FIRST DAY OF WORK! TOMORROW! EEEEEEE!

The day that I never thought would come is here- my first day of work as a MD!! Or least it will be here tomorrow. YIKES!!!!!!!!!!!!!!!!!!!!!!!! So many things are going through my mind. Despite all the years of education and experience behind me, I still have the same worries I had when I first started high school, college, and medical school (and probably kindergarten too): Will people like me? Will I be smart enough? What if I'm not ready? What if I'm the dumbest one there and everyone hates me?!

Most of the time when I think about starting work I am really very excited. Gosh how awesome- I'm going to my first choice residency program with my husband! And my program is just plain amazing: everyone is so welcoming and helpful and just plain awesome! And how cool- I get to do what I love doing everyday! Gosh and I'm going to be a doctor! Wow wow wow!

And then it's somewhere mid-wow that I realize it- shoot, this means I'm going to have all the responsibilities of a doctor. When something goes wrong with a patient, it means that I probably have made a mistake. When I'm in the operating room and a patient is hemorrhaging, I have to be the one to recognize the problem, stay calm, figure out how to fix it, know all the names of the surgical tools to help me fix it, and then fix things. OHMYGOSH!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! AM I READY FOR THIS?!!! How the heck do I do this?!!

I'm filled with a mixture of excitement, anxiety, enthusiasm, and fear. I know that life will never be the same again, but I'm not sure how I will change and what I will have to do in order to adapt. I know I'm going to have to work hard, harder than I've ever had to before. I know that I'm going to have more responsibility and less time than ever before. I also know that my husband will be just as busy if not more busy and we won't be able to help each other as much as we did in the past. I know that all these big changes are coming up fast and I'm not sure how well I will be able to adapt to these changes.

I'm going to try to do what I know I still do well- make goals and to-do lists- and hope that I have a spare moment every once in awhile to remind myself of the kind of physician and adult that I hope to be during (and despite?) my residency training.

Goals for myself during residency:

-Be friendly, smile tons, and be nice to EVERYONE, even if I'm post-call and/or stressed out.

-Try to read something in OBGYN literature every day. Goal: 30 mins daily.

-Find time for myself to do a small something only for myself everyday. I hope that this is running, but I recognize that after standing all day and staying awake all night, my legs might not feel like jogging.

-Ask for feedback frequently and don't take it personally when there is a lot to change

-Find time with my husband to go on dates

-Enjoy walking my dog every day that I'm able to

-Call home once a week

-Don't complain or let negative things take over

-Stay excited for my patients, work, and life

Ok that's enough for now! Now it's time for me to channel my nervous energy into tying surgical knots, remembering labor & delivery stuff, and finishing up errands before work tomorrow!!!!!!!!!!!!!

Catching up

So much has happened since I returned from the Dominican Republic. I eased back into a surreal world of urgent care clinic in a wealthy suburb back in the US (OMG who has disposable speculums with LED lights?!) and anxiously counted the days down to match day. On match day, the unbelievable happened- we matched at our first choice program! And after that, everything just speed up into a quick blur. Visits to our new city to check out housing in our new city, final wedding plans, selling our home, packing, selling things, enjoying our friends in Cleveland until we left...... and then in one quick week the wedding, graduation, packing up our home into a Penske truck, closing of our house, moving to St Louis, and leaving for our honeymoon. PHEW!

I'm happy to report that we have been in our new city for more than a week now with much less exciting things to do. We have been slowly unpacking, catching up with old friends and family, meeting new friends, figuring out our new places for takeout, stocking up the pantry, all smiley normal life things as we get settled into our new home.

Also, I changed my last name so I guess despite my blog name and enthusiasm four years ago, I never quite made it to Grob MD. :) I'm keeping the blog name because it still makes me smile. Even thought I have made the switch to the Dr prefix, it hardly feels like I deserve it yet. The road to becoming a physician is long and filled with lifelong learning. So even though I'm technically already Dr. G, I've still got much more to go before I feel like I'm done with my training. So I'm going to keep trying to blog whenever I have time and something I want to share. And I'm going to try to keep up that enthusiasm that I had about medicine and my profession that I had when I first started the blog and learning medicine.

