PGY-2.

Hello.

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This is Hermès

Instead of multiple insightful posts throughout my 2nd year of residency (“insightful”…haha) I have but this single entry to offer towards the end of the year.  A slow accumulation of random thoughts and useless rambling — 11 months worth.

Residency is hard, but we all knew that already. I have definitely changed; hopefully all for the better. I have learned A LOT (well that’s good). I can’t remember all the personally profound moments but there are some that are undoubtedly more sticky than the rest:

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I’ve become just a tad bit meaner. (Sorry not Sorry)

It happened. The one thing I had sought to prevent and was keenly aware of prior to Residency. The one stereotype I wanted to prove wrong — and one I’d still like to disprove, albeit on a lesser scale now. Over time I have become more direct, more succinct, and have become fairly shameless when interacting with others in the hospital. Small talk has become a painful annoyance that I try to avoid (at least as much as is allowed while still maintaining some ounce of human decency).

I’m unapologetic…because I have to. The slow surrender that I’ve accepted is that providing 24h Neurosurgical coverage (emergent and otherwise) at an academic level 1 trauma center means near complete sacrifice of social norms and inefficiencies.

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“I’m sorry that you’re going through a divorce but this man is dying from a brain bleed.”

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“I completely interrupted you because you’re wasting time
and this patient needs to get into the OR.”

Again, none of this was a surprise to me — as with most things, I just didn’t have a full appreciation until I finally dove in….head first…straight into the fire (mmm nice and toasty). I still do my best to be respectful, courteous, and empathetic. I take great pride in representing my small but highly visible department well — it’s most gratifying when people express disbelief at how “smooth” or “easy” it was to work with Neurosurgery.

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Represent.

In the end I’ve definitely been worn down, but I don’t believe I’ve changed at my core. Speed and, oftentimes, cold efficiency is necessary to make sure people stay well and alive. You are constantly working, vigilantly, because you never know what the ER or Trauma Bay is going to bring you next. I know I can come off as detached and robotic at times and I just appreciate all the nurses, techs, and support staff that put up with me; hopefully realizing that:

  • It’s not personal.
  • Sorry for the awkward silences, trust that I’m just quietly prioritizing in my head.
  • I’m pooped.

I am appreciating the small things more and more.

Nothing is more stress-inducing than the sound of my pager going off. Every time I hear the beeps a tiny piece of me dies inside and all the world’s puppies get sick. The onslaught from every nook and cranny of the hospital is relentless — the relief I get when I’m able to turn off that pager is pure bliss.

The good thing is that any free time I do have (not very much) is time that I value and cherish more than I ever have in my life. Sitting on the couch and watching TV. Going #2 at a relaxed, leisurely pace (and on your own toilet). Catching up with friends and family is no longer a chore but an awesome reprieve and privilege. When you are essentially a slave to the pager and the hospital it bestows a very harsh perspective and my priorities and beliefs have changed accordingly.

Wearing normal clothes and not scrubs is weird but refreshing. Eating something other than cafeteria food is a rare blessing — actually having time to eat at all is the true gift. Sleep is more valuable than money, fame, or power. Sleep is king. I don’t like being extreme and dealing with absolutes (for that is the path to the dark side) but I rarely, if ever, take anything for granted anymore. Just like becoming a little bit meaner I didn’t fully realize what I’ve had until recently when my freedoms are stripped from me in 24h increments (every time I’m on call). I always try to stay positive, however, and I tell myself this is part of maturing and growing up. Grown up life is hard.

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Neurosurgery is still cool.

They say the PGY-2 year is one of the hardest in Neurosurgery. You are no longer an intern so there is less leniency and no more “free passes”. Additionally, you are the absolute lowest person on the totem pole and must accept the most tedious and painful tasks. Even with how grueling and draining the past year has been, it’s comforting that I still can’t imagine doing anything else. Even when we see some of the sickest patients in the hospital I still find meaning and purpose in a specialty that deals with death and despair on the daily. I have seen multiple lives saved and have witnessed enough full recoveries to still be in awe at what Neurosurgery can accomplish. I lose sight of this often. It’s really hard to see the light at the end of the tunnel but it helps to catch flashes and glimmers here and there. Rare snippets of praise from my attendings. A care package from mom. Gratitude from patient’s families. Dinner with my new fiance. Cleaning my dog’s poop. The small things keep me going. They keep me alive. Writing like this also helps so I hope I can do this more. No matter how much I complain or vent I know that I wouldn’t be satisfied if the stakes weren’t so high. You appreciate the good times so much more when you remember the hardships you’ve overcome. The darkest nights reveal the brightest stars.

