23

23. That's how many days straight I am working. No days off, no 24-hour consecutive periods where I'm not at hospital. Instead, I've switched from days to nights to days again and have been at the hospital every day for the last 23 days, working at least 13 hours during each of those shifts. I have no freaking idea how there are zero duty hour violations.*

I am, unsurprisingly, grumpy.

It wouldn't be so bad if I was actually doing something during this time. You know, the usual intern things like working up floor issues, doing discharges, closing when I'm in the OR. But unfortunately, I'm at a program that gives more responsibility to its medical students than interns. It's incredibly frustrating, especially since I already have an intern year under my belt so I don't need the "practice" of being efficient at floor tasks and other basics of doctoring.

Last week, I was in a 12-hour OR case. I can count on one hand how many sutures I threw at the end of the case before the attending took the needle driver from my hand because it was getting late and he wanted to speed things up. "Let me close up so we can get out of here at a reasonable hour," were his exact words. I wanted to punch him in the face right then and there.**

Maybe I have unreasonable expectations about my role on the team. At my first intern year, they handed you the pager and said, "Good luck! Call me if you need anything," as they signed out a 50 patient list and peaced out. Here, you have to text the senior every time you place an order, including melatonin. It's absolutely ridiculous and incredibly frustrating, especially since I've already done this once.

But at least at the end of this stretch, I'll have some vacation and quality time at the beach. So there's something to look forward to even if I have steam coming out of my ears right now.

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* Somehow this doesn't violate duty hours, which blows my mind.

** He had sent me out for a break 7 hours into the case, and I was so hangry at that point that instead of grabbing a quick food and bathroom break and being back in 15 minutes (like I had initially intended/a good intern would do), I grabbed food from across the street, plopped down on the grass outside the hospital, and soaked up some vitamin D. I had zero regrets or shame when I strolled back into the OR 45 minutes later. In retrospect, I feel even less shame now that I know that this case contributed ABSOLUTELY NOTHING to my learning and my attending didn't even notice I was missing since by that point he was working under a microscope and I was watching unscrubbed on a monitor.

Progress

This whole year has been incredibly stressful not only because I've been worried about my future, but also because I've put an incredible amount of pressure on myself.

I've felt the need to be perfect in order to impress people at this program so they could advocate for me during the match. Every time I messed up that perfection (usually, only in my eyes), I would beat myself up about it mercilessly thinking I had blown my chance and the world was coming to an end.

Now that I haven't matched and I know I'm not staying here after the year is done, I've let all of that pressure go. It's been so freeing to not worry so much about the little things that really don't matter in the end.

For example, for the first time in my entire professional life, I overslept work. I woke up 10 minutes before our entire team (upper level, fellow, and attending) was supposed to start rounding. Obviously, I was going to be late, but I didn't rush in getting ready, I didn't speed, and I didn't jog from my parking space to rounds. I figured there wasn't much difference between being 10 minutes late as compared to 20. So, I took the usual amount of time and strolled in as we were talking about our 3rd ICU patient. With the exception of the PGY3 who had to hold the pager for those extra 20 minutes and unluckily got a consult in that time, no one seemed to notice. And I only apologized once, let it go, and went about my day as if nothing had happened

I'm not saying I didn't feel bad about being late, because I did and obviously wish I hadn't slept through the 4 alarms I set every morning*. But it was freeing to not feel guilty, angry, and awful about myself all day. When I'm at work, I kick ass and I think that speaks more to my character and work ethic than the one morning I overslept. It took me a while to realize that and it's been awesome.

This more Zen-like approach to my year has been so refreshing and I'm so happy I've finally reached this point. It makes my life less stressful and less angry at myself, which I sorely need right now.

I guess when you have bigger things to worry about, such as what I'm doing "next year" when really it's next month, the little things really don't matter.

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* I stagger my alarms for situations like this. They go in the following order:
Alarm #1 - It would be really nice to get up right now
Alarm #2 - I should get up if I don't want to rush
Alarm #3 - I really need to get up if I want enough time to grab things
Alarm #4 - OH SHIT, I'm going to late!

Hope

I got an interview invitation! Holy crap, I didn't think this was actually going to happen but here we are.

There are many reasons to be excited about this, but mostly it means that my general surgery program director didn't completely screw me over with his letter of recommendation. I had been worried about what it would say because the month I rotated on his service, everything went to hell.

There was one particularly bad week where on Wednesday, the home ortho program told me flat out they wouldn't match me, on Friday my dad called to say his cancer had reappeared, and the following Wednesday I got into a car accident and couldn't get my car fixed because I was on day 3 of working 12 days straight. So I was way off my game.

To top it all off, my chief (my PD's pet) and I got in a tiff that unnecessarily spiraled out of control.* To say I didn't make a good impression on my PD during that month is an incredible understatement. As such, I'm pleasantly surprised that the letter didn't turn out to be ruinous, and in fact, got me an interview.

