Leveling Up

August 7, 2019

If there’s anyone left still following along after all the extended silences and affirmative responses to the “are you still in school” question, it’s time to check in with what I’m doing now. While I did, in fact, graduate with some degrees a while back there’s still a long way to go on the path from “person with a degree” to…wherever it is I’m going. After the eight-year MD/PhD debacle I told myself “no more garbage hybrid programs,” so when I found out Child Neurology was kind of a combination of Pediatrics and Neurology, I immediately ran away decided to sign up. Algorithmic matchmaking subsequently placed me in the Child Neurology residency program at UCSD.

Now, I’ve put another year experience point into this whole doctor-doctor career, which is to say, I’ve been in San Diego for over twelve months now. How “real” of a doctor I am largely depends on perspective. While I’m no longer a student, as a resident I am not quite autonomous, making me something of an apprentice. Is a Padawan still a Jedi? They carry lightsabers…

Sitting in the hospital with a badge that says “MD” while having no idea what to do in the electronic medical record (EMR), writing orders that other, more experienced doctors are constantly checking, but still being the primary physician for the patient…is the essence of intern year, also known as the first year of residency. Accordingly, mine went by in a blur of hospital workrooms and progress notes, leaving behind miscellaneous projects-in-progress and about half a dozen unfinished posts.

In the breakdown of how the years of life are traded after medical school, medical degree, medical license, and medical specialty are all separate but related things. A medical degree is worth very little on its own, but is a prerequisite for the other two. A medical license is administrated by a state medical board and grants the ability to do things like write and sign prescriptions and see patients independently—essentially to “practice medicine” in the most general sense. Obtaining a license requires a medical degree, passing all of those Step exams I used to talk about, and completing some amount of clinical training working under someone else’s license, the specifics of which vary by state.

Every “type” of doctor you might have heard about is a specialty or subspecialty, and a license to practice medicine does not a specialist make. For that distinction one must trade additional years of life by completing a residency (the first year of which is called internship, just in case this all was making too much sense). Regardless of the licensing requirements, newly-minted medical school graduates are nearly always signed up to be in a residency for longer: Residencies have a variable length starting at three years and increasing from there. Those years qualify one to take the specialty boards of whatever residency was just completed: Family, Internal Medicine, etc. Then there’s subspecialties like Cardiology or Neurosurgery, which require more training called a fellowship and passing yet another exam, the subspecialty boards.

As for me personally, I passed the Steps, finished intern year, and the next, uh, step, is to apply for a medical license in the short term, and complete Child Neuro residency in the longer term—the specifics of which will require a wholly separate explanation.

Type I Hypersensitivity

November 6, 2018

I had another allergic reaction, once again after specifically inquiring  about a dish’s peanut content. I noticed suspiciously peanut-like “macadamia nut” pieces that tasted an awful lot like peanuts to my companion, but after being assured they were not peanuts, the first bite determined that was a lie. Perhaps it was the sauce? I haven’t seen poke with peanut sauce before but hey, there’s always a first time.

One might think it would be obvious that someone asking about a a food ingredient due to a peanut allergy would be interested to know if some other component of the dish was, say, peanut. I’m beginning to wonder if restauranteurs in San Diego know what peanuts are.

Regardless, having been reassured that there were no peanuts, I took a big, delicious bite, telling my friend, “I would know by now if there was…” Which is precisely when I began noticing the reaction. It was fast and bad. I didn’t have my EpiPen with me because of style: my messenger bag is breaking down, starting with the zippers. Instead, I slammed two diphenhydramine and excused myself to the bathroom to throw up while we waited for the check.

Flashback: one month ago

I did an elective rotation in Allergy and Immunology, in part due to self-interested curiosity. One of the many fantastic attending physicians I worked with was Dr. Stephanie Leonard, who specializes in food allergies, and has a peanut allergy herself (one of the many cool things she’s involved in is a research study about de-sensitizing kids to peanuts). She was incredibly patient, giving me the chance to ask years’ worth of allergy questions. It turns out items like peanuts, peas, and lentils are more closely related in their antigenicity than their classification taxonomy, a factoid that finally explains my off-limits list

As allergy kindred spirits, we talked about some of our recent dining mishaps. I told her the story of my first week in San Diego, innocently admitting that I have never used my EpiPen, only diphenhydramine. Her subsequent scolding was swift and culminated in me getting four new EpiPens (actually a different type of epinephrine autoinjector, but same idea).