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Neurosurgery or bust. Holla.

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1 almost done. 6 to go. brb.

Pager is goin’ off —  be right back!

be right back

oh yeah, the first year of Residency stopped by for a quick visit.
you almost missed it.

I can not count how many times in the past 10 months I’d tell myself I’m going home to write — to reflect on this mistake (so many) or share that small triumph (an endangered species). Something always came up. If it wasn’t another consult or another “critical” lab/radiology finding (cringe) it was my car’s engine literally dying or my Mom asking me if my life is like Grey’s Anatomy yet.

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yes mother. still working on that hair flow mother.

I haven’t really sat down to mull things over until now. Most of the time I was just tired. Not the ‘exhausted-and-fed-up-with-this-crap-rip-out-eyeballs’ kind of tired, mind you, but more of the ‘really-i-just-need-to-close-my-eyes-forget-food-pillow-drool’ variety.

To be fair, I definitely had fleeting occasions…what I designate as “no responsibility zones” on my calendar where I’ve thankfully been able to decrease my own intracranial pressure. Also known as “yolo days” I’ve been lucky enough to have short vacations and weekends where I could spend time with loved ones. For better or worse, almost everything else has taken priority over my silly musings here.

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i’m gonna go blog….jk….happy hour anyone?

I do miss it. This writing thing. I find it therapeutic. And now I’m sitting here thinking of how I can convey my “wow, time flew by!” sentiment without sounding like a clichéd tool. Sadly, I’m not clever enough. Also, it’s June 2016 suddenly. Where did the time go?

A lot has happened, it would be nice to reach back and bring up all the parts of my intern year that gave me pause — especially now that I’ve somehow broken through whatever internal barrier there was preventing me from typing away. In expected fashion I don’t know how or where to start. It’s almost as if everything that happened has inter-mixed into a giant amalgamation of nothingness. The price of not acting sooner. Priorities I suppose.

And really, that’s probably the most defining aspect of my PGY-1 year: priorities.

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right meow.

The ideal resident, I’ve come to discover, is the one who knows which of the zillion to-do items needs to be done now and which can wait a little. Sometimes it’s an easy choice: go see the ejected driver just brought in with a fractured skull before changing out that other patient’s arterial line. Sometimes it’s choosing the least worst choice: a patient has a fractured spine and can no longer move his legs but this patient with a brain aneurysm just stopped talking in the middle of dinner…with blown pupils. If nothing else, I’ve had the purest little taste of how heavy a lose-lose situation can feel.

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hard rock? first round’s on me. 😀

Does it build character? I hope so. What I can say is that I’ve been thoroughly conditioned to eliminate all indecision. I’m being groomed to stop hemming and hawing and to just make a choice when faced with a difficult decision.

“If you’re going to be wrong, be sure about it!”
-Attendings

Confidence. The worst thing you can do is nothing and the scarcest resource we have is time. When things are going downhill making a decision….any decision…is better than leaving a choice unresolved. In many cases a wrong choice made with conviction is celebrated over a correct choice that was timid or made through guessing/luck. This kind of thinking is espoused and reinforced on a daily basis — and it has, without a doubt, made me a better physician. It’s also what has led me back to trying this writing thing again. Just do it. Stop frontin’.

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“singin’ it slow now because you ain’t used to how fast we touched.”

Time always does the opposite of what you want. In taking care of patients and making decisions that can mean the difference between paralysis and a life worth living: this whole ordeal of priorities and decisions and not enough time often comes to the forefront. If you don’t study/practice more today you might not be able to save the next patient. If you don’t log onto wordpress today you’ll never write. If you don’t tell your loved ones how you feel today the chance may pass you up by tomorrow. As a Neurosurgery Resident I have seen too much regret in the tortured faces of patient’s families….and I’m barely 1/7th of the way through this wacky ride.

