What I would (now) consider when looking for a job as a senior resident

In residency (at least in my residency program), not alot of discussion (or explaining) went into finding a (real) job upon graduation. I guess I just kinda thought that once I'm done...the jobs'll just be there. Like, they're out there just waiting for me to graduate.

To be fair, however, I must admit that *I* wasn't really able to even *think* about what happened 'beyond residency.' It was some kinda of elusive concept that I just couldn't wrap my mind around. In our program, it wasn't (entirely) unheard of for a senior (who's all set to graduate) to be held back...unexpectedly, for lack of completion of a task or project. This freaked everyone out. Especially me, as I was pregnant with my second child at the end of my residency. I just couldn't be 'held back'...

...so my thoughts were: if I can just frikin graduate already...everything else will work itself out.

I'm no job hunting expert by a long shot. I'm still kinda 'floating' trying to find my spot. But, some of my 'mis-steps' may have been avoided...or at least anticipated, if I had just a tiny bit more information coming out of residency.

1: Read information from those who know. I would be sure to read Barbara Katz's column in our publications. I really took into consideration her advice...and without it would have likely had more mis-steps.

2: Expand your search area (a tad larger than you'd like). I am a California girl...and wouldn't even *consider* moving. But, I now realize that California is *big*...and I don't have to move outta Cali, but I may have to move. My point - moving isn't as bad as it seems, and if your perfect job isn't in your 'home-town,' consider expanding what qualifies as your 'home-town.'

3: Be honest with yourself. You should choose a job/location that (honestly) appeals to you.

We all know that many of the worst societal problems are recurring themes in the ER. The location of the ED will determine which of these 'societal problems' predominate your practice. I don't mind the drunks, the dumb assess who crash their bikes/cars, the assaults. I enjoy working with people of color, and am not at all intimidated by loud obnoxious men under the influence cursing and yelling. But the suburban, entitled drug-seeking woman, who goes to great lengths trying to convince me that she's not an addict (when she obviously is one)...irritates me. The barrage of demented, essentially dead, nursing home patients who should be allowed to die with dignity...but instead their family insists that everything be done (eventhough it's our *responsibility* to refrain from participating in futile care), annoy me. "Super nurses" - those who have issues with being nurses, and wish they'd have gone to medical school, but couldn't/didn't...and now want to run the 'healthcare team' - makes my time in some EDs overly stressful.

I enjoy nursing students, PAs, and practicing in an environment where everyone recognizes they are learning (always we are learning), and we bounce ideas off of each other...and we support each other. I realize that I don't mind if a hospital or ED doesn't exactly 'flow well'...as long as everyone recognizes that we are 'all in it together' and if something goes wrong it's useless to point fingers at individuals for systemic failure.

(Particularly) at rich hospitals, fingerpointing is the modus operandi. They are overly concerned with patient satisfaction scores and extrinsic accolades (to prove how great they are), while doing nothing more for the patients nor the physicians. Their idea of increased productivity is to crack a whip under the doctor's ass...instead of slashing some of the non-physician tasks we are asked to engage in. For instance, it does no good to put patients in a ER bed/room rapidly if it still takes the lab 2 hours to run a CBC. And it does no good to do 'rapid triage' when the actual ER care cannot take place for 3 hours because the paperwork is too overwhelming, or the doctors cannot get in to see the patients (post-triage) because the ED isn't set up to maximize physician productivity (i.e. patients scattered haphazardly through-out the department, or needed supplies aren't readily available - both which result in wasted physician productivity time...and delays patient care needs).

Also, patient satisfaction scores (that are so coveted at some places) are useless, and very unfair to the entire staff since many factors that determine 'patient satisfaction' are completely out of our control. Additionally, they are useless because, if I do my job correctly, people aren't necessary gonna like what I have to say...my advice, treatments, or recommendations. Being a good doctor doesn't necessarily mean making patients happy (I could go on and on and on on this...). In rich hospitals, there are meetings and committees, and everyone wants to feel important...but no solutions (practical solutions) are implemented. And the people who patronize the hospital seem to be oblivious to the fact that what happens in South Central *directly* affects them in Beverly Hills.

On the contrary, some people can't stand those damn drunks!! Or those people without insurance that 'expect us to work for free.' Or all those 'well babies' who don't have a primary care doc, so your ED turns into a pediatric clinic afterschool. Some people can't tolerate a hospital where you have to write everything down...and your xrays aren't on a pacs system. Or...the place is in a shady neighborhood and they feel they're going to get jacked everytime they go out to their car (or maybe they have been).

They cannot tolerate the internal politics and nepotism that promotes people to incompetence. The constant struggle with heavy topics such as poverty and race relations. They hate the fact that no one seem to give a shit that everything is all fucked up...and no one has an interest in fixing the problem. That many basic things are neglected, and patients suffer. No one is held accountable for anything, and a good doctor may find themselves unable to carry the burden of 'doing everything', without feeling over-taxed.

As stated, the ER brings out the worst in society. What can you deal with?

4: Are you interested in working alot or alittle? Some groups require many, many hours to consider your contribution significant enough to even recognize.

5: Do you need benefits?

6: What is the salary. Not the most important thing...but don't listen to those who say it doesn't matter. It does matter.

7: Be sure your contract (if there is a contract), doesn't prohibit you from leaving the group and going across the street and finding another job. You don't wanna have to move (especially in this economy) because you decide you don't like a place (or they decide they don't like you).

8: I would advise one to avoid accepting bribes gifts of money from groups unless you fully understand exactly what it is your 'buying'. ('Cause the money/gift ain't free). Like one HMO offers a housing loan forgiveness program (where they give you the down payment on your house)...the best piece of advice I ever got from anyone during this process was - 'do not take these gifts.' Indeed, they come with a very expensive price-tag!

9: What is your partner/spouse going to be doing? If you move to a small township, and s/he has nothing to do all day (but deal with the kids)...well, this needs to be honestly considered. Do you want your partner's sole reason for being in a place, to be you? That kinda sucks, IMO.

10: I think it's important to figure out how a job will fit into your *entire* life. This means a consideration of how much time is required of you...and what your life will be like when you're at work, and when you're not at work. I you're the only Asian woman in a town of very close-minded white folks...well, that will affect your life. If you are African American, and they don't sell your hair products for 200 miles, and there are no salons who can even cut your hair...perhaps you'd do better closer to a major city? And, if you're Latina...wouldn't it be nice to see people who look like you from time to time...and maintain your Spanish skills if you speak it? Do you like to ski? Go to the beach? Enjoy the sunshine? Miss the distinct 4 seasons? Need to be near your parents (or they near you)? Politically, if you love Hilary and want to show support, will your house get torched if you dare display a Hilary lawn banner? Will people yell 'mean' things to you if you drive around proudly with your Bush/Cheney sticker? I'm not suggesting everyone segregate based on different beliefs, cultures, ethnicity etc. but just that it's taken into consideration.

***

I don't have enough experience to give specifics on finding a job out of residency. I have learned that finding a job is complicated and very unintuitive. I have picked up a few pearls along the way...and I've shared a few here. As I learn more, I will share more.

filling my time with less frequent blogging...

I heard that blogging can be hazardous to your health.

It's interesting, because blogging can be stressful and overwhelming...especially if you're expected to produce new material more often than you actually *have* new material. After blogging about a year (more-or-less consistently), I find I have ranted and fussed about most of the things that bother me most (but don't fret, I still have a few annoyances I'd love to expose...and new annoyances things are always "coming up"). I have shared my enthusiasm for my profession. I have documented the process, the thoughts, and the transition from medical student to attending. And I've talked about memorable (pseudo-)patients. Now, I don't feel as pressured to write all the time.

Additionally, it's takes quite a bit of time on the computer to post even one (legible/comprehensible) entry. To translate your thoughts to print...and make them comprehensible by most who'll read them...takes time (depending on the thought). And, I've seen hours "disappear" as I update my blog, surf the net, return email, etc...all while the kids are on their 8th episode of SpongBob SquarePants of the evening (just kidding...kinda).

As the days get longer...and the weather warmer...and the kids get bigger (i.e. more activities, more time needed to engage them, more friends over, etc)...I think I'll have to spend less time on the computer. When they were in bed by 8pm - and me not until 11pm...I had lots of time. But now the little guys aren't in bed until 10pm (it's actually still light outside until almost 9pm in the summer here). So, I have less time to waste spend on the computer.

Just thought I'd post this for those who may wonder 'what happened?'.

Just enjoying the sunshine...

What was medical school like? Years III and IV

After completing years I and II, you have a small break. At our school, this break was only a few weeks....and it wasn't really a 'break' at all.

