All posts by pandabearmd

Sound and Fury

A Day In The Life Of..., Residency, Uncategorized

Family and Community Medicine

Latravia Kell was my favorite patient. I can’t think of one bad hand that life hadn’t dealt her but she was unfailingly cheerful, polite, and compliant with all of her treatments. I met her on my first day of family medicine clinic and saw her at least every month afterwards. I didn’t do too much for her. She had a small platoon of specialists following her various medical conditions. Rheumatology had dominion over her SLE, Orthopedics claimed her osteopenia, Infectious Disease had suzerainty over her HIV and OB/Gyn was following her for various pelvic irregularities. In fact she seemed to have all of her bets covered and I was not sure what she needed from me.

“I’m here for my Depot shot,” she said on her first visit, “All you have to do is sign the form and the nurse will give it to me.”

“Well hell, we can do that,” I said, a little relieved because she seemed a monstrously complicated patient to inflict on an intern. “Is there anything else I can do?”

“No, not really. I’m good.”

Although we later became friends and she hugged me and cried on my last day at Duke, on her first visit I think even my brief physical exam annoyed her.

Later I had to dictate our standard clinic note hitting all of the high points of the chief complaint, history of present illness, and review of systems even though these were completely incidental to the purpose of her visit. I suppose this was to give the illusion that we were actually doing something besides routing her to the shot nurse but it seemed like a lot of sound and fury for nothing. My assessment and plan was basically a list of who was following her for what condition.

But that’s family medicine, at least at a big academic medical center.

I had other regular patients. It’s not as much fun as they make it out to be and occasionally you look at your panel for the day and hope that particular patients decide to skip their appointments.

Like Mrs. Ribitz. I knew that she was old and sickly. I was aware that her bones were fragile sticks and that she had recently fallen and broken her hip and her arm. I knew that ortho had pinned and casted her and that she was in a lot of pain. Hell, she looked terrible. And she smelled like the crappy nursing home where she lived which is not a nice smell as it is basically the smell of stale urine and dried food stains.

But my God could that woman complain. About everything and everyone. After the obligatory “What can I do for you today” she would stare at me malignantly for a few seconds and then launch into a tale of pain and suffering that would have made stones weep if it was anybody but Mrs. Ribitz telling it.

And then she would cough, gasp for air, and take a rest while sucking air through her nasal cannula. Her emphysema didn’t deter her from smoking and my eyes watered in the small examination room from the fumes that permeated her clothing.

“Well, Mrs. Ribitz,” I began while her coughs subsided, “I’m sorry to hear that things aren’t going well but if you had to pick one problem to address today, what would it be?”

“My feet are swelling,” she said curtly, “And my back hurts.”

I took off her slippers and urine-stained socks to examine her feet which were indeed swollen and pulseless, an alarming finding except they has been like that since I started seeing her and no combination of medications or therapies had been able to make a dent in the problem. I threw the Doppler on her and was able to hear the faint, plaintive sound of her tired blood struggling to supply her foot with blood. It was all peripheral vascular disease and poor medical compliance (which sounds nicer on the note than saying, “Patient is an idiot.”) She had already lost three toes to gangrene and I noted that most of the rest were heading that way. There was nothing to do as Mrs. Ribitz was the poster-girl for poor surgical candidates. I confirmed her next appointment with vascular surgery but that was the extent of what I could do for her.

“Tell me about your back pain,” I said with profound regret.

The floodgates opened and I heard, for the tenth time, the story of her chronic pain (from vertebral compression fractures) which was untouched by enough narcotics to drop a small herd of elephants, after which we both looked warily at each other. A physical exam to assess her pain was out of the question. She would probably have a heart attack from the exertion of standing up, which she couldn’t do anyways because of her hip.

“I’m out of Percocet.” A statement. “I need another prescription.”

At one time Mrs. Ribitz had a pain contract but I believe by the time she had exhausted two residents the clinic surrendered and just gave her what she wanted.

“I’ll just write you a prescription and you can be on your way.”

Mrs. Ribitz grunted in satisfaction. I verified the dates of her next appointment with ortho, checked her vitals and stood up to let the nurse wheel her out.

“And don’t even start about my smoking,” she snarled.

“Ma’am. You’re 85. I’m not your father. I’m not going to lecture you but if you want to quit I’m ready to help you.”

