Admission & Orders

Ugh, poop on this.
Admission orders is one of those things where you need to know what to put in, but because every hospital is different there will be different important things to add. Also, who adds what changes based on what type of hospital you are in. Sometimes the residents do all of it. Sometimes the attending does part of it and the residents do the rest. Sometimes the ED doctors do some of them. It really all depends. But as a resident, you need to know what is important on what to add during admission orders.

First things First…

You need to accept the patient. Whether your attending does that for you or not doesn’t matter. Communicating with the ED doctors about accepting or declining admission is important. Once you have established the admission (or observation) then you can move forward with the next steps.

Then you do your regular chart review of a new patient. Write down what you need to know about the patient from what is in the ED note and any past/prior visits. You’ll want vitals, what was done/found, what meds were given, etc.

Write down what you want to ask the patient that you don’t see in the chart review to help clarify as well. Then go and see the patient. You can start putting in some orders before hand, but mostly you’ll want to see the patient first.

Orders

After seeing the patient you need to put in orders. You can do this prior to staffing with your attending or you can wait until after. If you wait, I suggest calling right away.

Here are 3 mnemonics to help remember orders:

I personally go off the headers under the orders tab in MEDITECH to remember. Since I can’t find an effective picture online OR take a decent photo from my computer screen (my stupid work computer won’t let me screenshot UGH), I’ll write the order below.

  • Consults
  • Diet- regular, heart healthy, carb controlled (for diabetics), renal, full liquids, clear liquids, NPO, etc
  • Labs- you’ll need to order what other tests you would like to investigate with AND maintenance labs for the following day (i.e. H/H vs CBC, BMP vs just an electrolyte).
  • Meds- what you are ordering during their inpatient stay
  • Nursing orders- includes SCD’s (compression devices/VTE prophylaxis), vitals, activity, shower privileges, home med lists, fall or seizure precautions, and any treatment clarifications
  • Radiology- any and all imaging studies
  • Rehab- this is for your PT, OT, and ST orders. If patient is above 65 they automatically should be getting at least PT. If your patient is struggling with household tasks or fine motor movements OT should be ordered.
  • Respiratory therapy- Your respiratory medications will be ordered under medications. But here is for oxygen monitoring/weaning, or suctioning, etc.
  • Med Req- I always do this last. I usually wait until the nurses are able to obtain the patient’s home medication list, review it, and place it in the chart. Then I can go in and re-order the medications that they take from home or hold what I don’t want them taking. If the patient happens to have their medication list or the bottles of medications with them when I am admitting them, I will just place this information in myself.
  • Also during admissions, I will update any allergies, PMHx, SHx, Family Hx, and Social Hx into the chart.
  • Oh, and don’t forget to add code status if that is your job to obtain and place! At my institution it is the admitting physician’s job (aka admitting resident) to verify with the patient and place in the order.

So yes, it can be a lot to remember. Some programs have prompts for you to help you remember. After a while you just remember what to do. At this point (7 months in) I remember most of what I need to. Anything that I forget I will usually remember after starting to type my note.

I know this is a short post and not the most helpful thing, but I do hope it helps give you some clarification. Remember, this will come with time and repetition. IF you are a medical student trying to learn what you need to put under plans, learning these orders and placing them under your diagnosis headings can be helpful in teaching you important management.

Cheers!

Not Matching Into Residency

What up?!?

This is normally a pretty touchy subject for students. Match day is stressful, and everybody is terrified about not matching. But as you know, I don’t shy away from touchy. Also, this actually isn’t that painful for me.

What are you talking about Joyce?

Well well well my chillens…. I didn’t match. Nope. I didn’t match at all. Nada. Big fat didn’t make the cut first round.

Alas… I’ll forever be the kid picked last on the playground!

JK. Well, it’s true I did not match. Although I interviewed very well, I only had 3 interviews in general surgery. And at most of those programs, they had very few slots available despite all 3 being D.O. programs or accepting mostly D.O. candidates.

So my chances were very slim to begin with. Now, that didn’t stop me from being hopeful. But again, I’m very much a believer that you are meant to be where you are led, even if it isn’t the path you chose for yourself. So I’m letting the universe guide my wayward soul to wherever it needs to be.

WITH that being said, I had “5” sub-I’s. Although several of them I was too sick mentally and physically to really show up for. But also, on those rotations interview season was closed or practically closed so I didn’t really care as much since they weren’t going to give me an interview. But I did notice that after choosing general surgery for fourth year, my mental health greatly declined.

Again, a touchy subject for people. I was excited at first to do surgery, however I slowly started to feel like I lost part of my soul in 4th year. I had a very hard time getting up and going to work; which if I was super excited to do I would want to get up and go. But I had a really hard time with my mental health and struggling to feel like I was smart enough, capable enough, independent enough, worth it, confident enough, etc. Like I’m talking it was a good day if I left my room to eat or shower. I was in a state.