After completion of year II, it was required that we take (and pass) the USMLE Step I. This first part (of a three part series) tests your basic science skills. Basically, the things we learned in years I and II are being tested. Our school was pretty good about teaching to the test (somewhat), and boasted a high first time pass rate. But you see, that 'break' was spent cramming for this licensing exam.

This exam was very difficult. You know, one of those exams that you can't even discuss afterwards because there were just so many uncertainties. You have no idea how you did. On other exams we've taken, most of us had a feeling about it:

"I think I did okay...but number 10, you know, the question with the xray...I wasn't sure if they wanted this answer or that answer...etc.'" OR, "that exam was horrible...what?! you put C for number 4?? geesh, I musta missed that one too...etc" (like this). After this exam, it didn't happen.

When I took the exam it was 2 days long...all day (except an hour for lunch). After lunch on day two...I just started marking everything 'B'. I was so tired of testing.

After you take that exam, you begin your third year. By now it seems as if everyone knows what they wanna specialize in. And if you do, that's a good thing. The sooner you know, the better. No one told me that...and I wish they had. If you know you wanna be, say ophthalmology, you can engage in research, and start kissing ophtho ass early. You'll take the rotation as soon as possible...and as many ophtho rotations as necessary to get the letters you'll need to match.

Years III and IV consist of clinical rotations.

Our 3rd year rotation schedule was made for us (i.e. we didn't get to choose the order of rotations). Basic required rotations were surgery, internal medicine, psychiatry, OB/GYN, family medicine, orthopedic surgery, pediatrics, and neurology. Our 3rd year consisted of these rotations. Most were about 6 weeks. You had about 12 weeks (maybe it was 16 weeks) of vacation. You could take that as a block, in two 6 week blocks, or however you could manage it. You requested your vacation time...and the university filled in your 3rd year schedule around it.

Our 4th year (frequently referred to as a 'sub-internship') we did our own schedule. There was a second round of required internal medicine...and many of us didn't necessary get all of the 3rd year (required) rotations completed in 3rd year (maybe because of vacation request, or scheduling, etc). So, you had to finish up those. Many of the rotations (the 'interesting' rotations) required the student to have completed a prior 'basic' rotation. For instance, an NICU (neonatal ICU) rotation will no doubt require the student to have completed pediatrics (and possibly OB/GYN) prior to starting. During this year, students typically take rotations like radiology, anesthesiology, emergency medicine, ophthalmology, dermatology, and maybe some bizarre elective at a far away place (but these electives are hard to get approved, and most students opt for pre-approved, 'normal', nearby electives). Also, you get to choose which hospital you'd like to do some of the required rotations. University hospital, County hospital, Community hospital, etc. There are some rotations that are notoriously easy (meeting like twice in 6 weeks) for an easy pass, and a nice break. I (am not ashamed to say it) *maximized* these opportunities. ;o)

During the rotations there are weekly lectures that your school 'requires' you to attend. These are usually very welcomed "breaks" from floor work/scut. Every day the students would try to get out of evening rounds by announcing: "uhhh, we have lecture this afternoon..." The residents and attendings were made *very* aware of the requirement of students to attend lecture...and were powerless to say or do anything except let us go (but beware, they'd sometimes verify that we're actually at lecture). Additionally, there were morning rounds, grand rounds, attending rounds, sometimes evening rounds. Lots of time in 'meetings'...really makes for along day when there's lots of scut to do.

The lectures were by in large *very* useful. And, in retrospect, I'm very happy I attended most of them. Learning pediatrics while doing a peds rotation...really solidifies the information. At the end of the rotation, there was an exam (on the lecture material). Some schools use the shelf exam, thankfully ours didn't. We had exams written by our professors. Everyone passed...eventually. You could take the exam multiple times, until you passed. Every (required) rotation had an exam.

Also during this time we had to take an OSCE (like a fake/simulated patient encounter). Completely bullshit (even in retrospect), where they bring in actors to play patients, and you're graded on how well you "play doctor." I hated "playing doctor." And I hear that this bullshit OSCE is now apart of the USMLE?? Requiring poor (literally, poor) med student to cough up money to take this BS? (but I digress...)

As a 3rd year, your presence on the team is largely unnecessary (despite what they tell you, and regardless of the student's arrogant belief to the contrary). You slow down the intern/residents; and all of your orders (rightfully) have to be cosigned...hence they are useless. In clinics you're really annoying to the people actually 'working.' In-house on the floor, the patients think you're 'cute' and they always 'know someone, who knows someone, who 'gonna be a doctor.'' And instead of telling you their deepest concerns and intimate medical issues...they wanna talk about *you.*

In retrospect I realize that much of that...that inability to be taken seriously by patients was my fault. I was insecure, didn't really know what to ask. My history was unfocused. AND I actually sat there with them for hours getting largely irrelevant information...which made me their "friend" and not their "doctor." (which is okay since I *wasn't* a doctor...).

The various rotations differed from each other tremendously (and I'll discuss that on a different post). But, in general, to do well in the clinical years involved working smart - and the realization that you're really gonna have to make some time sacrifices during those rotations that involve the specialties you're actually interested in applying to...because they will haze you.

Let's just take internal medicine as an example:

To do well in internal medicine you should try an be apart of the team. That means not leaving too frequently to attend "lecture" or whatever. That means arriving before everyone else does, and leaving after they do. When you have patients assigned to you, realize that *you* are not managing the patient - the attending and residents are managing the patients, and you are doing what they tell you to do. Your role is to listen and learn. But more than that, having assigned patients means you're responsible for *information gathering* for those patients. As a 3rd year (and 4th year...and intern) YOU ARE AN INFORMATION GATHERER.

Some will tell you to 'know everything' about your assigned patients. Well, that advice didn't help me much because, on a practical level, that is not possible. Better advice would have been as follows:

You come early and get the lab values (know the trends), the radiographs/results, the medication list with the antibiotic day number, fluid intake/output/weight change, any overnight events on the nursing note or per the patient. You should know what the physical exam shows (new rash? pressure sore? crappy lung sounds?) You should know the vital signs, and if any fever spike overnight (and if so, what time). You should know if any orders had to be written on your patient, why, and if what was done helped. You should know their bed number (and if they were moved, the new bed number, and why they were moved). You should know their working differential diagnosis...and do some reading about the disease(s) and how to treat them, what complications to expect. You should have written the daily progress note (to be completed after you are told by your team what the assessment and plan are). And you should anticipate (or have the handbook) of possible questions the attending will ask...and know the answers so you'll look like a star.

Your school will let you know if overnight call is required. There needs to be a place for you to sleep, and something for you to do. The nurses may (or may not) be instructed to call you first. And if they don't, well...it's kinda no point for you to be there. Especially if your orders all have to be cosigned. The intern will have to take every call, and write every order anyway...

...but at some community hospitals I rotated thru, there were very nice call rooms for everyone...and the nurses *did* take student orders...and they *did* call the student first (usually these are 4th year rotations where you're working as a sub-intern). It's easier to stay on-top of your patient information gathering duties if the nurses call you when there's an issue. And you felt important. Also, typically OB requires overnight call for obvious reasons.

Exactly what do you do all day?

Well, you go in early (whatever time makes you the first person there). You go physically look at your assigned patient (usually you'll have 2 or 3). Make sure they are alive, breathing, and are still in the location they were yesterday. If they are awake, ask them how they feel. Be sure they know you were there (this is more important as an intern and beyond, sometimes patients will complain that 'their doctor never comes by and see them' not realizing that *you* are the doctor...and see them multiple times a day. You can't have patients spreading rumors like that about you). Put a stethoscope on their chest. Pull back the covers gently and make sure there's nothing obviously wrong. Do a focused exam - meaning, check the part of the body that's causing them to stay in the hospital. Note any changes.

Then you have your paper/index card for that patient. You write their room/bed number on top next to their name and medical record number. Then you grab their chart and flip thru it...looking for the information I described above. Look at the nursing notes...and read what they wrote overnight. Look at the vital signs sheet for the last 24 hours. Look at the order sheets and see if/when anything was ordered. Read the physician progress notes, and note anything significant. Be sure to look at the medication list. Check the labs, and remember to check for any positive blood/urine/sputum cultures. Know the medication allergies. Look and see if any of the consultants wrote any (new/old) recommendations. Then, write your note with all of this information incorporated SOAP note style (leaving the AP blank until after rounds). If your note is good, only the attending will have co-sign, and it'll count as an official note (i.e. the intern won't have to write a full note, and they'll be happy).

Do this for every one of your patients. And with any time left over, you go eat, and read a bit about the diseases your patients have (and what to make of any overnight changes).

If your hospital still has plastic xray films, you should find them, and gather them. Carry them around for the attending to look at. If you have a pacs (digital) system, log on (or have someone log on for you) and look at the films. Look for any radiologist reports...and look at the images yourself. You should be able to identify any significant changes between today's xray, and the one taken yesterday. Lungs more white? Kinked chest tube? Free air?