Surprisingly, on my last appointment Mrs. Ribitz sobbed uncontrollably and told me I was her only Doctor who wasn’t a pain in the ass and that she would miss me. I guess I kind of grew to like her myself, once I realized that her visits were primarily social calls. She had the usual cadre of specialists addressing her medical problems. All I ever did for her was write for the occasional narcotic and listen to her complaints.

Not every patient was so complicated.

“I’ve got a drip,” said Mr. Ryan nervously after the nurse closed the door.

“I guess we’re not taking post-nasal, right?” I had seen Mr. Ryan several times before.

“Naw, it’s down there.” He gestured down there. “And it hurts when I whiz.”

“Sexually active?”

“Yeah. Do you think it’s the clap?”

“Could be,” I said, “Let’s take a look…yup…certainly looks like it. Tell you what, I’ll send these swabs for cultures and we’ll treat you in the meantime.”

“Hey Doc, don’t tell my wife, Okay?”

“Maybe you need to tell her. I think she needs to know.” This is one of those moral dilemmas they’re always talking about. His wife is also one of my patients.

I had seen his wife just a week before for unusual vaginal bleeding. Of course we ended up referring her to OB/Gyn, just to be safe.

The latest fad in family medicine is identifying “barriers to care.” Naturally, some of these barriers were intuitively easy to identify. Being poor and unable to afford a doctor visit comes to mind, as does being unable because of a disability to travel to the clinic. But some of the barriers are a stretch. Being angry and deciding to express this anger by not taking one’s free prescription medications seemed kind of weak to me but this was exactly the kind of barrier I was supposed to take seriously.

One of our initial clinical assignments was to visit a patient at their home and identify their “barriers to care. My patient was an obese, pleasant, single mother of two with the usual comorbidities, all complicated by medical non-compliance. We weren’t actually supposed to say “non-compliant,” instead substituting the more optimistic and non-judgmental phrase “pre-compliant.’

Having lost her Section 8 housing because of some fraudulent activity which involved subletting her subsidized apartment while she lived with her mother, she lived in a small but adequate house, the rent for which ate up most of her meager income from the public treasury. The first thing she complained about was the poor upkeep of the house and asked me what she was expected to do about it. The social worker who accompanied me nodded empathetically as if to say, “Here, you newly minted doctor and representative of ‘The Man,’ here is a barrier to care. How will you help her over it?”

In my written report I suggested that this was a matter far beyond our scope of practice, something best worked out between the tenant and landlord either amicably or in the City small claims court. Besides, this in no way effected her access to our clinic as her visits cost her exactly nothing and a broken window and leaky faucet are not exactly homeowner’s emergencies.

My wife and I managed a housing project years ago (before my wife quit after discovering a dead tenant which is another story) and we used to get calls at 3AM demanding that we drive across town to unclog a toilet. The helplessness of the dependency class does not admit to any effort, no matter how small, to take responsibility for anything in life. The typical response to the natural question, “Do you have a plunger?” was, “I’m not sticking my hand in the toilet.”

I once got a frantic call from a tenant’s whose apartment was on fire.

“Did you call 911?” I asked.

“No. Do I need to?”

“Not unless you think I’m going to get in my private fire engine and drive over there.”

But I digress.

I also pointed out in my report that despite her claims of poverty, the patient must have had other income. She had furniture, the babies were fed, there was a large (but not extravagant) entertainment center in the living room, and I saw no signs of deprivation of any kind. The children also looked clean and well-cared for. She even had a working automobile.

Apparently her mother helped out.

Lack of daycare was another barrier to care, as it prevented her from coming to clinic even though my wife sometimes has to drag all four of my kids to her doctor’s appointments. I discovered however that while the baby-daddy’s mother, the baby-granny, wanted to take an active role in caring for the children, my patient had refused her access to her grand-children until she bought them expensive clothes as a propitiatory gift. My patient bragged about this. Apparently greed and arrogance were also legitimate barriers to care.

It turned out that she was angry. Yes angry. Angry that when she came to clinic no one listened to her concerns and nobody explained her treatment regimen in a manner which she could understand. Nor did we respect her sensibilities as an independent, intelligent African-American woman.

