and pretzel cup, a California roll, a Snickers bar. Only the last item really helped my mood, although it’s possible that it was really a cumulative effect.
• I made it to the last 20 minutes of the dinner/mixer on Friday night, and everyone was delightfully welcoming and wonderful.
• My interview was great, and I ended up being more impressed with the program than I anticipated.

Here’s a photo of me in my interview suit, seeing a bit of the campus.

A reflection on Blogger stats

This blog, in case you hadn’t noticed, is hosted on Blogger, which uses a simple version of Google Analytics to tell you about how many people look at your blog, where they come from, and what platforms they are using. I like to check this out, as it has revealed an interesting conglomeration of both surprising and unsurprising things. I will leave you to decide for yourself which are surprising, and which are not:

• that my blog has been posted on a list of medical student blogs;
• that everyone loves Walter more than any other kind of content I could post;
• that some people don’t access my blog through Facebook, an RSS feed, or Google Reader, but instead search for things like “dr dre medical school”;
• that some people arrive at my blog after searching for keywords like “tree smells like poop” and “purple vegetables list”

Those of you who have been long-time, or even just diligent readers will recognize that those keywords most likely refer to one wildly popular post about the Bradford Pear trees on campus and to one very obscure post from back in 2009 about all of the purple vegetables I bought at the farmer’s market. I wish I had some way to predict which random posts would be most popular.

Residency interviews get off and running at the end of the week… I’m a little nervous, but will keep you all posted!

Cycling update

My last mention of a cycling-related topic was in a post about how little I had biked during my month in the ICU. Sadly, the two months that followed did not look much better.

 I had a few notable rides, and a few trips to and from the hospital for my rotations, but mostly I felt tired and sore from standing all day, and lazy because I wasn’t on my bike. You’ll notice, however, that is has leveled out since I started my month of vacation and interviews. Here are some highlights from my fall riding thus far:
1. Taco Tour Cinco! I didn’t take any photos, as I hadn’t yet gotten my new (fancy!) phone and I didn’t want to lug my camera around, but this was a great event. As per usual, the tacos were fantastic. My favorite is always Dos Hermanos, for their amazing black bean tacos, but this year Taqueria La Fiesta had a really fantastic nopalito taco that was a close runner-up for me.
2. New Jersey! I ordered a University of Michigan cycling jersey back in April, and was planning to wear it for the century ride. It got caught up in some administrative disaster, and I didn’t get it until just a few weeks ago. Since I ended up having to wait so long, however, I got a great deal on some other Michigan cycling gear. Now that I have it, it’s heavily into the rotation and I decide to try out all of it together on a ride this week. I probably won’t wear the full kit again (as I think it makes me look a we bit more intense than I am), but will definitely be sporting bits and pieces of maize and blue spandex on my rides!

3. Fall colors! This is the best time of year for beautiful rides, and my new phone takes way better pictures than the old one…

Dear Anonymous

Dear Anonymous commenter,

I’m not sure how many people read the comments on my blog, but those who do have surely noticed a large volume of comments from you, “Anonymous.” I have reason to suspect that you are only a single person, Anonymous, because the tone of your comments is always the same. You do choose interesting moments at which to comment, however, and you are always entertaining. Here are some of the things I have learned about you by reading your comments:

1. You, like everyone else who reads the blog, love Walter. You love him so much that his the primary focus of your comments.
2. You enjoy capitalization of words for EMPHASIS, and wild punctuation!!!! I suspect that you talk like this too.
3. You may be a crazy, dog-loving comparison shopper, given that when I posted about a dog bed, you posted a similar but less expensive one in the comments very, very quickly.
4. You care a lot about my emotional well-being, but somehow not enough to use your name in your posts and reassure me that I don’t have some creepy anonymous follower who may or may not try to steal the dog in my sleep.

