The echoes of my steps resonated within the expanse of the hospital garage. As I made my way to the end of the aisle to my stall, a couple caught my eye.
A tall man, his hair only beginning to turn grey, faced a woman of similar age, dressed in a beautiful white summer dress. Next to them a car, its trunk agape, half packed with a box of personal belongings and a white plastic bag full of clothes sat waiting. Still, they stood, pausing, ruminating.
They stared longingly into each other’s eyes, a deep seeded pain overwhelming them as tears trickled down their delicate features. A warm embrace as they held each other tightly and wept.
I wondered what terrible tragedy had befell them. Did a loved one’s health take a turn for the worst? Did a loved one just pass away? Did their mother, father, daughter, or son, just perish from this earth? I could not help but wonder.
But it was not my place to ask.
I watched helplessly as they buried their heads in each other’s shoulders and comforted one other.
I saw a patient on the ward on call recently where the patient’s complaint was some mild shortness of breath. Upon reviewing the progress notes, one of the issues low down on issues list was titled PE.
My heart skipped a beat.
Pulmonary embolus. My thoughts raced at the possibility that this patient had a recurrence. I quickly went back to see the patient but found that his story and physical exam did not quite add up to what I had imagined. I decided to go back and read the chart notes carefully again.
The more I read the notes in its reverse chronology, the less this PE sounded like a pulmonary embolus until I finally found the source, some ten pages back, buried in the middle of their already thinned chart.
Over time, a relatively benign finding had been unintentionally shortened to a grave and emergent issue by the student writer. I breathed a sigh of relief.
It was yet another reminder of how shorthands and acronyms can cause miscommunication.
To the reader MP who wrote me a message about someone they know and the situation they are facing.
It looked like there were two parts to your message and I only received the latter half, which makes it very difficult for me to understand the context of the message. However, if you are having concerns about his behaviour around others, then I think it is worth discussing the situation with him first. Have an understanding of his actions before seeking additional help from an outside party.
Without really knowing this person, I think I am ill qualified to make any assumptions or judgments about him. I think it is still best that you discuss this with someone who can support him or guide him.
For the students who have survived their foray into clerkship, congratulations for making it this far. You are only a year away from finishing your medical schooling. Here are some words of wisdom as you draw closer to the end as an undifferentiated stem cell and down the new path as a resident.
Stay healthy. Surely by now you will have managed to find a daily routine that allows you to work hard but also enjoy time away from medicine. However, third year is also a time when one can pick up bad habits. Plan ahead, and take this opportunity before residency begins to really iron out the sore spots in your life.
Explore your interests. Fourth year is really about finding your career interest and honing in on that goal. This is where you can start to expand on your career choice and take electives that give you inspiration, skills, or both.
Prepare early. Residency applications are meaty things and the deadlines come sooner than you think. Research the programs early, write cover letters early, and think about planning your electives early and in line with the residency matching schedule.
Have a backer. In third year, I mentioned that making a good impression was important. That trend continues on in the fourth year electives as well. The good will and social capital you accumulate with your attendings are what will fuel good reference letters. For a competitive program, these letters, particularly if they are from respected members of the faculty, can make or break an application.
Study and keep studying. Elective choices can change the entire atmosphere of fourth year. While flexibility is welcome, it is never a license to take the easy road. Still take some time to read and study. At the end of it all, regardless of what program you match to, the licensing exam tests you on all facets of medicine.
Big brother, big sister. When you began third year, you were the fresh face on the ward. There was some stuff you knew back then but a tonne more you had no idea about. Remember how stressful and terrifying it was once. Now that you are a fourth year, do not forget how that felt. When you meet a third year student on your team, help them along, guide them, impart your experience to them. Remember the kindness of your senior students and residents and pay it forward.
Have fun. Medical school goes by very quickly. As a student, there is a flexibility and freedom that you will simply never come across again. Enjoy your rotations with your peers. Make the most of your electives. Take the residency interview tour as a nation-trotting adventure. Never forget to have fun on this job.
hope you don't mind the question but around how much does an intern makes?
In actuality, the salary for a resident varies from year to year and from province to province. This website here gives a good summary of how a typical resident salary changes based on those two factors. Once you complete your residency however, a physician’s income becomes dependent on what kinds of services you provide, the number of patients you see, and how you set up your practice.
