Anxiolysis

I do not like to be anxious. I push things out of my head to deal with later (this is called suppression - one of the mature defense mechanisms, which probably contributes to the high frustration threshold I mentioned yesterday), and this exasperates Nicole to no end; not only does looming uncertainty increase her anxiety much sooner than it does mine, but talking and discussing the uncertainty, in an attempt to make things more concrete diminishes her anxiety, while it increases mine. When there are issues to be dealt with, I know that they have to be dealt with - I don't ignore them, but it takes some time for me to get to the place where I want to devote mental time to it, and am willing to submit to the inevitable tide of anxiety.

Right now, the anxiety centers around finding housing in NYC. There was a brief period last week in which it looked like we might be able to stay and complete the remainder of our clerkships here in Miami. It sounded awesome, but only the deal for psychiatry was signed; I could stay an extra six weeks down here - but when I found out that our landlord had already rented out the apartment (I had, after all, given him the date we'd be finished), it was like God telling me to go to NYC. Also, since the vast majority of landlords require a minimum 6 month lease, chopping into that just to stay here for a while sounds like a bad idea. I have no concerns about whether or not we'll find housing; it's just that it'd be nice to get decent housing, and I've learned that if I procrastinate too long, I'll be taking what's left, rather than having my pick. This seems to be the most pressing concern right now (taking precious time away from clinical musculoskeletal disorders).

More anxiety? Money. I don't worry about it for now; I worry about it for later - I've joked before about how Sallie Mae owns my soul, and I never quiet forget that I'm going to have to repay every dollar I spend with interest. Since that's not quite defined by any specific deadline (except for the repayment start date, which is, at this point, deferred for years to come), it doesn't spark anything more than little nagging blips of anxiety. Housing is expensive. Books are Expensive. Transportation is expensive. Food is expensive. And tuition? Don't even get me started. Add to that the rumbling Medicare thunderclouds on the horizon of medical reimbursement - the cuts keep coming, and it sounds like more and more doctors are becoming disillusioned with the whole business, occasionally recommending that interested folks consider other careers, and less frequently leaving medicine altogether.

What else? Board exams. I rocked my first set in November, and I'd like to keep up the momentum - the way I'm scheduled, I not only have all of my cores lined up back-to-back, but I have a few months between the end of my academic requirements and graduation; wiggle room. I'd previously considered taking that time to work and begin repaying loans, but it might be a better idea if I took some serious time off to study and locked in some great scores, perhaps even taking the USMLE step III before graduation, so I didn't have to worry about it during my first year of residency, like most US med students.

Hot on the heels of that nagging little "anxiom" (my sarcastic neologism for a a bit of anxiety-inducing uncertainty) is the unsureness of whether or not I'm learning what I need to know. On the island, they told us which books to use and gave us the lecture slides - you either knew them or your didn't. Here I'm preparing to be tested on some information, but I'm on my own as to where I get my version. Harrison's Princples of Internal Medicine is an exhaustive and exhausting reference - I'll never get through any topic in a timely manner. So I use Davidson's Principles and Practice of Medicine, because it's shorter, supplementing it with Step Up to Medicine - but are these good enough? Am I learning what I need to be on the wards, as I madly scribble down every word that proceeds forth from the mouth of the Attending? Am I practicing my physical exam skills properly - were those really rales, or just harsh lung sounds? Should we do a CXR or HRCT?

So I'm anxious about whether or not I'm acquiring the appropriate skills to be responsible for someone's care, but I'm also sometimes anxious about whether or not I'm growing up to be a competent adult - my very wording demonstrates that I don't feel like I'm there yet.

You know what, though? These Anxioms will never go away - never will there be a time when I have no cares whatsoever. I'll get a great job and a nice place to live, but by then I'll find myself beset by another, more pressing consortium of concenrs - the offspring of the anxsioms that trouble me now. Generations of worries will harry the various stages of my life, and so I guess I'd better get used to it...and get back to looking for housing in NYC; anxiolysis.

End of an Error

I've got what I believe to be a very high threshold for frustration - this probably contributes to my procrastination; the anxiety of rapidly approaching deadlines had not, until recently, inspired in me any sort of anxiety. However, when I reach my breaking point, it's game over. That happened last night with my old laptop, an HP TC4400.