I'm also very relieved to get the invitation from this particular program. I had become convinced that I had forgotten to apply there because it's listed under a different name on ERAS. I was beating myself up about overlooking them because they have a baller research opportunity for people who don't match, and I figured it'd be hard to explain that I wanted to do research with them when I didn't apply to their program in the first place. Luckily, that is not the case and not only did I apply there, but now I'm even interviewing for a PGY1 spot!

All in all, I'm incredibly happy that one program is willing to take a chance on me. My program is also being really good about giving me time off to travel, so not only do I get to go to the pre-interview dinner, but afterwards, I get to hang out with friends I have in the area. It'll be really nice to see old friends and get some time off from this general surgery nonsense, and hopefully recharge.

And I'm super excited that all my eggs aren't in one basket. I kinda sorta maybe have options. There's hope!

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* It started as me asking him to stop being an ass to me, but more importantly, to tell me when people were being admitted from the OR and to communicate their post-op plans. He really didn't appreciate me "telling him how to do his job" and was very vocal about it. Our conversation turned into a yelling match (mostly him yelling at me) and ended with me crying in my program director's office explaining everything that was going wrong in my life that week (as mentioned above).

The whole situation was no bueno and the timing couldn't have been any worse as I had just asked my program director to write me a letter of recommendation.

Feeling the need to be perfect

I realized that I've been so stressed for the past couple of years (ever since I started 3rd year in May 2016) because I've always felt I had to be at 100% every minute of every day. It's led to me beating myself up every time I get a pimp question wrong, worrying about making awesome plans for all 20+ of my patients, and just generally thinking I suck at life and my job. It's exhausting and completely unsustainable.

I've developed this weird mindset that I have only one chance to make a good first impression and there's no coming back from it. Therefore if I screw up on the first day or don't do things to my very high satisfaction, I assume that all is lost and there's nothing I can do to change it.

It started with 3rd year when I changed services nearly every week and every day was the first day of work. It continued through away rotations during fourth year for that very same reason yet even higher stakes. Because of my scores, I knew I needed to be the best med student / rotator they had ever met and it all began with that dreaded first impression that I thought I couldn't change.

Surprisingly, this same feeling has continued during my prelim year. I had hoped that by being in one place for a whole year, that pressure would disappear because I had a whole year to make good impressions and I could allow myself one "bad" day once in a while. But for some reason, it's persisted.

Part of it is the shortened time frame for everything...one month on ortho in July, needing a letter of recommendation from my PD by August, and switching services and chiefs every month. I've felt the pressure to be perfect at every turn because it's a new group of people and again, the stakes are super high (probably the highest they've ever been). Everyone has to love me on the first day, otherwise I have failed. It's a warped way to think of things and obviously has to change, because it's done a number on my mental health.

The problem with this way of thinking is that I can never be good enough in my own eyes and therefore I'm destined to "fail" (by my standards). I'm at a strong general surgery program, so all the interns have their shit together, which makes it hard to stand out among the super stars. In the back of my mind, I always knew I couldn't be top dog of the 15 or so interns in my class, but that doesn't mean I didn't put the pressure on myself to try to be the best. Of course, I had to be awesome on Day 1 and whenever I slipped up (as in intern inevitably does), I would get very upset and mad at myself, and would just spiral into self-deprecation, which would make me even more upset and the cycle would persist.

I realize I can't continue this way for the rest of the year because I have been absolutely miserable and it has affected every part of my life. I have to accept that I will make mistakes and that it's okay to be wrong. I don't have to be perfect because that ship sailed long ago and my fate is probably sealed at this program already.

What I can do is continue to improve throughout the year. I can go back to the basics of checking all my boxes, following up on labs and consults, and being agreeable and affable. I can give myself a break whenever I mess up or don't do something perfectly. I can accept the fact that I am not perfect and should not expect to be the best intern this department has ever had, because that's simply not possible.

My new goal should be to impress my bosses with my improvement and growth throughout the year. I won't strive for perfection, but I will strive for being solid and strong, and on an upward trajectory. Although rank lists are due in only a couple of months, I still have 6.5 more months with this program and I'm sure if I do all those things, I can get a solid letter at the end of the year for the next application cycle.

I keep wanting to throw in the towel because the first impressions have already been made and I've had a rough couple of months. But another way to get good evaluations is to show how much I've improved and that I can turn things around, and that should be what I strive to do with all the time I still have left here.

It's clear - I belong in the OR

I'm on a particularly hard rotation where I work even longer than usual hours, am writing way too many notes, and am running around several different hospitals all day. Being an intern, I never get into the OR.

But today was different. My fellow was in a super duper long case so I stuck around late to sign out to him. I eventually met him in the OR, where the patient started bleeding profusely through his dressings as we were moving him off the table. I held pressure to stop the gushing while they re-intubated, re-set up the room, and all that jazz. Once everything was under control, I asked the fellow if I could scrub while they re-opened the patient. The words came so naturally out of my mouth that I couldn't stop them. It was a no-brainer, literally. I am soooo glad I did because it lifted my mood instantaneously.