“I just don’t feel like you take me seriously,” was her explanation as to why she didn’t take her insulin as directed. The social worker soothed her ruffled feathers and I held my tongue. I was not kind to her in my written report. She was a stupid, lazy, selfish woman all of which characteristics are personal problems, not medical issues or barriers to care.

Her anger, I wrote, was a form of transference. Impotent and ineffectual in every other aspect of life, she gave herself the illusion of control by making her social worker and the physicians at the clinic jerk like puppets to her whimsy. The clinic, after all, was probably the only place in the world where she was taken seriously. In every other venue she was just a fat, dumb, single mother without the sense to take advantage of the help she has been given by the State.

Tragic, perhaps. A crying shame and a waste of her potential, no doubt. But not a medical problem.

This report was not received well by the program chairwoman. As if I was a third-grader, I was asked to rewrite my homework, not once but twice, in order to please the sensitivities of the program. And the second rewrite wasn’t good enough either. I was asked to write it again but decided to blow it of and never heard about it again.

Two Minute Drill V

Specialty Selection

“Opthomology”

The first rule of ophthalmology is to spell it right. Nobody does. I’m not even sure if I just did. The second rule is that nobody should ever mess with the eye unless he is an ophthalmologist. It’s the eye for crying out loud. We see out of them. The margin of error is small. I’m not exactly a crack addict but compared to an ophthalmologist, my hands shake as if I’m doing a couple of rocks a day.

As those of you who don’t confuse ophthalmologists with optometrists know, an ophthalmologist is a surgeon who specializes in the eye. Optometrists make glasses and there is an intense but one-sided rivalry between the two professions. One-sided because the ophthalmologists don’t care and if they did have been known (unfairly) to call optometrists “Chiropractors for the eyes.”

(Optometrists are not medical doctors but go four years of optometry school after which they are conferred a OD degree. There is a lot of overlap between optometry and ophthalmology. Ophthalmologists usually include retail glasses and contacts in their practice and optometrists manage some diseases of the eye. A better comparison would be that optometrists are like primary care for the eyes. Still, I have known several optometrists and there is some bitterness towards their MD cousins.)

What do I know about ophthalmology? A good deal less than I know about any other specialty. As you know I was a family medicine resident for a year and am currently an Emergency Medicine resident. I think I know enough about these to specialties to offer some tentative opinions. I have rotated on most of the specialties I have described in this series of articles and know enough to at least give you an outsider’s perspective of them. I am not a surgeon, for example, but I have done a total of six months of surgery rotations so I have at least a vague idea of what goes on.

I spent a week in ophthalmology during third year of medical school. Less than a week, actually, because Friday was a holiday, I made some lame excuse to slime out of going on both Tuesday and Monday, and went to one procedure on Wednesday where I did nothing and said nothing (which is all that is expected of you). On Thursday I went to clinic, shadowed the resident for and hour or two until his annoyance reached a certain threshold and he signed my evaluation sheet and allowed me to leave.

Ophthalmologists tie knots with suture threads so fine that it looked like the guy was using spider-web on the eyeball he had popped out of the patient’s eye-socket. You are not going to do much on a rotation like this, even if you want to. “Hey, Mrs. Smith, how about I let this third year medical student jeopardize your eyesight?”  One week is also not long enough to learn anything really useful, at least anything that will stick. I go to an ophthalmologist for my glasses and am as mystified at what he does as my patients are when they look at the squiggly lines on their EKG.

Ophthalmology is very competitive as specialties go. It will make even the best students in your class feel like losers when they don’t match, a common event. You might hear people say, “I’m trying for Ophtho but I’ve got derm as a backup.” The lifestyle is very good in residency but it is a surgical specialty so you will come in early and stay late occasionally, at least this is my understanding. You do have call. Eye injuries are common and every injury is an emergency until proven otherwise. Half of your brain is devoted to visual processing. The eye is important.

On the other hand you won’t be admitting patients to the hospital so how bad could it be? (I know there are exceptions to this but we’re talking generally)

The definition of “stressed” is an ophthalmology resident trying to manage a medical problem on the floor. I’ve seen it happen and it wasn’t pretty. But when it comes to the eyes they are magnificent bastards and everybody breathes easier when Ophtho shows up to give slightly bored guidance on the management of an ocular injury that curdles everybody else’s blood.

Orthopedic Surgery

How do you know a note was written by an orthopedic surgeon?

