Tag: ms4

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!

Case Presentation 1

Okay ya’ll.

I know it’s been a hot minute. Sorry about that. BUT! I’ve seen the results of my polls and I will try to make more of these. This is my first attempt at adding quizzes to posts, so hopefully it is helpful in learning what the next steps are, what to order, and to help expand your differentials. I hope you learn you some things. THIS IS LONG. There are multiple things in here to learn/quiz about.

Also, it forces me to learn and re-learn this as well. Have fun!

Case:

23 y/o Female presents to the emergency room for severe left sided flank pain onset 3 hours ago. She was at home studying when her pain began. It is currently rated a “10/10”, is sharp, and feels like it radiates down to her L abdomen. She started having nausea and vomiting an hour ago which prompted her to come into the ED. No reported fevers. She denies any recent fall or trauma to the area. She has had similar symptoms previously.

PMHx: Kidney stones in the past, otherwise relatively healthy.

PSHx: tonsillectomy and adenoidectomy at age 5.

QUIZ START

PE:

Vitals: HR is 107 BPM. RR is 14. Pulse ox is 98% on RA. Temp is 36.4’C.

General: In moderate distress due to pain. Walking around the room unable to sit still.

CV: Heart is tachycardic, but regular rhythm with normal S1 & S2. Radial pulses are 2+ and equal bilaterally.

Resp: Lungs are near to auscultation bilaterally. In no respiratory distress.

Abdomen: soft, non-distended. +CVA tenderness to left, none to right. Minimal tenderness to LLQ to palpation. No tympany. Bowel sounds present in all 4 quadrants.

Neuro: Alert and Oriented x3. CN II-XII grossly intact. All 4 extremities are neurovascularly intact with normal motor and sensation.

Let’s pause and take a look at things.

Well, let’s talk.

We have a young female, with flank pain, nausea, and vomiting who has had similar symptoms in the past. She has a family history of kidney stones. Otherwise, she is relatively healthy. On exam, she is afebrile but tachycardic, likely from pain. She has + CVA tenderness to her left side and minimal tenderness to her LLQ. Otherwise, her exam is normal.

We have an inkling that this is kidney stones. And in simple terms, we could consider that since this is the likely cause of her symptoms, we can do a workup and make sure there are no other concerning findings.

QUIZ START

Results:

CBC showed an elevated WBC at 13.3, hemoglobin at 14, and platelets at 300,00.

BMP showed normal electrolytes except for a Ca of 15, and a creatinine of 2.0.

HCG was negative for pregnancy.

UA was negative for bacteria, WBC’s, leukocyte esterase, or nitrates. It was positive for blood.

CT showed the following:

Left ureteral obstructing calculi seen with severe hydronephrosis present. (picture from radiopaedia.org)

Remainder of the CT results mentioned another stone in the UPJ, several in the bladder and not seen on the above image, but several renal calculi in bilateral kidneys. Hydronephrosis is present on the left. No other pelvic findings. 

Okay, so I did you a solid and tried to wean the important information for you. I only gave you what you need to know in order to make the next steps.

*Note* If you need help interpreting what the above means, let me help you. White count can be elevated from infection, inflammation, and stress. In general, infections tend to spike white counts. In something like severe sepsis, it is not uncommon to see a WBC of 20,000. But if it is slightly bumped (as in this case), it is likely due to inflammation/stress on the body. The hemoglobin and platelets are good here. If hemoglobin was down, we would want to look for bleeding. Same with platelets. Although platelets can be normal with a low hemoglobin, platelets can also be low with a normal hemoglobin indicating a clotting issue using up the platelets or issue making platelets.

For BMP, you need to know that creatinine tells us kidney function. In this case, her kidneys are not happy. Not happy kidneys = not good. She is young and healthy, so with some fluids and finding out the problem/fixing it, her kidneys should go back to normal. Just be aware that a bump in creatinine means kidney injury. Trending this number is important. Obviously, a high calcium is easy to spot. Well, an out of whack electrolyte in general is easy to spot.

As for the UA, we are worried about an infected stone. If you see stones AND a positive urinalysis, we worried. Infected stones involve more treatment and much more observation. We want to keep a closer watch. But she is afebrile, and UA is negative. So this is good stuff. Also, look for epithelial cells. If you see epithelial cells (like more than 0-1) the sample is contaminated. For positive/infected UA, your biggest answer is actually in the nitrates. Nitrate positive urine tells us more than bacteria or WBC. A true infected sample (like really bad UTI) would have all 3 likely. But if you are unsure, nitrate + will always yield a + UA. Whereas bacteria present can be falsely leading as if it is contaminated with skin cells (epithelial cells) then bacteria will be present. SO DON’T JUST LOOK AT THE BACTERIA PEOPLE.

Stop here and think about what all this information is pushing us towards.

We now know she has kidney stones, likely the cause of her pain given the hydronephrosis. But she has MANY kidney stones. Normal dehydration or medications likely wouldn’t cause this many at one time, at least not passing all at once. It is normal to have several in the kidney, but they may never leave the kidney or they may dissolve in the kidney. In this instance, many have passed.

