Well dang. That’s gonna make next year’s recruiting a lot harder.

Wise Wayfaring….I like the sound of that.

Anywho, yes, I have advice.

1. Make sure your Step scores are competitive AND show improvement from step 1 to step 2. When my program is recruiting we start with a Step 1 score baseline to screen people out. So if your score is good, that may get your foot in just so your application can be seen by programs. When there are academic troubles early on, we look for growth in the later years, so improved test scores as you advance further are key.

2. Do outstanding on your clinical rotations. Ask for feedback as you go along so you can be constantly working on improving yourself. When we see “functions as a fourth year” on a third year rotation evaluation or “functioning almost as a resident” in a fourth year eval it bodes very well. These are the things that get you interviews so you can then have the chance to explain your repeated year.

3. Don’t make excuses. There are a lot of reasons why people have to take a leave of absence or have to repeat a year. If your reason was purely just crappy grades due to your own crappy study habits, own up to it and then explain what you learned from it to make your grades better in the subsequent years. Tell the programs what you have changed about your study system in order to do better.

4. If you had to repeat or you got behind because of a personal or family tragedy or something, know that programs (at least mine) are forgiving about that kind of stuff. It’s not your fault that bad things happened and got in the way of med school. We occasionally see someone who had to take an extended leave of absence because they had a parent dying of cancer or something and we don’t hold that against them as long as they maintained good academic standing when they came back.

5. If you had a mental health crisis that led to bad grades and repeating the year, it’s important to show how your mental health has improved. You don’t have to tell all your business, but it does help to be sort of open and honest about what went on. Explain what you learned in therapy and changed about yourself. Tell them you’re on a good med regimen if you are. Have a plan for how you’re going to manage stress in residency so you don’t have another crisis.

6. Be prepared for interviewers to ask you about the repeated year. Have a good answer prepared but don’t make it sound like a practiced speech.

7. Don’t be a victim. Programs like to see applicants take personal responsibility. It generally translates into a resident who is going to be conscientious and a team player. Don’t act like the repeated year was the worst thing that ever happened to you, even if it was. Don’t dwell on the negative aspects of it. Talk about how you grew from it and how it’s going to make you a better resident.

Oh gosh, I could tell so many stories. What’s wild to me has more to do with the medicine than like psychiatric diagnoses though. As an attending I’m pretty much a white cloud so I haven’t had anything too wild on my call days (I only take OB call). But as a resident I had to commit a patient who was threatening to leave AMA because she thought another resident and I (who looked nothing like each other) were aliens switching bodies with each other to confuse her. I also had a patient who had a fixed erotomanic delusion about a semi-famous rocker plan to leave her family and move cross country to be with this person who she believed was sending her coded love messages through his tweets.

As for rural psych emergencies, I actually had an easier time getting patients admitted to psych facilities when I was super rural than I do now. That may have just been a function of bed availability though, which is the rate limiting step in most places. When I was in TinyTown we had 2 major and one smaller hospital systems that we admitted to, with the major ones being tertiary care centers about 60 miles away in opposite directions. With psych admissions I would call their admitting team and tell them the history and then just hope for a bed. Sometimes I had to send the patient to the ER for further evaluation and they’d sit there until they got a psych bed. The problem in lots of rural places, including my current hospital, is lack of resources. We have very few outpatient counseling resources in our town, so by the time we see people in the hospital they are in worse shape than they’d potentially be if they had earlier intervention with counseling. We also have a very limited number of psychiatrists in the area. All of our area psychs have wait lists around a year long. Inpatient psych beds are also in very limited supply, so patients end up sitting in the ER for days until they find a bed or convince a doctor that their psychiatric crisis is over. It’s a mess.

Hey buddy! Hmmm… joy…. Both being with my kids and having a place to go away from my kids. They can be super sweet and wonderful, but they can also be hellions. My job is still a delight, which is nice. I got a small article published in a major publication a few months ago, so I’m in a good place at work. just wish I had some more help at home so I could do normal life things like go to the gym or watch non-children’s tv from time to time.

If they’re too expensive for you to access, they’re probably good journals.

I’d stick to the big names: JAMA, New England Journal of Medicine, American Family Physician, Obstetrics and Gynecology (AKA the Green Journal). Every specialty has its own major journal and then smaller ones. The major ones are going to be decent.

But honestly, if you’re at an associate’s level right now, reading medical journals is probably a waste of your time. It will be above your head and the information will be obsolete by the time you have progressed to the point where you could put it to use. Stick to learning the stuff on your level really well so you can build a solid foundation. You don’t want to dig too deeply before you are ready.

We’re great! They’re the reason why I don’t post much anymore. Once I go home, it’s dinner-bath-books-bedtime before I get an hour or so to myself at night. We are closing in on two whole years together (3 for me and the oldest) this summer, which is wild because it doesn’t feel like it’s been that long. Of course the days are long but the months are short. The youngest is hitting the terrible 3s (2 was no big thing) and the oldest is just rambunctious and a bit of a bully to the little one. They don’t listen to me at all, which is fun. I am officially a soccer mom now and my oldest scored his first goal last night (in the wrong goal but that’s just details…). If I could just find a husband to help me out with them I’d be set at life.

I think it helps to celebrate your little wins. Celebrate making the right diagnosis, making a patient feel better by treating their depression, identifying a rash, getting a med covered by an insurance company. Those are everyday things that frustrate us when they go wrong but we forget to celebrate them when they go right. Celebrating the little things builds up resilience against the negative comments.

As an Enneagram 5, I constantly have to prove my competency (to myself), so when it is challenged, I go back through what I did to reassure myself that I did the right thing, and if I didn’t, then I learn what to do right next time. I guess the best way to fight against negative comments or feedback from patients is to make sure you’re being the best doctor you can be and that you’re living up to your own standards of excellence. If you can be happy with your work, then you can defend against negativity from people who don’t know what it’s like to do your job.

If you’re at the point of burnout, where you can’t see the small wins anymore and you are losing your ability to care *about* your patients, then you need a break to reset. Maybe you need a change in scenery, a vacation, or a new job. That’s something you’ll have to evaluate in yourself. We all get a bit jaded, but I think that can be fought against with finding the small wins every day.

Ok, here’s some basic definitions for kidney disease:

- GFR or creatinine clearance: a number indicating how well the kidneys are filtering proteins and other wastes out of the blood. A normal GFR would be >60. When they’re talking about % of normal kidney function that’s more of a layman’s term and isn’t as specific.

- chronic kidney disease: broken down into stages defined by GFR or creatinine clearance. Stages 1 and 2 are essentially normal kidney function. Stage 3 (3a is a GFR of 45-59. 3b is GFR of 30-44) is where we start having to adjust dosages on certain drugs because the kidneys don’t clear them as quickly as normal. Stage 5 (GFR of <15) is end stage renal failure, where a person would be on dialysis and/or a transplant list.

- protein being in the urine is basically from leaky filters. There are lots of things that can cause protein in the urine.

Kidney function can improve depending on what is damaging it. In the case of an autoimmune disease, it typically clogs up the filtration system with antibodies, so as the antibodies decrease, the filtration improves. The problem comes when things get so clogged up that the tissue can’t get adequate oxygen and dies. That would not be reversible and the kidney does not regenerate like the liver does. Knowing whether the damage was permanent or not would really require a kidney biopsy. Ultimately with kidney disease you try to slow down progression of disease as much as possible to prevent having to move to dialysis or transplant.

Check out my tag #why_family_medicine. There should be several things in there on why I chose my specialty.

In general, if you like a little bit of everything (including psych), do family medicine.