medical school

my theory about french rents is that there isnt the same culture of compensation in france that there is in london or ny or the bay area, where the high end of the market exerts an upward pressure on rents. also that french rent controls are better/exist makes sense too

that's pretty interesting I never thought about it like that. also having a pretty uniform architecture makes a building in the 16th look pretty similar on the outside to lots of 'poorer' neighborhoods + everywhere is pretty convenient - so you can def live in an 'upper class' part of the city but it's not as drastic a lifestyle thing the west village vs. the bronx. it's harder to be conspicuous even if you wanna be when everyone lives in pretty buildings and poor people dress well.

+ the rich people just aren't as rich

okay, so they make $160,000+ but is this net or gross or what? don't they have office expenses and insurance to pay, etc?
i don't know, i've just heard a lot of Canadian doctors talking about how when all is said and done re: expenses, they don't make "that much" money - like they are doing fine but aren't rich or anything, plus are overworked. but that is canada...

from what i've read, the richest doctors in canada are def plastic surgeons, oral & maxillofacial surgeons, dentists, whoever isn't covered under govt-funded health care system. but then, i knew someone in university whose dad is a gastroenterologist and whose mom didn't work and they had a sweet house on the beach, so...

I work in the Canadian medical industry and I'm friends with a buncha young doctors. Even the ones straight outta school are netting almost 100k a year and they don't have practices (hospitalists) so they have no overhead expenses of running one. I think Canadians just like to bitch.

I am walking away with somewhere between 200,000 and 300,000 in debt next year. I had 0 undergrad debt, actually turned a small profit on grad school, but went to a private university medical school in a city with a high cost of living. I interviewed at a few University of California schools (which would have been probably about $20,000 a year cheaper tuition-wise since I was a California resident, though San Diego, Irvine, and LA are not entirely dissimilar cost-of-living wise from DC; San Francisco is notably worse, but I didn't apply there). I also interviewed at Wake Forest, where housing prices were (probably still are) dirt-cheap, which also would have helped. But of the schools that would have been cheaper, I think I'd really only prefer UCLA (which by the way I am doing an away rotation at in a couple months! *Fist pump*). I know people who have undergrad debt, and a lot who took a special program here that costs basically the same as a year of medical school, in order to basically attend a significant part of the first year of medical school in order to improve one's chances of getting into medical school. If you count the people who are married to some sort of med student/law student/something there are almost certainly some people whose households will carry about a half-million dollars in student loan debt.

I am going to make somewhere in the neighborhood of $45,000-$55,000 a year starting next June/July, which seems to increase by a few thousand each year you get further along in residency; this is not terrible money, but it is not enough to really put a sizeable dent into my student loans, which will begin accruing interest six months after I graduate. So in all likelihood by the time I get to the point where a dumptruck full of money backs up to my house (after residency, and more likely given my professional goals, after fellowship), interest will have tacked on several thousand more dollars onto that sum. I'm not worried that I won't ever pay it off, but it's pretty likely I'm going to be in my mid-40s (or later) before that ever happens.

(For the record, the median salary listed for US Neurologists in the book they gave us all about specialty-choosing last year is $186,946. Neurosurg is $401,000; Ortho ranges from $350,000 to $482,000 for spine surgeons, Plastics is somehow $284,000 which seems really low, Derm is $221,000 which also seems really low. Obviously some people make way more and some way less. Primary care medians tend to be between $120,000-$150,000.)

the idea of that much debt is making me feel... not good.
but if you're making 100,000+ i guess it all gets paid off soon enough...
agh, they make you start repaying when you're still in residency? blargh

re: canada - i have a feeling rich canadians are the bitchiest of canadians

kidding! we are all bitchy (and rich)

yeah, I really have no sympathy for MDs complaining about their debt load. It's not like your debt/income ratio makes you un-creditworthy and you'll be living on the streets until it's paid off.