With ERAS opening up last week, I have been pretty bummed the past few days and have struggled to keep it together at work. I should be excited about this application cycle but instead, all those feelings of sadness from March and April keep creeping in. I'm terrified I won't match again and will have to settle for something else. I also feel incredibly incompetent at my job and keep screwing up, which my fellows and attendings have no qualms about pointing out. So it's been a rough few weeks.

For 1 hour in the OR today, though, even though I was doing the usual retracting, suctioning, and bovie-ing (read, nothing exciting), I was so content and even happy (gasp!). It didn't matter that I left the hospital at 11 pm or that I still had notes to write or that I truly hate (almost) everything about this current rotation, including the types of cases they do. I walked out of the hospital with a smile on my face and pep in my step simply because I got to scrub.

That's how I know I want to be a surgeon.

Next steps

The news is very belated but I SOAPed "successfully" a couple of weeks ago into a general surgery preliminary position. "Successfully" is an optimistic term because I can't bring myself to be too excited about a one-year position, and thus another year of uncertainty about my future. But I'm fortunate to have a job and to be moving forward with my life and career, so there's that.

I'm not even close to being over the fact that I didn't match ortho. Some days are better than others, but most days involve tears, and I'm not generally a crier. I'm also finding it hard to be optimistic about my future, at this point wondering if I can even manage to match general surgery next year and thus have any sort of career.

I've had a lot of lows in medical school and in life but I can safely say that this is the worst I've felt in a very long time. The little amount of confidence I had going into the match has completely evaporated and I've lost most of the hope I used to have in the medical establishment and more specifically, ortho program directors. I was told that crushing away rotations by busting my butt and being personable would help me secure a spot at a program, and I was too naive to believe that. In the end, I played the game wrong because no amount of hard work can overcome test scores from two years ago.*

I don't know what the future holds for me, and that's really unsettling. I vacillate between feelings of "I got this. I'm totally getting into ortho next year," to "Fuuuuuuuck. I don't think I even have a shot at general surgery." It doesn't help that the stats are not in my favor. The chairman at an ortho program I did an away at said I have a 3% chance of matching into ortho next year. That's very scary.

Everyone tells me I need a backup plan if I don't match again, with the most likely one being categorical general surgery. While there are parts of gen surg that I honestly do enjoy, I'm still repulsed at the thought of operating on bowels for 30+ years. I'm trying to keep an open mind because that seems like the most likely outcome and it's not a bad one. But I want ortho SO BADLY that not being able to do it is devastating.

I'm also somewhat regretting taking the prelim position. My Achilles heel was my Step 1 score and there's absolutely nothing I can change about that. I'm much better in person than on paper and in theory I'm really good at winning people over.** That's where the suggestion for the prelim position came into play. What I didn't think of was delaying graduation to do more away rotations and some research. It would've given me exposure to the program where I did research as well as my away programs. This way I'd have 4 chances to win people over instead of the single one I currently have.

I keep reminding myself that the prelim spot is the best path for me, but that doesn't say much considering it's the best option out of a bunch of really shitty options. On the plus side, with the prelim I have a whole year of the ortho department getting to know me instead of a month. I can prove without a doubt that I'd be an awesome resident (instead of a program having to extrapolate from my performance as a 4th year rotator). I can also slide into an ortho spot if any resident decides to quit. So there are positives...if it all works out. If I fail again, I'll always wonder, "What if?"

I wish I could end on a positive note but there's not much positivity in my life right now. My dean tried to cheer me up by saying I was ranked in the top 10 at my top program, but they just didn't go down that far this year. From talking to the PD, it sounds like they went to number 6 or 7 on their list (they take 5 residents) so I was 3-4 people away from matching. I know this information was meant to make me feel better, but it has the opposite effect. It hurts that much more knowing how close I was to being an orthopaedic surgeon and now I'm scrambling for any sort of career at all.

I know life isn't fair and in the end, I'll be alright. I'll have a good degree and I'll probably be able to get some sort of categorical residency position. But I (most likely) won't get to do what I set out for when I quit my previous career to go to medical school. It sucks that the dream I've had for 6+ years was crushed because of bad luck (and poor pre-clinical study skills).

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* This came out whinier than anticipated. I take full responsibility for not matching. I knew what I needed to do to be competitive (crush Step 1) and I didn't deliver. But ever since that test, I've worked really hard to do everything right, crushing Step 2, honoring most of my rotations, and kicking butt on my aways. I also know people with my scores who got terrible feedback after their aways ("none of the residents want to work with you") but managed to match because their orthopaedic surgeon father made a phone call for them. Like I said, life isn't fair and I knew this was coming. It doesn't make the outcome any easier to stomach.

** So I was told. See previous paragraph about losing faith in people.