The plan is to master this art of decisiveness one day. When I grow up and (hopefully) become an Attending I’d like to think I did something with my time instead of just sitting here with my HonestTea on the couch — despite it being a perfectly “tad” sweet.

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don’t want to end up like this slacker.

It feels good to write and search the interwebs for random memes I can loosely tie in to my ramblings. Fun even…I guess I’ll try to keep this up (we’ll see). And since nothing in life is guaranteed it’s probably the best choice right now to call back my dear old mother and ask about the newest gossip surrounding McDreamy.

i will have to

brb!

why i chose Neurosurgery.

Whenever someone asks me why I chose Neurosurgery I often joke that it’s so I can wear scrubs for the rest of my life.

Wearing pajamas to work….where a machine magically spits out a freshly cleaned pair in case I spill coffee on myself (which is often)….not to mention the non-form-fitting nature of most scrubs is very effective at hiding last night’s chili cheese fries (and this morning’s donut)….scrubs are nothing short of divine.

Overall, they’re just comfortable and familiar and universally accepted.

Why would anyone not want to rock them day in and day out?

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scrubs. so good.

And about 100% of the time I get a chuckle when giving this answer, I breathe a sigh of relief that I don’t have to justify my masochistic/lifestyle-damning choice any further, and the friendly banter continues until it fizzles out in a socially-acceptable manner. Although I always use this trick to misdirect away from my life and to coax a smile out of others there’s definitely a granule of truth within, because I’ve never really felt comfortable in suits.

barney_suit_upI’m definitely not a Stinson.

I often think about what make’s us, humans, uncomfortable — mostly because I’m a big proponent of stepping out of one’s comfort zone. I believe that’s how anyone grows. Mingle with a different crowd. Move out of your hometown. Stop getting that latte and try an iced tea. Even though this sounds nice and all (and disgustingly high and mighty somewhat), I can’t deny that I really like my routines and my usuals (just gimme the yoosh). I don’t want to rock the boat all the time….because being perpetually uncomfortable and off balance is not a good feeling either. Doing what is comfortable and familiar and universally accepted is usually easier.

Beliefs and ideals are fairly similar. Like believing in the easter bunny or santa claus it feels nice to hold onto thoughts that carry personal or sentimental clout….regardless of empirical evidence that says otherwise (yeah iced tea is probably healthier for me but I’m still getting that whole milk latte….and it’s going in my face no matter what you say). Routines are nice on the inside and the out.

These sentiments really came to the forefront for me this past week with one of my patients. It was a gentleman complaining of ear pain….and when I took a look it was apparent that his ear drums were irritated, which was concerning for an ear infection. The issue was that this patient had been on broad spectrum antibiotics for the past 5 days for a pneumonia — it should have been overkill for any run-of-the-mill ear infection. His developing a new ear infection on top of the pneumonia would be akin to something like starting a fire underwater or of me passing up free food….which is to say nearly impossible. Perplexed we called in the specialized ear, nose, and throat (ENT) doctors and to our relief there was no infection, he had just developed an effusion (fluid) behind his ear drum and the built up pressure was causing pain (a less pressing problem than a full blown infection). The world made sense again.

It was around this time that the lab was able to single out the bug that infected his lungs and we made plans to narrow down our antibiotics. I put in the order for the new antibiotic and went to check on him. As soon as I walked in he was smiling and thanking me profusely….that “new medicine” we had given him had completely taken away the ear pain!

Now I have to explain how this is entirely preposterous.
(and before your jerk-alarms go off let me explain)

Antibiotics are not like analgesics or anesthetics — they don’t treat pain….at least not directly. Even if he actually had an ear infection the nurse had just given him the antibiotic minutes prior and there’s no way it would have knocked out any bacteria that fast. At this point, I must admit, I was tired and hungry and honestly in some type of a robotic mood — I was extremely close to correcting him and explaining the (boring/heartless) pathophysiology of bacterial infections.

But I stopped myself. And am so glad I did.

Instead, I mentally spear-tackled myself and (also internally) gave myself a backhand to the face. Did I really need to shatter this man’s thoughts and hopes and newfound solace? No way. What was I thinking??

c45fe6c090894fc186cad46b866c35dfstap. just. stap.