I hope that you continue to enjoy the blog, because I continue to enjoy imagining a nameless follower I’ve never met who occasionally frets over my anxiety level, but also needs a regular fix of the puppy photos and has lots of OPINIONS!!!! You leave the oddest anonymous comments I have every seen. Please keep posting.

Sincerely,

Your daughter

PS. That's right, mom, silly letters aside, I know it's you.

PPS. Please don’t bother to start using your actual Google profile to post comments, as the anonymous ones are hilarious.

PPPS. Just for you...

When Walter gets sleepy, he can't keep his tongue in his mouth or ensure that his eyes point in the same direction. So cute!

To the polls!

I am often annoyed by the e-mails that the Michigan Democratic Party sends to me, as I have no money to give. None. At all. The last one contained a few useful links, however, and reminded me that around this time of year I usually post some election-related material (like this, and this).

October 9th is the deadline to register to vote in order to be eligible for the presidential election, so if you haven’t done so already, register now at the site the MDP sent, which seemed reputable and non-partisan when I clicked through some of it.

You can also confirm your Michigan registration or look at a sample ballot here, or get other voting related questions answered at the Michigan Voter Information Center Website.

As I’ve shared in the past, Michigan requires identification in order to vote, but if you don’t have ID you can simply sign an affidavit and vote anyway. Details from the Secretary of State about the law and how to get a state ID card if you’d like one can be found here.

ACLU Voting Rights Guide: This has information on what to do if you're told you can't vote at the polls, including the Election Protection Hotline: 1-866-OUR-VOTE and the Michigan Bureau of Elections 1-517-373-2540. You can also visit their Let Me Vote site to learn about state-by-state voting rights.

I’ve actually already got my absentee ballot since I’ll be in Seattle for a residency interview the day before election day, and likely flying home or getting ready to at the time when I’d need to be at the polls. If you’ve got yours too, check out the following websites to get information about the candidates. When I get to my ballot later in the month, I’ll try to post some updated links to information about the more obscure elections, which often don’t make it into national analyses.

League of Women Voters: They collect information about the candidates and line it up so you can compare their views on different questions.

Citizens Research Council of Michigan: Look here for nonpartisan analysis of the ballot initiatives that we'll be voting on here in Michigan.

Still have questions or didn’t find what you were looking for? If you don’t live in Michigan, visit www.publius.org to print out a ballot, find your polling place, and find contact information for local officials, or check your local Secretary of State website for details on how to vote near you.

Rolling, rolling, rolling…

Cross-posted on Dose of Reality

The residency application is definitely moving along. The official opening date for application submission was September 15, and everyone has been doing their best to get their materials in as early as possible. My application has been in for a bit, and the stress of watching my e-mail has increased so much! Here is a snap-shot of my thought process over an average afternoon during the past few weeks:

Hmmm, I should look at my phone and see if I have any new e-mail. I wouldn’t want to miss an interview invitation. Everyone keeps talking about how quickly the dates fill up after they are offered. Oh my goodness, look, an interview request that was sent 45 minutes ago already! Ahhhh! Let me open up my Google calendar where I have all of the potential interview dates entered and figure out what other programs are in the same region and need to have interviews that are near the same date. And also there are national holidays in November that I’d rather not miss. And also I would rather not fly to the West coast 12 different times. And also I need to make a decision on this half an hour ago. Ahhhh! Okay, it looks like this date should work. Take a breath, Andrea, so that your e-mail doesn’t read like some crazed and desperate applicant. Try for “Thank you so much for offering me an interview” rather than “I am so glad that someone will take me as a resident some day.” Okay, breathe. The tone is okay and the address is correct, so hit send.
Done.

There is a small amount of adrenaline that goes with each of these exchanges. Maybe a large amount. I’ll be glad when they are all scheduled and I can just deal with the anxiety of interviewing!