when I volunteered at a hospital I remember seeing a sign in the neurology department that said: NEUROSURGEON WANTED; 450000 a year. (MALPRACTICE INSURANCE: ONLY 210,000 A YEAR!)

but a large portion of the insurance bill (maybe even all of it depending on the organization) would be picked up by the hospital.

and even if it isn't, you're still making about 5x the national average.

heard the most amazing "aha" explanation for pre/eclampsia today, love it when someone gives you lightbulbs

want you to know that even though I don't know you personally I am proud of you. sticking it through is a real accomplishment and I have faith that you will make immense differences in people's lives

that is srsly the nicest thing anyone has said to me lately. thanks aero!

What was the lightbulb? I have Step 2 CK on Wednesday and haven't taken OB (or Peds) in like a year, and all I really know for sure on preeclampsia is "Give Magnesium, cure with delivery"

Although it must be said that if USMLEWorld is any indication, Step 2 is WAAAAAYYYYY less of a terrible beast than Step 1. Either that or I have gained hella knowledge since June 2010.

What was the lightbulb? I have Step 2 CK on Wednesday and haven't taken OB (or Peds) in like a year, and all I really know for sure on preeclampsia is "Give Magnesium, cure with delivery"

I am ON IPHONE and running out of batteries, but I'll post when I get home.

Teaser: search "renin like substance" and "estrogen liver angiotensinogen production"

heard the most amazing "aha" explanation for pre/eclampsia today, love it when someone gives you lightbulbs

― remembrance of schwings past (gbx), Monday, August 15, 2011 9:19 PM (2 hours ago)

a couple semesters ago i had like a 3 hr lecture on the role of the prefrontal cortex in schizophrenia - a fairly complex patho/therapy concept but i was just not_connecting_the_dots until i decided to look at the online powerpoints that were posted, and tucked away in the "additional notes" part or whatever of one of the 150 powerpoint slides were a few extremely clear but erudite paragraphs written by the professor that i only had to read once or twice to go "ohhhhh"

yeah love those moments too

ok. home now.

apologies if this is somewhat disorganized, but its been a long day. also, i've only done cursory fact-checking on this, but i think it's legit

first principles:
1. estrogen is increased in pregnancy
2. increased estro will increase hepatic production of angiotensinogen (among other things, like clotting factors)
3. pregnancy also increases volume
3a. increased volume means that you don't have to worry about JG cells kicking out renin, and thus activating that excess angiotensinogen (which would otherwise lead to AII-mediated vasoconstriction and aldo-mediated sodium retention).

so. angiotensinogen is being kept in reserve. file this.

NEW FACT (to me): placentae have the ability to produce a substance called, imaginatively, "renin-like substance" (here on out referred to as RLS).

why would a lil ol placenta do this? well, first, recall: normally, renin is produced 2/2 a decrease in volume*. "oh shit, i'm hypotensive, better jack up the vasculature (AII), maintain my GFR (AII), and hold onto all this fluid (aldo)." this (hypotension) is not generally a problem in pregnancy, since pregnant ladies are perfusing for two.

BUT. the placenta produces RLS in response to ~hypoxic injury~, not just hypotension. that is, ANY hypoxic injury. said injury could fall, roughly, into one of two categories:
1) mom is hypoxic, and so the placenta/baby is too
2) mom is ok, but the placenta is hypoxic for some other reason

let's consider (1). a generalized hypoxic state in mom (oops i did too much heroin OR wow its so beautiful here on everest) will compel the placenta to release RLS. this, in turn, activates all that latent angiotensinogen.

now this can be considered a pretty savvy adaptive mechanism. normally, renin gets jammed because of hypovolemia, not hypoxia*; however in this situation, "renin" is getting pushed because of hypoxia, fullstop. why? a: in order to induce vasoconstriction, which will maintain perfusion in the placenta. this makes sense---baby is a more delicate flower than mom, so a transient episode of hypertension serves his/her interests and mom can just f-in deal with it, because she can. eventually she'll get the O2 she needs (when she comes off the mountain), and in the meantime baby will have selfishly gobbled blood.

