David and Kevin present some old favorites

Almost 2 years ago, David and I started IDDx with the humble hope of turning this site into a blogging powerhouse that could be our one-way ticket out of the obvious career dead-end that is medicine. Clearly that has not happened. But we have still managed to build (and re-build) a loyal following of readers that have somehow found our inane drivel to be entertaining (or at least interesting in a car crash-y kind of way). We thought this would be an appropriate time to revisit some of our old posts as a kind of year-end-review and maybe serve as a best-of (or worst-of, as the case may be with Jess) list for the newer readers. (Re)Enjoy.

-Kevin and David

Medical student life: A few insights into the fast-paced world of call-taking, baby-saving, and retractor-holding.

David, Robby, Dan, Beth, and the Johns save lives while on vacation.

Kevin wishes these classes were real.

Kevin falls, David watches.

Pre-medical advice: Words from the arguably wise about facing the application gauntlet.  

David tells you what to do (in an admissions interview).

Kevin debunks 2 myths about med school.

David presents the 15-15-1 theory.

Comics: Only stick figures can provide a true window into the inner med student soul.

MCAT - Then and Now

OB exams are tricky

Ideal vs. Reality - Emergency Medicine

Guest authors: Who's better - Julia, Jess, Julia, or Julia? You decide.

Julia knows exactly the kind of doctor she will become.

Jess tries to reach the keeds.

Julia presents a landmark case of PMS.

Random thoughts, pet peeves, and theories about life: A potpourri of IDDx musings.

David Presents His #2 Pet Peeve: Considers It Tomorrow At Midnight Guy

David has difficulty with doors.

Kevin contemplates the diet of the Little Mermaid

David treats a wise child

During a recent shift at a pediatric urgent care center, a young boy came in with a scald burn to his arm. As I debrided his wound, we discussed some of the pressing issues of youth, including how awesome dinosaurs are and whether or not mall Santas are real (consensus: of course they are). All of 5 years old, he was a total fighter and didn't complain one bit throughout the procedure. 

After a heated debate about how fast Spot runs - we both said some things we didn't mean - the following exchange occurred:

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David: This must've been pretty scary, but you've been doing great.

Kid: Hey, I'm not scared of anything. 

David: Nothing? Really (unsure whether or not to entrust him with my fear of clowns)? That's pretty impressive.

Kid: Nope, nothing...

        ...except bush babies.

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Mildly confused about what he was taking about, I allowed the conversation to shift, and soon he was all fixed up and on his way home. Later, a quick Google search provided the images that will give me night terrors for the rest of my natural life.

Wise choice, kid...

Kevin might save babies like it's his job

The next installment of our career choice series.


3 reasons to do pediatrics
1. Congenital disease is fascinating
The magical journey from fish-like zygote to full blown baby is fraught with wrong turns and side streets to the bad part of town. Sometimes what comes out of the oven isn't what you expect. While most adult medicine follows some kind of logical pathology and things often dont stray too far from the norm, the presentation of congenital disease can be so bizarre it boggles the mind. Situs inversus (your insides are backwards), lissencephaly (your brain is flat), Transposition of the Great Vessels (your aorta and pulmonary artery are plugged into the wrong ends of the heart) are just a taste of some of the things you see as a pediatric specialist. A lot more interesting than COPD or diabeetus.

2. Plenty of subspecialties to suit your fancy
This is likely personal to me but during the first two years of medical school I always pictured pediatrics as a primary care residency with no subspecialty tracks. “Well where do pediatrics cardiologists come from?” you might ask. For some reason I thought you got there through internal medicine, cardiology then a fellowship in pediatric cardiology. Clearly I’m an idiot (but hopefully someone out there on the interweb is with me). In reality pediatrics is just like internal medicine, except you treat little people. This also means there’s a huge range of subspecialties to choose from, and as I mentioned in point #1, you get to focus on a lot of congenital malformations rather than the end result of a lifetime of self-neglect.

3. Saving lives (no seriously)
Adult medicine often revolves around management of chronic disease. Patients undergoing slow, methodical heart failure/COPD/diabetes/lupus(sometimes it is lupus), are never fully cured. The best you can do is manage their symptoms in order to extend/improve their quality of life. On the other hand, pediatrics is full of one-off illnesses that you can definitively treat and they can be on their merry way. Back when medical school was only 1-semester long and involved memorizing the 4-humors, congenital malformations was often a death sentence. Fortunately, we've come a long ways from then and there's a myriad of treatments for what ails children. You have a giant septal heart defect? No problem. Bowels outside the abdomen rather than inside? Just shove that right back in there. As a pediatrician you're really making a huge impact in the "total # of years saved" category. If there was a MD fantasy league, you'd want at least 1 pediatrician to pad those stats.




3 reasons to avoid pediatrics
1. Bad logistics
Unlike what your career counselor might have told you, you should never choose a career just because you like the subject matter. Every field has pros and cons in terms of call structure, location constraints, average salary etc etc that are all vital in making an informed career decision. For example, if you love cardiology but are on the fence on whether to treat big hearts or little hearts, here are some things to consider before you devote yourself to baby saving. Despite all my talk about congenital disease, kids are actually pretty healthy. And being healthy is bad for business. Because of the low demand, you will also make less money than your adult-caring counterparts. So do you really love congenital disease so much that you're willing to take a $100,000/yr pay cut? Furthermore, there are significantly less pediatric specialists than there are adult specialists. Because there simply isnt as many you, your group will be small, which is synonymous with lots and lots of call. What this also means is that there isnt a need for a pediatric neurologist in every town. If you want to subspecialize in pediatrics, you're almost guaranteed to be forced into a large-ish city in order to field the necessary amount of patients to stay afloat. Sorry, no country livin' for you.

2. Noncompliant patientsparents.
When I asked a lot of pediatricians why they decided to do pediatrics and not internal medicine, they often cited that they were frustrated by noncompliant patients such as COPD'ers that kept smoking or CAD'ers that kept eating McDonalds. For some reason, I have no problem with that. As long as the check clears, I dont care what you do. My job is to give you the knowledge, services and tools to allow you to live a healthy productive life. If you refuse, so be it. In pediatrics, the kids barely know what's going on so the work falls on the parents to follow through with the care plan. In this case, noncompliance by the parents means the kid is getting hurt. This I have a problem with. Even though CPS can step in during extreme cases, theres a huge gamut of noncompliance where you really can't do anything even though you really want to punch them in the head.