Warm Blankets

Cross-posted on Dose of Reality

Inside every operating room, or at least very nearby, is an appliance that looks like a refrigerator. It does not, however, keep things cold. Instead, it is devoted entirely to keeping things warm; specifically, it keeps blankets warm so that when patients first come back to the OR, or when they are just waking up, they can be wrapped in a warm blanket (or two, or three) so that they are comfortable in the subarctic temperatures that sometimes occur. Today, I got the opportunity to experience the warm blankets for myself. I was watching a laparoscopic operation (read: a procedure performed with instruments on the ends of sticks inserted into an abdomen blown up like a balloon, so that there is no need to really open up a giant incision). One advantage to these is that, during most of the procedure, there is not much for the medical student to do since it is all inside the abdomen and it is all shown on huge TV screens around the OR. There is then no need for the student to scrub, wear a sterile gown and several pairs of gloves, and focus vigorously on contaminating neither her/himself nor the operating field. Instead, the student can stand or sit and watch the TV. In the cold. The cold that is usually mitigated by said gown and gloves, as well as by the lights and the pressure of working not to contaminate anything. I was cold, and while I was lamenting not having grabbed a scrub jacket from the locker room, I saw that one of the nurses had a blanket wrapped around her shoulders. I snuck into the hallway, grabbed a warm blanket, and wrapped it around myself. It was amazing.

It turns out I am not the only one who loves warm blankets. In addition to at least one notable person in my life who extols the virtues of heated mattress pads and heated throws, look who else loves warm blankets. He snuck into the basket while I was turned away to fold a sheet:

As the weather turns toward the chillier, but it’s not quite okay to turn on the furnace, consider joining me in front of the blanket warmer, or if you aren’t quite ready to invest in one at home yet, in front of the dryer. It’s warm.

Puppy Love

I think I won points with my urology resident today because I have a cute dog. She also has dogs (who are both adorable), and we bonded over their love of being covered when they sleep. Also our love of them… She informed me of a product called a “cave bed” that is a normal dog bed, but with a plush cover that creates a cave in which your pet can snuggle. You see them here or here (complete with a review). Maybe someday, Walter…

Urology!

Cross-posted on Dose of Reality

Somehow it’s already been two weeks of my urology rotation, and I haven’t shared with you all how awesome it is. I have been busy with other things (like ERAS – the online residency application – which I will tell you more about later), so here are a few highlights:

• My first week included “the Nesbit,” which, as far as I could gather, is a symposium organized each year to feature interesting research from urologists at UMMS and other important people in the field. This hear it was specifically about Health Services Research, which was a fantastic coincidence. Everyone was very gung-ho public health (with the possible exception of one speaker, but he was there primary to remind us of how much we need to continue to work on communicating our work with colleagues who do not have lots of statistical background), and it was fascinating. Topics ranged from specific descriptions of interesting studies and funding mechanisms to frontiers in urology (both methodologically and geographically).
• I’ve gotten to spend some time with the Neuromuscular and Pelvic Reconstruction (NPR) service, who are the urologists that spend the most time with female patients. They do joint cases sometimes with the urogynecologists (with whom I thoroughly enjoyed a rotation last November), and provide a slightly different perspective on things going wrong in the pelvis. I’ve seen some crazy reconstructions, some procedures for incontinence and some interventions for painful bladders.
• I’ve also gotten to see other things that I’ll likely never do again, like the construction of a new bladder from a piece of stomach combined with a piece of small intestine, for a child who was effectively born without one. So cool!

I would highly recommend a urology rotation for anyone. Here are just a few of the the specific (and I’m sure widely applicable) skills I have learned or refined so far: foley catheter placement, suturing and knot-tying, cystoscopy, penis jokes, and smiling and nodding at gynecologist jokes.

By popular demand

Walter's tongue many weeks post-op - I think this is our new normal.

Same sleepy puppy...

Catch-Up

Somehow, in the midst of rotating with the midwives, a family wedding, and two board exams, the blog was a bit neglected last month. Oh, and the month before because of the ICU… Sorry! Here is a quick catch-up post to share some fun things that I did but didn’t blog about.