It’s written in crayon.

Other specialties make a lot of jokes about orthopedic surgeons. Heck, the orthopedic surgeons make a lot of the same jokes that they “tell on themselves” with great relish. I don’t know how it came to pass that other specialties think the orthopedic surgeons are dumb. Maybe it’s because most of them (and you will see this) are big, muscular, guys who look pretty easy-going. Maybe it’s because of the mechanical nature of the job which involves a lot of power tools that would not be unfamiliar to Joe Six-pack building a deck for his wife.

In reality orthopedic surgeons have higher Step scores and grades than most other surgeons and the specialty is a good deal more competitive than, let’s say, General Surgery.

But they do use a lot of tools. And it may be the only medical specialty where leverage is important. An orthopedic surgeon carefully balances precision and brute force. Just watch what is required to replace a hip for an appreciation of this balance. And when they’re done the patient walks as if she were a teenager (after rehab of course), or at least that is a reasonably expected outcome.

It’s a competitive specialty but I think there is a large element of self-selection. People who want to do ortho really want to do it. There is none of the wishy-washiness of prospective general surgeons, many of whom bail out after intern year because it’s not as cool as they thought.

Two Minute Drill IV

Specialty Selection

Anesthesiology

A poorly understood specialty, especially among surgeons who tend to look at the anesthesiologist in the same way airline pilots look at flight attendants. It certainly doesn’t look like much of a specialty. The anesthesiologist starts the lines, sedates the patient, intubates, turns on the gas and then reads his magazine or does crossword puzzles. If you think about it though, it’s the anesthesiologist flying the plane while the surgeons tinker around in the cabin. The anesthesiologist is responsible for keeping the patient alive and neurologically intact during the procedure.

Almost everyone who undergoes a major procedure gets general anesthesia which involves not only rendering the patient unconscious but also paralyzing his muscles. This explains the need to intubate as a patient in this state needs both ventilatory support and airway protection. The patient is placed into a drug-induced coma, the depth and duration or which are controlled by the anesthesiologist. This also explains the need for residency training as well as the high degree of operating room terror if anything goes wrong.

Anesthesia also involves pain management. If you think about it, the presenting complaint for almost all outpatient visits and hospital admissions is pain of one kind of another. A lot of this is chronic pain and a growing part of most anesthesia practices is pain management.

A lot of the pain is bogus and you will deal with drug seekers like my little old 78-year-old Baptist Aunt who has been addicted to Percocet for the last twenty years. Her doctor prescribed it for something she can’t remember and she has been taking it ever since. She’s not hooked, of course. She’s too respectable for that. But that’s a topic for another day.

It is a lifestyle specialty. The residency hours are pretty good once you get through a standard intern year. You will come in pretty early, earlier than most, but the trade-off is that you’ll have your afternoons free. The anesthesiology residents carry a lot of weight when they are on call, especially when there is a code. We almost never attempt an intubation of what looks to be a difficult airway without having them standing by. I’ve seen an Emergency Medicine Chief resident and a Medicine chief resident both fail to get an airway which the anesthesia junior resident put in while still half-asleep.

They also know the ACLS protocols backwards and forwards as they use them on a regular basis.

Dermatology

Somewhere in this unhappy medical world of ours is a happy place. A place where the grapes hang down from the vines and beautiful maidens cavort in the green pastures and cool forests of Elysium. In this place cows with full udders waddle happily to be milked and the cheeses and hams abound, rich provender for the easy taking.

They call this place “Dermatology.”

Or at least that’s the idea you will get talking to your fellow medical students, the majority of whom will be sick of smelly patients, bodily fluids, the indigent, and the kind of frothy green vaginal discharge that can only be experienced, never described. Dermatology provides an escape from all this. A way out. Not only is the residency, by repute, pretty easy but once you get done you become one of the only physicians around (with the possible exception of the plastic surgeons) who laughs, yes laughs, incredulously at the preposterous notion that he should work for free. And not just any laugh but the full-throated jolly guffaw of a guy who has the world by the scrotum…and has a comfortable grip.

No pay, no play. So sorry. Next.

Now, in reality Dermatology involves quite a few things that people don’t think about. Like severe burn injuries, perhaps the most horrific sight, bar none, you will ever see. It is a legitimate specialty. The skin is the largest organ of the body and if a simple organ like the friggin’ kidneys can have specialists then the so should the skin.