During rounds you present your patient the way the attending likes it. Be sure to at least mention (to someone other than another student), things that *you* think are important, but couldn't say on rounds. Remember, rounds isn't always about learning or information exchange...sometimes, with some attendings, it's about providing them a platform to flex. They may not appreciate someone like you making them 're-focus' on patient care.

Many teams will have short 'okay-this-is-the-*real*-deal' rounds after the attending leaves. Where the work is divided. Then everyone goes to morning report/rounds. Morning report is a lecture where an intern presents a case, and everyone does this mental masturbation exercise about the patient.

Then it's time to work. Most hospitals where residents exist aren't very efficient. The nurses don't do shit...and the students/residents do everyone else's job. This is what takes forever. This is the problem with resident education. This is why it seems as if the surgeons aren't as well trained with restrictions in place...eventhough they're in the hospital 88 hours a week. Are the surgical interns/residents so stupid that they cannot learn what they need to learn in the 88 hours/week, 5-7 years they're there training?? (I just love what the medstudent tells Bongi in the comments section of this post). Of course not!! They aren't doing all the necessary *doctor tasks* to properly train because they spend 90% of their time doing other people's work and miscellaneous non-physician/non-educational/irrelevant bullshit. Drawing labs. Finding lab results. Pushing patients to scans/xrays. Finding xrays. Massive clerical work. Trying to plead with hospital staff to do what they're supposed to be doing for the benefit of the patient (so they can get that study done, or that consult completed...so everyone can go home). Residents/interns play social worker, trying to discharge patients with no place to go. And during it all while being constantly interrupted by pagers. Some of the bullshit is unavoidable, but much of it can be changed if the higher-ups were really interested in change and patient safety...while maintaining the high quality of the doctors being produced.

But instead, they advocate for unrestricted resident hours...

Unwritten rules include:

it does you no good to make your fellow student, the intern, or resident look bad in front of the attending. If the intern is asked a question by the attending on rounds, and s/he doesn't know the answer...don't you jump in and blurt the answer. You say nothing...unless the attending directly asks "does anyone else know?" And still you wait a minute. I would advise that 'if your superiors don't know, then you don't know', period. If you are smart and actually *do* know, it will show in different settings - such as when you concisely present your patients to the attending with a focused differential, and the subsequent pimping session proves you know your shit; or when the attending asks you a question first and directly and you *modestly* give a correct answer. You do not get cool points from anyone being a smarty-pants know it all. And if one of your teammates doesn't know something about his/her patient, you can tell them discreetly, but never one up them on their own patient in front of the attending. And, please, *never* ask questions that you know the answer to. This annoys everyone!!

It's best to not talk negative about anyone. That can only come back and bite you in the ass.

On rounds you follow the pack. You stand if chairs are limited. You carry all the crap (the stethoscopes, the otoscope, tongue blades, whatever is commonly needed but not commonly easily obtained). You don't argue. If someone says you're wrong, you're wrong. Even if you're not wrong...just forget it. If you want honors, and a match into the specialty, you'll realize being 'right' doesn't matter.

Many times inappropriate comments were said (especially on surgery), and may put you in a difficult spot. Usually some sort of sexist jack-ass with a small dick blurts out some off the wall comment about women...but sometimes it's even more hateful than that. It was not unusual for surgical attendings to throw full-on (two year-old type) tantrums. Surgical instruments thrown across the OR because anesthesia had the table too low. Or verbally abusing everyone, just to see how many times he can make the resident cry.

What seemed to work well at our school - a group of students who agree that the person is out-of-line would go to our student affairs dean and complain because it's never just one episode of ignorant behavior, and many people can usually agree that the guy (it's usually a guy) is an ass. We'd express our concerns, and demand to be moved to another team, or another service, or another facility. Usually, if there was a (big) problem, you could be moved (as it should be being that you're paying up the ass for an education). And on more than a few occasions, students were not placed on certain teams, or with certain attendings with a reputation for being assholes. But realize that as an intern...the solution is not so simple.

Offer to do a presentation for the team. Bring in an interesting journal article (if you happen to find one), and educate the team about it. Have a happy disposition. Be reliable. If your intern relies on you, you cannot miss attending rounds...because they will not know the detail about the patient that you know because they were *relying* on you to know (and be there). (Even if you're sick, you need to come in for attending rounds...then ask to go home). And don't leave until all the work is done...or at least ask if there's something you can do to help out the 'slow-poke' before you leave. Usually the answer is "no", but if you acknowledge that they are still there, and offer the help...it will be noticed.

In order to graduate from our school the USMLE Step I must be taken and passed. USMLE Step II is taken during senior year. It does not have to be passed to graduate. There are strategies as to when to take Step II. Some do it early to make their application competitive. Others do it later, as not to tarnish an already acceptable application. It depends on the competitiveness of the specialty, and the competitiveness of the student. Also a consideration, if you did awesome on Step I...you may not want to take the chance that your Step II score will be lower, and some of your shine is lost.

USMLE Step II is easier (more practical information), than Step I. It was also 2 days long. Exam topics are those of the basic rotations - peds, IM, psych, etc. Some specialties consider the USMLE score to be the single most important part of the residency application.

***

Overall, in years III and IV you have much more control of your time. Only a few rotations are brutal, and only being so because of their long hours and the amount of scut (i.e. gathering information, and pushing the patient along in the hospital diagnostic/treatment process) required. Some rotations will be more stressful because you're trying to impress the staff. Usually, by mid 3rd year everyone is pretty sure what their interests are...and it's no secret to surgery residents that you're not into what they do. And they don't torture you as much.

You have time now to see a movie. The tests are easily passed with a day or two of studying. Even the USMLE has great prep material out there such that you don't have to study much more than a 150 page book and do well (enough). If you're a good team player, and do well on the exam, you'll honor at least a few (maybe even most) rotations. If you do very well, and people really like you, you may be inducted into the honor society, AOA. AOA on your CV looks very good to program directors of competitive residency programs. Also, you have time to engage in some research (not alot of time, but *some* time). And some students will take a year or two off after 2nd year to do research (or have babies, or travel, or get an MBA, etc). This will also look good on your CV (well, maybe not the 'have babies' part, but that can be disguised as 'research' if done correctly).

Many medical students decide to have children during 4th year. Some do away rotation in Costa Rica. Some take no vacation...and save it all to the end (this is what I did). This was fantastic since my last rotation ended in early February, and I had 'vacation/freetime' until I graduated in mid May!!

That was my last 'summer vacation.'

-

p.s. so, now that you understand what medical school is (sorta) like...you'll appreciate the (hilarious) humor in these videos on my sidebar:

This one. This one. and this one. (you just have to see them all. After the first one plays there's an opportunity to watch the others...)

I'm LMAO just thinking about them!!

What was medical school like? Years I and II

I remember being a pre-med. I had the full college experience, IMO. I studied to maintain an academic scholarship, had part-time work (intermittently), and pledged a sorority. I dated more than one guy, did some local traveling, and made lasting friendships.

I remember being very concerned about 'med-school prep.' I wanted to take the "right" classes...and do the "right" summer programs. I had to volunteer, and participate in campus organizations so I could distinguish myself from the 'average' student. I did undergraduate research that resulted in publications. I took MCAT prep courses, and followed the recommendations of the premed office on campus regarding which classes I should take when...when to apply to med schools, and which schools I'd likely get in to.

I gained early acceptance into medical school. This acceptance was arranged such that I didn't *have* to go to this school if I decided to continue on in the application process and I happen to gain acceptance into another (more desirable) school. I decided I wanted to come back home, so I applied to the local schools. Got accepted. Decided *not* to go to the 'early acceptance' school.

I was ready for medical school. I'd done 2 or 3 (med school/MCAT prep) summer programs. I'd taken all the requisite courses, including anatomy, physiology, advanced chemistry, microbiology...everything. I felt pretty prepared...but utterly unprepared at the same time.

I remember the first 'meet and greet.' Everyone seemed nice enough. I guess I expected everyone to look like 'revenge of the nerds' or something...but they all looked normal enough. They were social and some boasted full "prior lives" as policemen, firefighters, nurses, teachers, mothers, fathers, military...

The average age of my first year class was 30. That means that half the class was *over 30* in their first year of medical school. I had no idea everyone would be so...old. There were even a few people close to 50 (after having raised families or whatever)!!

There were quite a few smallish/informal meet and greets. Some indoors (dinners hosted by alumni, or AMSA, or some other group). Some outdoors, usually in the quad. Sometimes there were booths up urging us to join this group, or that group. Some upper-classmen were there, offering advice, or representing a club. We had picnics/BBQs. It was very nerve-wracking.