I caught myself just in time and simply told him how happy I was that he felt better and that we would continue to watch and care for him. It was at that point, walking out of the room….relieved that I didn’t Godzilla-rampage through his world, that I realized how much of what we do as doctors is intangible and innocently human. And yes, the placebo effect can be substantial but I don’t even want to paint it in that light so much. If his pain was gone, that’s all that mattered in that moment. If the tooth fairy brings excitement and happiness to a child….who cares right then and there that the money actually came out of mom’s/dad’s wallet?

It’s nice to hold onto things….especially ones that help us get through a world that’s mostly unforgiving.

And it was then that I thought about my scrubs joke and how I tend to bypass the ‘Why?’ question when it comes to Neurosurgery. I’m slightly uncomfortable because I already know there are preconceived ideas even before I open my mouth. The thing is, I recognize one can’t live in a kind of childhood bliss wholly or eternally (we have to accept at some point, unfortunately, that Hogwarts is not real). And the fact is, I have a lot of serious reasons for choosing Neurosurgery….some might be surprising actually. But if it’s not going to change management (friendly banter is friendly banter….an antibiotic is an antibiotic) why choose an outcome that can potentially be uncomfortable over one where everyone is happy and lighthearted?

I will say that I didn’t choose Neurosurgery because I wanted to be busy and stressed out for the rest of my life. It’s actually for the complete opposite reasons. Ultimately, I’d be happy to go into exquisite detail….it’s just that everything has its ideal time and place.

imgresDear Neurosurgery. Sincerely Me.

By the way….Hogwarts is real….and so is Santa and the Bunny and Fairy.

recognize.

wingardium leviosa!

doctoring is hopeless romanticism.

You can rest a little, tiny bit easier America.

Your latest batch of wide-eyed medical interns just completed their first month in the real world…and we now know at least some things. If you’ve been holding off from getting sick through the month of July fear no further — August First has just passed and there’s at least a little bit of swagger in our baby steps.

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Personally, I’m proud to say that I’ve succeeded in identifying multiple sources of coffee within the hospital; of varying attributes: free to wallet-crushing, iced to tongue-melting, and deliciously heaven-sent to mud-water that is totally acceptable due to its inherent caffeine content alone (if it’s “coffee” I’m not even mad bro).

Important question — why does decaf even exist?

But that’s beside the point…..Maybe. I brought it up though because I was making my ritualistic excursion to the Starbucks in the lobby recently and, perhaps in the spirit of completing my first month’s rotation, I began thinking about all the patient’s I had met and treated and discharged.

What were they up to?

Are they feeling better?

Did they notice the coffee stain on my white coat that one time?

It was through this pre-caffeinated haze that I realized how much Medicine is like dating….a professional Tinder if you will, but at least not as shallow (or filled with shame and guilty pleasure). Accepting a consult from the ER is like swiping right (yeah, sure I’m ok with taking this one). I feel as if I’ve been on dozens of small-talk-laden, slightly uncomfortable first dates in the past month….where every discharge from the hospital was a mutual ‘for the best’ goodbye.

I don’t think anyone can deny how intimate the patient-doctor relationship is. To provide the best care we find out everything about our patients: their medical history, their family history, their drinking habits, their creatinine levels, the amount and consistency of their poop — we strive to discover almost everything. Nothing is too personal. You’d think we were trying to move in together.

Like a jealous, insecure boyfriend I’ll admit that I’ve looked up some of my patients even after transferring them to different services to see how they’re doing. Go ahead, call it Facebook stalking. Even though they have a shiny new service/doctor I meant something to them at least, right? I mean I was their doctor first. Hmmphh.

But like the ex-boyfriend/girlfriend that finally matures and gets over it (and all creeper jokes aside) I know that all doctors simply wish all their patients the best when they are released back into the wild. The feeling is something like: we had our time together, and we learned a lot, but I hope we never run into each other again….because that would just be awkward.

f30c147ac9c68ceda3cb17f6e6777d89On Vulcan we don’t do Awkward Turtles

And as I mused over these thoughts, wondering if I’ve really reached a new level of weird for drawing similarities between professional medicine and the dating world, I felt vindicated after discovering the underlying sentiment….one that is actually salient.