3. Child abuse
During my peds rotation I had the displeasure of seeing 3 child abuse patients. One of was severely overfed, one was severely underfed and the 3rd was an infant that had a broken femur and two broken clavicles. Obviously by ferreting out child abuse you're saving the child, but it's still a terrible thing to be a part of. Seeing that on a regular basis can be a real drain on the mental psyche.

Comic: Ideal vs. Reality - Plastic Surgery

Julia ponders a career in Neurology

As one of our school's rare 3rd years over-eager enough to attempt Neuro before 4th year, the mantle falls to me to talk about the good and negative aspects of this specialty. That… and Jesse is trying to steal away my tiara for himself. For shame.

Jesse's MRI confirmed some long-held suspicions...

3 Reasons for going into Neurology:

1. You might actually get to see your kids grow up.
It’s no psych, but damn it’s good to be a neurologist. During my time on this rotation, on most days it seemed possible for the non-call residents to get their patients tucked in and notes written by mid-afternoon. Plenty of time for David to get home and watch the nanny take care of the kids. Definite life-style points.

2. Fascinating pathology
While the neuro hospital floor is primarily dominated by strokes and seizures, consults come from all over the hospital. Although much of this will inevitably end up being delirium (or even nothing), every now and then the illusive and coveted zebra appears. The brain truly is a wonderful and enigmatic organ, and just because everyone keeps cheering that we’ve made so much progress in the past 10-20 years it doesn’t mean you still wont be surprised.
For example, I will truly never forget the consult on a patient with anoxic brain injury where, about 15 minutes into the interview, I realized the patient was confabulating everything! Because of his brain damage, he had gaps in his memory where he would fill in with false information. If the lie is subtle enough, it can be difficult to discern the confabulations from the truths. But then again, sometimes the lies are so outrageous they become readily apparent. No sir, I dont believe I've asked you these same questions 30 years ago...

Anyways, just remember the next time you see a patient who just had a right-sided intraparenchymal hemorrhage (i.e. brain bleed), it probably is worth it to ask them to draw a clock face.

3. Informative physical exams
Depending on which specialty you go into, the physical exam could either be a crucial component of the clinical picture or only a necessary hassle for billing purposes. For example in surgery the physical exam boils down to two things: bowel sounds = good, no bowel sounds = bad. Neurology lets you do a bit more. If you like solving puzzles, this is where it’s at. If you’re savvy enough with your physical exam skills and knowledge, not only can you identify at which level of the nervous system the lesion is located, you could probably tell something about exactly where in the brain or spinal cord you expect it to be. Some party trick, huh? Then you order the appropriate scan plus labs to get a more definitive answer. Neurologists out in the community or away from a major academic center may be the true LOTPEs.

It's (reflex) hammer time

3 Reasons to stay away from Neurology:

1. You can't cure a lot of the things you diagnose
Here’s a quote from a real-life attending: “Hmm… you know, I’ve never really felt the need to cure anything—sometimes it’s enough to just be able to tell them what it is.” While this is true, in some cases just being able to put a name on what ails you is therapeutic enough, it may not be very satisfying to you. Not mention, even if you do locate a resectable lesion, the patient gets bounced to neurosurgery. Sigh, those guys hog all the glory (and reimbursement). So if you’re on your neuro rotation and find yourself feeling a little too excited and relieved by meningitis because you can kills the buggers with antibiotics, then maybe this isn’t the field for you.

2. Medically sanctioned elder abuse
The patient might look like your favorite grandparent or that sweet little old lady down the street, but if they’ve got a decreased level of consciousness you can be sure you’ll be giving them a strong pinch! The idea is that you’re looking at their ability to sense, localize, and/or withdraw from painful stimuli. Keyword: Painful. Abnormal posturing (e.g. decorticate – flexor, decerebrate – extensor) can tell you something about the severity of what’s going on in the ole think-box. However, when my patient’s tearful and terrified wife is standing right there, it can be a pretty uncomfortable to do what would be considered elder abuse in any other situation.

Your heart sounds great ma'am. Just FYI, I may or may not need to jab you with a sharp stick in the near future.

3. Half your patients are delirious
For me, this is the biggest problem in neuro. Inpatient neuro is dominated by strokes, withdrawal, seizures, delirium, coma, and bad ass brain tumors. In short, most of your patients are going to have some sort of altered consciousness, so the normal exchange of the physician-patient relationship is lacking. Oncology is another specialty where there is a relatively low “cure” rate, but in the battle against cancer you the provider can learn so much from your patients. For me, this is probably the most challenging aspect to deal with day in and day out in neurology. It's hard feeling connected to my patients when they're accusing you of stealing their Jello to give to our alien overlords.

Comic: G16P10

Jess tries to reach the keeds

Back and angy as ever, Jess attempts to unseat Julia as the premiere guest author with this, his latest rant. Enjoy.

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The recent revival of this blog and its stream-of-consciousness ranting affords a golden opportunity to similarly revitalize my own journalistic career – since this medicine thing may soon come to a screeching halt. I’m currently on pediatrics. I could simply refer you to Kevin’s elegant artistry to depict my feelings about the rotation, but that would ruin the cathartic nature of this medium. I’ll take a more positive approach than my colleague did with childbirthing – I’ll give one positive before launching into my top pediatric peeves.

The Good: A lot of kids are cute. When they’re in a good mood, they’re friendly and laugh and want to see how your tools work and it gives you that warm fuzzy/good feeling that you can only get from the sound of a child’s laughter – before passing them off to the demonized shot-giving nurse (which, by the way, must be the worst job in the world). I genuinely enjoy kids in general so this works out well. But there’s a lot to hate in general, so let’s not delay:

1.  The Vaccine Talk.

Every physician knows this one. For those of you unawares, let me break this down for you. We have, on one side, modern medicine and every doctor you’re likely to ever meet who contend that babies shouldn’t die. We have, on the other side, this guy. Now here’s the kicker: People believe Jim Carrey. To be fair, a “doctor” did originally perpetrate this bogus theory. One Andrew Wakefield proposed that MMR vaccine was related to a small subset of cases of autism via immunologic shenanigans. He then proceeded to present this and cause a panic which led to refusal of immunizations and then an outbreak of measles. Read that again. Of measles. Let’s get one thing clear: no one in the Western world should ever contract measles. The only time anyone should get measles is playing Oregon Trail.

If only YOUR MOM had vaccinated you.