but what about (2)? in this case, the "other reason" might be a derangement in the vasculature of the placental barrier. pre/eclampsia, iirc, has been shown or suggested to have a genetic component. so if mom has some inborn difficulty in producing an efficient O2/nutrient exchange (2/2 some problem with placental angiogenesis), then placental hypoxia is bound to happen more frequently. even, say, when mom isn't hypoxic herself.

so if this not-quite-functional placenta is more sensitive to hypoxia than mom, then it stands to reason that it will be more susceptible to releasing RLS. thus, it will sustain some insult under "normal" conditions and respond with an outpouring of RLS. this, in turn, will mobilize mom's store of surplus angiotensinogen and induce a hyptertensive episode.

*technically, renin is produced 2/2 acute hypoxia anyway, but this doesn't really undermine the model here, i don't think. it's my understanding that normal hypoxic renin production favors vasoconstriction over fluid retention. again, this makes sense, because you'd want to maintain cerebral perfusion. so, in the case of eclampsia, unnecessarily high cerebral perfusion--->hypertensive encephalopathy. PAGING PLASMON.

I really know for sure on preeclampsia is "Give Magnesium, cure with delivery"

this is how my sister was born

fwiw all i can remember is that Mg sets a pick such that Na can't rush in and depolarize any membranes, so no seizures.

I forget if I had learned about this Renin-Like Substance before. Intriguing...

I also found out a couple months ago while doing a quick presentation on Diabetes Insipidus that there is a Gestational Diabetes Insipidus that comes up sometimes because the placenta also makes vasopressinase, so clearly this placenta is up to some troublemaking shenanigans, I figure. (Really it is odd how the Diabeteses sync up: Central DI is basically DM I because the hormone-producing region fails, Nephrogenic DI is basically DM II because the hormone is being made, it's just not being adequately utilized by target cells, and also sometimes there's a Gestational kind.)

Favorite stupid thing I taught myself on medicine wards was the incredibly reductive guide to etiologies of hypervolemia (especially for hypervolemic hyponatremia): your heart sucks (CHF), your liver sucks (Cirrhosis/Portal HTN), your kidneys suck (ESRD/AKI), or your doctor sucks (iatrogenic fluid overload).

Favorite stupid thing I taught myself on medicine wards was the incredibly reductive guide to etiologies of hypervolemia (especially for hypervolemic hyponatremia): your heart sucks (CHF), your liver sucks (Cirrhosis/Portal HTN), your kidneys suck (ESRD/AKI), or your doctor sucks (iatrogenic fluid overload).

kinda love this, tbh

After one more overnight ER shift tonight, I am free for the next like 6 weeks for nonstop interview madnesses. I am beating up my credit card pretty badly, but other than that, 4th year is basically the best year.

Also now they have let me interview a few applicants for med school, and they are basically all smarter and more accomplished than I was, I think. However, it's too late now I am gonna be a doctor hahahaha suckers!

gotta say, i am doing psych right now (on an inpatient adolescent ward) and dang if it isn't making me think baout thangs

http://upload.wikimedia.org/wikipedia/commons/d/d6/Nervous.gif?uselang=he

LOL I am freaking the hell out and I am basically 100% confident I will match. I would be melting down if I wanted to do like, Plastics or Derm (esp with my grades & board scores)

Today we received an email that said for like the tenth time, "As you should be aware, all 4th year medical students registered with the NRMP match will receive an email tomorrow, Friday, March 9, 2012 notifying you that you are "SOAP eligible." DO NOT PANIC. This email does not mean that you have not matched. It will lay out the SOAP process in advance, so that everyone who does not match will know what to do."

Then it described what happens on Monday and basically Scrambling/SOAPing sounds like it is basically the most insane thing ever.

