Trying to figure out what to do with the rest of my fourth year. Some background (edit: WAY MORE background than is needed, lol)…

In September and October, I did a month of outpt peds and a month of outpt IM. However, those were pretty half-*ssed months for me as I was studying for Step 2 and burnt out - I was in 4th year but stuck doing a annoyingly basic 3rd year rotation I hadn’t been able to fit in during 3rd year. So really, the last clinical thing I truly DID was my peds sub-I in August. In November I took a journal club type course that met 1 hour a week, and in December, I did a “research” month spent almost entirely on interviews. For January and February, while most of my friends are doing super light electives, I am taking full-time graduate coursework in biostatistics and clinical research methods. I’m talking about homework assignments, lectures every day, recitations, lab sessions, exams, papers… UGH. It’s not all that bad but not what I want to be doing right now (I have to take these courses for my scholarship program). In March I will fulfill a med school requirement with a non-clinical course that will meet ~6 hours/day 2-3 days a week, and 3 hours a day on the other days. In May I am taking a vacation month - hubby and I will go on an actual vacation for a week and leave DD with the grandparents (eek!), and otherwise we will be working on finding a place to live, moving, etc.

You may have noticed I skipped April . Here is my dilemma. I am currently enrolled in an ICU elective for that month. The reason is not because I’m interested in the ICU (I’m not), it’s because it’s the highest rated elective in the entire med school. A couple hours every afternoon are spent in simulation sessions with one of the school’s most loved faculty members. All the course reviews say it is a “must take” course, “should be required”, “you will be comfortable running a code”, etc. These seem like really good reasons to take it. Also, it will be the only chance to do a get my feet wet with clinical work again before starting internship. On the other hand, the hours will be long(ish) - 7 am every morning (I know, that’s so not bad, but come on, I’m a 4th year!), going I’m not sure how late (depends on site and attending, I’m told). The alternative is for me to take some light easy elective (clinical or non-clinical), and have more hours to spend with my husband, be less tired with the time I’m spending with my daughter, finally finish that last manuscript I’ve been taking months to write up, be able to devote more time to all the administrative hurdles like looking for daycare, etc.

So I’m torn between the desire to be lazy and enjoy the lassitude of 4th year post-match, and the knowledge that maybe I should kick my butt into gear and actually learn something.

Other 4th years, what are your plans? To those who’ve been there before, what did you do spring of 4th year, and do you wish you’d done it differently? (Posting in General forum so non-med students can respond).

I am going to through my 2 cents in...remember that very soon, you will no longer have the comfort of the med student title and lack of expectations from patients. People will be calling you, "Dr. So and So" and expecting you to be more competent than you will be; while I can understand why you want to enjoy easier months...this rotation sounds like it will be invaluable prep for internship, which in my opinion was a frightening transition! Good luck, and do enjoy these last few months before the madness begins!

I did a critical care rotation in, I think, May prior to the start of internship and it was really valuable. I'd had a long clinical break, and the ICU is a great place to get back up to speed. Lots of interesting physiology, very sick patients ... plus, it's so fun. I love the ICU. (Granted, I'll probably tack a critical care fellowship on to my renal fellowship, so I guess I'm biased here.)

Anyway, I'd do it.

Yeah I'd do the ICU rotation - will be invaluable for intern year.

Man, I want to go to your med school!

I'm doing a sub-i in April (at the place I want to match--crossing fingers). My rotations this year were CICU, surgical sub-i, medical sub-i, anesthesia elective, subspecialty elective, and two humanities electives.

I thought my ICU month was invaluable (but stressful and exhausting)--and this is coming from someone with years of ICU experience! It sounds like you'll have plenty of time for particulars in May. Just my 2c Keep us posted!

I did a lot of ICU rotations 4th year, but I was going into anesthesia. Remember like mentioned above, depending on your internship, people will look to you to run codes and such.

But then how can you put a price on your time with your family?

It's a toughy.

You're going into psychiatry, right? Do you have a medicine internship? Do you have to do ICU months or not? I think back as a 4th year I would have advised you to do the ICU rotation, but now I would say ENJOY the down time. Internship is sink or swim anyway and learning is on the spot, not really from simulations etc. And in your case, it's really just about surviving the intern year. It's not like you'll have lifelong use for your ICU learnings.

Caveats:
1) I have a profound hatred for the sim suite. It's so unrealistic, I think it's useless.
2) In pediatrics, they would never let an intern run a code anyway (or maybe it's just my program?), and there's lots of supervision of interns in non-code situations as well(read: not that many responsibilities other than clerical of course). Lots of hand-holding. I acknowledge it's different in medicine.

Oh, yeah - if you're going into psych, you totally don't need to do it, in my experience.