Meanwhile, of course, autism didn’t miss a beat. Andrew Wakefield has now lost his medical license and practices homeopathic medicine in Texas. There are even new allegations that he fudged his data – but by God, that doesn’t matter, because a lack of understanding of basic statistics or physiology is no reason you should listen to your “doctor” about vaccines, because he’s probably just brainwashed and doesn’t think for himself (I swear, people say this). And you’ll hear the same random half-baked logic:

“Too many shots these days,” “given too young,” “those diseases don’t exist anymore (AND WHY MIGHT THAT BE?!?!)”

It wouldn’t be so bad if these people listened to reason. Or at least attempted to listen to reason. The following is an almost word-for-word transcription of my preceptor’s attempt to convince someone to get their kid a meningitis vaccine:

“Here’s all the excellent and well-founded scientific reasons why your kid is way more likely to die from meningitis than from getting this very safe vaccine.”

“Yeah but I don’t give my kids shots until they’re 1 year old.”

“Why?”

“I just don’t. I’m convinced I know better than decades of data and scientific research and besides I can selfishly rely on herd immunity which, by the way, I undermine by not getting vaccinated.”

“…..Kay. But seriously, why?”

“I just don’t.”

You get the picture.

2.  Schools waste doctors’ time. 

Everyone has had this experience –little Johnny had a cough/cold/stubbed toe but, because he missed time from school, he requires a doctor’s note to allow him back. This means that little Johnny gets to wait in the office for 2 hours with all the bacon-lungers so that he can get a doctor to confirm that yes, in fact, he was coughing, and no this was not some elaborate falsehood perpetrated by the parent. But even if he wasn’t sick, he sure as hell is now. In which case, of course, he’ll have to come back and get a separate doctor’s note just so he can expose everyone to it. At what point did we stop believing parents when they say their child is ill? Congratulations, Principal Jones, you’ve once more saved the integrity of your pedagogical bureaucracy – but at what cost? 

At least they're NOT VACCINATED.

3.  First-time parents possess no common sense.

This may represent a failing of our public education in some ways, but so many new parents seem to have no other option when their child is ill but to come to the ER in the middle of the night and/or demand to speak to the pediatrician on call. I understand that you can’t tell for sure how sick your 10-month-old child is. He can’t talk. But with a few tidbits of arcane medical knowledge, several ER visits could be avoided: 

1) 99 degrees is never, under any circumstances, a fever. I don’t care that your baby usually runs 98.4 so it’s a little hot. Being asked to write a note justifying school or daycare absence for a temperature of 99.1F rings hollow. Pediatricians don’t get too concerned until 100.5F, so don’t bother them.

2) Babies are rashy. Please do not demand to speak to the on-call pediatrician because your child has one new red mark on their skin. It’s not cancer. It will likely be gone within a week without a single symptom. Go to bed.

3) Babies are loud. If your baby is crying, try feeding the baby. Try holding the baby. Try rocking, cuddling, or singing to the baby. (Do not ever shake or throw your baby). If these don’t work, does baby otherwise seem sick? If not, it’s probably not an emergency.

4) For God’s sake, triage nurses exist for a reason. Self-explanatory.

I enjoyed my time on peds, but as you can tell, there are more than a few things which could be more satisfying about the setup. I did almost entirely outpatient pediatrics, so I was mostly in clinic the entire time – which can be numbing on its worst days.

David breaks down Surgery

3 reasons to become a surgeon:

1. You get to do stuff and see if it works

Surgery is the pinnacle of immediate feedback; you identify a problem, do something concrete to fix it, and then evaluate whether or not it worked. More than any other specialty, the outcomes are measurable, tangible, and observable. You may sacrifice the continuity of primary care fields, but you also experience the unique satisfactions of knowing what’s wrong and getting your hands dirty trying to make things right. Fields like neurology, psychiatry, and others may involve long battles with nebulously defined disease processes where victories are measured in small, incremental improvements over years. That process yields its own personal and professional rewards and frustrations, but may not provide the same acute results that some students may find particularly appealing and which surgery deals out in spades.

2. Certified badassery

Few things in medicine are cooler than surgery. Though it may not be for everyone, no one can deny the sheer awesomeness of removing tumors, transplanting organs, and augmenting breasts (just kidding…?). Perhaps more commonly than in other fields, decisions are realistically life or death; a miscue here or a careless error there in the OR could have disastrous results. What’s more, the wealth of new technologies and general trend towards minimally-invasive procedures ensure that general surgery and the many surgical subspecialties will only further badassify in the future. Sure, more surgeons spend their lives in the bread and butter world of inguinal hernias and appendectomies than in the rarified air of reconstructive plastics and neurosurgery, but even the more vanilla procedures provide all the benefits listed above and below and may, due to volume, be even more targeted for technological advancement in the coming years.



















I can’t believe Da Vinci painted the Mona Lisa and invented this robot…

3. Options like whoa

It is generally believed that medical students should first and foremost decide whether they want to be surgical or medical. If surgery is your cup of tea, there is a seemingly limitless array of opportunities to pursue. A general surgery residency is a common gateway to further subspecialty options such as burns, cardiothoracic, vascular, and pediatric surgery, among others, while other students choose to enter fields such as orthopedics, plastics, and ENT straightaway. Going further, many surgeons identify a specific procedure or set of similar procedures that becomes their uber-specialty within their broader branch of surgery. Basically, if there’s some type of cutting you want to do, you can probably make a career out of it.

3 reasons not to:

1. Training don’t quit

More than any other field, surgery demands an extensive period of training. A typical general surgery residency lasts five years, and further subspecialty fellowships can push that requirement into the two-digit territory. An R3 I worked with recently is pursuing a career in pediatric cardiothoracic surgery, a path that, with a general surgery residency, two years of research, a three-year CT fellowship, and a one-year peds CT fellowship, will ultimately require 11 years of training after medical school. Assuming one entered medical school immediately after undergrad at 21-23 years old, this would push off attending status – and the benefits of a legitimate salary and some semblance of a personal life – until one’s mid-to-late 30s. And though in a badass field like peds CT surgery you’d make it rain early and often thereafter, you’d still be spending the majority of the prime of your youth before ever realizing many of your career goals.

2. The hours never stop

Similar to OBGYN, surgery in nearly all of its forms is notorious for an extremely demanding workload and long hours on call. Though some subspecialties and practice settings may be less demanding, the fact remains that surgeons spend more time in the hospital than almost any other type of physician. When you factor in the extensive training required before even reaching the attending level, the demands of the subsequent career may simply not be something many medical students want in their future. (On a related note, it's worth mentioning that the hours / training demands take their toll on relationships as well; some surgical residencies have been known to have divorce rates exceeding 100%. In other words, residents get divorced, remarry and get divorced again. Just FYI...)