Back home and throwing up several more times in the bathroom, I heard Dr. Leonard scolding me in my mind. Already flushed with shame from ruining dinner (and, I suppose, that whole anaphylaxis thing), I found an EpiPen. Ever the scientist, I did use one that was three years expired. Jabbed it into my thigh…click…count ten seconds…withdraw. I noticed that somehow I had managed to bend the needle while it was in my leg. A drop of blood pooled from the injection site as I waited. It grew larger and began to run. And, miraculously, my symptoms started to subside: the constricting airway, vomiting, cramping, and prickling of early hives all faded away. 

About ninety minutes later, we got Wendy’s.

Note: Type 1 hypersensitivity is an immune system response that involves an immediate allergic reaction provoked by exposure to a specific antigen, such as a peanut. It’s also the process involved in milder allergies, like hay fever. 

Pager Trouble

August 20, 2018

One of the first items I was issued when I started residency, along with my ID badge, was a pager. Yes, we still have pagers, which has invited derisive remarks from local churls if we go out immediately after work and forget to leave them in the car. You may be surprised to learn that we heavily rely upon fax machines as well. Modern medicine!

Turns out one of the first things you need as a resident is a pager.
Turns out one of the first things you need as a resident is a pager.

At UCSD, our pagers aren’t even two-way, which causes much consternation when, as a Millennial, I receive what are essentially text messages to which I cannot respond. There have been other challenges as well: For example, my pager number isn’t attached to my name in Epic, our EMR. I initially tried asking the IT department in charge of Epic to update my profile, but apparently if you’re a resident, that task is delegated to Someone Else. One might think they could simply enter the number into the appropriate field, but I guess it’s grayed out for them or something.

Every so often I receive pages meant for someone else, causing an initial moment of panic as I am the least qualified person to address whatever the paged issue entails. This was especially common immediately after starting: My first week of internship I repeatedly received urgent pages from some kind of cardiac transplant dispatch, leading to an extended phone call where I patiently explained that no, I am not the doctor in question, nor am I their authorized representative, and in fact am an intern-level resident in Child Neurology at UCSD. At one point all of us interns received what appeared to be a series of emails in German. Herr Ottar is missing some information about his chronic pain patient; however, the entire UCSD Pediatrics Intern Class is well aware.

This week I got a “test page” from someone in Cardiology. While questioning whether or not I was expected to call back, a flurry of pages began to arrive from people informing the initial sender that they had paged the wrong person. A look at our intern group message confirmed: Something was amiss at Pager Central. We had a hospital-wide reply allpocalypse in effect, complete with an exasperated plea from some unfortunate soul who most likely was working nights and attempting to sleep.


Some unfortunate soul
Since when did pagers even have a "reply all" function?!

Intern Insecurities

August 11, 2018

Now that I’ve finished my first month as an intern, I can admit I was afraid that the first time a nurse asked me a question, I would freeze, burst into tears, and run away. So far, so good.

Perhaps the most awkward experience this month was not, in fact, showing first-time mothers how to breast feed an infant, but when my attending insisted that I introduce myself as “Doctor” Castello. It felt immediately pretentious and I shied away from it like a horse from a particularly imposing shrub. I quickly realized there was a practical element to this proscription: When I introduced myself as a doctor I stopped getting dirty looks from moms who apparently thought I was about to steal their newborn. Still, it’s weird. I don’t feel like I know anything.

Game. Set. Match.

March 21, 2018

Game news dominated my Facebook feed on Friday night, when, after years of  “up and comingstatus, my alma mater UMBC secured a place in history by knocking out UVA in March Madness. If, like my med school colleagues, you managed to miss what will likely be the biggest sportsball upset of the year, the Retrievers are now the first 16th-seeded team to beat a number 1 seed in the NCAA men’s college basketball tournament (a feat accomplished a mere twenty years earlier by the Harvard women’s team). As a fringe benefit, excited UMBC-related updates effectively obliterated the slew of posts concerning another moderately significant event from earlier that day. Checkmate!