Then, our first welcome lecture. The one where they introduce lots of faculty. The one where they give you your first taste of what medicine is *really* like. They explain the horrible state that is American healthcare...and basically express frustration with the field. They seem to hate so many things...and are so bitter. Jaw on floor, you try to take in all of this information. You try to understand the bitterness, and convince yourself that "I'm not going to be so bitter when I grow up." Then, as if they're reading your mind, they say "you just wait...you'll see. Come talk to me in 10 years."

And school hasn't even started yet.

There was the white coat ceremony, where a few friends/family get to listen to a lecture about how wonderful being a doctor is and how doctors love patients so much (stark contradiction to the lecture *you* and your classmates sat thru just days prior)...and you get the (short) white coat (as if it's important or something). Everyone is so proud of you.

Then, the first real lecture happens. The big lecture hall. Everyone stakes out a seat. I liked to sit on the front left side, about 5 rows back. I liked to have the seat next to me empty. Everyone's very excited. The lecture is introductory and entitled "is healthcare a right?" Clueless to the political implications (as many medical students are completely apolitical), you start formulating your thoughts based on this lecture...and others that follow.

At our school we had these 'classrooms' where everyone had a desk (with lots of locked storage). In each of these rooms (there were about 10 of 'em) there were about 16 student desks - arranged alphabetically by last name. The person that happened to be sitting next to you, was your partner for the year. In these rooms there were slides, microscopes, bone sets, television with videos...learning aids, stuff like that. Immediately everyone brought artifacts from home to decorate their spaces. Magnets, plants, pictures, books, lamps, snacks, etc.

I remember the first day of (real) class. After the intro courses, and the welcome to our school speeches...the first real day. We were each given a stack of papers about 1 and a half feet tall. "Learn all of this by December." In addition to the stack, we had pre-filled notebooks for lab (gross anatomy and histology). Learn this too...and be sure to be able to identify these slides (box of micro slides handed to each of us), and you have to show up once a week for ICM (intro to clinical medicine).

I don't remember all of the classes off hand, but I do remember anatomy (lecture/lab), physiology (which is *quite* separate and much more difficult than anatomy, unlike in college). Microbiology (lecture and lab). Biochemistry (like hard core biochemistry); pharmacology, neuroanatomy, preventative medicine (epidemiology) embryology, and family medicine/ICM. The exams were during 'exam week' with 3 exams a day M W F. The multiple choice wasn't 'regular' multiple choice. They asked us to 'choose all possible correct answers'. If you chose too many, you missed the question. Missed one...also missed the entire question. There were k-type questions. I'd never taken a *multiple-choice* exam that was so difficult.

And they try to trick you. You have to read the questions very carefully, and consider the *exact* wording of the question. For instance, they'd show a picture of a large white blood cell...surrounded by a bunch of small red blood cells. White blood cells are big, have nuclei; red blood cells are smaller, and do not. (see above picture for example). Well, the question will be: "what are the characteristics of the predominant cell type in this slide." You ask yourself, predominate as in this big ass WBC? Or predominate as in the sheer number of RBCs shown. They were talking about the RBCs...and basically wanted to know if you knew that they had no nuclei. But, many students assumed they were referencing the WBC (that was huge, front and center)...and they missed the question.

Year one was also the year of gross anatomy. We had a few people who had issues with gross. The smell, the dead bodies, the thought of dead bodies...the dissecting. They would faint, couldn't stand blood and gore. We had pregnant students who had to wear respirators. But these issues are all worked out (through desensitization exercises). The only time it was difficult (for me) was when we got to the hands (and some of the women actually had pink fingernail polish on)...and the face. Usually, everyone kept the face and hands covered until the moment we *had* to actually dissect them).

There were all sorts of bodies, all sorts of ages. Mostly old white men...but lots of old white women too. Not so many of anything else...so when someone actually had a black body, it was very cool to compare/contrast the structures and such. Likewise, a young person, with well-defined muscles, offered something that the old people didn't. The bodies (on the inside) of course were more alike than different...but there are differences.

We had lab coats in plastic bags in lockers located in the gross lab. We were divided into groups of 5 per cadaver. We started with the back. Two people are supposed to dissect, one on each side of the body, and two others give 'instructions' on the proper technique/strategy by reading aloud the directions provided in the notebook. The notebook had key terms, and a list of structures that we're supposed to find and learn. And learning, not just their identity, but their blood supply (and the origin of said blood supply, it's branches, where it ends, what type of muscle lines the walls of the vessel), the nerve supply (and any thing else that the nerve innervates, muscles, organs...and where the nuclei of the nerve is housed...and which nervous system is responsible for the actions of the nerve).

If you cannot find a structure (either because your body didn't have one...but more likely because you destroyed it dissecting)...you had to come back to the lab after others dissected their bodies, and find someone who did it right. The person dissecting is supposed to switch day to day. Lab was 2x week. Lasted from about 1-6pm. There were TAs and tutors there for part of that time.

Lots of things to recognize, and the exam consisted of secondary/tertiary questions. Never are there questions like "what is this structure?" Too simple. Rather, a cadaver arm will be completely dismembered from the body, laying on a stool, covered with a towel...except for a 2x2 inch window. Three different color pins will be stuck into 3 structures. A card next to the arm will read: Where are the cell bodies located of the nerve that innervates the structure indicated by the red pin?

Even if you know the structure indicated...and even if you know the nerve that innervates it...damn if you know where the cell bodies of that nerve are located.

And 'knowing' what the structure is in the first place is a minor miracle in itself - being that you can't tell which way is up/down/right/left (since the arm, at least you think it's an arm, is detached from the body). And, to make matters worse, the tiny 2 inch opening makes it difficult to orient yourself with even local cues.

There are like 30 or so stations, with a portion of the class scheduled to take the exam at various times during the day. The questions are shuffled, but are the same. Each station has one student. Each station has 3-5 questions. You are timed. At the end you are (sometimes) allowed to go back to previous stations for 5 minutes or so.

Micro was alot like gross, except you get seasick looking at slides. And part of the exam was administered via a slide show.

All lectures were optional except ICM. Some students would show up for the first day of the semester...and disappear with their stack of notes, slides, and notebooks until exam time. We had a note taking process where the notetaking responsibility was shared among all students. So one student would attend a particular lecture, tape it, take notes, and go home and type them up nice and pretty. Then distribute them to the rest of the class.

There were tapes and videos of the lectures. And old lecture notes and exams from years past. So, there was plenty to study. I went to class everyday, but didn't attend every lecture. Some professors were great...and others wasted your time. Some topics were very confusing to try and do on your own...and others were quite clear after reading the notes. So, you pick and choose which lectures you wanted to attend. Our medical school spoon-fed us...which I think is a good thing being that I'm now over a quarter million dollars in debt because of it. It's the least they could do!! I deserve to have 'eaten well' for that much money!!

Medical school is like....they took everything you've learned in all of your undergraduate science courses and composite it into 2 days of lectures...as your introduction. On day 3, no matter what you've done in undergrad, no matter which courses you've taken, or how great your professor was at teaching it...on day 3, it's like you had *no* prior knowledge of the material. On day 3, everyone is on the same level playing field...science majors, biochem PhDs, art majors, and those who took every premed course they could. No matter.

I remember sitting in front of the computer, taking a practice biochem exam (WITH MY NOTES OPEN), and still utterly confused, flunking the practice exam one week before the real thing...and I graduated from undergrad with a degree in CHEMISTRY and a minor in biology!

At my medical school it was imperative that you pass all exams. There was a curve so that almost everyone passed...except in a few subjects. If you failed an exam, you had to retake that exam and pass it. If you failed the retake, or didn't take the retake, or it was the last testing period of the year (hence no time for a retake)...you had to retake the entire year's course in the summer. If you failed the summer course, you had to repeat the entire year of medical school. There were always a few students who had to repeat their first or second years.

The students helped each other. There was no pyramid nor was the curve based on the highest scores. The curve only served to lower the pass percentage in the instance that more than 10% of the people scored below 70%. Pass was 70%. Honors was 90%. Our grades were pass/fail/honors.

Do not need to be smart, per se, since it's mostly memorization. You just had to know what to study, and how to study. And you had to know how to take the test. Anticipate the questions...learn to read carefully...do the practice exams...and study in groups (at times). You had to use your time efficiently, especially if you had other things going on competing for your time. I didn't know anyone in my class that worked...but there were a few parents. I realized that I had to read the material 3 times in order for it to stick...and that was straight forward stuff. The complicated stuff...physiology, epidemiology, and biochem...I actually had to *figure out* before I could attempt to memorize.