I. Love. This. Question. Because I think medicine is like Supernatural. Seriously.
I’m about to miss a TON of my favorite people (I apologize!!) but I’m going to do my best.
cranquis: Bobby Singer. In the medblr universe he is our fount of knowledge and humor. He reassures, jokes, keeps it real. Also, I imagine he, like Bobby, would probably say this regarding some of his more…colorful patients:
baffledinbrooklyn: It was HARD deciding this one! But I’m going with Chuck Shurley. Like Bobby, he’s someone whose looking at the big picture that we medblrs will often visit for information. Chuck is endearing because he, like baffled, makes an effort to emphasize that he’s a normal person with a far-from-normal (leaning more towards amazing) job.
wayfaringmd: Ellen Harvelle. Down-to-earth, capable, no-nonsense. Her tumblr is like the Roadhouse, a critical pitstop for the roaming medblr in search of knowledge or a good chuckle. When I need advice or a tune-up, I always listen to her. :)
imaresident: Sheriff Jody Mills. From her posts, she always strikes me as the person who has a level-head even when nothing around her makes sense or is going bonkers. I’d want her as my senior resident.
medicalstate: Sam Winchester. He’s smart, well-spoken, thoughtful. But EVERYONE can tell that Tom is a beast on the wards. He is undoubtedly nailing it right now in his intern year! I also imagine that he gives good hugs.
descantforhope: Mary Winchester. descant brings her nurturing, positive energy to the medblr community. A gorgeous, wonderful mom who also kicks butt, academically, personally, and in all other areas of life.
aspiringdoctors: Charlie Bradbury. The geek-chic sister everyone wished they had who loves LoTR and is a proud nerd. Won’t hesitate to defend what’s important and right. Also, both are on top of their fashion game.
mynotes4usmle: Tessa the Reaper. Lovely, wise, and an unexpected guide. While in Supernatural, Tessa is a surprising guide and ally to Dean, Renata is a parallel for me and many others in a world where some would rather hoard their test tips and knowledge than empower others(I’m looking at you, SDN). She’s someone you want in your corner!
ladykaymd: Linda Tran. Whip-smart, capable, loving, a fearless champion. When you think you know everything about her and how badass she is, she surprises you and reminds you that she is exactly what you thought: a medical goddess in the making. Everyone wants to be her. This is fact.
Imagine, instead of Crowley, anti-vaxxers, misogynists, and the patriarchy as ladykay slaps them hard with knowledge.
ermedicine: Balthazar. Because you have to be committed, smart, and a healthy dose of sassy to survive a hectic ER. I imagine ermedicine slinging awesome lines like this during his shifts:
beyondtheoath: Kevin Tran. Thoughtful and gifted with a natural ease in a profession that is pretty much all about the unnatural.
hartmd: Castiel. It’s something about the writing style. Analytical and meticulous but ringing with a lot of heart.
ninjatengu: Garth. He balances crazy medlife with a fulfilling life beyond it. Sports! Friends! Food! Yummy drinks! And he’s got a refreshing, unique take on medlife, much like Garth.
irandommomentsdevida: I wanted to say Gabriel, but…you gotta be Becky. Minus that creepy episode with the love potion. I deny it’s existence. Because Becky is enthusiastic, unapologetic for her passions, and always genuine. She’s fun and reminds us all that yes, the Supernatural/med world is often scary and serious, but it can be a lot of fun too!
kyidyl: Krissy Chambers. Hunter/medblr in training, but already showing some serious badass potential.
thebiopsy: If we have a Bobby, medblrs must have a Crowley. A fan favorite, funny, and he’s the man with the skills and knowledge you need when you’re in a bind (podcast, med school consults via social media). I imagine you to have excellent sartorial style as well :D
“My friend, old and passing, said,
“There is more to life than staying alive.
Don’t rescue me too much.”
On his farm, twelve miles out
by rough gravel roads, he is done
with plowing, spraying, harvesting.
But he is not done watching the sun
sink below the windbreak or listening
to the nighthawks above his fields.
Don’t make him move to town.
There is more to tragedy
Today marks the end of my first week as a doctor. To say the least it has been exciting, interesting, but above all, scary.
I have hit the ground running here, starting my first rotation in internal medicine. The days thus far have been long, hard, and busy. Everything feels more real, more high stakes; after all, I am now the one who needs to make the decision overnight.
However, every resident feel like this when they begin practice. What I would like to share instead are some of my other experiences:
People are addressing me as doctor: This continues to feel very out of place to me. While I now do refer to myself this way, I still ask people to address me as Tom.
I can give verbal orders over the phone: As a medical student, I was never allowed to give a verbal order over the phone. In order to start investigations or medications, I always had to go to the ward and write it myself. Not anymore.
What orders should I give over the phone?: While I used to have time to think on my way to the ward as well as the luxury to phone the resident for approval, this is no longer the case. I cannot emphasize enough how awkward it is to be asked for directions on the spot. “Can I call you back?” or “Let me lay eyes on the patient first.” are my go-to phrases now.