It was a sexy little machine at first - I picked up her just before MERP, at the beginning of my medical career. She's a tablet and is thus like a petite laptop gymnast - cute and flexible. However, true to my nature, I didn't want to spend full price on her, and, in perhaps my greatest tech mistake, I bought a factory refurbished unit, rather than springing for a new model. Somehow, in my mind, this convoluted logic made sense, even though I decided to splurge on an extended warranty, knowing that there might be problems. I think I expected them.

I carried her to MERP, and the honeymoon period was fantastic. Things behaved as they were supposed to, and, whether real or imagined, I felt that my tablet tech was as impressive as another brand-new device, the first iteration of the iPhone. The first sign that things were perhaps not so peachy was a short, neon-blue line that popped up on day at the bottom of the screen. I thought nothing of it.

I took her to the island, and she must have gotten pissy, because that's when all the problems began - you see, as a tablet, the screen is supposed to flip orientations when she moves between tablet and PC mode. She is not supposed to do that on her own, whenever she wants, whenever she's connected to an external power supply. It drove me crazy. I couldn't send her in to get repaired because the warranty didn't apply out of the country. I emailed back and forth with tech support, and finally settled on disabling the screen rotation altogether, functionally removing all of the features that had made her a cool tablet. We fell into an uneasy peace, then - for whenever she'd push against my restrictions and try to rotate her screen, she'd get (we'd get) a big, obnoxious error message - it was generally only three or four, but I've occasionally been assaulted by stacks of 40 of them. At the same time, the cursor would go and spasm in the right lower corner of the screen, clicking on whatever was there, completely beyond my control. There were no patches, there was no software to download - it was like she'd contracted a personality disorder, and no drugs could fix it. Actually, it was more like recalcitrant grand mal seizures - she'd go into her fits, and there was nothing I could do but wait them out.

After our time on the island, I brought her back to convalesce in the US. 5th semester came and went, and her condition worsened - midway through my step prep time, as the warranty deadline neared, I contacted tech support to get her taken care of. There began the disaster - I wasted hours on the phone with Hewlett-Packard, unsuccessfully trying to get her fixed remotely and then, when that failed, begging and pleading with them to send a box so that I could have her repaired. I had to continuously supply them with the e-receipt of my extended warranty because, according to their records, it had already passed. I tried, and they failed me - the whole damn company. Shortly thereafter, she contracted some rampant Russian or Albanian virus in the guise of antivirus software and, instead of taking her in to someone, I just wiped her hard-drive clean, reinstalled her operating systems, and bought the best antivirus I could find. Fortunately, I'd had everything backed up. I'd hoped that a complete mind-wipe would do something for her seizures - sort of like a corpus callosotomy ( the corpus callosum is a bundle of nerve fibers the two brain hemispheres use to communicate - historically, it was cut to prevent seizures from spreading from one side to the other). However, this didn't work either.

I put up with her little fits for months, occasionally reaching the place where I was ready to smash her to bits but, at that point, she'd behave, as if her performance was merely to show me who was in control. The breaking point came last night when, the the midst of one of her first, the successor to the virus from last year slipped past Norton's defenses to assault me once again. I ran Norton over and over, but the damn software kept on finding "no virus", and the fits continued. I'd had enough.

So today I went out to Best-Buy and picked up a new girl. It felt like a whim, but it really wasn't; I've been browsing laptops on the sly for a while now, wishfully-thinking. She's a fiery red Dell Inspiron 1564, with 4GB of RAM, 320 GB of memory, and a nice i3 processor - not top of the line, but I'm not yet ready to drop 2-grand on a computer, especially with student loans. So I think my new girl and I will be getting along nicely, but some of my bum luck continues. Over Christmas, I'd purchased an external hard-drive to protect myself against my old girl's fits. The new one must be a little possessive - she didn't recognize the external hard drive, and by the time I got it open, it looked as if I'd never backed anything up at all (possibly due to the difference in operating systems). At least I've got my trusty pen drives at home. Good bye, old girl.