1. Hell’s Kitchen. I went to Minneapolis to see my lovely cousin get married, and in doing so got to see my mom and sister, among others. On the Saturday morning before the wedding, we decided to try Hell’s Kitchen, advertised as the most amazing place since sliced bread. We’d gotten mixed reviews from some, but wanted to check it out. It did not live up to the hype. I got the huevos rancheros, which were by far the best of anyone’s breakfasts, and they were fine. Not amazing, but fine.

2. Creamy Turnip Soup. This was an adaptation of Mark Bittman’s Creamy Carrot Soup, and used up many of the turnips that my CSA so vigorously produced. It was delicious, and delightfully simple. Sautee a chopped onion and as many turnips as you wish (or carrots, in which case you may wish to add a potato) until they are just tender. Add about 5-6 cups of water or stock and cook until the vegetables are soft. Use an immersion blender to make it smooth, and season with salt and pepper.

3. A lovely picture of peas. Nothing more to say, just wanted to share this pretty picture from my CSA back in June. Join a CSA here!

Tub Birth!

Cross-posted on Dose of Reality

For the past month I’ve been rotating with the midwives, as I outlined here. One of the things I was most looking forward to this month was getting to attend a tub birth. Delivering in the tubs, which are fairly spacious and definitely still located inside the hospital room, seems to make most of the physicians delivering babies nervous. As a result, I’d never seen one, and was very curious. It didn’t seem that this wish would be made reality until the last day of my rotation. Due to some quirks of the healthcare system that I won’t enumerate due to HIPPA requirements, this particular mother decided to labor in the tub. The whole process went very quickly and easily, and she and I caught the baby together. So exciting!

This whole rotation has made me think a lot about how I’d like to do antepartum, intrapartum, and post-partum care in my own future practice. While lots of things, like having 30 minute rather than 10 minute prenatal visits to allow for questions and teaching, have helped me to understand why so many women so strongly prefer the midwifery model to the physician model of care during pregnancy, few things seem to emphasize this as starkly as the tub birth. In the world of low risk, low intervention pregnancies and births, there’s no reason not to get in the tub and deliver there if that’s what the woman wants. It’s warm, is really helpful for pain during labor, and is a great way to get skin-to-skin with your baby right after birth. In the world of high risk, high intervention pregnancies and births, it seems that behind even the most benign of deliveries lies a strong concern about something possibly going wrong, and the need to do everything possible to prevent that.

This preoccupation with potential problems is what physicians are trained to do. We see the possibility of a critical airway with every cough, spinal cord compression with every twinge of back muscles, and hidden malignancy with every fever. While we are continually told in school to think “horses, not zebras” when we hear hoof beats, the rare and the bizarre are emphasized in lectures, exams, and the questions we’re asked on rounds. How then, is the well-intentioned medical student to take a step back and recognize a truly uncomplicated and normal process as it takes place, rather than waiting and finally conceding after the fact that nothing went wrong? After working with the midwives for a month, I confess that I haven’t shaken the niggling doubts I have each time someone mentions a mother pushing for seven hours before her baby is born. I think that most of the midwives have some doubts too. But they’ve helped to remind me that most women know how they want to birth their babies, and that most of the time, they’re right.

Whoa...

Cross-posted on Dose of Reality:

Somehow a few weeks have flown by since I last posted. This may be related to how much I'm loving what I'm doing right now... No, I'm not thrilled to be studying for boards, which I am also doing, nor to be preparing my resident application. Neither am I incredibly pleased that the dog required another small procedure to get rid of some infection at his old surgical site. The primary thing I'm doing this month, however, is working with the midwives, and it is fantastic. I'm actually posting from the callroom, so I will be brief. Here are the things I've loved so far:

• Prenatal visits in English and Spanish and with patients across the demographic spectrum that Ann Arbor and Ypsilanti have to offer
• Natural deliveries and the proud and happy mothers and babies that result
• Hands-on learning; I've helped with a couple of deliveries, a few repairs of perineal tears, and lots of physical exams, prenatal teaching, and post-partum follow-up!