Accepting my orders as they are: On very few instances when a pharmacist is on hand, no one has questioned my orders. It is a scary burden to carry as a new resident. “Is what I am about to order safe?” Unfortunately, no switch flips on in our head when we become a resident, granting us all the knowledge and competence we need to make these decisions on our own. Even for some of my simpler orders, I still run them by my senior resident first.
The work does not change: Honestly, while the responsibilities have increased, the work we must do is the same. That also means that time for sleeping, eating, and peeing is still at a premium. Already, I have done a 36 hour straight call shift. And more are to come I am sure.
Billing: I never had to learn about earning money as a medical student but now it is part of my daily life. The flip side to doing all of the clinical work is all of the paperwork, now billing included.
There are still two years ahead of me in this residency and much to learn, see, and do. Expect more thoughts on this transition in the future.
In the 1970s, Noel Burch described four stages of learning any new skill and it could be summarized as follows:
Unconscious incompetence, where one does not recognize a deficit;
Conscious incompetence, where one does recognize a deficit and how to improve their skill;
Conscious competence, where one is competent but requires concentration to perform the skill, and;
Unconscious competence: where the skill has become second nature.
Everyone strives for unconscious competence. The mastery of a skill has become so complete that you can do it effortlessly. The scariest state to be in is the first stage. “You do not know what you do not know.” That can be a terrible position to be in, especially when a patient’s life is on the line.
That is why receiving feedback is so important. That is why we train for so many years, under the watchful eye of so many experts to be a master of the craft. Sometimes, in order to make that transition to the next step of our competency, it requires someone else to point out where we need help.
It still shocks me that I am only a few days away from beginning my residency. Four years have come and gone. I now have a degree and letters behind my name to show for it. This last year has presented with its own unique challenges and a lot has changed in four years. Let’s have a look back.
It was here that I first learned how to correctly use my stethoscope, how to speak with patients, and how to act like a doctor. These were my baby steps. I studied a whole host of topics, covering the broadest and biggest organ systems. It was also here that I learned anatomy and had the privilege to work with cadavers.
In many respects this was the most stressful year. While clinical work is taxing in its own right, nothing came close to the mental toll this year had on me. Studying was both a necessity and a compulsion. Easily I spent entire days sitting a library, reading, memorizing, understanding. I had never studied that much in my entire life.
This time, the stresses of clinical work were balanced between the mental and the physical. By far the most challenging year of all but also the most enjoyable. Having sat in class for the better part of my life, now I would have to do.
It was an adjustment to work in a hospital, to see volumes of patients, to do call shifts. But I adjusted and grew used to the pace of the ward. Gradually, I learned to move from knowing how, to showing how, to doing.
On top of the clinical work, I had a number of additional challenges this year. I had an all encompassing OSCE, residency applications and touring, and a licensing exam to complete. By this point, clinical rotations were not quite as overwhelming or scary as they used to be, but I still had many hard days.
The brunt of the stress this year came from the latter additions. Those three things were for all the marbles, and the consequences of missing any one of those were a constant worry. The OSCE wound up showing some of my weaknesses that I would need to improve on. The CaRMS tour would take me across the country from colder to coldest winters in Canada. The licensing exam ended up being a two-week mad dash to the finish line. For six months, the pressures mounted through these three main events.
But I eventually reached the end of my four year journey. I graduated, I was admitted to a residency program, and I passed my exam.
It has been a roller coaster ride through four years of medical school. I am happy I could document it all here in these posts. Now I start a different journey through residency and look forward to reflecting more on this new adventure.
When I first started writing on the Medical State of Mind, there were very few medical tumblrs, or medblrs as we are known now. I could count on (less than) two hands, how many strongly medically oriented tumblrs existed.
Looking at this list now, and the many additions since by fellow bloggers and readers, it is truly impressive how much the medical blogosphere has changed. Having said that, there are still many barriers and challenges from within and without to create standards that allow everyone to both speak their minds and respect the boundaries of the profession.
We have our work cut out for us to move at the same speed as the change around us.
I am very honoured to be a part of this list and encourage everyone to check out some of the other blogs on this list as well.
Today, I received a new ID badge from the hospital.
With the transition from student to resident, it seemed as though even the dimensions of the card had an upgrade. It was longer and wider, needing a larger sleeve to put it in. The gloss coating on it was shiny and impeccable. Beneath it all, a swath of vivid colours depicted a man with a beaming smile that could be described either as overjoyed to be a resident or overcompensating for his anxiety and nervousness.