This whole thing....the crashing and replacing of computers and digital information in general has me thinking. I'm always a little chagrined when some catastrophe occurs to computers. Here we've built up these complex little machines that only a few of us can understand (I'm talking DOS, not Windows, but even then....), and we rely on them so much. I'm sure this a long-dead horse, but it's a little chilling in a sci-fi esque sort of way - not that they're going to become sentient and rise up against us (I'll be that's where you though I was going), but that we place so much importance on them, and when they mess up, we're kinda screwed. I lost a lot of data in this update, but nothing truly important - the important things all exist in real life. It's not fair to say that electronic music, picture, and document files don't actually exist, but that's sort of the case. We can view them and alter them, we can enjoy them - but if they're not tangible, they only exist in one place - inside the human mind - and are backed up on our pretty machines. Every once in a while I write down my musings and story ideas, and I panicked for a moment when I thought that all the newer versions were gone...but they're not; not only do I have them printed out somewhere, but I have them in my head.

If all the digital music were gone, where would we listen? If our little laptop Windows to the world suddenly went silent and dark, we'd have to go back out there for our art and literature, for our enjoyment, our learning, and our work. This whole experience has reminded me that they're just tools - nothing more. Just as electronic medical records are required by law to have their hard-copies stored in hurricane-proof housing, no necessary bit of information should exist solely online.

Yet...as quickly as prized information can disappear into the abyss, if I were to post vulgar pictures of myself on facebook, or blog about ideas that are radical and hateful, I may never get a job; people would be able to find those things forever. A conundrum, eh?

And so I extol the virtues of the hard-copy, and turn a wary eye to deceptive conveniences of the digital; I am devolving.

Chiaroscuro

I should be fervently poring over diseases of the respiratory system, but I wanted to capture the essence of today's experiences before they faded. First: A Gripe.

This is the second time now that my clinical experience is being short-changed by someone's vacation. The first time was two weeks ago, when I was supposed to be following a doc around the ICU. However, he was in Europe, and I ended up spending the week in the clinic with his PA - he was a nice guy, but going from high autonomy in the previous clinic to nothing of the sort in this one wasn't pleasant at all. The second time begins on Wednesday - I'm supposed to be rotating with a pulmonologist this week, but he's heading to South Africa for the world cup. Thus am I once more relegated to the outpatient clinics.

On to the Dichotomy. For the past week in the ICU, I was rotating with a doc at Cedars Sinai, the hospital recently purchased by the University of Miami Miller School of Medicine. This morning I met the aforementioned pulmonologist at the famously financially failing Jackson Memorial Hospital. I'd expected them to be relatively similar, given the fact that they're literally across the street from each other, but such was not the case. Though the floor on which we rounded was a step down from the ICU, it seemed to me that these patients were staring Death in the face, wondering who'd be the first to flinch.

There was a young woman who'd had a septic, embolic stroke and was now effectively paralyzed, though she was getting better. There was the older man in chronic liver failure, who was essentially non-responsive. There was another young woman with atrial-fibrillation and such severe GI bleeding that she was anemic and on the cusp of transfusion (the healthiest patient). There was a young AIDS patient whose liver failure resulted in the anasarca that I blogged about a while ago; he had an altered mental status from the hepatic failure. There was a young man who'd dived into a swimming pool, cracking his 7th cervical vertebrae, and is now on the cusp of quadriplegia. Next door to him was a young man - just a kid, really - who'd busted his head in a motorcycle accident, had no insurance, and so had lain in his hospital bed for 2 years, unable to move.

Then we hopped in the doc's BMW SUV and drove across the street to Cedars. It's like one is the fair and popular, new and advanced sibling, and the other is the dark, secretive, old-fashioned older brother. However, that younger, fair sibling is arrogant and spoiled- for some reason, I couldn't put my finger on it before. There's such an air of self-importance and arrogance at Cedars - it's generally from the younger folks working there; I can't name anyone specifically. I just feel as if the hospital is looking down it's nose at me - and everyone else - which probably isnt' fair, because I can't cite a single definite example; that's just my perception. It was different at Jackson - old Jackson. I don't mean to imply that they were all bubbly, they were about business; but I just felt so much more....comfortable at Jackson. At we left the floor, I glanced at the portraits of all of the interns in internal medicine who'd begun in 2006. The first thought of my head was "I could be there" - and I've never entertained any ideas of residency at Cedars.

Cedars is definitely newer, and the floor we were on in Jackson looked like it hadn't had a new coat of paint since the eighties. However, Jackson is a bit more advanced; they've got more toys and the only trauma center in Miami. Am I morbid? Is there something wrong with me that I loved it? I feel like if I do a residency at someplace like that, I'll be able to handle anything. I guess that's why "old-school" has positive connotations, and the opposite doesn't.

The only Emergency in Dermatology...