Still, it is the good life, especially as a resident. No call to speak of (“Somebody page the Dermatology resident…his rash is out of control and I’m out of ideas”). Decent work hours, too. Sure, you may work a little in the burn unit but the rest is all outpatient clinic. Nine to five, baby.

This explains the extreme competitiveness of the specialty. The smartest and most capable medical students, all other things being equal and unless they have a zeal for some other specialty, will match into dermatology. Kind if ironic when you think about it because I don’t think anybody professes love for the skin in their AMCAS essay.

We must all weep, as we toil through months of Q4 call, that we are not Derm residents.

Dawn of the Dead

Articles You Must Read, Futile Care, Uncategorized

Loaves and Fishes

The body of Mr. Dubois recedes into the shadows as the nurse turns down the lights. His family wants some time with him before he is taken wherever it is we take the bodies of those who finally exhaust our ability to reanimate them. Mr. Dubois did not go quickly or easily. His death has spanned months, if not years. The massive stroke which finally finished him off was just the last in a series of insults, all of which steadily whittled away at his intellect, his quality of life, but never the conviction of his family that he needed to be kept alive at all costs.

The details of Mr. Dubois’ decline are familiar to anyone who has worked in an intensive care unit. Already in poor health from numerous chronic medical problems as well as mildly demented, he suffered a minor stroke and became bed-ridden. His wife, in poor health herself, was unable to transfer him from his bed to a bedside commode and his children eventually moved him to a nursing home where, with the exception of dialysis three times a week, he spent his days laying in his own urine. Over the course of a year he made several visits to the ICU where he was treated for pneumonia and sepsis, urinary tract infection and sepsis, sacral decubitus ulcers and sepsis, and finally a COPD exacerbation with pneumonia and sepsis. This lead to the final, massive stroke which should have finished him off except that after years of neglect, his family was still not ready to let him go.

They were perfectly willing to park him in a nursing home, you understand, as long as they didn’t have to think about him. I’m sure they visited even if the visits eventually tapered off to a hurried fifteen minutes every other week, visits more to demonstrate that they still cared than to look after Mr. Dubois who lay in his bed literally rotting away both mentally and physically.

At the end the family didn’t want Mr. Dubois to suffer, at least not while they were around. I’m sure they didn’t lose sleep over the suffering he endured as an immobile piece of bodily-fluid producing meat in his fly-blown nursing home. But in the hospital, with the doctor and skilled ICU nurses it was all sanctimony and reverence.

The contracted, slack-jawed body of Mr. Dubois continued its leisurely spiral towards death as we used every expensive weapon in our arsenal and spent tens of thousands of somebody else’s dollars in our absolutely inexplicable desire to play along with the family’s delusions.

The family’s delusions, like most, grew in isolation of the basic facts. I suppose if his family had taken care of him at their home as was the case for almost all of human history the story might be different. If they were the ones cleaning his bowel movements, spooning soft food into his mouth, or living with the rotten smell of ulcerating bed sores, one of which had eroded down to his sacral bones, they might have been relieved at his death, both for their own sake and his.

Nor did they give a thought to the cost of his many hospital stays, the total amount of which is almost impossible to calculate. Somebody else will pay, they always do. He’s paid taxes his whole life, goes the mantra, so let Medicare handle it despite the fact that one week in the ICU probably ate Mr. Dubois’ entire lifetime contribution to the system.

A day in the ICU costs several thousand dollars with only a minimal level of care. Then there are the many paid specialists continually consulted to tell us what we already know, namely that Mr. Dubois is dying. The nephrologists shakes his head sorrowfully over his kidneys. The cardiologist writes notes and orders expensive studies which reveal that his heart is bad. The gastroenterologist fails to discover the source of his frequent melanotic stools and the hematologist advises that even though his leukemia is going to kill him in a few weeks (guaranteed) we should go ahead and transfuse four units.

The vascular surgeon, the only realist in the bunch, when consulted for a possible repair of Mr. Dubois’ dangerously bulging abdominal aortic aneurysm says, “Are you fucking kidding me?”