Haha, I guess that added bit of background would have been helpful. Yes, I'm going into psych. At the top two places on my rank list (for now, at least), I would be doing a pediatrics internship (6 or 9 months, depending on which program). If I ended up at another program, I might do medicine, but only 4-6 months. Could possibly end up doing ICU at one of those programs, but don't expect to go there, and if I did, it's 1 month at a community hospital and the residents there described it as more of a step-down unit.

I wonder if that changes any of your opinions on the matter?

You have all managed to convince me that I should definitely do something clinical with my time. (asunshine, you put me to shame!). I guess I just got all caught up in the idea that I shouldn't be working now, and conveniently forgot about the fact that I'm about to be a DOCTOR, and should probably take some responsibility for my education. Though honestly if it waited one extra month until residency, I don't think it would make a huge difference on the other side...

Anyway, now that I'm thinking in this vein, I guess the question becomes do the ICU month, or do something more pertinent (and probably enjoyable) like a psych or peds elective. There is a peds ID elective people love, a developmental peds elective (though reportedly it is mostly shadowing), and there's a child psych C&L elective that reportedly would give me a lot of autonomy (and is something I've always been interested in experiencing). Many others to choose from... For those of you in peds or psych, any 4th year electives that were particularly valuable or that you wish you'd taken?

I guess my greatest source of hesitation in passing up the ICU course is the abundance of glowing "YOU MUST TAKE THIS COURSE!" reviews. I have this irrational fear that if I don't take it, I'll be missing out on some huge life-changing experience and I'll be a total failure of an intern, lol. On the other hand, adult medicine does NOT excite me, I don't enjoy procedures, and the idea of spending a month in the ICU is just so not appealing.

Easy easy: 1) pain clinic; 2) sleep medicine clinic.

You will spend a HUGE amount of your time talking about pain and sleep, with little formal training. If you have any room in your schedule whatsoever, that's where I'd spend it! If you can only do one, do pain.

Hmm, well there doesn't seem to be a sleep medicine elective. There is a pain medicine elective, but the reviews are pretty negative (all procedures, except most attendings won't even let you do it, so it's really just pre-op type histories and watching procedures. Yuck). There is, however, a substance abuse rotation at the VA (it's actually an IM-based rotation, not psych) that gets really good reviews and sounds like a mix of inpatient consults and suboxone clinic. So I bet there are a lot of pain patients there?

OK, so, I admit I'm biased here ... but how is ICU training not useful for psychiatrists? Every time I'm in the ICU, we consult psych pretty frequently and I really admire my psychiatry colleagues who know their way around the ICU. Maybe it's different in peds, I admit I know nothing about that.

And in a totally self-serving vein, as your friendly neighborhood medicine-resident-soon-to-be-nephrology-fellow, in my dream world, all psychiatrists would be world experts on hyponatremia. This would have saved me approximately one billion consults over the course of my medicine residency. Maybe a renal elective?

(To be fair, I am sure that there are plenty of topics that my colleagues in other fields wish I would brush up on ...)

I think it's good to do stuff you won't get the chance to do again. There will be plenty of chances to learn more about pain and sleep in a psych residency. There will not be other chances to learn about the ICU (but there will be many opportunities to feel stupid if you haven't).

This is a very interesting point - thanks for mentioning it. It is true that psychiatrists are, first and foremost, physicians, and should all be comfortable managing the basic medical issues of our patients (though maybe not world experts on hyponatremia ;)). This is why the better (IMHO) residencies place a much heavier focus on medicine than others. During the application process, they are interested in our IM performance during med school, may even require a letter from an IM attending, and during training place a heavy emphasis on getting a rigorous medical training (for the admittedly few months spent on it).



Granted. This is a good point. I think AmmaMD was trying to say, however, that psychiatrists are expected to manage tons of pain and sleep issues without ever getting formal training in it, so it would be useful to seek out some formal training. I'm sure that one could do that to some extent via residency electives as well. Also, just to play friendly devil's advocate, if one should focus on doing stuff she won't get to do again during residency, why should future IM and anesthesia residents do ICU during 4th year?

I have to say I'm a little surprised my opinion wasn't more unpopular. I expected uproar! Let me clarify:
- agree with doing something you'll never get the chance to do again *if* you are interested in it, think you'll enjoy it, don't mind the extra hours. Not for the sake of it.
- agree one needs some ICU time to be a good non-ICU physician. But it doesn't have to be long and doesn't have to include daily simulations or codes. And you'll probably get that sufficient experience as an intern (even in a step-down unit). I'm a little frustrated that I have to do something like 5-6 months of ICU in my 3 years of training when I will be doing outpatient as a career. Sure it complicated and there's lots to learn, but really, a month was enough (along with another gazillion months in the ED) to know sick or not sick. Even if a kid crashes in my office, I guarantee I won't be starting a dopa drip. And never again will I wean a vent or wean sedation or... The list goes on.
- if your internship is going to be in pediatrics, then the (most likely heavily if not entirely adult-focused) ICU elective is actually less likely to help you with your internship.