Set up for a St. Patrick’s Day get-together occupied most of Friday. Hosting something is sort of tradition for us, and this would be the final incarnation prior to an impending major life change. We made a concerted effort to avoid re-watching The Boondock Saints yet again and in doing so, neglected to find a relevant substitute and wound up not watching anything at all. Consequently we found ourselves playing games, inadvertently amplifying social interaction.

Match Day played out a little differently for me than most, resolving the Schrödinger equation not with a bang but a whimper. To say that a loud party for this particular piece of news “wasn’t my thing” is a gross understatement, which shouldn’t come as a surprise given the set-up in my previous post on the matter.  Sometime soon after waking I developed a resting hand tremor that didn’t resolve until later that evening. I got the email in the car on the way back from Costco, immediately showed Rachel, and spent the next eight hours cleaning the house, ignoring my phone, and mentally preparing to break the news to our family. After limping through the family conversations, I told my friends at the party, and finally began to triage the vast number of notifications that had accumulated–including a voicemail from the program I’ll belong to for the next five years. Sorry about that.

…and now via this most circuitous route we arrive at the part you already skipped ahead to read because it was set as a heading in its own paragraph and highlighted in bold:

I matched to UCSD for child neurology.

While I’m not interested in disclosing the particulars of my actual rank list (feel free to stop prying, post-interview surveys…), I will say that this program was among my top choices. In addition to working at an institution with a fantastic AI division, I’m going to be living in what I think is one of the most beautiful cities in the country. If you didn’t know I was applying to child neurology, well, let’s chalk it up to that whole five years of silence thing for the time being.

A Match Made to Profession

February 28, 2018

You finished medical school. Time to get a job, right? Wrong! Finishing allopathic med school gets one an MD but does not allow one to actually practice medicine. For that you have to complete what is more or less a paid apprenticeship, termed a “residency” because it involves essentially living at the hospital for the duration.  The first year of residency is known as an “internship,” in order to keep things nice and straightforward for everyone following along at home. Intern year is a trial-by-fire Immersive Learning Experience where your decisions suddenly matter; in between breakdowns you take Step 3 and collect a medical license. How many additional residency years are required after the internship depends on the specialty you are pursuing (this is the big-category stuff: family, pediatrics, internal medicine, surgery, psychiatry, and so on). After that, you can go on to do a “fellowship” where you get additional training in a particular subspecialty (this is the specific stuff: cardiology, endocrinology, colorectal surgery, child psychiatry, and so on).

For my video gaming friends, it’s a tech tree, where the points you spend to level up are earned by trading years of your life. Once you’ve knocked out a bunch of the low-level skills you unlock class selection (mage, warrior, etc.). Once you’ve committed to a class you then have additional options to further adjust the class to your playstyle (berserker, battlemage, 1H vs 2H weapons, etc.).

Okay, back to the whole “getting a job” thing. You need an internship to take the last test to get a license, the internship comes bundled with a residency in some medical specialty, the residency unlocks the possibility of a fellowship. Getting a residency involves picking a specialty, filling out a centralized application, paying to send it to a bunch of places, waiting for those places to invite you to interview, and going on a bunch of interviews. Here is where a reasonable person might expect job offers to arrive, but no! That is not what happens.

Instead of simply getting a job offer, there is a process known as OkCupid “The Match” where all the applicants in a specialty create a list ranking the residency programs where they interviewed, and all those places create a list ranking the applicants. In March, some people press “go” on a legally-binding algorithm that attempts to connect all the applicants to a residency spot. Hopefully one of your top places also thinks you’re a top applicant so you get lucky have a place to work come July 1st.

Are there enough spaces in the medical specialties for everyone who wants one? No, no there are not. As a result it is possible to fail to match, in which case you win the right to participate in The Scramble, rebranded by People Who Are Not Medical Students as the “Supplemental Offers and Acceptance Program (SOAP).” This involves spending the next several days frantically applying to everywhere you can think of in the hopes of getting an open residency spot in your specialty of choice at some place that also didn’t match a student, or failing that, an open spot for any specialty anywhere.

Finally, at the end of the week, The Match sends out an email telling the people who did match exactly where they matched. After that we all go back to our regularly scheduled rotations because it’s still March and there are several months of school remaining, only now we also can fret about moving to wherever. At some point after graduation, the no-longer-students take their shiny new (but useless) MDs to the residency program, where on July 1st they become interns and realize they know absolutely nothing…but that’s another story.