My Life Since May

So I haven't set aside much time lately to write about what has happened since May.  Olive was sick with a stomach flu today so I took the day off to watch her. She is now napping so I decided to take a therapeutic time out and reflect on the past few months. I will summarize it as fast as I can.

May-June

In May I got out of school and began studying for my USMLE Step 1 and Comlex Level 1. I kicked Hailey and Olive out of the house and told them to go to Utah for about 5 weeks so I could focus on studying, not really, but they did go to Utah so I could study. It payed off as I was able to dedicate about 12-15 hours a day just to board studying. I took my Comlex, which is the DO board exam, first on June 13. Then I took the USMLE, the MD exam, on June 22. 

After taking the exams Hailey, Olive and I took off for Lincoln City, OR to spend some relaxing time on the Oregon coast. We stopped off in Tilamook and saw the cheese factory, then drove down the coastal highway. It was an amazing trip full of exploration of new places, a few risky hikes, and a lot of good food and shopping(see Facebook for pics). After about six weeks I got my scores back and scored really really really well on my Comlex and I did just really well on my USMLE. I was way happy with the scores and so grateful for Hailey and her family for giving me the time to be able to study for that.

July

I started my first rotation on July 11th. I started out in Family Medicine. I was in a privately owned family medicine clinic for six weeks in Richland, WA.  The experience was amazing.  The practice was partly a concierge medical practice, meaning that many of the patients payed a yearly "membership fee" to receive same day appointments, 24 hour access to their doctor, 30 minute appointments, free yearly labs, and 90 minute comprehensive physicals. It was an interesting business model that has formed recently because of how messed up our health care system is right now. Insurance companies are really pushing the quantity over quality bit. I think the hardest thing about medicine right now for me is understanding that I am not really in full control of what I can and cannot do with the health of my patients. Insurance governs so much of what we can do for patients. For example, if I want to give my patient the best treatment for rheumatoid arthritis, then I must first start out giving patients the cheaper medicine first that has been proven to have horrible side effects. The patient must then have documented side effects for the insurance to justify switching to the more expensive and effective RA drugs. I understand the reason behind insurance, but I still feel a good fair amount of people are getting ripped off by such a complex system. Anyways, I think a decent amount of doctors are switching to concierge medicine because it's easier on the doctor and the patients. On days where we did not have concierge medical patients we were seeing 4 patients an hour. Now that doesn't seem like much as far as a patient load, but that means each patient only gets 15 minutes from start to finish once they enter the doctors office.  The doctors office has to address the chief complaint of the patient, take vitals, review medications, review recent consults from specialists, obtain a thorough history from the patient, update any changes to the medical record, and then the doctor comes in and has about 5 or less minutes to complete a physical, answer questions(which usually bring up even more medical issues), and educate the patient on often very complicated issues.  When I was assigned certain patients to examine, I really struggled and was frustrated when I realized how short my time with patients is. I still struggle with it because I feel patients deserve more; however, I cannot  and will not be able to give them more time without losing my ability to pay for my student loans and provide a living for myself. The reimbursement from insurance just stinks.

Here are my pros and cons of family medicine: 

Pros: Flexible hours, see a wide variety of patients from babies to kids to adults, I can have some family time, own my business, ability to take on PAs and possibly earn more money, lower stress(relatively speaking), develop wide variety of skills, change the lives of many patients(because we have to see so many), front line of prevention, influential in the community

Cons: Not enough time with patients, deal with lots of chronic illness that patients often times never change(diabetes, HTN, Hyperlipidemia), lower paying(compared to other specialties), always feeling like the middle man(takes a lot of time to get paper work/results from specialists and the communication network with medical records sucks!)