These last few weeks have been a flash-back to the best weeks of medical school, my OB/GYN rotation, but with an extra emphasis on the collaborative relationship between pregnant women, their families, and their healthcare providers. So wonderful!

Picture made from 1,000 words

Last year I posted a few images generated from the RSS feed from this blog. The website that generated them seemed to intuit how my life changed over the course of the first half of M3 year. I decided to repeat this again today, just to see how different it was now. Turns out that I posted a lot about the ICU... Also about radishes, which I think are wholly deserving of their front-and-center placement here.

Thoughts?

Another box checked

Today was my last day in the ICU. I have the MSTP retreat this weekend, so I finished on Thursday instead of the usual Friday. While I feel a little bit sad about the end of such an intense experience, I can safely say that I’m looking forward to having a lot more free time next month. This sums that up reasonably well:

I biked a total of 4 miles this month...

Pickles and other reasons the summer is lovely

The ICU has been sucking away my time, so this will be somewhat brief. In fact, the title is now blatantly misleading, as I’m really only going to talk about radish pickles.
These pickles were amazing. I try to cook seasonally, and in Michigan, that means eating a LOT of vegetables in the summer, and preserving some for the winter. These were my first attempt at a recipe from the canning book I got for Christmas, although I will note that they were not actually canned. I will also note that they were so delicious that they did not need to be canned. They probably didn’t even need to be refrigerated, given how quickly I ate them (as evidenced in part by the fact that I couldn't even snap a picture before the jar was half empty). Also they were pink.

Radish Pickles
adapted liberally from the Ball Complete Book of Home Preserving


2-3 cups sliced radishes
2 cups white vinegar
2/3 cup granulated sugar
1 tsp mustard seeds
2 tsp whole black peppercorns
sprinkle of red pepper flakes

Place the sliced radishes in a large glass or stainless steel bowl and set them aside. Combine everything else in a saucepan, and bring it to a boil over medium-high heat. Reduce the heat and let the liquid boil gently for a few minutes. Pour the liquid over the radishes, and then let it stand for about 30 minutes, or until it’s cooled to room temperature. Pack the radishes into jars, and ladle the pickling liquid over them to cover. Put the lids on the jars and refrigerate. The recipe recommends that they marinate at least two weeks and up to three months. I think I made it about 5 days, and they were all eating with two weeks. Yum.

33-40%

Cross-posted on Dose of Reality

I don’t often think about my life in terms of percentages, particularly as a way of judging success, but there are times when it is hard to avoid. For example, as sub-interns (the fancy word for fourth year medical students on more intensive rotations, such as in the ICU), we are expected to have off one day in every seven, or a total of four for the rotation. If a normal workweek, one in which the weekend is free, is 5/7, or 71.4%, then my workweek is 6/7, or 85.7%. This leaves only 14.3% of my time as free, which is small. Smaller even than the proportion of arterial lines that I have successfully placed, which is what prompted the writing of this post. An arterial line, or art line, or a-line as you may hear, dear readers, is a special IV that goes into an artery, most often the radial artery in the wrist. It allows for the easy drawing of arterial blood for labs, for continuous blood pressure monitoring, and for the humiliation of every medical student who ever did an ICU rotation. I have attempted the placement of five arterial lines, six if you count the one that I missed the first time but then got later after the one my resident placed failed, and that I subsequently got, as two separate lines. I have successfully placed two. That’s right, two. That gives me a resounding 33% or 40% success rate, depending on the counting I mentioned above. This is not reassuring. It is, however, profoundly humbling, which is probably not a bad thing. Maybe humility is what the ICU teaches most effectively of all?

Negative Margins!