I can’t think of many other situations where I’ve felt as powerless as immediately after a breakup. The hospital discharge is pretty close, however, and maybe in someways more disabling and soul-crushing. I have been on the Stroke Service this past month and with every discharge I’ve hoped with all my being that my patients would stop bad habits, and take their medications, and attend their follow up appointments….because one stroke is devastating but any more would be nothing short of catastrophic.

Ultimately — as I sipped my lukewarm coffee and chuckled at how good of a comparison Tinder was to accepting ER consults — it became blatant that the helplessness felt when discharging patients is a potential source of burnout and jadedness within this profession (why would I even try hard if they’re just gonna start smoking again when they leave here?). I guess becoming a really good doctor is like trying to find true love. If you go into every relationship with skepticism and low expectations then of course it won’t flourish. Doctors have to enter every patient relationship like a high-school, hopeless romantic — with the naive belief that this is gonna be The One. This patient is going to be compliant and will get better and everyone lives happily ever after. There’s really no other way to practice good Medicine.

Nice try real world, but challenge accepted. You have me jaded on Love but you shall not pass when it comes to Medicine.

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(two nerd refs? I outdo myself.)

Welp — it’s probably time to get more coffee. But wait a page from the ER?

I got a new match!

We can either keep the cake or eat it….but let’s try both!

There I am — the hunched over intern…typing away.

Type-ity. Type. Type. What I lack in knowledge and experience I make up for in keyboard prowess, with all the might of my Millennial heritage. Am I considered a Millennial? I’m not sure, I’ll look it up later. EDIT: Yes I am — Google confirmed. Go figure.

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Type-ity. Type. Type.

As a medical student I knew that Resident Life would entail a lot of face time with computer monitors. I knew that, sadly, I would often spend more time communing with printers and shoddy internet connections instead of with patients. I realize now that even though I was aware, that it was more of a peripheral thought. I didn’t really care until recently — a result of living such an existence nearly every day. Granted, it’s not so much of an issue until the patient list grows, the pager keeps going off, and I receive multiple e-mails about improving my documentation for billing and coding purposes (which seems like all the time).

So you’re saying I have less time with each patient yet I’m supposed to write more about each one?

Of course I don’t have a choice. Much like all my colleagues we make it work somehow, day in and day out.

This isn’t so much a complaint….ok, maybe it is but I’m not going to rant about it. I understand the rough and tumble “figure it out” mentality that all Residents must embody….especially within my chosen specialty. I bring it up though because it alludes to the age-old battle between quality v. quantity, detail v. speed, esthetics v. function. Since the beginning of time, I imagine, humans have always had to choose between ‘quick and dirty’ and ‘nice and slow’, but I’m gonna plant a seed here:

Let’s try for both. You know what? Let’s DO both and see if it works….after all that’s what Yoda says.

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(Obligatory Nerd Reference: Check.)

I’ve of course been mentored and guided by my seniors on how to become more efficient. I’ve been shown the most streamlined way to put in orders, the fastest way to write progress notes, the most concise way to discharge patients, and to move-move-move. It may seem careless but it’s often for the best and is always well-intentioned….how else are we going to devote time and accommodate the endless stream of patients from the infinite portal known as the emergency room? I’ve been chastised (lightly and often playfully so don’t get me wrong) for writing notes that make use of esthetic spacing, bolded fonts, underlines, and other members of the punctuation toolbox….because I could be soo much faster.

And I agree, I’ve been slow and that’s not good.

I’m not the only one though. I’ve seen numerous notes that are not only well-written but well-presented….and I often find that I not only better understand the course of treatment but that I better understand the patient (are the best lectures/speeches the ones with the best information/content or the best charisma/jokes? Both right?). I recognize the value in a “pretty” note and so I’ve resolved to typing at furious rates to make notes that are both fast and nice. I’m not saying I have the answer or that I’m awesome….I just want to see if it’s possible….because I’m human and I’ve realized it’s the human thing to do: maybe we can have it all???

Trust me. I know there’s a real world. I know that if we forego what is practical and drift off into fantasy land that it could be disastrous. But I offer that if we won’t daydream occasionally that progress is impossible.