And so my downward spiral began. And instead of getting better at each new location or as the year went on, it got worse. I thought it was just severe burn out and I needed a vacation. But because of the way things have panned out, I’m starting to think that maybe because I feel like I lost part of myself and that maybe, surgery just isn’t really for me.

I thoroughly enjoy being in the OR and using my hands. It’s hella fun. However, the lifestyle takes a certain type of person. And quite frankly, I’ve had a hard enough life in certain aspects (won’t get into that here) and maybe, just maybe, I sub-consciously need a break. If I would have been at this crossroads when I was younger, truthfully I would have still had a full enough tank to tackle this. But given where I am currently in life, I clearly needed some divine intervention. Obviously the spirits, angels, and my ancestors were NOT a fan of how this season of my life was shaping up and decided to step in and do an intervention. AKA, me not matching.

It’s aiight. I get it. I wouldn’t wanna watch my favorite character tank either.

And so here I am, in the evening of the day that I found out I didn’t match. So what are the next steps?

SOAPing steps

So, you sign into the NRMP site (match site) that Monday of Match Week. There are helpful videos on the NRMP site explaining how the SOAP will go and the timeline of everything. They also walk you through things on the ERAS site. At exactly 9am ET, you find out if you match or not. If you didn’t match, your school was sent a list of students from that school that didn’t match earlier in the morning to help them prep contacting you and assisting you, supporting you, etc. The site will also email you saying if you matched or not.

This is technically the “scramble” part of the match. It was renamed the acronym SOAP several years ago. However personally, it makes more sense to call what happens after the SOAP the scramble in my humble opinion…

If it says “sorry, you did not match” you are automatically signed up for SOAP if you are eligible. Since you were eligible when you applied for the match the first time around you should be eligible for SOAP. This year, we had exactly 1 hour from NRMP releasing if we matched or not and access to start re-applying to open slots on ERAS. As soon as you find out if you match or not, you can look at the list of “unfilled positions” under the SOAP tab up top. It basically shows you how many specialties have unfilled positions, how many are categorical, how many are preliminary, how many are for those who did a transitional year/prelim year and are applying their second year of residency, etc. You do the clicky clicky where you want and it will pull up a PDF list of all the sites open for that specialty.

I then used FREIDA to look up these programs. For surgery at least, there are LARGE hospitals that will have several prelim spots. Like I’m talking 12-25 spots. They usually always have space for prelims. However, they will work you like a dog and likely not take you into their program the following year (so I have been told by other surgical prelims). So, take that with a grain of salt when applying. So I used FREIDA to help determine how many prelim spots programs had compared to how many categorical spots they had. If there was a large portion of prelims compared to categorical spots, then I likely wouldn’t match to that program after my prelim year. I also used it to find out if they tended to take D.O.’s, if they took COMLEX scores, and percentage of D.O.’s in that program, etc. If they were MD biased or didn’t take into account COMLEX, I passed.

You get 45 application slots on ERAS. You do NOT have to use all 45 slots. You search the programs that you want to apply to on ERAS and apply just like you did for residency the first time around. The difference is the site will tell you if you click on something that you can’t apply for (like a categorical that isn’t available or a program that isn’t on the SOAP list). You don’t have to spend any additional money on applying during SOAP. It is $0.00 to apply during this time. Make sure to assign everything and that there is a green notification next to each attachment for your application. Just like the first time around; your LOR’s, COMLEX/STEP scores, personal statement, photo, all of that need to have a green notification next to it for each program. If they do not, your application is not technically complete.

I ended up applying to 24 surgical prelim spots and 2 unfilled categorical spots for general surgery. There was an additional categorical spot in Michigan, however I know that hospital and have heard from many DO students that they turn their nose up to DO’s and don’t even offer them sub-I’s. So you bet your ass I wasn’t going going to waste a spot on that sorry excuse of a program. (Hair flip, thank you!)

THEN, after a long discussion with my significant other and some soul searching (I was honestly surprised that I hadn’t shed a tear at all at this point) I decided that maybe surgery wasn’t for me. I took most of the day to contemplate if I wanted to do this or not, but I decided to go for a transitional year spot as well.

I did this with the following thinking: If I ended up in a surgical prelim, I would continue to pursue surgery. I spent all of 4th year doing surgery thinking that this was for me. If I ended up with a transitional year, I would look into a medicine specialty that I overlooked before.

EITHER WAY, I would be getting valuable experience as an intern. I hope at this point that this will help boost my confidence and the repetition in knowledge to help me be a better doctor. Because right meow I do not feel like I know or remember anything. I can take a mean history and an okay physical, but the rest of the shit I’m supposed to know how to do is shaky at best. So this next year will be helpful.