I don’t have much time for a good post, but wanted to update you all about Walter’s exciting medical drama (background here and here). I got the call from the vet letting me know that Walter’s margins were negative, which is basically the most positive possible outcome. It means that it is unlikely that any cancer was left in his mouth when they cut out the side portion of his jaw. It also means, since the path came back as a sarcoma, that he doesn’t need any further treatment. Walter is a survivor! (I apologize if that term is offensive to anyone who is a human cancer survivor… I don’t mean to demean your experience at all.)

He is basically back to being himself, as you can see below. The primary side effect from the surgery is that he can’t eat things as efficiently as previously, which is great. Those of you who have ever seen him eat anything know that he used to inhale food and other random semi-edible objects. Now it takes a minute, which gives me a fighting chance…

You can hardly see where the teeth are missing...

Unchanged love of sleeping in clean laundry. Only now he sticks his tongue out as if to spite me...

Climbing rocks and having fun, just like pre-op.

Ever the snuggler...

Medical decision-making

Cross posted at Dose of Reality

I know the title sounds approximately as riveting as not at all, but I’ve been thinking a lot about it since I’ve started my ICU month. While I’ve been reflecting on the medical decisions I’m making, in the time I take to process everything I’ve seen, I’ve been focused more on those we expect the patients and families we care for to make. We call on them during their most dire hours and ask them to consider options they don’t necessarily understand, to weigh risks and benefits that are hard to put into context, and to make calls that no one ever wants to have to make. And they do it. Not always with the calm and rational process that would be easiest for the physicians working for them, but more often than not with an incredible degree of grace and reflection mixed into the grief and frustration.

The conversations are almost always accompanied by a great deal of sighing, sobbing, and shouting, which can be disconcerting to those of us working to provide medical care. I think what made me most frustrated back when President Obama’s plans to encourage the discussion of advanced directives turned into a death panel debacle, was the callousness of it with regard to the families of critically ill patients. How many of the individuals who were most loudly heard during that national discussion had been in the position of trying to determine the appropriate goals of care for a loved one at the end of life? I’d hazard a guess that there were very few. Anyone who has had to weigh these questions, particularly without the benefit of a signed document crafted by the patient him/herself charging the course ahead, would think twice about protesting a more considered approach.

With or without a mandate from the government, however, I increasingly believe that physicians and other healthcare providers have a serious obligation to discuss end of life care with all of their patients. A few questions about code status when a person is hospitalized (i.e., whether or not an individual would want chest compressions, shocks to the heart, or other measures to bring back a patient whose heart has stopped while in the hospital) are simply not enough. Although I have been impressed with the way many of my teachers and mentors have navigated these challenging situations with hospitalized patients and their loved ones, I can’t help but wish that as a nation we could pause, reflect on what we want from our last weeks, days, and hours, and take a moment to write it down.

Looking for more resources on Advanced Directives and Living Wills? Check here for the UMHS Publication.

100 miles… done.

Sorry for the pause in the posting... I started my ICU month on Monday, and it's set things a bit behind in all other aspects of life...

I did it! In the process of training I rode over 1,000 miles, over 500 of which were in June alone. It paid off though, in that most of the 100 mile ride was very comfortable. The last few miles up some very steep hills (really, ride organizers, really?) were rather painful, but I don’t think anything I could have done would have prepared me more for those. As was decided by you all in this post, we rode the Covered Bridge Tour, and I couldn’t recommend it more!

 

We started out in the historic village of Fallasburg, which is about 30 minutes by car outside of Grand Rapids. After registering and eating a very quick breakfast, we hopped on the bikes. Our first stop was in Ida, a mere 14 miles down the road. They had delicious snacks, and a beautiful covered bridge:

It was beautiful and shady for the next portion of our ride, and when we stopped again in Coldwater (past another bridge, see below) I hardly wanted to slow down.

We were about 25 or so miles into the ride, which is where I tend to really hit my stride. I’m properly warmed up, but not tired, and really enjoying myself. After that we went straight north back into Fallasburg for lunch. They served delicious pasta, garlic bread, strawberry shortcake, root beer, and chocolate milk (from the local dairy farmers, no less). Have I mentioned before that I primarily enjoy biking for the food? It was fantastic, and a good prep for our next 50 miles.

