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…

Bikes, books, and bakeries

Cross-posted on Dose of Reality

As has been discussed here previously, I’m training for a large bike ride that is coming up in less than a month. As usual, I’ve been tracking not only my mileage and speed, but also my ranking on BikeJournal. I like to think of it as my keeping-up-with-the-crazy-cycling-Jones-o-meter. If I’m rising in the ranks, then I’m biking more than the average member, and if I’m falling, I’m not keeping up. Granted, in order to stay even one really only needs to bike about 2 miles per day, but it’s still an interesting metric, and plotting it over time makes it even more interesting.

Look how much awesomer I am than last year! So far my predictions about dermatology and research rotations as good for biking are bearing out. Check back in another month or so to see what kind of curve the ICU month generates...

My training schedule marches ever onward, and I’ve been looking for longer rides to fit into my training schedule. Luckily, I received a copy of Cycling Michigan: 30 of the Best Bike Routes in East Michigan by Karen Gentry for either my birthday or Christmas over the winter, and stuck it on my shelf for summer reference. I pulled it out a few weeks ago and was pleasantly surprised! It features lots of rides, as the title suggests, in the eastern part of our lovely state, and includes quite a few that start in or near Ann Arbor. Because Michigan has so many beautiful places to ride, it can be hard to find a book with more than one ride in any given place, but Ms. Gentry does not disappoint.

 The first ride from the book took us through some beautiful countryside out to Manchester and back. Here is my bike posing for the picture.

My one complaint about the book is that each ride is described in copious detail without a succinct cue sheet or list of turns, and the maps are not detailed enough to use alone. On the first ride I did from the book, I simply copied the pages describing the ride and stuffed them into my jersey pocket. I had to stop frequently to read through the text to figure out where I should turn next. Two weeks later, much the wiser, I went through the book before the ride, typing up a cue sheet and copying the map onto the lower half. It was much easier to just follow the turns and glance at the map for reassurance. I love the routes in the book, but would recommend a little prep work to make for a better ride!

 The second ride went through Dexter, Pinckney, Brighton, and yes, Hell, MI. 

Another thing that makes for a better ride: doughnuts! I could not write a post about my recent bike rides without mentioning the Dexter Bakery. They make by far the finest apple fritter I have ever consumed, as well as wonderful soft pretzles and regular doughnuts as well; I would highly recommend it as a cycling stop. It’s conveniently located about 11 miles from downtown Ann Arbor, making it an imminently reasonable cycling destination. Yum!

And he returns home a survivor…

We won’t know the final pathology on Walter’s mouth mass for 7-10 days, but at least for now I’m letting myself hope that we’re out of the woods. I picked him up this morning following his surgery, and was pleasantly surprised at how normal he looks. I know I should just be glad that the cancer is gone (at least for now…), but I was really worried that he would go from being the ridiculous-looking adorable dog to the funny-looking lower-jawless dog. Turns out he’s still ridiculous looking and adorable, and now he occasionally sticks his tongue out a little by accident, particularly when he’s really tired. He’s got a little bandage where his IV line was, but is otherwise ready for a restful few weeks at home before our follow-up visit. He's still pretty sleepy. Here are some post-op photos to reassure you all that you’ll still want the Walter 2013 Calendar when it’s available…

 This is the best shot of his incision, which is the darker area on his chin. 

 

Here is Walter looking vaguely peeved that I am taking pictures of him during his delicate convalescence.

 

 The promised little tongue. He keeps it in his mouth pretty well for having just lost a chunk of his lower jaw. It's cute. 

 Surrounded by blankets, recovering on the couch.

Send the wimps* your love…

Some of you are probably tiring of hearing about this, but I wanted to post about it here because many of you love the dog and don’t see us on a regular basis. Here’s the quick(-ish) version of the story:

Two weeks ago I noticed that the dog’s mouth was bleeding a little bit after he was playing. I looked more closely and saw an ugly looking growth behind his teeth. Fast forward a few weeks and his biopsy showed that it was a malignancy, most like a sarcoma, but his blood work and chest x-ray suggested that it hadn’t metastasized yet. We met with the veterinary surgical oncologist yesterday, and scheduled surgery for today. I dropped Walter off at the vet this morning, and he was a champ through his surgery. They removed a piece of his lower jaw, slightly larger than anticipated because the mass ended up being slightly larger than they expected, but the vet said that he thinks Walt will bounce back quickly. Walt’s staying at the puppy hospital overnight for monitoring (as expected, not because something went wrong), so please send him your love this evening and for his recovery process. We’ll be awaiting the final pathology (7-10 days from now) with baited breath, hoping that it shows that the tumor was of a sort that is only locally invasive, and doesn’t require chemotherapy or radiation in addition to the surgery. Fingers crossed!
 