Good luck with the match!

yes, good luck to you both!!!

i don't even know why i read this thread except <3 evan and C-L

good luck one and all

(I match next year)

yeah i was wondering what you were referring to, you're third year, right?

haha a friend of friend was just talking [via stats updates] about this on fb

gl 2 1 and all

i'll probably get a PGY1 residency, not worrying about it too much right now other than trying to get next february off for interviews

I am distracting myself by thinking of ways we could make it more of a ridiculous spectacle. (My school goes with the "Everybody opens their envelopes at noon, chaos ensues" approach, which is probably less ridiculous than the "people are called up one by one to open their envelope and announce it to the room" option.) My favorite thing is to hire a guy who looks like David Stern and have him open all the letters and announce, "With the next pick in the 2012 Residency Match, the Mayo Clinic Department of Internal Medicine selects..." or whatevs. (I actually ranked Mayo kinda low, btw.) I think a couple of my friends are gonna wear flat-billed Gtown hats and put them on if they match back here. I wanna do my prelim here so I might also participate. Maybe I could get a mustard-colored suit before Friday...

The actual insanest thing is apparently what they do in India state med schools, according to a Psych resident I had, who said that there is a big board full of all the available residencies in all of the state and the class is brought up in GPA rank order to select their preference from what remains. He said he ended up doing Psych in the states because Psych ends up being one of those things that is left over at the end so a lot of the attendings and residents are on their like fifth choice specialty, which makes them not particularly motivated.

i love this thread!

could someone, to an extent, break down what is happening?

Sure, I will in fact give you a brief timeline of the mild chaos that has been my life over the past few months.

So I decided to become a neurologist, which is a three year residency after a one-year internship that sometimes but not always is at the same place as residency. In my case, the combination of being in a relationship out here and knowing that several of my top choices did not offer the combined ("Categorical") internship-residency option led me to apply to a bunch of intern only "Preliminary Medicine" years. All told, I believe I applied to 20 neurology residencies, and 27 prelims.

Of these, I was offered 15 neuro and maybe like 10 prelim interviews, most of which I went to. (I like interviews, although at this point I do hate plane flights with a burning passion.) Pretty much between about Thanksgiving and mid-January I was averaging about two interviews a week (I never did more than three in a week, thank God; some of my friends who did ophtho did three in three days in three entirely different parts of the country, which is insane.)

So on I think February 22nd, or thereabouts, we were required to certify our rank list, i.e. send in our list of the programs we were willing to match to in the order that we liked them. The programs were also required to turn in their list of the applicants they liked the most, in the order in which they liked them. A giant computer somewhere (I like to believe it is a magic computer in the sky) sorts through these lists using an algorithm that is apparently student-favored; i.e., if I rank X #1, and X ranks me #12, but has ten spots, then I will get X unless 10 of the 11 people above me also end up with X as #1. (It gets way more complicated as the matching process goes on.)

The neuro programs I applied to all have somewhere between three and nine residents per class (although the Partners residency, which is the MGH/Brigham & Women's program, has like 17 spots). I sent a letter of interest to the Neuro program and prelim program I was most interested in, and blessedly I also received either a phone call, email, or letter from four programs, including my top two, plus one from a prelim place. It is considered a violation to try and persuade somebody by saying "We will take you if you rank us first", so all of these MASH notes from applicant to program and program to applicant do not explicitly guarantee that I will rank there. However, they are as good an indicator as is known, and at any rate, my home institution has a de facto guarantee that home students are ranked at the top of the list. So I am, thankfully, 100% confident I will have a neuro spot waiting for me on Friday, and like 97% sure a prelim spot will also be there.

If I wanted to do something more competitive, especially with my grades/board scores (which are fine, but are not outstanding), I would be freaking the fuck out right now.