August-September

So I just started my Internal Medicine in-patient hospital rotation. In a nutshell, I am with doctors, called hospitalists, who admit patients to the hospital from the ER or post surgery and take care of their medical needs and decide when they are to be discharged.  This is my second week and I love it.  Probably just as much as I love family medicine. We get to see hundreds of interesting illnesses and complicated patients. Our patient load now consists of a patient with pulmonary hypertension, a morbidly obese patient with COPD, a patient with recent fall and brain bleed, a patient with an infected cardiac pacemaker, and a patient with dementia and a possible herpes infection in the brain. So the variety of the illnesses of the patients is crazy, and I have realized how little I actually know. When my attending(boss) physician asks me, "what is your plan with this patient?" I usually just say, "I don't know." Then just look at him like a deer caught in the headlights.  Don't get me wrong on some patients I know what to do, but its hard to know how to do it, who to call, what to order, what to dose, which medication is safest, where to discharge the patient, and the list of things to do goes on and on. The main goal of my education in my 3rd year of medicine is to really discover why the patient is sick, develop physical exam skills, and to come up with basic diagnosis skills and plans. My 4th year and my residency are more focused on developing the specific care plans for my patients which tends to be the hardest part because that involves the most critical thinking and depends on experience gained through seeing hundreds to thousands of patients.  

Pros and Cons of Internal Medicine

Pros: Work in hopsital(depends), payed a salary, high demand, payed insurance, payed retirement, variety of patients, time with family, can be in a private practice outside hospital, develop a wide variety of diagnostic skills

Cons: Work in hospital(depends), long hours(usually 12 hours shifts or longer), work mainly with adults and no pediatrics, more difficult to own a practice as PAs aren't used as much in internal medicine, not as hands on as family medicine(depending)

Anyways thanks for reading about my journey.

A Brief Explanation of the Journey

So currently I am finished with my second year of medical school and I am halfway done until I graduate. I am taking this time to explain the journey of becoming a physician so that people understand and don't get confused when I explain the terminology. I will start start from year one!

Year 1of Medical School (book work)
1. Review and learn about all the basic sciences and how they relate to the human body
2. Subjects include biochemistry, genetics, pharmacology, epidemiology, anatomy, physiology

Year 2 of Medical School (more book work)
1. Learn about each human body system and everything that can go wrong and everything we do to treat the problems
2. Body systems are categorized as Cardiovascular System, Pulmonary System, Endocrine System, Musculoskeletal System, Nervous System, etc

Summer between Year 2 and Year 3 
Students take their 1st Boards. This is where I am at now.  Now to make things a little more complicated there are two different tests I can take.  The test that all Doctors of Osteopathic Medicine aka DOs are required to take is called the COMLEX Level 1.  This COMLEX Level 1 exam is 400 questions long and is a nine hour test.  Why is the COMLEX important? My future residency program will judge my competitiveness and future based on this score. Now if I want to pursue a residency that does not accept the COMLEX Level 1 exam, then I have to take another exam called the USMLE Step 1. This exam is required for any Doctor of Allopathic Medicine aka MDs to take, but is optional for any DOs, like myself, to take.  The benefits of taking both the COMLEX and USMLE will basically open my options to apply for more residencies in the United States. Especially residencies on the West Coast as many of the residencies prefer USMLE over COMLEX for political reasons.  I will be taking both these exams in June.  So far for studying I have done about 5,000 practice questions and countless hours of board review that are about to drive me crazy, but I love it. That's why I sent out those crazy movie I guess. Work, work, work, work, work!

Year 3 of Medical School (clinical work)
This year is called Rotations....not Residency. I repeat, the third year of medical school is called ROTATIONS.  This year is still guided under the supervision of my medical school PNWU. I have not received a degree yet.  What are rotations? Each medical student is pared one on one with a physician in a core speciality of medicine for about 6-8 weeks. The physician who teaches during a rotation takes each student under his/her wing and teaches students medical procedures, lets student examine patients, helps students develop clinical knowledge and basically apply book knowledge to the real world. Then the student moves on to another physician for 6-8 weeks. Then to another physician and then another. The medical student does this for the entire 3rd year. The core specialties include family medicine, pediatrics, surgery, women's health, emergency medicine, internal medicine, and psychiatry. I just want to repeat once again that third year is not residency, it's called rotations. Haha.  The most important part of 3rd year rotations is finding a field in medicine that I am passionate in and want to pursue as a physician. My top 4 now are Family Medicine, Internal Medicine, Pediatrics, and OB/GYN.  Not really sure what real medicine is like in these fields and how they are going to change in the future so I am keeping my options open.