...is nothing I've seen recently (thank God), but I'll get to that in a bit.

My week has been good, but for some odd reason, I've been absolutely exhausted, which is odd, because the hours have been decently cush. I'm still loving the ICU; we were with this doc for only a week, but we'll be with another one, who'll also have some ICU time. I've mentioned my new fascination to other people, and my declarations have been met with horror; as if my morbid excitement is indicative of some character defect. Nevertheless, it is awesome - whether or not I'll end up as an intensivist is known to God alone, but if I go into internal medicine (a likely scenario), then I will be caring for those on the Precipice - those men and women, young and old, who find themselves perched precariously on the border between this life and the next, standing on a bare and windswept landscape, staring down into the yawning Chasm of Death.

For some, it's simply their time, and no amount of medical heroics can slow their inexorable leap. For others, however, as they find themselves drawn towards the Chasm, the long arm of medicine can pull them back. This happened on Tuesday or Wednesday with one of our doc's patients. We were rounding somewhere else when they called the code - we didn't exactly rush because Cedars has dedicated code teams - and by the time we got there, they'd cancelled the code. Our doc explained her medical history to us as we walked down the longest hallway in the world - she's a type 1 diabetic, blind, in kidney-failure, and bedridden, in her early fifties. They'd stabilized her, and a gaggle of nursing students had clustered around the room. It must have been the head nurse who canceled the code; he was explaining to them his reasoning, and as I walked into the room behind the doc, he turned his full attention on me, as if I was more than a third year medical student. According to Nicole, the nursing students turned their full attention on me as well.

I have no desire to silently convey incompetence. And so I posture a bit; I hope it isn't too much - I merely try to carry myself confidently. However, my ID says "observer" rather than "M.D.", and I always feel like I'm one question away from being exposed as someone who has no clue what to do in the ICU; a pretender. It's not really a front; I've just noticed that, occasionally, the words "I'm a medical student" evoke the same reaction from patients as "I'm going to cut your tongue out". They freeze up for a second, with a wide-eyed deer-in-headlights stare that occasionally makes me want to look over my shoulder to check for the Headless Horseman. Do I misrepresent myself? No....when I'm interviewing the patients on my own, I tell them who I am and that I'm a med student working with the doc (who will, of course be right in to see them, lest they fear that they're not going to get any sort of medical attention whatsoever but mine which, in their eyes, is nil) but if I walk into a patient's room with the doc, I'm just not going to do anything other than greet the patient, and listen to whatever I can. It's stressful; I feel incredibly inadequate not knowing what to do all the time. This is compounded by the drug names. In school we learned the generic names, and I learned them very well; once I know what it is, I have a good idea of what it should do and shouldn't do. The problem, however, is that in the real world, they use trade names -the patient knows what it is, of course the doctor knows what it is, and I'm in the corner with a dunce-cap, tapping away at my blackberry, trying to figure out that Crestor is rosuvastatin, that levophed is norepinephrine, or that Tinoretic is atenolol and chlorthalidone (those damn combinations get me every time).

But I learn more every day. There's hard work (which has been, perhaps, lacking this week; I am so tired of reading about diabetes), smarts, and a little bit of serendipity. While I was failing to force myself through a re-read of endocrinological disease, I found my way to one of the videos on the NEJM app - chest tube insertion. I watched it, figuring that if I wasn't going to dig deep into the different kinds of thyroid inflammation, I might as well learn something. And so Friday morning comes, we have a delicious lecture on major depressive disorder with a focus on pharmacology, and get to the hospital. We round a bit with the doc, the day passes, and what should present, but an opportunity for a chest tube! This poor old woman had been having some heart problems, and someone had dropped her left lung by putting in pacemaker leads. The surgeons who'd generally do this procedure were doing what they do (surging? Surgering?), and so our doc went to put it in - and it was almost exactly like the video.

Here is a trustworthy saying that deserves full acceptance: "See one, do one, teach one." This is a medical motto, defining the natural course of procedural knowledge and, in some cases, it is quite literal. This strikes fear into the hearts of medical students everywhere (it should strike fear into the hearts of patients) - but not me; I love it. Only.....I'm not going to just "see one" - I'm going to watch the doc do it, I'm going to youtube videos, I'm going to read about it compulsively, and I'm going to practice in my mind while pantomiming in the air. And then I'll do one, because they won't let us do anything we're not ready for, and they're not going to leave us alone. As the OB I rotated with said "Let me know when you're ready to jump in and do things; there's nothing you can screw up that I can't fix".