Also, she has no infected stone which is good based on the UA results and being afebrile.

However, her calcium is really high. Oh, and she has renal injury based on her creatinine numbers.

You go back to ask some more history…

After further questioning, she tells you that she had started having pain days ago, but since it resolved she didn’t think much of it until tonight when symptoms re-appeared and she started vomiting. She has also been fatigued “for a while” but feels it is stress related. She is usually constipated “all the time” but states this is relatively normal for her and has intermittent myalgias and bone pain.

QUIZ START

The following labs you ordered returned:

PTH: Elevated

Phosphorus: decreased

Vit D: level within normal limits.

QUIZ START

Medical Decision Making (Try to do this on your own first!):

This is a 23 y/o F who presented to the ED for severe L sided flank pain with N/V with a history of kidney stones. Upon further investigation, she had reported similar pain for days, in addition to chronic symptoms of constipation, fatigue, and myalgias/bone pain. She has a family history of kidney stones. On exam, she is afebrile, with + CVA tenderness to her L and LLQ pain. Studies showed multiple stones present in the GU system with hydronephrosis, but no urinary infection. Her WBC is slightly elevated, likely due to pain and stress response. Her calcium and PTH were elevated. Her kidney function was elevated as well, likely multifactorial with stones, hydronephrosis, and hypercalcemia. She was given pain medication, and started on IVF, calcitonin, and bisphosphonates. She will be admitted for further management to medicine with consult to urology.

Let’s talk about causes of hyperparathyroidism!

Hyperparathyroidism can be caused from many reasons (see images below for difference between the types). In layman’s terms, PTH from the parathyroids causes an increase in calcium resorption and circulation in the body. Whereas calcitonin decreases circulating calcitonin. I’ve added added a handy dandy brief pic/flow chart on how PTH works. It’s the basics, but should help jog your memory!

Primary hyperthyroidism is a problem with the main gland itself. In this case, that would be the parathyroid gland. Something regarding the gland itself is causing the issue. Such as hyperplasia (enlarged), adenoma (benign tumor), or carcinoma (cancer/something like small cell lung carcinoma which secretes PTHrp or parathyroid hormone-related protein which mimics PTH in the body). Long story short, the cancer creates a peptide similar to PTH, and it circulates in the body mimicking things and the body responds as if it were PTH. But that’s a different discussion.

Secondary is as it sounds; the cause is secondary or outside of the gland itself. Can be from many causes. Renal failure is probably the biggest one. Basically, another part of the chain above is not working properly. Due to this, the body increases PTH to try to increase the calcium levels that the body desperately needs.

There is also tertiary. Long story short, this is basically also due to renal failure, but long term effects of it.

So in her case, she had primary hyperparathyroidism. We know this because we also checked her phosphorus and vitamin D levels. Sure, we could say her kidneys caused it, but this is less likely given her young age and no prior medical problems. We would have to trend her creatinine to know for sure, but the above two levels may also be normal in this state.

While admitted…

Urology saw the patient to place a ureteral stent to her left ureter to help pass her obstructed stone. This will also help with her hydronephrosis.

As an astute med student now looking at the case, you think endocrine should be involved. As a healthy young woman with primary hyperparathyroidism and a family history of a “syndrome”, but no other clues, you are considering a neuroendocrine cause. You think it is MEN syndrome, particularly MEN1.

QUIZ START

MEN Syndromes: There are 3 types. They are genetic mutations and run in families. Typically, you are diagnosed when a child or when young as you present with symptoms by this point. (I’ve changed this case a bit from what I actually saw hence why this patient is older here). Tumors develop on multiple endocrine glands and cause excess of hormones. Tumors can be benign or cancerous and it is important to check other endocrine glands as well. Although there is an easy chart/way to remember MEN syndromes for testing purposes on exams, in real life there is more cross-over between the endocrine glands.

Back to the case…

Because of the concern for MEN1, she also underwent imaging studies to evaluate her pituitary gland, parathyroids, and pancreas.

CT brain showed no tumors or hyperplasia of the pituitary gland.

CT abdomen/pelvis showed no abnormal findings.

Thankfully in our case, there are no other glands affected at this time. We would need to do a genetic screen on her and her family members to confirm MEN syndrome type 1, but that can be done at a later time.

Treatment for hyperparathyroidism is as follows:

  • Surgical therapy is the most common/gold standard. So a parathyroidectomy would need to be done and then the patient would need to be on hormone replacement with her calcium and vitamin D levels monitored.
  • Medically includes hydration and exercise, along with moderating calcium and vitamin D intake. Although this is not recommended unless the patient is not a surgical candidate.

At this point, I’m not going to go into the whole surgical aspect and the actual surgery portion for this case. You are welcome to look up a total versus a subtotal parathyroidectomy though!

Well. That was long. And also hard to actually create. I know it isn’t amazeballs by any means but I do hope it helped you figure out how you should be thinking! Until next time. Cheers!