In big bold Helvetica, the title Dr. preceded the name. My name.
Doctors faced with the tricky task of spotting rare genetic diseases in children may soon be asking parents to email their family photos. A computer program can now learn to identify rare conditions by analysing a face from an ordinary digital photograph. It should even be able to identify unknown genetic disorders if groups of photos in its database share specific facial features.
Let this be proof that Tammy and I are alive and well. I apologize for the lack of posts lately. There has be a significant challenge with usable internet that still plagues us.
Currently though, I have enough down time to at least update everyone on how I have been.
Emails are still on the back burner at this moment but I am unfortunately grounded “somewhere in France” due to unforeseen events.
The Société Nationale des Chemins de fer Français (SNCF) workers here have been on strike and our train that was to lead us on our next leg of the train was grounded. We have had to make some significant adjustments to our itinerary.
Having said that though, we are making the most of it and enjoying our slight detour in France for the next few days.
By the 22nd, I should be home, by which time postings should resume their normal schedule.
Thanks to everyone for their patience and I look forward to updating you all again soon!
Sincerely, Tom of the Medical State of Mind
EDIT: A reader has correctly pointed out that it is the SNCF that is on strike, not the entire EuroRail system. Thanks for pointing this out.
Recently, I have been receiving some questions from my sister-in-law regarding how my niece is developing. She knew some of the milestones to look out for but was asking me if there were others that she could be aware of.
In light of this, I sifted through my resources to find this chart for her. The Denver II assessment tool is something that I have regularly used while on paediatrics and maps out developmental milestones in all four spheres of growth.
For any readers who are expectant, new mothers, and medical students currently going through paediatric rotation, this may also prove useful.
When the chaos and dust had finally settled for our wedding, we were finally in bed by four in the morning. I awoke at seven to start the day yet again, a heavy fog clouding my mind, a hunger for sleep in the pit of my eyes, and a lumbering grogginess in my step.
A feeling began to well up inside me, a familiar emotional reaction I had not felt for a long time. A sense of running full sprint through an endurance course à la Le Mans.
I felt like I had just been on the busiest call shift to date.
After more than a year of planning, the day seemed to have come and gone in a blur. We had hurriedly scurried from one place to the next, ate little, and narrowly averted disasters, all while keeping up smiles and appearances for our guests.
In the end, the weather was perfect, everything flowed smoothly, and we all survived.
Thanks to everyone who has written in with well wishes and congratulations. Tammy and I are very humbled by your support as we approach our big day together.
On a different note, apologies for the break in form. There has obviously been a shortage of medically-themed posts recently but I assure you that will return in due time. Thanks again for your patience and understanding as we celebrate this once in a lifetime moment.
The HIV/AIDS ward at St. Paul’s Hospital is closing due to a decline in the once-deadly disease, the B.C. government announced Tuesday.
“This is a proud day for British Columbians as we mark another milestone in our leadership in the fight against HIV/AIDS,” said Premier Christy Clark.
“Thanks to the dedicated efforts of the community, those at the BC Centre for Excellence in HIV/AIDS and health professionals across the province, a ward that once served those dying from AIDS, now supports those living with HIV.”
And I wish I could tell you a story about fancy heroics - about an exploratory laparatomy, a chest thoracostomy, or a patient that coded and I was the last person to perform the chest compressions that brought them back to life. But I can’t. But I can tell you that I saved a life.
For the third and last time, we walked across the stage to receive our medical diplomas from the dean of medicine, conferred to us by the president of the university. Convocation was the final chapter of our graduation.
Finally after eight years of university schooling, I was an alumni. It took tremendous amount of academic fortitude to reach this point. But it also would not have been possible without the support and understanding of my family and friends. These are the unsung heroes, the honorary MDs who were there when I took my first blood pressure reading, who volunteered for my abdominal exam, who learned and taught me about being a patient and being a physician.
At the time of being admitted as a member of the medical profession:
I solemnly pledge to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude that is their due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets that are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honour and the noble traditions of the medical profession;
My colleagues will be my sisters and brothers;
I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I will maintain the utmost respect for human life;
I will not use my medical knowledge to violate human rights and civil liberties, even under threat;
I make these promises solemnly, freely and upon my honour.
”—World Medical Association Declaration of Geneva.
The graduation festivities continued today with valediction speeches and some key words of wisdom from classmates and physicians respectively. Instead of donning the white coat today, I received my graduation gown for the hooding process. This is the act of conferring an academic hood to signify the completion of my degree in medicine. In addition, we all swore our Hippocratic oath for the first time while preceptors and physicians present for the event reaffirmed theirs.