On my way to match day ceremonies

I'm about to leave with David to go to our school's match day ceremonies. I can't believe 4 years of medical school have culminated in today. At noon we find out where we will be spending the next 5 years of our lives together.

OHMYGOSH!!

In the meantime, a good article describing what will be happening at our ceremony:
http://www.kevinmd.com/blog/2010/03/match-day-medical-school-celebrates.html

"Congratulations! You have matched."

Email at 11:55am today from NRMP (National Residency Match Program)
"Congratulations! You have matched.

Check the Match Site at https://services.nrmp.org/r3/ on Thursday, March 18, 2010, at 1:00 PM eastern time to find out where you matched. Because you are matched, you will not have access to any information about unfilled programs."

Short but deliciously priceless.


For those non-med readers, some explanation is warranted. After selecting the field that you are most interested in, you submit an application. A few months later, you start getting interview offers from hospitals in this field. Interviews start as early as October and some go into mid-February. Of course, you foot the bill for all that traveling so choose wisely! After the interview process, you get to rank your programs in your order of preference. This seems easy enough but with so many great programs across the country, it can be tricky, especially if you are matching with someone else (i.e. "Couples matching"). After submitting your rank list, you have to wait an agonizing few weeks to find out where you match. The NRMP computer algorithm matches up the rank lists of the hospitals (who rank the applicants) and the candidates (who rank their choice of hospitals) so that both parties get the highest match.

Today, we found out that we matched. Horray! This seems a bit strange because this means we have legally signed a contract to a program because we have matched... and yet we have no idea where that program is. Now, we wait until Thursday to find out where we will be the next few years in our life!

I hope that this brief description helps you understand a bit more about the residency match and why it's such a stressful/exciting time in our lives! I can't wait to find out where I will be! In the meantime, I'm counting down the hours until Thursday at noon and trying to stay as busy as possible to stay sane. :)

Become a follower!

Hi everyone!

I'm happily back in the US! I will be uploading some of my favorite pictures onto the blog later this week. In the meantime, I hope you like the new design of the blog and some of the new features. Please click on the link on the right to become a follower of my blog! I'd love to know who is reading my blog! :)

USA! USA! USA!

I feel like I’m making up for missing the Olympics this year with my huge enthusiasm to return home! USA! USA! USA! :) I couldn’t be more excited to go back!

I am a bit surprised by the things I have missed the most from home during my time aboard. Of course, I missed David, my parents, and friends and family. I also really missed my awesome pug Olive and all her snoring and excitement. I want a huge plate of stir-fry from Stir Crazy (particularly odd considering I don’t really eat there often and haven’t in a few years). I missed running by myself with my ipod and not worrying about safety. I missed my awesome gym back in Cleveland. I missed having hot water to bathe in. I miss hot chocolate warming me up on a cold day.

Some things will be harder to say goodbye than others in the DR. I’m going to miss meeting new people every day. I’m going to miss speaking Spanish all the time. I’m going to miss the super salty and super sweet food. I’m going to crave rice and beans… and yucca, oh yucca! I’m going to miss how inexpensive life is here. I’m going to miss the amazing thick Dominican coffee. I’m going to miss my new friends. I’m going to miss the sunshine and warm weather. I’m going to miss my siestas. I’m going to miss the music and livelihood of everyday Dominican life.

It’s been a fantastic month but I’m ready for next adventures coming up in the next few months-finding out where we match, planning my life for the next 5 years after we find out where we match, finishing training for my marathon as best as I can (still not sure if I will make it!), wedding planning, lots of traveling for wedding stuff, getting married, graduation, honeymoon, and starting residency this summer.

The adventures I’ve had here

My goal in coming to the DR for a month was simple- I wanted a new experience. I wanted to learn about medicine abroad. I wanted to improve my Spanish. But mostly, I wanted an adventure. Below is a list of my favorite adventures this month. Don’t worry, pictures are coming later in the week.