3. High-intensity work environment

By its nature, surgery is a high-stress world. The patient is commonly under general anesthesia and the manipulations of the procedure often entail significant blood loss. Small or careless transgressions can kill a patient either immediately or as a post-operative complication, and the surgeon running the show is ultimately responsible. Many surgeons trumpet the philosophy “trust no one,” something potentially disheartening on its surface but logical in a world where the surgeon is held accountable for any number of errors in the pre-, intra-, and post-operative setting. All these truths foster an environment some find less than hospitable, especially to those lower in the training hierarchy. Surgeons, on average, may be blunter and less forgiving in a professional environment than other physicians, and this, coupled with the long hours, can create a working world some students may choose to avoid.

Kevin struggles to find a Thank You card

After returning home from my most recent rotation I stopped by the stationary aisle in my local grocery store to look for a Thank You card for my preceptor, just a simple gesture of my gratitude. Little did I know, it would be the most frustrating 15 5 minutes of my life. Finding a card, whether it’s a thank you card or a birthday card, is tricky business. Not in the sense that I’m afraid the opposite party wont like the card, but more that the card is an extension of me and I don’t want to be represented by a glittered up pink butterfly with a bad sense of humor. The fact that I have to give a note in a professional capacity adds a further wrinkle into this dilemma. Sorry Mr. Butterfly, not today.


If you’ve ever spent any time in a card aisle or Hallmark store, you should know that it’s obviously geared towards women and children. The cards come in three general themes: cartoons, flowers or kittens. Even when I did find an acceptable design, there would be some message scrawled on the inside that was so sentimental it made me uncomfortable just reading it.

That's really nice, do these come in Mens?

This was also something I never understood. Why do people want their cards to have messages preprinted inside? Isn’t that a little impersonal? Most people write in messages anyways so the text just becomes some odd impediment to a continuous paragraph. If someone doesn’t write anything, it’s not like the receiver will attribute the printed text to the giver. They’d just assume the giver was a lazy asshole that didn’t write anything. Either way, the text is worthless at best, a net-negative at other times. Much like Jess. Anyways, I digress.
After much shuffling around and digging, I finally settled on a generic green card with no text inside. I guess that’s the best I can hope for. Now if I only knew what I should write…

Comics: Ideal vs. Reality - Pediatrics (2009 edition)

Kevin might want to be an Ob/Gyn, yet might not.

Choosing the right career is a difficult task and it certainly doesn’t end with your acceptance to medical school. Finding the right specialty is a challenging thing and the first 2 years of medical school really aren’t that helpful. Sure preceptorships give you a quick glimpse, but it really doesn’t give you the full experience of what a doctor does everyday. In an effort to help future medical students, and perhaps just to put our own thoughts down on paper, David and I are starting a new series of articles that weigh the pros and cons of each particular specialty. Each article will feature 3 reasons why we liked that particular specialty and 3 reasons why we didn’t. Even though each article will likely be personal to our own interests and preferences, hopefully it’ll bring up some interesting points to think about as you make your own career decisions. Enjoy

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3 Reasons why I want to be an OB/GYN
1. It’s the black and white cookie of medicine

When choosing a medical specialty, one of the biggest questions people consider is whether they would like to do a lot of procedures or whether they’d prefer something more cerebral. One would naturally lead you down the surgical path and the other likely towards something like internal medicine. But for those who would like a little bit of both, Ob/Gyn offers an intriguing alternative. Before my rotation my only knowledge of Ob/Gyn is that you probably deliver a lot of babies and treat a lot of gonorrhea, neither of which were particularly appealing. But what I didn’t realize was that a lot of things can go wrong south of the border and often times you gotta cut ‘em to fix ‘em. The docs I followed did about 2 procedures each morning on Monday Wednesday and Thursday and a full day of procedures on Tuesday. This ranged from tumor removal to urethral slings, prolapse repairs, ovary removal and every flavor of hysterectomy you can imagine. That’s a lot of surgery considering a general surgeon without specialization likely does less with more training time.

Mmmm... tastes like placenta

On the medical side there are a lot of diseases to that can happen to the entire baby making apparatus and you’re the guy/gal to fix it. Often times symptoms can be vague or the etiology multifactorial so there’s a reasonable amount of brain power that must be expended to properly take care of your patients. Not too shabby

2. Good subspecialty options
I only spent 2 days with a gyn/onc but I found the subspecialty pretty fascinating. It’s the only surgical oncology specialty that also manages chemotherapy. So there’s a good amount of continuity of care that lets you manage a patient’s cancer from presentation to remission. Pretty cool.

The surgeries themselves are pretty interesting as well. They’re not particularly challenging from a technical standpoint but the stories I’ve heard at hilarious. My preceptor told me about an obese patient she had that had a slow growing tumor inside her that weighed over 70lbs at time of presentation. In order to do to the surgery, she had to perform a pannectomy as well. By the time the patient left the OR, she was half the weight she went in.

3. Strong continuity of care
My main preceptor was an older doc who had been in practice for over 30 years and many of his patients have been with him for about as long. He’s delivered entire families and really followed some patients from the beginning of motherhood to menopause. This seems like a rewarding process and something a lot of other specialties don’t get to experience, especially if you’re in surgical field.

3 reasons why that might not be a good idea
1. The hours are terrible
OB probably has one of the worst call schedules ever unless you’re part of a large practice with an elaborate call system. When a mother is ready to deliver, she’s ready to deliver and there’s nothing you can do about it. If you have a large patient base and there’s 3-4 women laboring at any given time, you could be in the hospital constantly, at all hours of the night. It sucks.

2. Childbirth
I think I’ve said enough on that subject

3. You get sued a lot. A LOT
Hopefully, if you give OB/GYN any consideration, you would know this fact but it bears mentioning again. Ob/Gyn's get sued all the time. Their malpractice insurance is some of the highest in the entire industry and everybody has had at least one case brought against them for something or other. Basically, it sucks ass. All kinds of things can go wrong and 98% of it isnt your fault, but that doesn't stop patients from suing your ass because little Timmy isn't reading up to his grade level.

Kevin learns some important facts about childbirth

Ah, 3rd year. The promised land every 2nd year is dreaming of and the 9th level of hell that every 4th year wishes they could forget. So far David has given you a glimpse into the life of a 3rd year surgery rotation student. Now that I’m done with my OB/GYN rotation, I feel obliged to share some intriguing insights into the entire miracle of childbirth that people might not know.