Of all of the things I knew I’d have to do as a pet owner, I didn’t think that talking about code status would be one of them. The staff at the vet were good though, and made sure to ask me whether, in the case of something really terrible happening, I would want them to resuscitate the tiny Walter. Of course I said yes.

These are some pre-surgery pictures from last night and this morning. As they will demonstrate to you, the dog is in no pain at all, and didn’t even whine that he couldn’t eat this morning (perhaps because I gave him a bonus dinner at 11:00pm last night).

*For those of you not in the know, the dog has a million nicknames. His given name is Walter. He goes by Waltini, Waltez, Wimps, Wimpenstein, Wimptini, Wimpsalloo, and pretty much anything you can imagine that starts with "W." 

Chilled Arugula Soup

The CSA has started up again and as is apt to happen in the early part of the season, I have masses of salad greens. I like salad as much, maybe more, than the next person, but there is only so much one can eat. When I noticed that I had two bunches of arugula that were looking a wee bit sad in the fridge, I started trolling How to Cook Everything Vegetarian for a recipe I knew I’d seen Mark Bittman do somewhere. I think the recipe I was remembering was this one, for lettuce soup, but I was struck by the possibility of a creamy chilled soup that really featured some spicy greens. The recipe called for cream or milk, but I boiled some turnips (also courtesy of the CSA) in vegetable stock instead. Here it is:

Chilled Arugula Soup 
adapted slightly from How to Cook Everything Vegetarian by Mark Bittman

2 tablespoons olive oil
6 cups (roughly) washed arugula or other spicy green (watercress, sorrel, and spinach are all recommended in the recipe)
3 cups vegetable stock
3 turnips, cubed
tiny, tiny drizzle of fish sauce (at the recommendation of Lynn Rosetto Kasper)
salt and pepper to taste

In a saucepan, bring the turnips, vegetable stock and fish sauce to a low boil. While you do this you can wash the greens. If they are large, you can chop them, but if you have a decent immersion blender you really shouldn’t need to. Once the turnips are soft (about 10 minutes, but it depends on how small you chopped them), in a large soup pan, heat the olive oil over medium heat; when it is hot add the greens. Stir until the greens wilt, then add the stock and turnips. Bring almost to a boil, and get out the immersion blender. Blend until smooth, and season with salt and pepper to taste. Chill and serve.

If you don’t have an immersion blender, you can chill the un-pureed soup and then put it in the food processor, blender, or food mill once it is cool. Esteemed Chef Bittman includes some cream or milk in his recipe at this point, but I opted to leave this out. You could try soy milk or rice milk for a vegan alternative, but I found that the turnips added enough creaminess for me. Enjoy!

Congratulations Camille and Rajeev!

I went to a really lovely wedding last weekend. My upstairs neighbors (parents of Dante, a charming Corgi mix, to those of you in the know) got married and I had a simply delightful time. I got my hand decorated at the Friday evening Sangeet:

It got much, much darker overnight, but is starting to fade a little bit now. Most of my colleagues at the clinic are intrigued by it; one asked to clarify whether my hand was just dirty, or whether it was left over from the wedding.

They also had a photobooth, where I took some cute pictures of myself. Brighter folks than I took quick cell phone photos of the strip of pictures and posted them various places – I’ll try to remember to add that here when I’m back in Ann Arbor.

Out of phase life transition #1,000,000

My sister graduated from law school this past weekend. I'm super proud of her and am so looking forward to hearing about the amazing things she is doing now that she can put ",Esquire" after her name. That said, this is yet another person who by all rights was suppose to finish graduate school after I did who is now sprinting breezily across the finish line. And did it with style (Summa Cum Laude!). The psychiatrists call these events "out of phase" life transitions - like when a child dies before a parent or something good happens but it's still out of the order that you'd expect it to happen. Like when the students I taught as undergrads graduated from medical school before I was an M3. To distract myself from my seemingly never-ending graduate school career, I immersed myself in enjoying NYC for a weekend. A few pictures follow (with a bonus one of the dog thrown in for Claire - congratulations again!):

I was obsessed with the bridges on our Harbor Tour...