Second year material is more complicated than first year. Second year was organ system based, and 'illness/pathology'. Whereas first year was micro/histology, second year was pathology. Whereas first year you're learning about the heart and cardiovascular system, in year 2 you're learning about congestive heart failure and strokes. It was easier than first year because you are now an 'experienced' medical student, able to pick and choose what's important to study...and how to take the exams so you pass. Also, a few things are repetition, and you have a base to hang new knowledge on...
***

Overall, most people who flunk out of med school, do so during 1st and 2nd year. And of those, almost all flunk out because of some competing personal issues. Family, marriage, financial, illness, mental, emotional, etc. Not because the work is too hard. Because, actually...it's not. It's memorization. It's being able to choose the 3 most important points in a given lecture...and commit those 3 points to memory...then reproduce those points in one way or another on an exam. It's knowing what to study. Focused study. If you don't focus, you won't do well. You cannot know everything...and if you try, you will have a more difficult time.

It takes some time to become okay with going from being the top in your class (from kindergarten, onward) to being "average" among your med school class. It's hard to incorporate 'family time' and 'friend time' into your life. You feel guilty for spending your Thanksgiving "goofing off" with family rather studying in preparation for mid-terms. And movies are out...2 hours of "lost time" is just...unacceptable. You take your backpack *everywhere*, just in case you get 'stranded' you won't fall behind in your study. And don't even think about getting sick...

No one in our class had outside employment. There were a few parents, usually fathers with stay at home wives and the rich grandparents supporting the young family. Many students even stayed at home where their parents prepared healthy meals daily and washed their clothes. No wonder they did well!!

You cannot spend the time worrying about money...so you must take out loans to support yourself (if you don't have rich parents). You have to have a car and a computer. You have to spend money taking exams and joining organizations.

Living close to school is a plus (that way you avoid wasting valuable study time on the road). If you must spend lots of time in your car...get some audio lectures to listen to.

There were a few women who managed to have babies in med-school and do very well. They often did not attend lecture, spent all day studying in the library instead. Stayed late (until 6 or so) in study groups/labs. Were very focused and didn't take breaks or goof off during 'study-time'...and did well. On the other hand, those of us without kids/families spent 12-14 hour days in the library, 6 days a week (easily). We snuck food into the group study rooms. We did alot of chit-chatting, and often went from study site (i.e. library)...to another study site (i.e. cafe')...and yet again to another study site (i.e. someone's apartment). Our lives were studying in different locations...sometimes inefficiently moving from place to place, talking about off-topic things.

The first 2 years are fun...but requires lots of attention (to say the least). There's no real patient contact (that ICM bullshit doesn't even begin to count as 'patient contact'). Your life is your backpack. Your notes are guarded with watchful eyes and taken everywhere (there's no way you can lose those notes after spending 2 months color-coding everything, and highlighting the pertinent points). And the fun you have is...in the gross anatomy lab, eating pizza and drinking beer while comparing the structures in various cadavers!!

Obama's speech - in case u hadn't heard

"the greatest jobs in EM are never advertised or interviewed for" - your questions answered.

I've received lots of questions regarding my last (few) post(s). I'll answer a few here.

It seems as though you're disappointed with most of the emergency medicine groups out there. Which groups are you referring to when you mention that "you've found a group that fits your personality?"
I'm not "disappointed" with EM...I'm just 'finding my way.' Everyone, no matter what career they choose, will have to find their 'spot.'

I'm not referring to an umbrella group (i.e. a large partnership/membership with multiple contracts)...but rather I'm referring to very specific work *sites* within said umbrella groups. A group could be great (for instance CEP has a great reputation among physicians for fair treatment and comparable pay), but some CEP sites are better than others. For some, certain sites may be intolerable (for a multitude of reasons). Everyone has preferences/thresholds...and finding a site that fits isn't always the easiest task.

What sort of politics do you speak of? And how can I avoid such politics?
One thing I learned as a resident is...the workplace is very political. As a student I was shielded from the 'inner workings' of the Departments. I did my student rotations, everything seemed fine...and I moved on. My anesthesia residency was at my medical school. How I didn't see the tremendous influence of 'office politics' on the day to day running of the place is beyond me (in retrospect). The residents weren't happy...and told me to *stay away* even. I didn't understand...somehow. I guess I thought "my experience won't mirror their experience because (insert whatever random reason here)." I listened to the people with the smiling faces in lieu of seeking those faces that weren't so happy.

I don't think there's a way to *avoid* politics. I think it's smart to try to discover how they are at play in a program/group. And, it's exceedingly difficult to get this information until you actually start the job...AND develop allies. BUT, in your development of allies...you, yourself, become political. Most people manage by being quiet, and supporting (or at least pretending to support) the current management (or leader of the strongest political party, so to speak). To try to make friends with people from both groups. So when the 'weak' party overthrows the 'strong' party...you'll have some friends in high places (after the 'revolution').

You imply, however, that there are places that you can avoid the politics?
There are places that are less political. Where the director (and executive staff) aren't so hungry for power...and really value fairness and treat people with respect. Politics are still present, it's just not so thick and indoctrinated in the inner-workings of the department as to stifle free speech and creativity. Usually the less you work, the less interested people are in involving you in the politics (for better or for worse). And, the less you'll likely care about 'fitting in' and 'kissing ass.' This ability to separate yourself from the workplace is very liberating IMO.

I seems impossible to enjoy EM because the likelihood of encountering power hungry, machismo, personalities is high.
This is true. Lots of my colleagues would fit what my girlfriends and I consider 'overcompensating' for some lack in mojo. The marginalized nerds in high-school have grown up, and now to get some attention (and perceived respect) by having an equivalent of a mid-life crises every few years. You know, the guy that everyone laughs at...and he tells himself "one day they'll all be sorry..." These guys either grow up and bomb schools, shoot their fellow college students, or become "dictators" of those who rely on him for something they need (jobs, money, etc). Absolute power corrupts absolutely.

So you're planning to just float from ER to ER indefinitely?
No. I'm looking for something specific. And if the day comes that some sort of 'guarantee' is offered in our specialty (or in life in general, I guess), I would only do a single thing. But, that day is not today...and over relying on one income source seems dangerous to me right now.

Don't you think that you've idealized 'fitting in' and there is actually no place that's perfect?
At first, yes. But who can tell a wide-eyed, idealistic young person anything?! I try now telling medical students the real deal about medicine...and they can't comprehend what I'm *really* saying. But time makes us wiser...and after a job or two I realize that medicine is fucked up, in general. And many of my "issues" were a result of a system that has marginalized the physicians, and other (non-physician) people are creating healthcare policy. One place was just like the next...just like the next. And I had to somehow decipher the difference between things that were group/site specific, and things that are just apart of the ridiculous game that is the practice medicine today.

BUT, I've also learned that there are distinct differences. And how would I have acquired this knowledge if I worked in only one spot? Now that I understand the "game", and I can recognize the various ways the rules are implemented depending on the team playing. Some teams play fair (the "rules" they play by are fair). Some teams play dirty (and are you the type of person who can play dirty...and be okay with it?). I can now get a sense of this when I first set foot in the Department. And now, now I can actually "hear" what people are saying when they tell me about their experiences working at a particular place. I can *hear* the "don't come here", and the "I like it but...". (of note - the 'don't come here' means "I hate this place, and everyone I know hates this place...the people who aren't leaving stay because they CANT leave; the 'I like it but...' means, this place is great, and everyone here likes it...and you can come to like it if this/these specific issues don't/won't bother you.) I know what things *really* matter in your day to day practice...and it's not the number/type of back-up specialists you have on the call panel.

I am not looking for shangri-la. Eventhough I was overly optimistic initially....I am much more realistic now. And, realistically, there are places people stay for their entire careers and would recommend the place to younger docs. I'm looking for the type of place *I* can stay my entire career, and honestly recommend it as a place that "I like but...". Even as I consider involving myself in multiple non-medical interests....so I can have the *liberty* to work (or not work) in the ER when I'm 50.

Have you ever been fired, or left on bad terms?
No, I haven't. When I interview for a job it is known that I work at other places. I don't promise to do more shifts or become full-time...and usually a full-time person hasn't been something the good groups needed (actually trying to find a full-time gig here is a difficult task). I haven't violated any contracts (in those groups that actually produce a contract). And to my knowledge I have acquired no enemies. Obviously when you decide you don't "fit in" and therefore seek other employment...it's a form of rejection for the group...and they don't feel all nice and fuzzy about that.

Do you think you're burring bridges?
I don't think so...but perhaps. The way I see it, I lose more by staying at a place that I shouldn't. The sooner you part ways, the less negativity surrounds the departure. I mean, what will be said about you if you scale back your shifts at a site gradually over months? That you didn't stay long and they aren't sure about you. What that means is on the next interview, you have explain a bit more thoroughly exactly what it is you're looking for, and why you think the (new) place will fit. It's not too difficult to convince people that what they like (that their group) is superior to the others. Especially if you believe it too.