-Driving in the DR and living to write about it

-Climbing up and jumping off 27 waterfalls with David

-Take a crowded gua-gua (local minivan that fits >20 people = bus system here) to the end of the road in Las Galeras by myself. Oh and there were chickens on the gua-gua

-Almost delivering an infant in the dark during a power outage

-Learning how to surf

-Coaching a new Haitian mom during her delivery- yep, I learned some Creole from my Spanish-speaking colleagues

-Seeing an enormous whale shark on my humpback whale-watching trip

-Sleeping in a thatched-roof cabana during a thunderstorm

-Daily runs along the ocean-front, some views better than others

-Riding a motoconcho home at 3am (sorry Mom!)

-Meeting awesome new friends in the hostel

-Becoming dedicated to blogging and finding a bunch of new blogs to follow

On being called a gringa

To be honest, my last week in the DR was a bit annoying. After working and living in the DR for a month, I started feeling more comfortable with the language as well as daily life here. My expectations changed. I guess the fact that my expectations changed shows how much progress I made but I can’t help but still be a little irritated by my last week abroad.

Prices in the DR are never really set. Everyone haggles prices and the starting point is different based on a number of factors (how rich you look, what time of day it is, rain, etc). As someone living in this country by herself with super pale skin (thanks med school in Cleveland!) and super blonde hair, I always got charged higher prices than locals. At first, it really didn’t bother me. Who cares? It’s only like US $0.50… why bother getting upset about it? After a few weeks of living here, however, I got better at calling people out and knowing how much things should really be costing. When David came to visit me, we spoke a lot of English to each other. Locals heard that we spoke English and charged us ridiculously high prices for everything. I felt so cheated out of money! And it felt so unfair to me. I didn’t feel like a tourist anymore and it bothered me that I was being treated like one.

Someone at work called me a gringa during my last week. I am not a gringa- a negative word used to describe outsiders, tourists, people who don’t take the time to understand the place they are visiting. I took it really personally. It was a huge insult to me. I have worked so hard to improve my Spanish, learn about their culture, live their life, and all on borrowed money. I finally was feeling like I made progress during my month here until that person called me a gringa.

Money was also a big issue of frustration for me this week. Any Dominican you ask would jump at the chance to go to the US (especially NYC where there is a large Dominican population). And for whatever the historical reasons are, people here assumed I was wealthy because I am from the US. As a medical student with student loans up to my ears and a nice minimum wage residency in my future, I definitely don’t feel like I have any money. It bothered me that co-workers asked me if I would give them my $150 stethoscope or asked me to buy textbooks for them with my credit card. It bothered me that people I considered friends here were suddenly wanting money from me. I felt so used.

I talked to several Peace Corps workers here who told me that they had similar gripes about living here in the DR. I’m glad that I wasn’t the only one to feel this way. I’m a bit disappointed that my last days here in the DR were a bit jaded. That said, I still learned a lot about myself, medicine, and the person I hope to be one day during this month abroad. I always knew there would be hard days. I’ll count myself lucky that my most frustrating days occurred when home was just around the corner.

Partograms

I recently visited 21 hospitals during interview season for residency. I had a long list of criteria that I made sure to evaluate each hospital and each residency program with so that I would be able to fairly come to terms with my rank list and the couples match process. One of the things that I looked at each hospital was their central monitoring system for labor & delivery. What computer system did they use to watch live tracing for contractions and fetal heart tones? Are the computers and the systems used the most up to date possible? Oh look! Leather chairs in one of the central continuous monitoring rooms! How comfy!

I can tease myself a bit at how I evaluated central monitoring rooms in the US because for the past month I have been using partograms. In medical school, I never learned what a partogram was because we never used it in the US. Instead, I spent countless hours learning about how to read tocometer and fetal heart tone patterns. This month, I learned that pretty much every country except the US uses a partogram. A partogram is a graphical representation of labor. The one used by the hospital I worked at in the DR and recommended the World Health Organization includes information about cervical dilation measurement, fetal station, counting the number of uterine contractions, and listening fetal heart tones. After obtaining this data, the physician plots the points in order to graph the progress in labor. Any deviation from a normal slope of labor was cause for concern. My first day in labor and delivery I was in disbelief- THIS is how you monitor patients here?? How can I possibly know whether there is fetal distress without looking at continuous live tracings?? Where is the fancy flat screen TV?! Where is my portable bedside ultrasound?

