The 2012 Residency Draft.... aka: "The Match"

In the real world, when you graduate from school, you have the freedom to go apply and interview for a job in your field. Now you may or may not get that job, but that's ok because you can just apply for another one if you don't. In the med school world this practice is thrown out the window. Most people are under the assumption that once you graduate med school, you simply apply for a job at a hospital or a practice and POOF! You're a doctor! Well, allow me to elaborate on what med students have to really go through.

After four years of undergraduate education and four years of medical school... you then have to go into residency. You'd think that after eight years of torturous biochemistry, pathophysiology, and gross anatomy, along with two years of clinical learning, that you've earned enough street cred to just go practice medicine. Well, technically as a resident you are a doctor, but I liken it to a "doctor with training wheels". And exactly how long you have to wear those training wheels depends on which specialty you go into. I'm going into Family Medicine, which requires a 3 year residency.

Now applying for residency is the tricky part. There's this big online application program called ERAS (electronic residency application service), and you HAVE to apply to residencies through this and only this (which costs $ of course). So you upload your transcripts and your CV and you write a personal statement about how awesome you are. All of this is compiled into your application. You then pick a list of residency programs to apply to. I applied to 12. Then ERAS sends all your info to these programs, at which point they decide whether they like you enough on paper to invite you for an interview. Please refer to my previous post: Hi, My Name is Maria. I want to be a Resident at your Program! on what that's like!

After interviews are all said and done is where the tricky part comes along. Programs can't just call you and say, "Congratulations! You got the job." Instead, you have to enroll in THE MATCH ("The Match" will remain capitalized from here on because when I say those words, I would like to have that "dun dun dun...." connotation with it. That's how serious it is.). It's another service, which of course costs more money, in which you have to submit a Rank Order List. A Rank Order List (ROL) is a list of the residency programs you'd like to attend in descending order of likeness. At the same time each residency program submits a list of their own, which includes the medical students they've interviewed in the order in which they like them.

Then comes match day, which this year is March 16th. Some big magical mystical computer system goes through your ROL and the residency programs lists and matches students up based on how each have ranked each other. So if I'm lucky enough that the number one program on my list, ranked me high enough, then I will likely get matched to that program. If not, then it goes to my number two, then number three. So on and so forth. If for some reason, which there are many, that you do not match with a program then you have to "scramble". To scramble means that you have to call programs that may still have an opening and hope that they like your credentials enough to give you a spot. This is every fourth year medical students worst nightmare.

The morning of THE MATCH you will receive an email or a letter from your school, which states where you have matched. Whether you matched at your number one choice or your number 10 choice, you are contractually obligated to fulfill your residency at that program. So it's really important to only rank programs you know you will be happy at. The residency director usually calls you and congratulates you, and then you can breath a giant sigh of relief knowing that you will have a job after almost a decade of schooling. Most coincidentally, THE MATCH falls right before St. Patty's day this year, which means that my celebration will continue throughout the weekend (or I'll be drowning my sorrows in pints of green beer if the unthinkable happened and I did not match).

When I tried to explain this whole process to my family, they looked at me quite puzzled. "So.... It's like the NFL draft?" they said. Well, kind of... minus the whole giant televised event where someone's up at a podium and goes, "The New England Patriots in the first round of the 2012 draft choose Maria Boylan!" And I walk up and put on a white coat and the residency director shakes my hand and we freeze and pose for a picture. And then I cry like Tom Brady did when he was drafted. Ok, not exactly like that. There's no big event, and you don't get a jersey and a million dollar contract. But I imagine the feeling is just the same.

So at this point in time, I'm getting ready to submit my ROL and then just crossing my fingers and hoping for the best. The fate of my future lies with THE MATCH gods. Luckily, I think I've got a really good group of programs on my list and would truly be lucky to do my residency with any of them. But I think they'll be pretty lucky to have me too :)

Death and Dying

People ask me all the time how I deal with my patients dying. Quite honsetly, I think I do pretty well with it. After all, you're looking at a girl who's father has worked in "the business" since before I was born. And by "business" I don't mean he's involved in some sort of illegal mob-type situation (though he could surely pass for a member of the IRA). He's currently the superintendent of a cemetery and crematory, but before that he started out as a gravedigger. I remember being five or six years old and going to work with him on Saturday mornings and riding my bike around the cemetery. Then when I was older and in college, I worked for him delivering cremations or doing secretery work. I'd have to read through the death certificates and plug information into the computer, and I remember being so intrigued reading the cause of death. Cardiac arrest. Cerebral hemorrhage. Respiratory Arrest.

It's funny how something that we all literally have in common, is such a sensitive subject for most people. It's that dreaded conversation you wish you never have to have with your sick patient, uttering those powerful words, "You are going to die." And then the even worse conversation you have to have with the family afterwards where you tell them that their loved one has passed. But as doctor's we're so afraid of dealing with the dying part of our job. We put so much into taking care of our patients and trying to prevent death, that admitting a patient is going to die almost feels like a failure on our parts. But I'm learning more and more that actually accepting that your patient is terminal and then making a conscious decision to help them during their process of dying is one of the most important roles you have as a physician.

I recently had a patient with severe congestive heart failure. I saw him a total of two weeks in the hospital. He was my first patient I'd round on every morning because he was my sickest patient. I'd check his labs, check his vitals, talk to his nurse about how he did overnight, and then finally go in the room to ask how he was feeling and examine him. I'd then sit down and write my note on him which always ended with my treatment plan. And each day it became harder and harder to come up with a plan, mostly because we did everything already to try to help him. I consulted all the speciatly docs, I ordered all the labs, I ran all the tests. It eventually came to the point where I just didn't know what to do anymore.

Then one morning his nurse asked me about having the palliative care team come in. And she was right. I'd done my job up to this point and it was time to change my train of thought from helping him live to helping him die. I've never worked with the palliative care team before or really knew what they did. It was quite an eye opening experience. They're job is to speak with the patient and get an idea of what they really want out of their remaining time. Whether it's to just be "comfortable" and pain free or to have more aggressive measures taken to prolong their life. And whichever way the patient decides, they try to support their wishes as best as possible. But therein lies the point. The patient chooses how to die. They have the control and we, as doctors, simply help them with that.

After the palliative care team got involved and I sat down and spoke with the family in great detail, the decision was made for him to go to hospice. The day I discharged him to go, I went into his room to examine him one last time. I remember he looked more peaceful than I have ever seen him. There was calming music playing, the lights were dimmed, he was sleeping comfortably. I wished him well and said it was pleasure taking care of him. Then his sister pulled me aside and thanked me for all I'd done. I said I wish I could have done more, but she said I'd done more for him by helping him be comfortable and die peacefully.

This experience has made me realize that we can do everything in our power to prevent someone from dying. We can pump them full of fluids, puts tubes in their chest, shock their heart, inject hundreds of drugs.... but despite all that, death is inevitable. The greatest courtesy we as physicans can bestow on our patients is to talk to them about dying. What would their wishes be? By doing heroic measures are we really improving their quality of life or just prolonging life? Every patient should be given the opportunity to die the way they chose to and to hopefully die peacefully and comfortably. And it's the doctor's job to help them get to that point.