So in about ten minutes we will get an e-mail describing in painful excruciating detail what will happen if we do not match; it is a slightly different process this year so nobody is exactly sure what will happen. It used to be known as "The Scramble" but now is known as the SOAP process; basically what happens is that the unmatched applicants and unmatched programs have a handful of days for reapplication to go down in rapid sequence before actual Match Day on Friday. I can tell you that our school is turning the lower level of the library into basically a War Room for SOAP scrambling next week.

On Monday, at 11:30 am, our school is notified of the students who did not match, and at noon, everybody gets an email telling us to go check on the National Residency Matching Program website to let us know whether we have matched. Our school has indicated that the non-matched students will be called before noon and told to get their ass down to the library. Between 11:30 and 12:05ish, let's say, in three days, every 4th year medical student will be a complete wreck. Most of us will match, so it will all be anxiety for naught, but really, medical school is four years filled with situations of anxiety for no real reason, so whatevs.

Between Monday and Friday at noon, those of us who have matched are left with nothing other than sympathy for those left to scramble (unless they are jerks, in which case, LOL), and the paralysis of not knowing what the answer will be.

On Friday, at 12 noon EST (I believe it is 11 CST/10 MST/9 PST, so everyone knows at the exact same moment, but I could be wrong), we open the envelopes to find out where we spend the next three to seven years of our lives. Chaos ensues. Most people at my school tend to end up happy, and I am in a not-that-competitive specialty with a lot of positive reception on interviews, so I am not like, a mess, but I just NEED TO KNOW ALREADY.

On Friday afternoon/night/Saturday, we party.

And that, ILXors, is how we match.

Addendum: I am now SOAP-eligible, as are several thousand other people, as of right now.

168 hours to go!

That sounds better in so many ways than my drawn-out waiting-to-hear-from-PhD-programs process.

man I am not looking forward to that

you should just wear the sorting hat imo

good grief!

what are the interviews like? full days meeting dozens of people/boards/patients, or a 30 minute chat?

what are the most competitive specialities? dermatology, right? what else? do you know anyone who thinks they won't match?

i have a friend or really friend of a friend hows matching pediatrics which is apparently p tough

it's funny how euro-esque a lot of the american med school process is, just in terms of like the ridiculous top-down structures and paths you have to take

it sounds like mlb

the ROAD to happiness (and most competitive) is comprised of Radiology, Ophthamology, Anesthesiology, Dermatology. basically, specialities that offer a tasty mix of extremely high earning potential, low stress, and decent "lifestyle"

all the surgical subspecialties are tough to match into (vs medicine, where the subspecialization happens in fellowship, by and large)

primary care is generally p easy, with family med and psych at the bottom of the pile

anecdotes:
- friend of mine went into family. applied to 6-7 programs, almost all in state (MN has like 11 FM residencies), interviewed at five, never really stressed about matching
-other friend: going into med/peds. applied to maybe fifteen, interviewed at 8ish, a little nervous
-ortho dude: listed oh about ONE HUNDRED programs, interviewed at under ten, very nervous
-sad rads man: candidate with a flawed app (failed an internal med rotation, low step 1 score) but determined to go into radiology (got a masters in medical imaging during med school), and only listed rads program (over seventy). did not match, scrambled for a surgical intern year, will try again next year

fwiw: "competitiveness" is quantified by the percentage of spots filled by intl graduates. that is, as an American student, you are automatically prioritized over a foreign grad kinda no matter what. and if you apply to a dizzying number of programs in a non competitive specialty, you are assured a spot practically.

also FYI I don't know the exact number, but you're only allotted so many programs on your application. After that, it costs extra to add additional programs. So these rads/ortho peeps are paying significantly more for the application process than the family med ppl, which I'm sure only makes the process more unbearable

Dermatology - meh. My impression of the specialty: ordering biopsies for ten thousand samples of tissue from 'suspicious' moles every year. Removing one or two thousand of them when the results come back (mostly inconclusive, but better safe than sorry). Actually helping maybe 30 people a year to avoid cancer, but you'll never know which 30 they were.

also 30: the number of hours you work a week