After a month of working abroad, I’m a believer. You CAN monitor a patient’s labor without a computer in sight. During my month here, I learned how to be a better clinician. I learned how to listen to fetal heart tones with my stethoscope and plot this value on a partogram. I stopped relying on bedside ultrasounds and used my hands to determine the position of the fetus each and every time. I didn’t have an attending to double check my steps, so I had to grow up and confidently assert my cervical checks on my own. I learned how to read a partogram and how to know when trouble was occurring.

How accurate are partograms, really? Can you really know enough about how the fetus is doing by just listening and plotting on a chart? I looked into this today. I hope to do a more comprehensive search on this topic once I return home and have access to my school’s internet connection and all the free journals we get access to! In the meantime, here is my best attempt at answering a question with evidence-based medicine here in the DR on my own.

Partograms were first introduced by Friedman (1) in the 1950s, which was later improved by Philpott and Castle (172) by the addition of “action” and “alert” lines to the graph (2) which alert the clinician to fetal well-being and labor progress. An alert line represents the slowest 10% of a primigravida’s labor progress. An action line is placed 2-4 hours after the alert line to prompt management of slow labor progress. Current partograms recommended by the World Health Organization (WHO) are available on pre-printed paper that the clinician can fill in with the appropriate data points (3) like the one seen below. They are inexpensive and relatively easy ways to monitor care in obstetrics.

Although world organizations such as the WHO have recognized the partogram as an incredible advance in obstetrical care, many practioners in high-income countries question its effectiveness. I looked into a Cochrane Review article on partograms (4) to help answer my question. This review compiled data from five randomized controlled trials involving >6000 women in spontaneous labor at term. They found that there was no evidence that using a partogram had any effect on aspects of labor care or maternal or fetal primary or secondary outcomes. They looked at clinical outcomes such as section rate, duration of labor, artificial rupture of membranes, APGAR scores and found no significant difference in any of these clinical outcomes with and without the use of partograms. They suggested that partograms may be more effective in countries with limited healthcare resources which, importantly, were not well-represented in this review.

In under-resourced settings, such as where I worked for the past month, partograms help keep vigilance for adverse obstetric outcomes. One case–control study from Pakistan found the partogram reduced the frequency of need to augmentlabor, postpartum hemorrhage, ruptured uterus, sepsis, and perinatal and maternal morbidity and mortality (5). This study does not provide conclusive evidence to change established practice but is a nice look into the use of partograms in under-sourced settings. An article from Lancet in 1992 (6) found the following data: neonatal resuscitation rates and stillbirths were 9.8% higher in women who crossed the alert line and crossing the alert line had a sensitivity of 27%, a specificity of 93%, and a positive predictive value of 17% for neonatal resuscitation. The results show the usefulness and efficacy of the partogram as a method for medical intervention.

My conclusions: partograms can and do work anywhere in the world so it's good to know how to use them, but should not in my opinion be used to replace continuous monitoring if available. Also, I will be happy wherever I match, regardless of what the central monitoring room looks like. :)
1. Friedman E. Graphic analysis of labour. American Journal of Obstetrics and Gynecology 1954;68:1568-75.
2. Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. Journal of Obstetrics and Gynaecology of the British Commonwealth 1972;79:592-598
3. WHO. World Health Organization partograph in management of labour. The Lancet 1994; 343:1399-1404.
4. Lavender T, Hart A, Symth RMD. Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database of systemic Review 2008, issue 4. Art No.:CD005461. DOI 10.1002/14651858. CD 005461.pub
5. Javed I, Bhutta S, Shoaib T. Role of partogram in preventing prolonged labour. Journal of the Pakistan Medical Association 2007;57(8): 408-411.
6.Dujardin B, De Schampheleire I, Sene H, and F Ndiaye. Value of the aleart and action lines on the partogram. Lancet. 1992, 30; 339 (8805): 1336-8.
7. Soni BL. Effect of partogram use on outcomes for women in spontaneous labour at term: RHL commentary (last revised: 1 June 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.