Too bad he can’t write that in his consult note. The dry precision of medical prose gives the illusion that we are in control of Mr. Dubois and could turn him around with a little coordination between the medical specialties. The family certainly buys into this notion. Aren’t all of his medical problems being managed? Don’t doctors have all the answers with their extensive education and big words? Surely all of those monitors, pumps, and flashing lights must be doing something. We’re not asking for loaves and fishes here, doc. Just keep his heart beating.

So that’s what we do. In the end all we are really doing is giving the house staff valuable experience running ACLS codes. We get a carotid pulse back and beam with pleasure at the good thing we have done despite the fact that it is taking three different pressors to keep his blood pressure compatible with life and to remove any one of them will be the end of Mr. Dubois. What we’ve really done is paint ourselves into a corner. He is never coming off the pressors. In about a day, if he lives that long, Mr. Dubois’ toes and fingers are going to start rotting off.

Perhaps then we can withdraw support, if it’s all right with the family that is.

Hell on Earth

Medical School, Uncategorized

Problem Based Learning

Lecture is a pleasant, drowsy picnic where you nod in and out of sleep while listening to the far-away drone of bees and the faint ringing of goat-bells as the local peasant girls herd them to the high alpine pastures.

Problem Based Learning is like being sodomized in prison by a big sweaty guy named Ronaldo who has bad breath and hands the size of dinner plates.

Problem Based Learning (PBL) is a system of medical education where instead of following a rational curriculum that lays out the subjects in which you should be proficient in an organized manner and instructing you accordingly, the lunatics are put in charge of the asylum and it is up to them to figure it all out. Of course it sounds good in theory. Its proponents use phrases like “self directed learning” and “team based approach” to disguise the fact that it was implemented primarily to spare professors the onerous burden of teaching poorly attended lectures.

How does PBL work? Well, first let’s imagine a traditional lecture-based curriculum. In this system, during first and second year you attend lectures Monday through Friday which are organized into discrete subjects like Pathology, Microbiology, Biochemistry, and the various other big medical school topics. Some medical schools mix the order a bit by having their lectures “systems based.” In this scheme the lectures of the standard medical subjects are tailored to the particular organ system that you are studying.

If you are on the cardiology block, for example, you might have lectures on heart pathology or heart-specific medications and their properties. I rather like this system, by the way, even if there are some subjects that need to be taught en bloc and not broken up between different systems.

Microbiology comes to mind.

Whatever the case, in a lecture-based curriculum you will usually have a syllabus with concrete learning objectives stating what you need to know to master the material. The fact that lectures are often poorly attended speaks to a strength of this system, namely that you know what you need to learn and can dispense with the inefficiency of listening to somebody else talk about it when you can read about it on your own.

In a PBL curriculum, you are broken into small groups and the learning happens, so they tell me, through interaction and self-exploration.

I remember my first PBL session (My school had a smattering of it). The facilitator started us off by presenting a case and then asking us for a differential diagnosis.

Blank looks from the group.

Beuller…Beuller…Anyobdy?

You have to understand that at this point, two weeks into first year, the only medical experience most people have is the month they spent working at a homeless shelter passing out condoms, free needles, and empathy. It was at this time that most of us probably realized everything we did or claimed to have done on our AMCAS application wasn’t going to help us a bit.

“Um…I think my grandmother had that,” said one of the more adventurous students, “They said it was her heart valve…or something.”

This comment died a silly, embarrassing death in the general silence that followed.

And that’s how it went until the facilitator, clearly relieved to be absolved of facilitating, started to lecture us on the relevant aspects of the case. I suppose this was better than listening to the crickets chirping but much of what we were told in this and many other PBL sessions was presented without the necessary background in medical science which you’re supposed to learn before getting jiggy with medicine. It’s like asking a group of people who have lived on Ramen noodles since high school to whip up a gourmet meal by consensus. The spirit yearns for Beef Wellington but the mind only knows noodles.

Eventually, I suppose, you get the hang of it. You learn to do a quick google search a couple of hours before the session so you can drop a few buzz words and pretend you care. Or you learn how to surrepititiously surf the internet on your laptop while pretending to be feverishly taking notes.

I also suppose that eventually you can learn a lot in a PBL session but it is so damned inefficient.