 

Mom insisted on singing the Emma Lazarus poem quite loudly as we approached the statue by boat. She threatened to reprise this performance when the guide read the poem as part of the tour.

 

A trash boat!

The graduation - my sister does not love photos of herself on the interwebs, so there aren't any here!

She loves Walter's face appearing on the interwebs, so here he is!

Welcome to M4 year, the best year since kindergarten

Cross-posted at Dose of Reality

I learned a lot last year, and one of the oft repeated nuggets of wisdom shared by residents and more advanced students alike was the joy of the year to come. They promised a less intense grading environment, electives chosen for purposes other than fulfilling core requirements, and more free nights and weekends. So far this is mostly true. I’m in the midst of a dermatology rotation at Henry Ford, a community teaching hospital in Detroit that is connected most closely to Wayne state, but at which UM students have the opportunity to do a few M4 year rotations. In spite of the fact that everyone seems slightly horrified that I’m not planning to go into dermatology, I’ve gotten to see a wide variety of dermatologic complaints while working with delightful residents and attending physicians.

Lessons I’ve already been applying from M3 year:

• You will never know exactly where you should be or what you should do, so don’t be afraid to ask questions.
• Smile a lot. People are less likely to think you are dumb if you also appear friendly and they like you.
• Fake it. Listen closely to what your resident asks of patients so that when you have to see a patient by yourself, you know what questions they will think are important to ask and report back. Eventually you will make it and understand why they have asked those questions.
• Wear gloves. Especially when someone has a rash on the palms of their hands, as it could be secondary syphilis and that is contagious through the rash.

New lessons I’m already learning about M4 year:

• The word elective not only means something you chose, but also something that is not required of everyone. This means that the rest of your medical school training is unlikely to have covered this material and you will need to read a lot.
• When someone tells you that something will be the best “X” since kindergarten, they do not necessarily mean that the entire thing will be filled with naps and snacks. They might mean that you can pick your poisons and that your schedule will be more predictable than previously.
• Smile more. Especially when someone gives you the stink eye after you delicately explain that you are leaning strongly toward (read: have already chosen) another specialty and are just there to learn about their specialty, not to audition for their residency program.

Anatomy of a bike ride…

I went for my longest solo ride this season this morning, and during the few hours on was on my bike I thought a lot about training. Last week, I took Monday as a rest day after my 35 mile group ride on Sunday, and then did relatively short rides on Tuesday, Wednesday, and Thursday. None of them were great rides, and I was feeling pretty frustrated about my training regimen. I felt slow and sore, and really wasn’t enjoying riding my bike. Adding insult to injury, the only five minutes that it rained really hard on Wednesday were during the last few minutes of my ride. It had been sunny, with blue skies and fluffy clouds, and just before I arrived home, the temperature dropped by 10 or so degrees, the sky darkened, and the rain poured. I was cold, wet, and miserable. I wasn’t sure how to solve what seemed to be a combination attitude and athleticism problem, but a little voice in my head said “Is it possible that you are pushing yourself too hard?” I had brushed off the same little voice as I headed out on Thursday, and ended up cutting my ride short because I just didn’t feel good. As I looked at the beautiful, cloudless sky on Friday, I decided to take another rest day. It wasn’t on my calendar, but I thought an extra day of stretching might make me feel better. Lo and behold, it did. This morning when I got on my bike, I felt much fresher and was able to enjoy the burn up the hills, the wind in my face, and the perfect temperature of the air. I also warmed up properly, letting myself amble along for the first ten minutes, spinning faster than I needed to and pushing less than I could. I realized that I might have been sabotaging myself, pushing hard right out of the parking lot, straining cold muscles up the hills while lamenting slow progress, day after day without enough recovery time to get stronger.

For the record, it only rained a tiny bit on my ride today, which I consider a major victory. Also, my second lesson of the day was that I can, in fact, feel cold fronts move in while I ride my bike. They are not pleasant and I wish they would hold off until my ride was done…

Here’s to learning important things at the beginning of the season, and riding stronger AND smarter the rest of the summer!