Besides, this is the way the game is played. Out of residency you probably won't get your dream job. Why would a Medical Director hire you...if they can get someone just like you with 5 years of experience? So...you may have to wait until something opens. Maybe someone retires/moves/leaves, and you go from working part-time to full-time (the most likely scenario, and the reason most great jobs are never advertised or interviewed for). But, you have to do something in the meantime. And you have to supplement the part-time work (especially if the part-time work is at your dream site/dream group). So you settle for (other) work in other places because it's available..and you do 'rotations' and learn what you like. Then, when the full time gig opens at the place you've been doing part-time work, you're there. Or when you (finally) find a place with a full time spot, you'll be able to recognize the opportunity, and assess whether or not it's a viable long-term option for you.

Are you talking about specifically 'such and such group?'
I've worked for 5 different groups (not counting the specific 'sites' within the groups) - just to get experience (but sometimes with the hope that I'll like it enough to pursue it as my main gig). I have friends who work in the area, so I have some insight (either primary or secondary) into most of the groups. So, yes, I am talking about (insert any medical group here) 'such and such group'. PEOPLE are more alike than they are different...so the GROUPS are more alike than they are different. It's the *cultures* that are different. The things that are praised and tolerated vary. Attributes that are valued and those that are an asset vary. If you possess the prized attribute (or can acquire it easily), and agree with those elements that are praised, and can deal with those that are tolerated...you'll likely fit in well. But, if the group is doing what you perceive to be shady shit, and praises those who say/do things that you cannot deal with...well....you'll have problems and be unhappy. And eventually you'll leave, either they'll throw you out...or you'll leave voluntarily.

Typical politics.

So...you have to find a place where you 'fit.'

Wouldn't it be nice to 'test out' a place for a week or so? Kinda like that show where potential buyers get to spend the night in the house before they actually make a decision to purchase the house - Sleep on It on HGTV. That's what working at multiple ED has been for me. A decision refining experience...helping me determine what I can and cannot deal with easily. What can be changed and what is hard-wired into the practice of medicine regardless of where I go. What attributes I possess, and where they'll be valued. Where what I have to offer exceeds any perception of any liability I may possess. Where I can deal with (and maybe even *participate in* the internal working mechanics of group), instead of pretending I know nothing/hear nothing/see nothing as to avoid getting pulled in to group policies that undermine my values.

I realize that I really love going to a place where 'everybody knows my name' (in a good way) and I feel I belong. This is more valuable than anything else (money is a close second). This is not something elusive that only exists in fantasy-land. Therefore I'm confident, that as I continue to experience and (re)define what's important at the work-place, I'll find my spot.

*picture courtesy of Yahoo TV.

How do I choose a job?

I'm sure you've heard that 70% of new (EM) physicians will leave their first doctor job within 2 years, right? Ever wonder why? Some think that it's just a sign of the times...

...staying in one job forever is today’s recipe for career suicide. At the beginning of one’s career, it is nearly impossible to find something right without trying a bunch of options. After that, you will experience more personal growth from changing jobs frequently than staying in one job for extended periods of time. And if you change jobs frequently you build an adaptable skill set and a wide network which are the keys to being able to find a job whenever you need to.

There are many people who give great advice about job searching, and things to consider. And I listened (and still listen)...really, I did. Nonetheless, it's still very difficult to choose a great job. And, despite my best efforts...I'm finding it (have found it) to be somewhat of a process of elimination.

I trained at a very high acuity ED, level I trauma center, with the full gamut of specialists, neonatal ICU, Neuro ICU, in house residents of all specialties, vascular surgery, hand surgery, neuro surgery...everything. We were a base station, did peds trauma, and had the helipad to accept patients from throughout Southern California. I actually can't recall transferring out anything. We even had military rotate thru our department to learn/practice 'war-time' medicine and MASH-type stuff.

Anyway, I felt I was prepared for *anything* after graduating from this residency. We'd intubate 6-10 patients per day....did thoracotomies and crics probably way too much. We even did burr holes!! Our patients were young/healthy men, so we saw them live (despite our 'interventions').

What I wasn't prepared for was...the difficulty of finding a job that fits.

I had no real preference for academic vs. community. I felt I could handle a trauma center and anything else for that matter. I could move fast...but I also enjoy taking my time. Partnership was okay, but employee (if treated fairly) was fine too. I could work with one nurse, or a full complement of nurses. Even location was negotiable. I preferred some support (and didn't want to be the only doc in a box out in Podunk, CA). I also preferred some basic specialist coverge...ortho, peds, OB, medicine, surgery, etc. Residents were okay...but I find them to be very arrogant and somewhat dangerous at times...so, I was okay not having them around.

Basically, I was pretty open to whatever. I thought being open would allow me to adjust to my new position with ease. I thought being open would allow me to be more selective since I'd have more to choose from.

Even the money was negotiable. Benefits were negotiable (I have a working spouse).

When looking for my first job I considered the longevity of the group, the entire benefits package (rather than simply the salary). I even made a list of 'must haves'

- located in/near a major city. I value diversity, and didn't want to end up in Podunk with a whole bunch of ass-backward folks who think a brown-skinned person makes "chocolate bath water."

- competitive salary/benefits package; I didn't want to sell myself short

- fair scheduling; the schedule is your life.

- and the option of doing 8 or 10 hours shifts; exclusively 12 hour shifts were a deal breaker for me.

***

First job was okay, and fit most criteria...except the salary. The benefits package was comparable (I guess), but as a new grad, I needed more money and less "benefits." So, I thought I'd simply pick up extra shifts, or moonlight in other EDs to make up for the deficit. But, with this group you were not permitted to work outside of the group. And, working any additional shifts for the group...after the taxes/benefits/etc were taken out, you ended up with like $350 for a shift. Not worth my time. AND, the final (bad) thing was, they required 40 hours/week of work. So, not much extra time to pick up those extra shifts. AND, if you cut back, your salary was proportionally cut.

Let me put it into perspective -

So, working what would be a full load elsewhere, there you'd only bring home about $9,000/mo. A mortgage on a (very) average home in (Compton) California (such as this one) is about priced at $750,000 which makes payments/taxes/insurance about $6000/mo. Student loan payments exceed $1500/mo. Car notes and insurance on 2 cars (which is a necessity in California) is about $1200 (average car notes of about $400 each). Already we're at $8700...and we haven't paid for childcare (which runs minimally, at home daycare centers, at almost $200/wk).

At this point your spouse's income kicks in...cuz yours is completely accounted for...and groceries, gas, other insurances (life, disability, etc), utilities, and his student loans still have to be accounted for. There was no savings. Living month to month....without the possibility of (significant) advancement in salary...until you retire (at which time you get to live on 60% of your former inadequate salary). No trips, credit cards just accumulating more debt...and we still relied on our parents for help with incidentals (new water heater, for instance).

You need at least $12,000 bring home to live a solidly middle class lifestyle in Big City, California.

And I didn't want to work 40/wk in the ER for that...when I could work half that for the same money with another group (sans the "benefits"). Actually I consider my 'benefit' is having my money now...

So, I left the group when my contract was up for renewal...

***

My 2nd ER job is better. I make more money. And I get to work at multiple sites because they have lots of contracts. This is nice in some ways. Working at various sites has provided me with some additional insight, and a sense of security that "all of my eggs aren't in one basket." That the closure of a hospital, or loss of the contract of one group doesn't mean I can't pay my bills. It also helps keep things in perspective.

I realize that personalities and politics play a *huge* role in these groups. I (naively) thought that I could just 'fly below the radar', working only a handful of shifts at 2 or 3 places...to avoid fighting for shifts, and getting involved. But, it seems as though people need, actually *need* to cause dissension among the group in an attempt to create their own real life soap operas. They seek drama (it's human nature). And the more removed/aloof you are, the more interested they become in you. They try to pick fights, and create problems where there are no problems. I know some people who like to keep things "unstable" as a mechanism to maintain 'power.' And these things are difficult to prove...and even more difficult to realize prior to actually getting involved with the group.

But, it becomes painfully obvious...and when you talk to other group members they concur...and basically ignore everyone/everything. They bitch and complain among themselves, but really, just wanna be left alone. And, mostly they are. But, in the back of their minds they realize that they could easily be written off the schedule...with little recourse but to find another site/job. So, most have secondary and tertiary sites (or jobs) in which they work - so they'll have income security if/when the politics at their primary place 'gets out of hand.' Because, tides change...and if the place is overly political, one day you will find yourself on the wrong side of the politics (even if you're currently the 'chosen one').

***

My point: the criteria used to choose a job is multifactorial, indeed. And I fully realize there is no utopia of work sites/groups. Everything is about balance, and personal preferences/considerations, etc. But don't downplay the money, because you will feel the negative impact of 'not having enough.'