1. It takes a long time
I know what you’ve seen in the movies: Katherine Heigl is out eating some dinner, talking about nothing, when suddenly her water breaks. She goes to the hospital and 15 minutes you have a baby. Not so much in real life. Life on the labor and delivery floor for a medical student is long and tedious. Your duties include watching the mom groan for a really long time, checking the fetal heart rate and then going back to watching the mom groan. Luckily most women are reasonable enough to ask for an epidural (or they’re so beaten down by the constant sensation of having a human being pass through their vagina that they’re willing to compromise on their previous beliefs) so that it’s mostly just waiting without having to hear the groaning. But really, the entire process from onset of labor to actual delivery can take hours, hours where you’re not allowed to sneak away and go watch ESPN in the doctor’s lounge. Or so I’ve been told…

Sigh... if only

2. It smells really really bad
Despite all the lectures about fetal positioning, physiology of pregnancy and the birthing process, no one bothered to tell me child birth is by far the smelliest processes a human being can experience. I mean seriously, it’s awful. First of all, everybody poops, especially in childbirth. When the pushing process takes an hour or two, it’s just a constant dribble of little poop balls. Luckily the nurses are really good about whisking them away but unfortunately the smell is always just hanging in the air. Then once the baby is delivered, there is a huge gush of amniotic fluid, blood, vernix and sometimes meconium. In case you don’t know what vernix is, here’s what up:

“Vernix has a highly variable makeup but is primarily composed of sebum, cells that have sloughed off the fetus's skin and shed lanugo hair.”

So in other words, if you were able to collect BO from 100 fat hairy dudes and somehow condense it into a paste, you’d have some vernix on your hands. I’m absolutely sure vernix was invented just to be the bane of my existence. Well… at least 80% sure.

This reminds me of one delivery I was on where I caught a vernix covered baby onto my chest, right between the numbers. Even though we clamped and cut the cord in a reasonable amount of time, it was too late. I was pasted in baby goo. No matter where I turned, the waft of vernix followed me. Unfortunately I still had to deliver the placenta (another thing people never tell you) and check vaginal lacerations. But, after being hit with the fetus grenade all I could focus on was not vomiting. Every time I moved, it would stir the air and I’d get a little more of that cheesy goodness. By the end I think I was taking about 1 breath a minute. If I was on a pulse ox someone probably would have called a codeAfter that delivery I had to excuse myself to dry heave in the bathroom.

3. You have to be happy for the parents
Maybe this is just a personal struggle of mine but I have a lot of trouble mustering up the happy feelings at 3am in the morning to congratulate the mom and dad on their new baby. Clearly the birth of a child, especially the first, is one of the greatest moments a person can experience… unless it’s not your baby, and especially if you’ve already seen 5 that day. At the end of the day, I really have trouble feigning the fake joy necessary to congratulate some new parents on their new baby, who happens to look exactly like the baby I saw 15 minutes ago. I can say he looks cute but really, that’s not true at all. New babies look like pink little aliens that cry a lot. That’s about all they do. It takes awhile before they develop the chubby cheeks necessary to look hilarious in lobster costumes, which you can then spread across the internet and hopefully haunt them in their adulthood. Until then, they really bring nothing to the table.

This is payback for being so smelly

David Takes Call

As you may have noticed, many moons have passed since our last post. Due to a mind-boggling lapse in (Kevin’s) judgment, our previous intertube oasis at iddxblog.com has been seized by web squatters. Still, in an effort to better the world (and stop Amanda from crying), we will soldier on at this address until Kevin can undo his folly.

Meanwhile, Kevin and I have narrowly avoided board failure and transitioned to the world of white coats, SOAP notes, and Jesse’s iatrogenesis. For Kevin, this has meant a fantastic voyage of babies and bad smells, while on Surgery, I’ve realized I was never truly tired at any point in my life until now. To illustrate, here’s a quick running diary of a recent call night.

0400: Mmmm, a fresh new day! Only 30-plus hours until next we meet, bed. I’ll think of you fondly while I’m gone.

0505: Pre-rounds and dressing changes. Note to self: Try not to do heroin.

1015: OR, first case. I don’t even know what you’re asking, but I’m going to go with “atelectasis.” Please don’t take my suture scissors away; they’re all I have…

1400: Second case. Pros: I’m actually touching a beating heart. Cons: I can’t feel my legs.

1600: Back on the floor. Are those my bowel sounds or the patient’s? Will he see if I eat some of his pudding?

1830: ED: Hmm, so that’s the most common orifice to hide drugs and drug-related paraphernalia...

1945: I didn’t realize so many people are allergic to "everything but 'Dah-lowd-ee.'” Must be an epidemic.

2100: If I crawled into the scanner and acted somnolent, would the nap be worth the repercussions while they imaged my head? Tough call.









































This is the dream…

0020: If only I had some No Doze…

0200: Boo-yah, there’s my second wind. This isn’t so bad. That stapler wasn’t an awful pillow and that guy waiting in the hall stopped giving me the stink-eye.

0600: Rounds II: Son of Rounds. I don’t even remember life on the outside. This must’ve been what Brooks felt like in Shawshank Redemption. I hope the sun is as bright as it is in my dreams. I hope…













It’s OK, Brooks. I understand.

0945: Clinic. Can you turn your head and cough, please?

1215: Off. If I don’t make it home alive, at least I touched a heart.

Comic: What I really think about

David breaks down his USMLE Step-1 study habits

*Including debating which Pandora channel best accompanies studying and using First Aid's cheap paper pages to wipe away tears.

David questions Kevin's sanity

Just like grandma’s first resting tremor, Kevin’s recent post is an unfortunate sentinel sign of a burgeoning neurodegenerative disorder. Yet worse than Parkinson’s, Kevin’s affliction is a severe case of Nicolas Cageophilia. No other reasonable conclusion can justify his inexplicable love for the actor that brought us such cinematic asshattery as Snake Eyes, Ghost Rider, and The Wicker Man. Just look, if you dare, at the list of his four latest “films”:

1. Knowing - "Knowing is Everything."
2. Bangkok Dangerous - Something's happening in Bangkok, and it's probably not safe...
3. National Treasure: Book of Secrets - Fresh off a thrilling adventure in the first installment that involved a hidden treasure map on the back of the Declaration of Independence, the gang is back to uncover ancient Native American gold hidden within Mount Rushmore!
4. Next - Nuclear terrorism is afoot, and Nic Cage, Vegas magician, is the world's only hope.