Nicole and I met up with PAgirl for lunch today, and then found ourselves drawn back to Dolphin mall (we were last there.....yesterday). I took along an article on the revised thyroid cancer guidelines, thinking I'd park myself at Starbucks and let the girls go play. What I thought would be a quick trip turned into an all day affair, as I searched for the perfect pair of Miami shoes - those loafer-looking shoes you wear without socks. I'll never give Nicole a hard time about shopping again - looking back, I am the super-shopper.

And now to the reason I snagged your attention: his name is Stevens Johnson. You see, there's a trend in medicine - according to correlations between board scores and specialties, the best and the brightest of medical students do not go into the hardest specialties, or those where their big, meaty brains can be of the most benefit for mankind - but rather, they go into specialties that pay the most *cough* plastic surgery and orthopedics *cough*, and so-called lifestyle specialties - those nice ones where you can reasonably expect to sleep through every night, epitomized by dermatology. Seriously - those derm guys have some of the highest board scores, and they deal with rashes all day. However, there is one hellishly feared complication; in fact, it's just about the only dermatological emergency. Rather than a single entity, it's a continuum, beginning with erythema multiforme, continuing into Steven's Johnson, and ending with toxic epidermal necrolysis. This is essentially an allergic reaction (generally to medications) in which the skin self-destructs, eventually looking like a horrific third-degree burn, and killing the patient. This is exactly what just happened to Manute Bol. I've never heard of it killing anyone, but I new that it could.

ANASARCA

Today was the beginning of what I foresee will be a long and torrid love affair - tempestuous and ambivalent - with the ICU. I should be writing up a month's worth of SOAP notes (which are due tomorrow, since they're a requirement now and all), but I feel compelled to share. I'd been getting tired of outpatient medicine; I'm not putting it down, but when I fantasize about medicine, that's not what comes to mind. And thus, I had high hopes for today - part of me feared that, after looking forward to it for so long, I'd realize that I didn't care for the acutely ill. That couldn't have been farther from the truth.

The first patient of the day was an acutely ill woman who'd been brought from her nursing home yesterday with some respiratory distress, had worsened in the ER and been intubated, and then had had seizure. She was unresponsive when I saw her this morning, lovingly attended by her sister - who now decides that she's supposed to be DNR. This woman's electrolytes were all out of whack, her heart was going a million miles a minute, and respirator-rhonci were almost audible sans stethoscope. I'll be following her all week - I'm fascinated by this. More time was spent with the computer records than the patient, because (1) she was unresponsive and (2) she really wouldn't have been able to answer questions in the detail necessary. She wouldn't have known that she was hypokalemic, or why - was it due to the steroid injection, or one of the 29 (that's right - twenty-nine) medications swirling in her system, each of them changing her regular and disordered physiology in their own, unique ways.

Next door to her was a man with cardiomyopathy, and by that I mean that his heart was failing. However, he was being kept alive by a tandem heart - a cardiac assist device that helps to circulate up to 5L of oxygenated blood when the heart isn't doing what it ought to - textbook cardiogenic shock, rescued from the depths of the grave by science an ingenuity.

The doc we're with is a lot of fun, and told me something I found fascinating - apparently, precalcitonin is a more sensitive marker of bacterial sepsis than either cultures or neutrophilia. That may mean nothing to you, but it's frickin' awesome to me.

Now, I'm thinking about cardiology and thus that Tandem ought to have been the hi-lite of my day. However, that honor was reserved for one gentleman in liver failure. This guy had some end-stage liver disease, hepatorenal syndrome, and hepatic encephalopathy. When we got to his room, we learned that his family had taken him off the transplant list and made him a DNR. The thing that I will never forget, though, was that he had edema everywhere.

Now, I saw pitting edema every day in the outpatient setting; folks may not have their HTN meds or whatever appropriately managed, some of it's just due to age - and so their ankles swell, and when you press your thumb over their tibia, it leaves a lasting dent in their skin. This guy had anasarca - which is when you get that pitting edema everywhere. In his case, it's because his liver pooped out and was no longer making albumin, which keeps fluid in the vascular compartment, instead of leaking out into the skin and the interstitium. I kid you not...this guy had pitting edema of his abdomen.

I love it. I mean...poor guy; he's not going to live long - but I'm fascinated and excited. This is more interesting than delivering babies.