And, realize that many times you cannot know the internal politics, the personalities, the dirty laundry, or how *you* will fit in...until you actually start. I don't know how to avoid getting caught up in politics (who likes who, who gets away with what, etc). Here's some advice for surviving office politics. But, I think the other docs have it right...

...just keep quiet (the tides always change). Have other places you can work (in case they don't). Realize that today, "job security" is something *you* create (unlike 20 years ago when having a 'good job' meant benefits and a pension...or friends in high places. Those things aren't as stabilizing as they used to be, and trusting your future to an extrinsic source will leave you with your ass exposed). Think about a side business (or make ER your 'side business'). And make enough money so you can weather the storms.

***

Overall, I enjoy the flexibility and the diversity working in multiple EDs affords me. It allows me to compare/contrast and appreciate the drawbacks/benefits of various components of the groups. For instance, I used to think I'd prefer a more educated patient population...now I realize that it really doesn't matter because the 'educated' are frequently so *not*. I used to think I'd hate night shifts, but I actually enjoy the *peace* that comes with a night shift.

By working at multiple sites, and with multiple groups, I think I've found the group that fits my personality, and without all the drama. A group where I can just go, do my shifts, and leave. A group where I feel apart of the team (kinda like a dysfunctional family), that values my contribution...but leaves me out of the politics and drama. A group with similarly like-minded docs, who really aren't impressed with what patients and staff think - as long as safe, sound medicine is being practiced. A group who's just as concerned about practicing safe medicine as they are about collecting as much money as possible for their bonuses (i.e. you'll find some groups that play roulette and understaff or overemphasize 'productivity' in lieu of both safe patient care, and support of proper physician documentation/communication).

A group that supports the physicians, advocates for us, and doesn't just bend over and get fucked in the ass by every administrator (or the nurses, or anyone) on *every* issue (compromise is one thing, but chronic surrendering is the reason healthcare is so sloppy, as the physicians continue to stay silent) because they are terrifed of losing the contract. (Afterall, healthcare needs us to speak up...and cannot be done without us - we need to remember that and step up to the task). A group where people feel compelled to participate...and are free to speak their mind. The group has issues...but I think I fit nonetheless. Time will tell...

...and even if so, I fully intend to always divide my eggs between more than one basket.

Perfect Job, perfect specialty??

I remember how difficult it was for me to choose a specialty. Initially (as in before medical school), I wanted to be a dermatologist. I loved cosmetics and hair products, and as a college student I thought I'd go into some sort of 'beautifying' medical specialty.

Once in medical school they forced upon us that primary care crap tried to encourage us to consider careers in primary care. And I did...seriously. I really, really liked the idea of family practice. The doctor that sees the entire family, and watch the kids grow up, and have continuity of care, and keep the family healthy, yadda yadda yadda.

Then, I started having doubts. I met no one (even with all of this brainwashing exposure) who actually *enjoyed* family practice. It's a thankless job really. Anytime I asked a FP "do you like your job?" the response would start off "....wwweeellllll....". Not a good thing. And what followed was usually some combination of justification, hope, and regret.

So, I considered internal medicine. I guess I was stuck on this continuity of care issue, and thought that would make my practice worthwhile (you know, seeing the smiling faces of the patients I help, and eating the fresh baked muffins they'd bring with them to their office appointments to show their appreciation for my time and expertise). So, as a result of all the negative comments regarding primary care in general, I thought I would preserve my option of subspecializing (just in case the naysayers were right about primary care)...and internal medicine seemed better for that purpose than FP.

So, up until 4th year (FOURTH YEAR), I was all set to go into internal medicine. Then, in 4th year I did an elective anesthesia rotation. I thought about endless rounding that was internal medicine hospitalist care. I thought about the rushed office visits, and the lack of depth of knowledge (the "jack of all trades issue") and that kinda bothered me. What would I be doing all day as an internist? Rounding, taking call....clinic and referring? On the other hand...anesthesia pays well over $300,000 year, and you have only one patient at a time. There is no rounding, and the job is mostly low stress. And did I mention the over $300,000 yr salary??!!

I applied to BOTH internal medicine programs, AND anesthesia programs. I ranked anesthesia higher, and matched at my first choice spot. I did my prelim year in internal medicine...and off to anesthesia.

Well, I realized I hated anesthesia (at least my program sucked bigtime - which is no doubt detailed on this blog somewhere in another post). So now what do I do?

I didn't work this hard, for this long, and for this much debt to *hate* my job!!

I thought about my rotations as an intern. My ER rotation was the best. Not necessarily the most exciting specialty ever...but I just felt 'fulfilled' on that rotation. I felt healthier since I had time to get out in the sunshine on our days off. I felt disconnected (mentally and physically) with no beeper or hospital responsibilities on my time off...and the prospect of going back to work was exciting. Everyday I started with a clean plate. No inpatient ward 'rocks' or a patient that I was responsible for, yet someone else was just 'covering' for me. I enjoyed the 'we have a life' attitude of the ER residents. And I liked the fact that I could basically 'play doctor' with the patients until they became too complicated, or I became uninterested...then I could call someone else to take care of 'em.

So...I applied to EM programs (as a PGY2 anesthesia resident), AND internal medicine (in the case I didn't match in emergency medicine which was/is very competitive, I'd just finish up 2 more years in IM and be done). I guess you can say I decided on a EM career a bit late!! And even then, I *still* I wasn't completely sold...
***

I tell my story to demonstrate that choosing a speciality is very difficult indeed. With that said, I had a young woman send me a very thoughtful email:

I was telling my husband that I was really thinking about doing ER for the flexibility and the hours, because I'm really wanting to have kids...
...he responded by saying: I should do 'whatever I'm passionate about, no matter what the hours look like' because 'we didn't go through all of this to do something we're not passionate about'.

My Take -
Overall I think this is a very naive point of view. No, you don't wanna do something you hate. That wouldn't be fair...."after all of this time" you don't wanna go to a job everyday you *hate* (like me with anesthesia). But passion about a job.....??? I don't think that's a requirement at all, and if that's the *sole* determining factor in your specialty choice...you will be disappointed.

There is no way you'll *love*, say OB/Gyn if you cannot have your *dream life* because of it. Period. And, since being a 'part-time' OB is difficult....don't do it. It's kinda like buying a big house. Med students are basically telling themselves "you've worked hard...you deserve a mansion." So, you go buy a mansion....you're passionate about the house, and love the house....but after working 2-5 years around the clock, and never really having the opportunity to appreciate the home (or any other aspect of your life), you realize that you're just a slave to this house. Working to pay the mortgage....

...and you realize that you would be happier in a smaller house so you can work less and enjoy your life (and the small house) more. So, instead of finding joy swimming in your personal Olympic sized pool at your mansion (which you never had time to do anyway b/c you were working all the time)....you instead find joy swimming in the pool at the sports club you're a member of....and you actually have time to go and enjoy it.

Do you just absolutely LOVE your little house....??? Not necessarily. But, do you love your life...and the time this smaller home allows you to have free? Absolutely.

Do what you love. Love what you do!!

***

I don't like the lack of continuity with patients. I don't like not building relationships with families. I don't like the way it is in general...

My take -
I was very idealistic...."I wanna help people and build a relationship with them....". But, honestly, medicine isn't like that for most of us. Ask around...I think you'll find (I'm sure you'll find) that the *concept* of continuity of care is attractive, but the *practice* of continuity of care...sucks. You'll realize that, in your family medicine practice, you'll never see your "well patients" (the nice ones that do what you tell 'em to do...because they aren't sick frequently). And with all of your patients (in order to make a living) you can only spend 10-15 minutes with them (I get more time than that with my patients in the ER...and I actually probably get to know them better than their crazy-busy primary care doctor during their sometimes 6+ hr stay with me).

As a primary care doc you work long hours for little appreciation (and even less pay). And you realize that you'd rather have continuity of care with your own children, than with patients who don't listen to you, may actually sue you when they decide they have a bad outcome for not listening to you....and want it all for FREE!!

I say, continuity of care ideology is nice...but not the reality, and I wouldn't choose a specialty thinking that the continuity will be good thing.
***

I've never considered myself to be the type to gravitate toward "jack of all trades".

My Take-
Emergency medicine is the best of all worlds. No matter what area of medicine you go into, you will not be the most specialized person in the field. And doing the same thing everyday sounds very boring, doesn't it? If you're not a 'jack of all trades' you'll be seeing the same stuff your entire career.
***

"I don't think I'm an ER doctor type."

My Take-
Most of emergency is medicine is non-emergent stuff (so it's not like you'll be running around like on the TV show ER - of course depending on the hospital). In a given month (10-12 shifts) I may see 5 true emergencies. The rest is ruling out very unlikely things just to protect yourself (CYA), and urgent care/primary care things. I see these same people *way* more than I'd like - so there's the 'continuity of care' b/c they don't have access to primary doctors' offices.