This is a guy about whom YouTube videos are made en masse (thanks, NicCageFanClub1) solely to evidence the sheer ridiculousness of his frequent affronts to cinema. The actor whose movies even Kevin (and his early-onset Alzheimer’s) agrees he’d be most likely to avoid among Hollywood’s current leading men. The man who, after making the epic failure that was Ghost Rider, actually decided to re-up for a sequel to further his quest to make more people voluntarily claw out their own eyes. An actor whose recent run of movie-making futility has been so painful, I’m actually scared to turn on the TV during the summer for fear of watching 30 seconds of his next “I’ll-grow-out-my-hair-and-then-look-thinky-for-2-hours” debacle.


Knowing: Ooh, I’m thinky…


Next: Oh yeah, now my hair’s even longer, and I’m still thinky…


This isn’t even a movie, that’s how thinky I am!

Sure, Cage made a couple of decent movies in his distant past, but few of them depended on his acting prowess – The Rock was great, but does Nic Cage deserve a ton of credit for playing Overwhelmed Guy? – and none of his recent offerings have done anything but steal money from audiences and make babies cry. And yeah, he won an Oscar, which is basically a Hollywood political popularity vote, allowing him to join the illustrious ranks of Jennifer Connelly and Kate “The Female McConaughey” Hudson in the acting pantheon.

What’s worse, if Cage does possess any true talent, he’s even more unlikeable for electing to unleash such a garbage parade on humanity over the past half-decade. You can’t really criticize Keanu Reeves for poor acting; it’s all he can do. But if Cage can do better – and at this point, who would actually believe he can? – it’s an even bigger slap in the movie-going public’s face that he continues a nearly unprecedented run of sad clown cinema just to cash a check. In the medicine metaphor, Cage isn’t the plastic surgeon who sells out with breast augmentations instead of cleft palate repairs in the third world, he’s the doc that runs a healthy patient through the excessive work-up ringer to squeeze out as much insurance compensation as possible, delivering substandard care (and perhaps a bit of iatrogenic psychological trauma for good measure) to line his own and the hospital/movie studio’s pockets.

Honestly, Nic, how do you sleep at night? At least Kevin’s cortical tau body extravaganza gives him a legitimate excuse for supporting you…

Kevin is incensed at David's blatant consumption of Nicholas Cage Haterade

So David and I were chatting about movies yesterday when the subject of Nicholas Cage came up. Throughout the course of the conversation it became clear that while David has yet to obtain his MD, he has long since obtained his PhD. I know Nicholas Cage is not the easiest actor to defend but I felt the need to step in to prevent David from OD'ing on Haterade. Allow me to make a few points in support of our friend Nicky-G.

1) He's a good actor
Yes, he's put out a lot of stinkers (more about that later) but he has also put out a lot of quality films. Let me just list off some awesome movies he's been in:

1. Leaving Las Vegas
2. The Family Man
3. Adaptation
4. Matchstick Men
5. Lord of War
   
6. The Weather Man

These are all quality films that span quite a few genres. His acting was bananas in Adaptation. Lets not forget that he actually won a god damn Oscar for Leaving Las Vegas. DIf you haven't seen any of these movies, I suggest you stop being like Jesse and go rent them now.

2) He makes a shit load of money for himself
Despite having been in several really solid movies, I admit he's had his share of clunkers. But I would argue that he knew these were crappy movies going in and is only in it for the money. And how can you fault a brother for just wanting some cheddar. He loves classic cars and castles, and last time I checked, neither were on the Wendy's 99c menu. A lot of people do things "just for the money," especially David and this whole "medicine" thing. All I'm sayin' is, if plastic surgeons are allowed to fill their pockets w/ boob job money, Nicholas Cage shouldn't be hassled for cashing in his $20 mil. for National Treasure. Plus, even his crappy movies are reasonably entertaining if you just want some mindless action. The Rock and Face/Off are action movies staples that every man should have seen twice if not three times. Simply put, he's stared in some kick ass movies.

3) He makes a shit load of money for the studios
From my research, he's starred in 48 movies, 7 of which have gone on to make over $100 million dollars. Furthermore, the average gross of his last 10 movies was $74 mil, which actually beats out the likes of John Travolta, Pierce Brosnan, Bruce Willis, Denzel Washington, all of whom had similar per movie salaries.

Overall, I'm not saying Nicholas Cage is at the acting caliber of Russell Crowe or Edward Norton nor is he as bankable as Brad Pitt or Tom Cruise but he's not as awful as people make him out to be. He takes good 'actor-y' roles when he wants and then makes $100 mil. in between those to fund his little hobbies. Just let the man enjoy his money.

David and Kevin escape MS-2

As of approximately 4:30 PM tomorrow, Kevin and I, along with the rest of our intrepid graduating class of 2011 (and Jess, knock on wood), will move from the dark, windowless classrooms of MS-1/2 and on towards the glorious hit parade of life-saving, personal fulfillment, and sleepiness that is sure to be 3rd year.

All that remain in between are a few weeks of faux-summer and a wee board exam. Bring on the sweet downslope of this curve.

Comic: OB exams are tricky

David, Robby, Dan, Beth and the Johns save lives while on vacation

Recently, our MS-2 class finished winter quarter and moved one precarious step closer to the wonders of clinical Candyland and all its third-year clerkship glory. To celebrate this historic accomplishment, several of our noble band – including Dan, Old John, Stalker-y John, Robby, and Beth (Mrs. Robby) – traveled to Montana for a manly wilderness adventure. (Kevin wasn’t allowed because the state of Montana has an Asian quota that was met when I joined the trip).

This sort of trip means several things: (1) an ungodly amount of pork consumption (Beth managed to create this); (2) an uncomfortable amount of “That’s what she said" jokes; (3) a nonstop country music bonanza; and (4) 5 med students and an RN (who knows approximately 4.3x more than the rest of us combined) having nerdy faux-medical debates for 4 days.

After a productive morning of snowy adventuring (them) and sleeping (me), we cranked up the country and were treated with a stirring performance of Rascal Flatt’s “Skin,” which tells the story of Sara Beth and her fight against an unknown hematologic malignancy.



We did what any reasonable Spring Breakers would and beat the song to death with the following lively discussion:

After listening to the song, one thing’s for sure: someone’s a poor historian. Seriously Sara Beth, how can we help you without more details? Associated symptoms? Fatigue or fever? Throw us a bone. And Rascal Flatts, did you even go to med school? This OCP is just awful. Even the referring physician’s dropping the ball (“Between the red and the white cells, something’s not right?” At least give us a blood smear.). Clearly we have to do all the work…

First, Sara Beth’s only a teenager, so we’re immediately thinking ALL.