Another thought: in the spirit of taking advantage of being in medical school and doing something I won't ever get the chance to do, what about a humanities type class? No, it won't give me clinical preparation for intern year, but it could give me exposure to something interesting (dare I say fun?) that I will likely not see again. Two available examples are History of Medicine and a course on medical leadership, management, and administration (covers healthcare finance, cost effectiveness, managed care, patient safety and quality improvement, to name a few; gets really positive reviews).



So, BabyE, what would you suggest instead?

Dunno but here's my experience: I'm in psych (just finished residency and currently a research fellow) and never did an ICU rotation - there was a small amount of ICU on my medicine sub-I, that's it. I liked medicine a lot btw - just as much as psych actually - but essentially skipped 4th year of med school; it was 3rd year, sub-I, and out for me. If I'd had even a single elective month I would have chosen ICU actually.

Our psych consult service gets a lot of consults from the ICU (mostly delirium and sleep-wake cycle issues, occ severe psychosis or depression) and it is hard to do that type of consult and not look like a fool (which I did) if you don't know your way around the ICU (which I don't).

By the way I agree about the hyponatremia point for the psych floors, although I'm not sure you need an ICU month to learn how to handle that. Nonetheless for Emily, in practice even if you know how to work up and manage hyponatremia the attending will still make you call the medicine consult for CYA purposes. Just don't let them find your patient chasing their 60 mg of Prozac with a liter of water when they come to the floor to do their thing.

Definitely not. But a little renal elective never hurt!



Yah, I always figured this was the case from the sheepish look on the face of the (smart) psych resident calling the consult. I suspect the inverse of this is the o-so-common medicine --> psych consult for fake/vague SI that's unrelated to the reason the person's in the hospital ... the only thing more painful than calling this consult must be receiving it.

Sorry to derail!

Well I would suggest taking it easy, but if you truly want to be prepared for internship, then a NICU or pediatric ID elective would be helpful. But again, not much use for your psychiatry career! Development would be good too, but as a mom you already know a lot, it's a requirement for peds residency and often done in internship, and you will see plenty if you do child psych. So many more opportunities for it. The management/admin course sounds intersting AND chill! I would do that!
Baby E,
Founder of resident burnouts anonymous

PS - was just at dentist, got unfortunate IV dose of lido+epi and my first thought was: I bet *he* didn't do ICU. No joke!

Ok, I just can't resist addressing some of this, since I feel like it is important to talk about. Obviously, this is just my opinion... also, I've had to write it in pieces on a busy day, so appologies that some of it was written before some of the above additional comments...

-- You come out of intern year in psych knowing a LOT more medicine than your attendings are comfortable letting you do under their license. It doesn't matter how comfortable you are managing hyponatremia, your attending is going to insist on a consult if *they're* not comfortable signing off on it.
-- It would always be nice for everyone to know more about every field. I could give you a whole list of basic psych things I sure wish every internal medicine resident knew that would save me a ton of consults! And, more importantly, improve their day to day patient care - things that given the amount of psych that primary care MDs do on their own, it would actually make a lot of sense of them to know. In fact, it baffles me that your standard primary care doc generally gets nothing but the 4-6 weeks of psych they did as a med student in terms of formal psych rotations - but dole out the vast majority of eg antidepressants given in this country. That said, every field has more to know than you have time to cover the way you should. And so yes, there's always a chance that knowing some extra ICU stuff would help you from time to time... but it's almost certain that more experience with chronic pain or sleep disorders would help you frequently (and yes, I mean specifically more experience than you're going to get just going through residency without seeking this out). After that, I'd probably go for endocrine. And after that, I'd probably do renal, given the frequently issues with renal function, psych Rx, and lithium. Or perhaps some extra neuro - especially outpatient and movement disorders. ICU is way, way down there.
-- I didn't do an ICU rotation or even a medicine subI. I did do a month of my medicine rotation somewhere with an open ICU, so I took care of ICU patients in that context. I'm not going to independenly mess with someone's vent-settings, but I have not a momment's regret about not doing an ICU month.
-- Even if there's not a formal "sleep elective", just see if you can hang around the sleep medicine clinic for a couple of weeks and see patients - whether it's a formal rotation or not doesn't matter much, at this stage
-- Yes, addictions stuff will always be helpful. Of everything, you will see this again in residency, but it's often handled very differently in different places, so seeing variety could be super helpful.

Ok, back to my real work!

You could do the ICU elective, but April of 4th year you'll prob be pretty burned out. As a current 4th year I say pick something easy! Intern year will be hard enough, no need to go crazy now.