The second half of the route was much less shady and included a few more busier roads. The rest stop, however, was at a beautiful historic home in Ionia, MI. They were so gracious as to let me use the bathroom – probably the nicest one on any bike ride anywhere…

After that we cycled past the prison (seems you can’t bike more than 50 miles in this state without hitting a prison), the State Recreation Area (which looks surprisingly similar from the perimeter), the city (town? village?) of Lowell, and some of the most gigantic hills I’ve ridden ever on my bike.
And then it was done!

Polka-dot jersey kind of ride…

Last weekend Alicia and I did another long ride – this one 71 miles round trip. It felt a lot longer, however, because of the hills. Part of the route was similar to the preceding week’s ride, but the part that looped a bit farther north was also quite a bit steeper. We agreed that we should go around perpetuating the kind of graffiti we appreciate so much on Huron River Drive:

You see, the polka-dot jersey is awarded to the Tour de France cyclist who is the best at climbing hills. They get points for big climbs that are separate from the overall race, and throughout the race, the rider with the most points gets to wear the jersey. There are a number of different classifications, and each of them comes with a special jersey. The yellow jersey is worn by the rider with the best overall time, the green jersey by the rider with the most points, the polka-dot jersey for climbing, and the white jersey for the best young rider. Some enterprising individual painted a tiny polka-dot jersey on the road at the top of the largest hill on Huron River Drive, and it is a delightfully motivating little symbol.

Only a few days left until the big ride, so I’m taking it pretty easy. It’s also 101.8F today, so I’m trying not to die as well.

The longest ride to date…

Last weekend I completed a 73 mile bike ride. This is the longest ride I’d ever done, and honestly at the end of it I felt great. This made me feel even more great about my training regimen and my capacity to do the 100 mile ride in a week and a half. Here are some highlights from the ride:

1. The Waterloo Farm Museum is on the route. It appears to be run by the Waterloo Area Historical Society, and is pretty cool even from the road. When we biked past, there were signs for “Blacksmith, Soldier, and Log Cabin Day” at the museum. While that struck me as a rather odd combination of things to feature all in one day, who am I to really judge. We saw an assortment of interesting folks dressed up in interesting ways, but thought it might be rude to snap photos from the road.

2. Zou Zou’s was our planned lunch stop after the first 50 miles. I had a delicious sandwich with mozzarella, roasted peppers, and pesto. Alicia also enjoyed her sandwich, and their convenient bike rack makes it the ideal place for a stop.

3. Alicia mentioned an entertaining, but wildly functional new product they have at the store: DZ Nuts Bliss. I’ve known about the company for a long time, as they have a rather hilarious take on advertising their anti-chafing products (i.e., their slogan is “Protect your junk,” and the name of the company is derived from the founder's initials and their main focus). They’ve started making a women-specific chamois cream that, apparently, does not tingle like the men’s version. I have not ever tried the men's version, but I do not understand why anyone would want a tingly chamois cream. Their products also don’t have any petroleum derivatives in them, which is nice. The instructions for use start with “Slowly…methodically…shimmy riding shorts down to ankles (background music optional).” Looking forward to trying this out (but probably not to reviewing it in any depth here…)!

More greens

If you are under the impression that I spend a great deal of time thinking of things to do with greens, as evidenced in posts here, here, here, here, here, here and most recently here, you would be correct. I’ve concluded, as I am not the first to learn, that eating seasonally in Michigan requires equal parts creativity, dedication, and insanity. Or maybe there is a serious flaw in my logic and the insanity is not a pre-requisite, but rather a result of eating so much kale…

In any case, during our very brief stint of cool weather a while back, I made another soup. I ate a serving or two if it while it was cold, and then popped it into the freezer for next month when I’m working in the ICU and will likely have less time to cook (and will be eating in the hospital, where the vagaries of the weather are less likely to affect what I feel like eating).