Easy bruising? Sounds like thrombocytopenia.

Mixed “red and…white cell” involvement? Could be an expected pancytopenia.

An aggressive chemotherapeutic regimen with a ~70% cure rate (lowered to "six chances in ten" for Sara Beth due to her older age and its negative prognostic contribution)? Perhaps a little CVAD induction therapy.

If needed, we’ll be ready for marrow transplant on second remission after relapse.

Go enjoy your prom, Sara Beth. We’ve got it from here. Now, if you’ll excuse us, the kid from "John Q" needs a cardio consult for his hypertrophic cardiomyopathy and then we’ve got a 3 o’clock to get a CD4 count from Andrew Beckett in "Philadelphia."


Your son's next, Denzel...

David tells you what to do (in an admissions interview)

Previously, I’ve given advice of variable seriosity to pre-medical students, both here and in person, usually with respect to the MCAT, personal statement, and general application process. This year, due to a clear administrative error in the selection process, I was allowed to join our school’s admissions committee to serve as a student interviewer. In addition to granting me a golden opportunity to implement my subversive personal agenda, this position has further demonstrated how important the interview is in the admissions process and where applicants commonly stumble or succeed in separating themselves from the pack.

When Kevin and I are asked to speak to pre-meds about admissions, people often think of the interview as a high-stress, nebulous obstacle shrouded in enigmatic mysteriousness with a black-boxy finish. To assuage these concerns, and so that future generations of medical students will learn from those who came before, I present a few suggestions for anyone with an upcoming med school interview:

1) Prepare, prepare, prepare:

This one’s obvious, right? In med school interviews, as in “8 Mile,” you only get one shot. You spent weeks/months preparing for the MCAT and years kicking ass in your science courses, during extracurricular activities, and while saving babies in the free health clinic you established in between curing cancer and playing varsity lacrosse for a school that isn’t Duke. That work ethic is what got you to the interview in the first place, so don’t abandon it now. You’d be surprised how often people seem un- or underprepared to discuss the most basic topics they MUST know will be coming down the question pipeline. There is a 105% chance you’re going to be asked why you want to go into medicine, why it excites you, and what experiences led you to the decision that the next 7+ years of training and three subsequent decades of practice are what you want to do with your life. Think about how you’d answer these questions and practice discussing them in some sort of mock interview format. You don’t need a canned script, but if you don’t have a compelling reason why you want the MD, why would the admissions committee make one up for you?

Along these lines, make sure you’re familiar with the specific program for which you are interviewing. Why does the curriculum appeal to you? What’s unique to that school that will help you reach your professional goals and why are your strengths well suited to that school? This stuff is coming, so you might as well prepare for it. Be Eminem vs. Papa Doc, not Proof. (RIP, Proof.)


Your interview should be like this, but less profane and with fewer tanktops.

2) Research the health care system:

This is an extension of (1); you’re entering a system almost universally recognized as broken, with a myriad of significant issues and just as many proposed solutions. As Atul Gawande once said, “The infrastructure and delivery of American health care are wack, yo*.” This issue is all over the news and, more importantly, is going to affect you every day of your professional life. So spending 10 hours reading about our system and its major pros/cons, about the employees who studied in online medical coding courses, nationalized health programs implemented abroad, recent legislation, etc., would be extremely high-yield. And really, it’s not like anyone expects the applicant to solve the health crisis in one hour. Still, it’s reasonable to expect a candidate to be familiar with the major issues of the profession she wishes to enter; it shows the applicant cares and, just as significantly, that she took the effort to prepare for the interview.

3) Be honest:

Adcoms interview a lot of people. They hear a lot of stories and develop a sensitive radar for half-truths and general BS. If you don’t know in what or if you want to specialize, I think that’s fine, but a vague story about how reconstructive surgery is your calling will ring hollow if you have no experiences to back it up. If you get asked a factual question you can’t answer or are asked to discuss something that requires background information you don’t know, it’s better to admit it and ask for what you need or discuss ways you’d obtain the information required than to make stuff up on the fly. No one expects you to have all the answers. If you did, there’d be no need for med school. You’d just stop by the front desk for a white coat and board certification and be on your life-saving way.

4) Be engaging:

An interview is as much about figuring out who you are and how you interact with others as it is a discussion of your credentials / experiences. An interview is inherently subjective. Think about what types of interviewer-interviewee discussions would positively resonate with an interviewer when he or she evaluates a candidate. An applicant who is warm and personable makes a more favorable impression than one who is excessively reserved. Sure, the interview is serious, and it might not be the time for a risqué joke, but it’s still important to connect with your audience. Your demeanor during the interview can provide a window into how compassionate you might be with patients and how well you’d interact as part of a small team. Don’t affect insincere enthusiasm, but try your best to enjoy the interview and show your true personality. Smiling doesn’t hurt.

All of the above may seem intuitive, but you'd be surprised how often otherwise well-qualified candidates struggle in these areas. Mostly it appears to be an issue of preparation, so spend as much time thinking/talking through these issues as you can. It will definitely pay off in the end.




*He didn’t really say this. I think it was actually part of the Flexner Report…

Kevin is unimpressed with some of his future colleagues

Recently David and I went with many of our classmates to a medical student research conference to present the groundbreaking research we all did this summer. There aren't a lot of requirements for submitting an abstract but nevertheless it’s a great opportunity to waste 4 days in a cool location meeting students from other medical schools and boozing it up at night. At the end of the weekend you get your “research” abstract published in a journal that will likely benefit no one. But we're really hoping JAMA accepts Beef Stew.

Anyone presenting at this conference is assigned a specific time slot which falls into one of many half-day time blocks at various rooms/locations around the conference site. The format is rather simple, you give a 10 minute talk followed by 3 minutes for questions from the audience. Our school was very insistent about students maintaining a certain level of professionalism at this event. Most of it is pretty straight forward: wear a suit, be respectful, don’t be drunk during the day. Easy. They were also especially adamant about students attending the entire half-day session they were assigned to rather than just showing up for your specific time slot then peacing out after the 15 minutes was up.

All this seems straight forward and self-apparent but not so for some of our colleagues from other medical schools... especially this one from the north. Instead of waking up early and showing up at the start of the half day session, these kids would swoop in about 5 minutes before their slotted time. Inevitably 10 of their classmates would also march in to root them on. When it was his turn the main kid would give his schpiel aboot his research into something related moose-related hunting injuries. Then as soon as his/her presentation was done, the entire posse would stand up and dash out before the moderator could make a passive-aggressive plea for students to stay.