I could have applied straight into a medicine program; however I didn’t have any LOR’s ready and I really wasn’t sure if I wanted to commit to something in medicine yet. I want to explore all that shit and then make an educated decision. It is my future after all.

So, the remainder of my 45 slots went to transitional positions around the U.S. I picked programs in states/areas that I wouldn’t mind living. I wasn’t going to be worried right now on if I would have to move again at the end of next year. That is a next year problem for next year Joyce. She can figure it out then.

Tuesday and Wednesday of SOAP Week:

Interviews:

So these two days are set aside for programs to contact you for interviews. You are not allowed to contact a program during SOAP before they contact you. It is a violation and you will basically be pulled from the SOAP process if you do so. Programs are allowed to look at applicants at 8 am on Tuesday of Match week. Some people (according to reddit) started to receive a call by the afternoon or evening. A lot of people didn’t hear anything my year.

During Tuesday I was still in good spirits. I was able to keep myself busy. I spoke with friends and family. Took walks. Read books. Tried to keep a decent schedule. I went on a long drive (I’m in Arizona for a rotation) and enjoyed the weather.

Wednesday is when some people started getting interviews. I was told by my school that surgical programs typically called in the evenings. However I got nothing. Nada. No interviews.

Surprisingly I was still okay. I had a little bit of anxiety and that pit/hollow feeling in my chest but was able to still be busy and productive throughout the day.

Thursday of SOAP Week:

SOAPing rounds:

You can look on the website, but there are 4 rounds. 9 EST, 12 EST, 3 EST, and 6 EST. Or at least these were the times set for the rounds for my year. Since I was in AZ, my day started at 6 am. The way it works, is you are given offers at each round. You can either accept or reject offers. It is HIGHLY recommended you accept whatever is given to you. Once you reject an offer you are not offered it again.

My first two rounds I got nothing. At this point I actually had a little breakdown. Truthfully I’m surprised I lasted so long without doing so. But I started to get anxious and question life and you know the whole story because I’m dramatic. I be cursing out the universe. Ya know, normal dramatic Joyce things over here.

40 minutes before the next round I got a phone interview. I believe it went well and I was nervous that it was too close to the next round of SOAP offers but I was also super excited that I even got an interview. Given that I had heard nothing all week.

Thankfully, I was offered a spot at the place that interviewed me and I will be doing a transitional year!

IF YOU DID NOT SOAP, you can either try contacting programs directly to see about open spots or do a research year. Some programs don’t meet the cutoff for SOAP, etc so a list of programs that weren’t available before may be available after SOAP rounds finish. Those are the programs you can reach out too. This varies from year to year.

FRIDAY of SOAP WEEK:

MATCH DAY!!! This is where you find out where you matched. If you were lucky to find out you matched on Monday, then Friday is when you find out where you matched. If you had to SOAP, you already know where you matched from the SOAP process and get to celebrate with your classmates. Typically this is a day of celebration for everyone who matched.

Recommendations:

Well first and foremost- if you need to take time to process not matching do so. Give yourself an allotted time to grieve if you need to, or just settle and accept what happened. Likely, there wasn’t anything additional you could have done to change the outcome. I bet in most cases that you are being nudged to either look at your current position and reflect; either re-address and go a different route, or re-assess what you overlooked. Maybe you didn’t apply to enough? Maybe you didn’t get enough interviews? Maybe your LOR’s weren’t as strong as you liked or your personal statement could have been better.

Two, make sure to research the places you are SOAPing/applying too. Also, make a list of the places you applied. That way when they call you for an interview, you can look up what program it is, where it is, and what speciality it is for (if you applied to more than one speciality during the SOAP rounds).

Three, you can absolutely draft an email for the scramble/SOAP if you need too. Maybe it will help prep you. You may even need to actually use that email. However, things have changed and this current year you were not allowed to contact any programs until they contacted you. If you feel you need to send an email to that program after an interview with them, then having a drafted email with all your information, personal statement, MSPE, etc linked for easy access.

Four, get yourself some patience. There is absolutely nothing you can do to hurry shit up. Programs will contact you on their terms on their time IF they contact you for interviews. Programs don’t get to see anything of yours until Tuesday morning, meaning most places don’t call until that afternoon or the next day. Make sure you have things to help keep you calm and distracted; you’ll need it.

What’s Next?

Well, I know I will be moving to Florida for my 1 year transitional intern year. After that I will have to re-apply. I will let ya’ll know (when I have time to write) how that works, how re-applying has been, etc.

Congratulations to all those who matched this year! Congratulations to those who SOAPed! And for those who did not, do not give up. You didn’t get to becoming a physician by stopping when shit hit the fan. It’s just a bump in your road. Pick yourself back up and don’t let someone tell you no. At least that’s always worked for me 🙂

Cheers!