Curry Broth with Whole Wheat Noodles and Greens
Adapted liberally from How to Cook Everything Vegetarian by Mark Bittman

3 tablespoons neutral oil (I used safflower)
1 small onion, chopped
2 tablespoons minced garlic
1 tablespoon peeled and minced fresh ginger
2 tablespoons curry powder
2 quarts vegetable stock or water
Long, skinny-ish, whole wheat noodles to taste (I used udon, the recipe calls for spaghetti, so go crazy…)
3-4 cups spicy greens, sliced into thin ribbons (I had a combination of radish and turnip greens)
Salt and pepper to taste (this will depend a lot on the stock)

In a large soup pot, heat the oil over medium-high heat. Add the onion and cook until soft, then stir in the garlic and ginger and cook for another minute or two. Add the curry powder and a little salt and pepper (unless you are worried that your vegetable stock is a bit salty already – it is always easier to add more later) and stir it around in the oil for a moment while it smells amazing. Then add the stock and bring to a boil. Add the noodles and cook until they are done – this will obviously depend on the type of noodles you have selected, but 8-10 minutes is probably a reasonable estimate. Turn off the heat and stir the greens into the soup. If you like, garnish the soup with fresh herbs (per Chef Bittman cilantro is a good bet, but I had already blended mine into some dal earlier in the week), or just enjoy!

Cape Cod Redux

Not quite two weeks ago I had the pleasure of celebrating with Allison and Katie at their beautiful wedding in Provincetown, MA on the tip of Cape Cod. I will never cease to be amazed at the uniqueness of each wedding I’ve attended (and it’s been three this year so far, with one or two still to go) and the “rightness” of each for the couple getting married.

This one started with the rehearsal dinner of a lifetime, featuring none other than the one and only Melissa Ferrick. For those of you not in the know, she is an amazing folk singer. For those of you in the know, IT WAS SO EXCITING!!!!!! I’m not sure what agreements were made, so I’m not posting any photos of her on the blog, but I will reassure you that I have pictures, and it was amazing.

The actual ceremony was also stunning, and took place on the beach. It was simple and heartfelt, and included the dog, which I appreciated a great deal.

 

The brides dip their toes in the ocean after the ceremony, and Stella gets ready.

Lest you think my trip to Cape Cod was filled only with wedding-related events, let me reassure you that it was not. The remainder of my time was filled with two activities, riding bikes and eating lobster rolls. This made for a truly idyllic weekend. I had not had a lobster roll before, and I tried several across the spectrum. Based on my research, the more expensive the roll, the more lobster and the larger pieces; the less expensive, the more mayonnaise and vegetables on the sandwich. I actually enjoyed both a great deal, and came to the conclusion that my previous belief that I disliked lobster was incorrect. Revised conclusion: I really, really dislike the smell of crustaceans before they are disarticulated and the meat is removed. I like both crab and lobster meat, but if I had to extract it myself from the shell, I’d never eat either again.

Yum...

The biking was equally wonderful. On Saturday several of us rented hybrids/cruisers and headed out toward the beach trails. Lots of lovely hills and beautiful scenery; it was the perfect pre-cursor to the wedding ceremony. On Sunday, I rented a road bike (!) and headed down the harbor side of the Cape. I made it down to Wellfleet, about 17 miles from the bike shop in Provincetown, riding part of the way with a nice real estate broker from Eastham who was doing his morning loop near Wellfleet as well.

 

 

 
Riding home I got a little lost, and added probably 5 miles and quite a lot of anxiety to my ride, but Google Maps saved me and helped me navigate safely back to the Inn and the bike shop! I thoroughly enjoyed a little foray into faster hill-climbing and awesomer first impressions on the road bike, but my fear of flat tires on my trusty hybrid is much less. Someday I’ll get a road bike, but only when I don’t have to sell my bike first…