They doubted Henry Ford when he said he could make a horseless carriage quickly despite it’s unheard of mechanical complexity — and now we have the concept of assembly lines and economies of scale and sexy cars. There’s no way that humans could survive without constantly moving and finding new food sources — unless we plant these weird things called seeds, give rise to agriculture, and eventually lay the foundation for civilization. And what about the most human quality of all: Love? Wow, I actually care very deeply about this person instead of just wanting to score….or even more robotically….to procreate.

You’re human. You can have it all sometimes. You can care about someone, score, AND procreate. #Win

Above all, I see this human tendency in the patients I see everyday — and I submit that it’s the very foundation of Medicine. Why do we give drugs with so many side effects? Why did we think of something as brutal as surgery or as devastating as chemotherapy? Why are we trying to defy something as powerful and universal as Death?

Because we believe we can have it all. We have hope. We’re human. You’re not only going to recover from this illness but you’ll learn to walk again. You will not only regain your speech but you’ll sing. You’ll beat this cancer AND make it home for the holidays. If we don’t think we can have it all we won’t have anything really. Why try? We should just stay at home.

So. I’m gonna go for it — writing a million notes that aren’t haphazard walls of occasionally misspelled text. If it doesn’t work out then it doesn’t. But to bring it back to my earlier seed (that has hopefully sprouted a little), it would be great if we tried for “both” more often in whatever silly human activities we are involved in. I don’t think there always has to be a trade off.

Maybe sometimes we can have it all???

on Independence….and this first week of Residency.

Firstly, congrats to my fellow 2015 doctors. We’re here. Actual doctoring is something else isn’t it?

I hope (and am confident) that many of you were not the bumbling, clueless mess that I was this past July First.

Surely we are all amateurs but I have to admit that I was beyond Jon Snow’s level on Wednesday — I literally knew nothing.

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But all Game of Thrones references aside it was definitely a huge reality check. Even though I did my best to mentally prepare myself (essentially lowering expectations of my own fledgling abilities and knowledge) and even though we’ve been warned about the sudden lifestyle change by those who’ve come before us….it was still a sucker punch straight to the face.

Why does it have to be July 1 anyways? I have a theory.

I can’t speak for all of the newly graduated but one of the biggest changes I was personally looking forward to was autonomy. No more shadowing. No more writing notes that don’t actually count. No more doing things ‘just to learn’ or ‘just for practice’. I was ready to take ownership of patients and feel like I was doing something productive — something helpful.

It felt good to be assigned patients: to put in their orders, go over test results, and communicate with other physicians as a colleague. The best part? Witnessing a patient’s improvement from admission to discharge and knowing you played a major role in that positive outcome — one that involves day to day and often hour by hour medical management.

It’s not that simple or glamorous though. This newfound autonomy comes packaged with responsibility — and you can’t have one without the other. Mistakes are inevitable and thankfully no major ones occurred for me this week….though I had my fair share of poorly formatted notes, misordered lab tests, and wayward diagnoses that highlighted how much of a novice I am (good thing Medical School is followed by Residency). There was more than one occasion where I questioned whether I learned anything in med school at all. Everyday I went home thinking about my patients; mulling over treatment plans and medication doses (did I do everything I could for the patient?) — I guess we’ll never be rid of ‘homework’ in this profession.

But that’s what I find reassuringly appropriate about this First Week. On July Fourth we celebrate with pools, and barbecues, and star-spangled debauchery….but it also serves as a reminder of what Independence costs and what it took to get to where we are. We look forward to July 4 as much as senior medical students look forward to July 1. I’m biased (obvi) but this is a great country and I’m proud to be a citizen of one that stands for freedom, and marriage equality (holla), and the overall pursuit of happiness. I feel lucky. All these rights and privileges didn’t just appear out of nowhere, however, and they have to be maintained with ongoing work and progress. Sound familiar?

In the end I propose that all of this is a brilliant masterplan — another ‘oh there’s a reason for this thing I thought was just silly coincidence’. July 1 is our profession’s Independence Day. The week is ever so cleverly punctuated at the end by America’s equivalent. Am I digging too deep for a connection here? Without a doubt. But I hope others will agree with me that this week was a roller coaster mixture of nervousness and excitement….just like the calm before the final volley of a fireworks display.

Fun theory? What do you think?