Anyway, what is an 'ER type'? I think it's the type of person who values their time off...and realize that getting paid is important, and that life outside the hospital is more important to your health (sanity, and job satisfaction) than life inside the hospital. It's a person that realizes that having a dream life consists of balance, and that a job/career does not replace meaningful relationships (that require time and nurturing) with friends/family. That it is not necessary to become a martyr or forgo everything else to be a good doctor.

Now, what these ER types *do* with their time off...varies greatly (sometimes depending on gender).

Other pluses: you feel like a *real* doctor...not a technician or a pawn in a larger political game (at least not most of the time). And, you can always go work in a GP or walk-in clinic and see patients on an ongoing basis as a EM trained doctor.
***

Overall, it's important to remember (cuz lots of docs don't, and they are unhappy):
You don't have to LOVE (every aspect of) your job for it to be the PERFECT job.

*pictures from Life is Good Collection...it's an awesome collection. Check it out.

A groove...and time *not* being a doctor

I finally feel like I'm getting into a groove (I'm reading Vicki Iovine's book shown here...and love it).

I've been out of residency 2 years, passed my boards, and my hands no longer tremble when I have to intubate someone. My heart doesn't skip beats (as often) when I hear the MICN on the box taking a full arrest run. And, I'm more-or-less comfortable sending well babies home without worrying (too much) about whether or not they'll develop meningitis in the next week or two...

I've developed a (usually) polite, yet firm, way about me and my practice...in order to get things done. Both patients and ancillary staff typically respond better to a physician who is decisive and confident. But, I know how to listen and take advice (i.e. hear the subtle, or not so subtle, inflections in the voices of family and nurses when I should consider rethinking my disposition). I know how to ask for help without feeling incompetent. I can explain myself to the second-guessers...and feel even more validated in doing so. And, interestingly, I'm not at all shy about admitting what I don't know.

I'm actually enjoying myself most of the time.

Of course I still have times where I'm nervous, overwhelmed, or simply just not feeling up to the task. Since it's difficult to take 'a sick day'...we doctors (and nurses) often come to work regardless of how we're feeling - and probably when we shouldn't. But I digress....

The biggest thing however is my new-found *balance*. I have found the perfect number of shifts...types of shifts...and places to do said shifts. This, my friend is key. I believe that being rich means having choices, period. Money certainly allows for more choices (to a point), and is therefore a necessary part of the equation. But, choosing how you spend your time, where you spend your time, who you spend your time with, etc...for me actually defines "rich." If I'm working 25 shifts/month, I may have a $30,000+ bring home salary/month, but really, I'm not rich if I have to go to work frikin 25 days/month!!

I realize that working about 10 shifts/month allows me to bring home more than enough money to cover our expenses plus savings...AND I get to spend the rest of my time (get this)...doing other things!! Additionally, I realize that I actually enjoy working at 2 different EDs, each with their own flavor. Working in two different EDs allows me to not get all caught up with the politics of a place. My residency program was the *most* political program ever (I'm sure). Every word, every action...political. Very stressful.

I also realize that I actually *enjoy* working at an urgent care center/walk-in clinic. It offers a completely different perspective. It's nice to have time to sit here and update my blog (finally), and see patients intermittently while doing so. It's nice to take a lunch break (imagine that, a lunch break!!)...and its nice to visit the toilet from time to time when necessary.

Also, it's nice to refer patients that you don't wanna see (for whatever reason) to the ER. Shortness of breath? Hmmm...you need to go to the ER. Pregnant vag bleed...yep, ER for you. I see why so many clinic docs dump refer their patients to the ER...it's just so frikin easy. Not that I would ever do such a thing. All the patients I send to the ER actually belong in the ER...and I should know.

I was talking to a colleague the other day. We both have young children, are both female, and we pretty much are at the same place careerwise. She works like 16-18 shifts/month. Keep in mind that 18 shifts/month means 22 days since overnights count as two days. That leaves 7 days off in a given month. That's not nearly enough off days to do your other "full time job" of mommy/wife (or daddy/husband for that matter), IMO. When she told me, I couldn't believe it: "wow, you work a ton" I told her.

After telling her about my 10 shifts plus urgent care part-time, she was like "why don't you work more?...don't you enjoy the money?...what else do you do with all your time?"

Seriously??!!

You know what I do? I cook healthy meals because this non-organic/fast food shit is killing us. I read for pleasure (for the first time since college). I keep my babies out of daycare from time to time so I can take them to the park, then to the ice-cream shop...and maybe even to the mall. I manage the business that is a household (which is a full-time job). I make sure the bills are paid on time; I negotiate online payments, allocate funds for various usages, manage half of our accounts, and basically (since it is my strength) manage the finances. I am the historian of our family - blogging, documenting, video-taping, photographing, and scrapbooking our lives...so we won't forget, and so the children will have a sense of what their childhood was like.

If not me, who will go thru my kids drawers and determine what fits and what doesn't, what I adore and will save for them vs. give to a shelter? If not me, who will decide where I want things to go in my home...how to decorate...and how to organize? If not me, who will take inventory of what we have, and what we need as a family? There are some things a house-keeper can help you with...other things, I'd rather do myself. If I don't change my own kids diapers, how will I be able to tell the pediatrician that their poop is consistent with prior poops? If I don't bathe them, how will I know that my little guy likes to play submarine with his Thomas the Tank Engine train set? Or even more importantly, how long would it take me to notice an injury or a rash if someone else (or various someone elses) are doing the parental tasks? If I don't read to my kindergartener, how will I know she's progressing as she should in school...and in life? If I don't find time to really talk to her, how will I know who her friends are, and what they're like? I wonder if my colleague knows how much fun she's missing when she leaves the house before having had the opportunity to dress up her cute little girl in almost-as-cute clothing...and spend time fixing her hair just so? Isn't this why we dream of having daughters? Why would you want to delegate all the fun stuff? And...if I don't have sex with my husband, and listen to his hopes and dreams, how can we stay connected in this partnership that is raising our family...and enhancing our lives? I waited almost 30 years to be 'mommy/wife'...and I want to be intimately involved!!

You know what I do? I walk my (often neglected, despite all my "free time") dogs, and train them to obey me. I do yoga so my back won't be sore after my shifts. I get massages and facials...and my eyebrows threaded. I do my hair, my nails, and read fashion magazines. I have like 4 blogs in progress...and enjoy being 'in the world' in this way. I'm (still planning to) write a great book (but there isn't quite enough time).

I've discovered that I actually love photography...and it is not my style to do things half-assed so I actually devote a bit of time to this hobby. I am in a Sorority, and like many sororities, our membership doesn't end upon college graduation...and there are time commitments involved as we serve as mentors, organizers, advocates, and community activists in my Sorority as a graduate. I plan awesome trips for our family (that we have time to take because I don't work all the time). And not huge extravagant/over-compensatory (i.e. I work all the time so when we go 'on vacation' it has to be big so our friends will be impressed, and my working all the time seems justified) 3 week European-type trips...but rather Disneyland Resort trips...Legoland trips...Vegas trips...Tahoe trips. Frequent trips. Easy trips.

You know what I do? I can attend school field trips with my daughter. I can keep the laundry done (most of the time). I can be mentally and physically available and present for my husband. I can unwind and tend to my needs so I can be patient and understanding with my kindergartener and toddler without yelling all the time over spilled milk, literally. And without sitting them in front of TiVo'ed Little Einsteins cartoon for days on end (hours? maybe. days? no).

I can have 2 hour conversations on the phone with my parents...and/or my girlfriends. And I have the time/energy to spend a weekend or two a month (or at least every other month) socializing with good friends as a family (their kids, our kids, red wine, good food, background jazz playing, with the BBQ grill going, or tandori chicken and naan waiting for us in the family room...OR maybe an exciting night out at the bowling alley - the one with bumper guards to keep the bowling ball in the middle of the lane). And I have flexibility, and enough 'extra' time off that I can actually pick up shifts quite easily from other partners who need/want days off...but the schedule is already printed.

Above all...I just have time to think. You know, be bored...like a child in the summer, back in the day ('cause these days, kids are overextended and never have the pure luxury of just being bored). To just think. Think about investments, think about purchasing property, think about our next trip...and just let the creative energy flow. Think about ways to be more fully involved and engaged in this life I've been blessed with. Think about life. Think about my purpose...expanding my spirituality.

And, of course...time to *not* think...and just be.

Just be.

There are so many things to do when not cooped up at work...running around crazy, neglecting your own needs. There are so many places I'd rather be, despite the fact I love being a doctor. Actually, I love being a doctor *because* I have plenty of time to *not* be a doctor.

I've said it before...and Dr. Leap repeated it here:
It'