If you are going into psych, I would say ditch the ICU rotation. I concentrated on rotations that would really help me in my field because by default they were the ones I really enjoyed as well. If you are having questions about it, clearly you are not that excited.

You are not going to see a lot of your family in the intern year.

Now, this advise may be influenced by the fact that I wasn't able to take any extra time off this week, am stuck at the hospital on call, and sitting here really wishing I had more time with my son....

I think you should do something easy. Maybe one of those "humanities" classes you listed. The one about business, finance, etc will be helpful to you in the future no matter what you do. Have fun, it's fourth year!

If you are interested in the "medical leadership, management, and administration" course, I would do it. Most of us don't get enough exposure to these topics. I really wish I had more experience in these areas coming out of training. I also agree that no matter what direction your career takes you, it will be useful.

Given what you've said in your posts, I would drop the ICU rotation.

Ok, so I'm currently struggling to decide between two options: the ICU elective, or the medical leadership course.

Pros for the leadership course: interesting, chill, will learn a lot about useful and important stuff that I will likely never have another opportunity to see, more time for myself and family. (As an aside, I really don't feel like May is going to be sufficient time for all the "particulars", between 1 week of actual vacation, finding housing, packing, moving, and oh yeah, visiting preschools with DD BEFORE moving. While DH might do a good amount of the work that goes into finding housing, the investigative and administrative tasks involved in finding a preschool will fall solely on me. It's not worth arguing about this, it's just the way it IS).

Pros for the ICU month: For me, it's really not about "getting ready for internship" or "I really ought to get some ICU exposure". The compelling factor is that this course has 990 reviews logged, and while I certainly didn't read all of them, the last 100 or so are ALL overwhelmingly positive. It's the most popular and best loved course at my school, and I worry I'd be doing myself a disservice by graduating without taking it.

So torn.

It's awesome they are both, in effect, really good options. I'd still probably go for the medical leadership course if it were up to me. But, I'll bet whatever you do will feel like it was the right thing!

lol nbp, take the leadership course. Sounds like you do not want to take ICU--it is TOTALLY ok if you don't. That's opportunity cost for you--for every choice you make, you're not choosing another. Such is life.

asunshine, are you teasing me for agonizing over what really shouldn't be such a big deal? But this is how I keep myself from agonizing over my rank list!

By the way, total tally right now not including myself is 4 votes for ICU (5 if you count my husband) and 6 for leadership. Yes, I counted.

I totally LOL'd when I read that! Particularly since my current obsession is cleaning my closets. Seriously. At least your obsessing is semi-academic!

But I was serious in that you should do something that makes you happy (ICU tends to make me happy-ish, so I'm biased). Extra point in favor of leadership: sim-people are creepy, especially sim-babies.

Oh man, I WISH I was obsessed with cleaning my closets. That would make packing so much easier when the time comes. Every time we move we end up with multiple boxes of "eventually we will sort this stuff" that just end up sitting in storage. Each move leads to more of these boxes. Just thinking about dealing with all the clothes and toys DD has grown out of... ugh. See, "particulars"! Need time for particulars! :P (Though somehow I'm guessing I'd somehow find a way to use that time for anything other than cleaning out the closets, lol).

P.S. If you run out of closets to clean and would like more material for that obsession, feel free to come visit and get your fill here!

I'm nesting. Mine manifest by inability to look at disorganization and clutter. My house is getting sooooooo clean and uncluttered. *sigh of contentment* We are making regular trips to the Goodwill. I actually enjoy cleaning. I got up at 4 this morning and cleaned for 1 1/2 hours before getting ready for work. If I could only nest about once a year (without actually being pregnant), I would be set.

Btw, leadership course does sound amazing. I agree we don't get enough exposure to that stuff.

Wow, you got up at 4 am *voluntarily*? That is just unfathomable to me. I wish I could channel my excess anxiety into cleaning and such, but it seems the only way I can occupy myself is to obsess over decisions (don't think closet cleaning is going to cut it there).

Speaking of, I made one! Look at me! I really appreciate all of your input - you all had some excellent points and it helped me put things in perspective. I ultimately decided to go with the leadership course, because it was clearly what I WANTED to do. The ICU course is so popular, I am sure there is someone who is thrilled to have my spot, and I feel much better about it going to that person than to good old ambivalent me. And while there are certainly potential benefits to doing some clinical work closer to residency and getting some ICU exposure, they just didn't outweigh for me the desire to do something different, to have some down time for myself and my family, and the internal groan that surfaced every time I thought about getting up at 5:30 to go to an adult ICU. Bleh. (No offense Emily!). So there you have it. I decided, and I feel much better about it now.

Okay, quick, give me something else to obsess over, so I don't revert back to my rank list!

I have now turned my obsessing towards whether we should buy online groceries and how, if that helps.

5 bags of clothes to the goodwill and more to come. Some of that stuff I had since high school!