So essentially a large gaggle of students would loudly file in during the middle of another student’s presentation, stay for 15 minutes for their friend's topic, then make a run for it when the next student is setting up his slides. Way to go guys.

*I just wanted to add that while I witnessed a few of these incidents, personally I was not a victim since there were no students from that school scheduled after me.  

Julia knows exactly the kind of doctor she will become

"Sorry, can't educate you about this Fragile X Syndrome your baby boy has, but I CAN talk to you about German health care reforms from 2003-2007."

Ladies and gentlemen, since you were aghast at the long silence on this blog, let me tell you what has been keeping our two class-clowns from their ranting: our med school’s obligatory course on health care structure, policy, and reform*.

Yes, this is a good idea at its core… after all, if we didn’t know anything about the organizations that will be paying us some day that would be pretty lame. However, this class is decidedly a scheduling bully—perhaps a little insecure about itself, and therefore going to make your life miserable to puff up it’s own sense of self-importance. Weekly quizzes requiring recall of minute details from the readings and lecture slides? Awesome. In-class “debate” group presentations, where the professor may-or-may-not call you a liar? Hmm… alright, I guess... Arbitrarily restrictive, two-page, double-spaced paper proposing 1-3 major health care reforms, while giving background and then providing objections to it? Ugh, just leave me alone already!

This class single-handedly managed to eat up more time weekly than musculoskeletal, genetics, and hematology combined!

So, while that pain in your shoulder causing you to be unable to raise your arm to shoulder-level may be very concerning… Can I interest you in a discussion on the pros-and-cons of a physician’s duty to follow public health mandates during a disaster?

David fails to understand honors (/pass/fail grading)

In the long months since Kevin's illuminating "year 2 is just year 1's uglier, more high-maintenance sister" entry, we have received countless e-mails with pressing questions and comments about the absence of irreverent med school insider-y wit filling the empty spaces in the lives of our devoted public. Here's a sampling of our fan mail:

Whyyyyyyyyyyyyyy???!!!!!
- Julia

I miss you guys so much it hurts sometimes.
- Jess

My one goal in life is to live long enough to see just one more post.
- John (the old one, not the stalker-y one)

Well, the posting drought ends now. RIP, John. (Oh, and Kevin has promised to write several more posts in the near future, though the quality may not rival 'year 2/year 1' brilliance.)

-------------------------------------------------

Second year, in all of its we-survived-first-year-and-now-we’re-almost-to-third-year glory, has added a new wrinkle to our academic lives: the ‘H.’ Whereas our med school employed a strictly Pass-Fail system during year one, we now face the world-altering prospect of a 50% increase in the number of possible grades. And though popular wisdom places these grades well down the totem pole of importance in one’s residency application, most students are nonetheless interested in filling their transcripts with as many pre-clinical H’s as they can muster.

The logic behind second year grades seems pretty clear: after a transitional first year where mastery of basic concepts is most important, an H/P/F system gives students a chance to distinguish themselves as the material becomes more advanced/clinically relevant. It rewards those who make the extra effort to excel, and such sustained motivation can only have a positive influence on one’s ultimate clinical competence.

Grading systems are designed to both motivate students and, by definition, stratify them based on performance. Grades provide valuable feedback to students and also give administrators at the next step in the academic ladder an essential signal about student achievement. There’s a reason med schools don’t let pre-meds take their pre-reqs P/F; a P only indicates the student demonstrated the minimum competence required to complete the course. Student X may have excelled or almost failed, but no one can know for sure within a purely P/F system.

The major downside of the H/P system is that, though it provides more information than the P/F system, it falls short of a third choice with a full range of grades (akin to the GPA system in college or HS) for no real reason. If adding the H makes sense, why not just take the plunge to a 4.0 scale with the traditional complement of +/-‘s? The purpose of grading is to provide valuable information to all interested parties: to students about their performance, to teachers about how well the material is being learned, to residency administrators about the academic prowess of prospective applicants, etc. If information is the goal, what benefits are there to purposefully providing less information in an H/P/F-only system*? Here are a few I’ve heard, but for the most part, they don’t stack up to deeper review:

1) The H/P/F system is less stressful.

In our system, a final grade of 90% or above usually qualifies one for honors. There may be extra essays involved to reach the holy honors land, but there’s always a numerical cut-off that separates the two strata. Thus, grading is essentially an all-or-none exercise. There is really no major difference in mastery between someone who scores 90% and someone with an 89.1%, yet there’s a reasonable chasm in their ultimate grades. The person with the 90% is in rarified air. The sub-90 % kid is left with a grade that is indistinguishable from a 70% effort. Compare this to a system in which 89% is a B+ and the resultant grade-point differential of a question or two is far less consequential. Which one is more stressful?

2) The H/P/F system motivates students to excel.

Though this is true, it fails to acknowledge that a more traditional grading system incorporates the same educational incentives without dragging along a few major downsides. In a typical 4.0 system, a student who gets an 85% in every class collects a series of B’s that ends up numerically equivalent to a colleague who gets half A’s and half C’s. In the H/P/F system, the former is left with a dreaded P-fest (teehee) while the latter gets rewarded with 50% H’s. Yet who is really the better student? The person who does consistently well but never aces anything or the one who completely ignores half of his classes in order to honor the other half? There may be no clear answer, but it is intuitively obvious that the H/P/F system incentivizes just this sort of all-or-none effort. Grades can both motivate students toward better performance and lead them to utilize practical ways to game the system.

3) It doesn’t really matter; preclinical grades are of little importance and it’s what you learn that determines how you perform when it really counts (during Step 1 and on the wards).

Sure, those other things are more important predictors of matching success than the preclinical transcript, but that doesn’t mean the latter is insignificant. At our school, preclinical grades factor into the behind-closed-doors ranking system that determines whether or not we’re eligible for AOA, which almost everyone agrees is a meaningful distinction. And regardless of how much they ‘matter,’ we should still try to find the best way to dole ‘em out.

4) Stop ranting and go do something useful like studying.

OK fine, you win. But instead of studying, I’m going to figure out if there’s some sort of 15-15-1 equivalent to residency applications…

*It’s not even so much, or at all, about how high the ‘H’ threshold is – it’s actually a lot easier to honor any given class at our school relative to the stories I’ve heard from friends at other institutions – but rather about the utility of the H/P/F system itself.