Confession

Blogger forgive me....it has been....a while since my last post.

Since then, OB has ended, and I have begun [what I consider to be] the most important of all of my clerkships: internal medicine. So weighty is this among the other clerkships, that many simply refer to it as "medicine".

This is the second cycle in history of Ross' internal medicine rotations with Miami Beach Community Health Centers/ Mount Sinai Medical Center, but already it's far more organized than the other clerkships. I spent the first month of my three month clerkship conducting outpatient medicine at one of the Miami Beach Clinics with one fascinatingly intelligent internist. I've always thought that doctors who go either into internal medicine or pathology have the broadest and deepest fund of knowledge with which to approach the disease process, and I certainly hope I am one day able to think like this doctor. Fortunately the feeling was mutual; he wrote me a stellar evaluation - I'll certainly be requesting an LOR.

Every once in a while - twice a week, it's supposed to be - we have ER rotations. My first one was last month, scheduled from 3pm to 2am (my next shift was supposed to begin that same day at 6am, but we got that changed). Anyway, it wasn't terribly fascinating; so many of my colleagues want to go into ER medicine, but I believe that they either (1) don't know what they're talking about and just like what they see on t.v. or (2) do know what they're talking about and want ER medicine because of predictable shift work. However, after doing my second shift in the ER today, I've come to a conclusion - it's just too ADD for me. Every physician should know how to respond to emergencies - just as we should all know how to deliver babies, but, to me, emergency medicine is a faster-paced, slightly more exciting version of family practice. I say this because the Aventura ER is not a trauma center; in fact, Miami's only trauma center is Jackson Memorial (absurd, I think, that Miami's only got one...). Were I at a trauma center, it might be different. However, my comparison is based on this fact - both ER docs and family practitioners know a bit about a vast amount of disease presentations - enough, in fact, to know exactly when to refer, and to whom to refer.

Someone goes to their PCP (primary care physician) reporting that they get winded more easily, and get chest pain sometimes: referral to cardiologist. Someone goes to their ER complaining of crushing chest pain, nausea and vomitting: stabilization - and then referral to a cardiologist.

Someone goes to their PCP wondering if they may be pregnant: referral to an OB. Someone goes into their ER with severe lower left-sided abdominal pain after not having had a period for 4 months: stabilization, and then referral to an ER.

Someone goes to their PCP reporting a lump in their groin: referral to a surgeon (assuming it's an irreducible hernia). Someone goes to their ER reporting a terribly painful lump in their loin: stabilization, and then referral to a surgeon (assuming it's an incarcerated hernia).

Someone goes to their ER complaining of feeling down for months as well as feeling anxious: referral to a psychiatrist. Someone goes to their ER acutely psychotic, and must be Baker-acted (committed to care against their will because of the imminent likelihood that they will harm themselves or someone else): stabilization, then referral to a psychiatrist.

I'm mention these commonalities not to put down either of these very worthy professions, but rather merely to show that the reason that neither of them particularly appeal to me is what they share in common. It seems that, if I were to consider anything as far as the ER is concerned, it would deal with trauma surgery.

I hunger and thirst for depth and mastery. I do not desire to merely dabble, to but dip my fingertips in many different flavors - the excitement of variety is something that family practitioners and ER docs have both told me drew them to their respective fields. However...it doesn't do it for me. They all know more than I do, obviously....at this point. The internists, on the other hand, dig deep; they dredge the depths of the disease processes - perhaps I am drawn to disease as a mental puzzle. Do I, then, see myself as an internist? Only perhaps for three years.....or the amount of time it takes to complete a residency, and move on to a speciality - for internal medicine as an endpoint may be too general.

It is a thinking profession. And yet....the reason I fell out of love with psychiatry (aside from the oppressive shackles of their scope of practice) was that, in the anatomy lab, I learned that I loved working with my hands. In my head - in this....blissfully limited experience of mine - it all may come down to how much I end up loving my surgery rotation. Now there's a hard life...more than the three IM requires, surgery exacts 5 grueling years of sleep deprivation and....and what? I don't know. I have heard it's a difficult life. And at the end of 5 years, one has only attained the status of a general surgeon - fellowships require more years.

How many years are enough? I ask not from weariness of the path - merely curiosity.

Anyway. This next week, I'm supposed to be in the ICU - now that is going to be fun!