First of all, I hate studying in a group. It’s bad enough that a good portion of medical knowledge is incredibly boring without having to suffer through your classmates, all of who have different studying styles, trying to get a handle on it. It’s all I could do to read about some things. Listening to an amateur droning about them made me yearn for an ice pick to the brain. Teamwork is perfectly fine, of course, and I understand that “team” is a talismanic word that invokes all kinds of goodness to it’s believer. But not everything has to be a team effort. I brush my teeth and dress myself almost completely without assistance every morning. I even have been known to read the paper in silence without calling all of my friends to tell me what they think.

Second, because people like to hear themselves talk, the alpha-students will quickly eastablish their dominance and you will eventually here something you probably haven’t heard since third grade:

“That’s true, Jane, but how about letting one of the other students answer?”

But that’s actually all right with me. I was always content to zone out and let the titans fight it out among themselves. Either that or I surreptitiously studied my class notes from which were a lot higher yield.

Some medical schools are all PBL. This must be a living hell. You can’t even skip and study on your own because your absence from a small group will be missed. Some are a mix of PBL and lecture. Some are mostly lecture but like a malignant cancer, PBL (like empathy training) has metastasized to the entire body of medical education.

No Solution

Medical School, Uncategorized

It Sucks to be You

My post on my first day of third year seems to have struck a nerve and a few of you have asked some variation of the question, “What can we do to end the abuses which are so much a part of medical training?”

The short answer is, “nothing.”

As long as there is a steady stream of people willing to sell their mothers to get into medical school it will always be a seller’s market and there will be no incentive to change anything. On top of that, too many people look at medicine as a religious calling which means that, like any Pharisee, they will defend their beloved orthodoxy against attack from reformers.

Not to mention the operation of human nature which ordains that many who have been made to suffer feel it is their duty to inflict pain on others. This explains the sanctimonious old-school attending who defends the abuse of medical students because he had it much worse in his day.

So on an institutional level change is going to come very slowly. The increasing numbers of non-traditional medical students who are less willing to put up with the usual chickenshit is an encouraging development. A twenty-something medical student who has gone straight through from high school to college to medical school without seeing how the rest of the world works is a lot more inclined to accept the status quo as normal than somebody who has worked outside of medicine. Additionally, a resident or attending who knows nothing other than the life of academic medicine is inclined to believe that nobody else works as hard as he does and this makes him more than a little self-righteous.

In reality, other people work hard, often for much less money and prestige than doctors. As a Marine, for example, I endured hardships that would make the Chief of Surgery’s blood run cold. But you don’t see me running around abusing people because I humped a 120-pound pack up and down the mountains during arctic warfare training or spent week after week sweating in a central-American jungle.

About the only thing we (you) can do is to stand up for yourself. There is no rule in medical school that forces us to be pussies. Let’s say you don’t know the answer to a pimp question, instead of getting flustered and embarrassed as we usually do, why not try saying, “I don’t know.” And then just look at the guy like he’s some kind of idiot for pressing you on something which you have just told him you don’t know.

“I said I don’t know, Bob. What part of that don’t you understand?”

If enough people take a stand against abuse by not tolerating it the whole sorry house of cards built by the insecure to protect their fragile egos will come down. The worst thing that can happen, as long as you are reasonably respectful, is that you might get a bad evaluation here or there. The days are long gone when your attendings had the kind of absolute power over you that they once had. There is nobody at your hospital who can stand in front of a review board and explain how he has the right to mistreat his subordinates.

Still, you need to go through medical school with good humor. Most of your attendings and residents are decent people and their knowledge and accompishments should command respect. They have a duty to instruct you and this involves criticism. You need to be able to take legitimate criticism even if it is sometimes delivered with a little well-deserved sarcasm.

I can, however, tell the difference between criticism and plain old bad manners.

Mr. Smith Has an Epiphany

A Day In The Life Of..., Articles You Must Read, Emergency Medicine

I’ve got Your Back

It’s my wife. The pager displays our super-secret marital code for “Everything is all right. I just want to see how you are doing. Call me at home.”

“Hey baby,” I say when my lovely wife picks up, “How’s everything going?”

“I’ll be home in another hour. Sorry. Things are kind of busy tonight and I have a couple of patients I can’t sign out just yet…OK, I’ll see you when I get home…I love you too…bye.”

Mr. Smith sits in his hall bed and gapes.