Summer of year 3
This is where students take COMLEX Level 2 and the PE. Level 2 is a multiple choice exam and the PE is a day full of fake patients that test the knowledge and clinical skills the student has developed during his/her third year. The PE exam is not very fun as students have to take the exam in Philadelphia and the exam is pretty stressful.

Year 4 of Medical School (more clinical work)
This is the main preparation year for residency.  Each student by now has an idea what he/she want to do in medicine so now it's time to find a residency in that field. So each student sends out applications to different residencies in order to do what is called an AUDITION ROTATION.  This involves going to the residency and rotating with the doctors(faculty) and residents(students) in that residency. At the end of the audition rotation the student gets an interview with those uncharge of the residency and they treat it kind of like a job interview, but for residency. These auditions vary in length, but hopefully at the end of the audition the faculty and residents want you in their program and will be looking for you name when you submit your application for residency. Audition rotations are expensive and time consuming. Student's have to travel out of state and live out of state for weeks at a time for these rotations. I am not looking forward to these, but hope I can find one that I love.

Graduation from Medical School (get a degree)
After 4 years of medical school students graduate with a degree. Mine will be a Doctorate in Osteopathic Medicine.  For Allopathic medical students, it is a Doctorate in Medicine. Both are equal as far as scope of practice, our training mainly varies depending on our residency and wether or no we incorporate osteopathic philosophy and treatments in our practice. If doctors tell you that they are not equal then they are full of prideful crap because a good chunk of my professors who gave me my critical education were MDs and not DOs. So the education and training is basically what we make it. So now that a medical student is no longer a student and has a degree they go off to residency.

Summer after Year 4
Students take the final part of COMLEX called COMLEX Level 3.

The Match
A giant complicated system exists that is design to match each student to a residency.  Each students submits his or her application to this system called The National Residency Matching Program. This program has algorithms and formulas that are designed to match students in one of the residencies they have chosen based on scores, letters of recommendation, experience, etc. Students will usually pick 3-10 residencies they want to be in and hopefully they match to one of those residencies or they are stuck in limbo for year.

Residency (our first job...kinda)
This is the time a doctor becomes a real doctor and not a student.  Residents are actually payed during residency. The salaries on average are about $40,000-$60,000 a year depending. Each resident sees his/her own patients and for the first year is under the close supervision of another physician. During this first year residents can't prescribed medications without an attending physician's approval. After the first year in most programs, residents can then legally prescribe meds and are not under as close as supervision as the first year. As far as the length of residencies, if a residency includes surgery, these residencies are 4 or more years long. Family medicine, pediatrics, and internal medicine residencies are each 3 years long. After those three years, internal medicine and pediatric residents can choose to further specialize in another fields which often requires another 3-4 years of training.  Just a side note. Not all hospitals have residencies.  Residencies are national funded training programs for doctors.  A branch of Medicare pays for a majority of the funding of residencies so establishing new residency require a lot of hoop jumping and red tape cutting if you know what I mean. Residencies also have political struggles and biases when it comes to which medical school students they allow into their programs. After residency training residents take their final specialty boards and are real doctors.

Finally a real doctor!!!! Money in the bank!!!!

Hopefully everyone can get a feel of what the journey is like. I feel it stinks and is too long and complicated. In the end it will be worth it. I just can't wait for the day when I finally am on my own and can focus on my patients and care for them the way they want.