“Don’t gape, Mr. Smith. Even doctors have families. Hard to believe, huh? You probably think that we live here which is understandable because we’re never closed and there’s always someone here when you come in with one bullshit complaint or another. It’s not like you’ve ever been turned away when you come looking for narcotics. You might not get them every time but somebody always takes you back, treats you with more respect than you probably deserve, and listens intently to your latest drug-seeking gambit.”

“In fact, I even like to go home at a regular hour if you can believe that. Sometimes I can’t because in this department we try to get a disposition on everybody before we leave, something I had almost accomplished until I made the mistake of picking up your chart. But why should I mind? My children will get to bed tonight just fine without me and I certainly spend too much time watching TV with my wife anyways. The importance of your chest pain, on the other hand, does not diminish just because you’ve been here six times in the last two months with a similar complaint. I’m pretty confident that you’re going to be just fine but I’d feel bad chasing you out if this time, and I’m just talking here, it was a real heart attack. I don’t see how the world could get along without your vibrant soul.”

“Oh no. Don’t get up. Sit. Stay a while. I’m on a hunt for cardiac enzymes and this time your blood is going to score! The normal EKG was disappointing, I’ll admit, but your constant “ten-out-of-ten” chest pain radiating up your neck encourages me. This could be the big one. You’ve just got to believe, Mr. Smith.”

“Are you falling asleep? Brave soul! Your pain is so intense that it is no wonder you seek the oblivion of slumber. It was even untouched by the morphine I reluctantly gave you before I realized who you were. I’d give you something stronger but I’m at a loss for what to give except that we both agree it probably starts with a “D”. How can you expect me to remember its name if you can’t?”

“I understand what you mean when you say that you have no power and the man is sticking it to you. On the other hand, here we are. I have a college degree, two years of graduate school, a medical degree and two years of residency training. My attending has all that plus a few years of a fellowship. You may have not graduated from high school and be the most hard-luck guy in town but you have the power to make us dance like trained monkeys just by uttering three little words:”

“My chest hurts.”

“Now that’s power. Not to mention our highly skilled nurses cleaning up your urine and the fine technicians in our lab feverishly analyzing you blood as if you were the great Tsar of Russia himself.”

“So no, I don’t mind seeing you. The paper work is not too bad. I feel kind of silly writing out your discharge instructions seeing as we’ve done it exactly the same many times before. I know you get a good laugh out of “Return to Emergency Department if pain returns and is not relieved by nitroglycerine.” I think it’s funny too. Especially that part about following up with your primary care physician. That guy is always out of town. How on earth can you follow up with him?”

“Don’t worry, Mr. Smith. I got your back. You’re covered. Sleep, gentle spirit. When you awake I hope to give you the good news that your heart is fine and Motrin, not narcotics, will ease the pain.”

Tomorrow Will Suck

Articles You Must Read, Third Year, Uncategorized

Third Year in a Nutshell

I wasn’t really looking forward to patient contact. Because we spent all of first and second year far removed from the clinical practice of medicine I paid lip service to the idea that something was lacking in our medical education but to tell the truth, we had a pretty good racket going. We made our own hours, had no responsibility to speak of except the relatively easy task of passing a test now and then, and it seemed at the time that we had always lived liked this and always would. First and second year of medical school are like an endless vacation once you get the hang of things, especially if you have worked at a real job before going to medical school. We had people slime into class in what looked like their pajamas and flip-flops. How tough could it be?

So other than a few tense moments early in first year when it seemed like the body of medical knowledge we were asked to review was terrifying and impossible to assimilate, I rather enjoyed the first two years of medical school and dreaded the inevitable start of third year. I pretended to be excited about it, and it was true that this was an important milestone towards actually getting done with medical school, but I’d be lying if I said I looked forward to what I knew would be a complete loss of freedom. We had six weeks off at the end of second year. I used almost five of them studying for Step 1, after which I took a deep breath, looked at the sun and stars for the last time, and tried to stretch my last week of vacation out as long as I could.

The first day of third year was orientation and included a tour of the hospital, that big mysterious building attached to the medical school which we seldom visited as it had nothing really to do with us. The usual paper-work and disclaimers were signed and by noon we were done and given instructions to page the Chief Resident of the services to which we were assigned. My rotation group was starting on Surgery and I was assigned to Vascular for the first month along with another person from our rotation group. We paged the Vascular Chief and hit our first snag. There was apparently no Vascular Chief Resident, just the attending and a couple of upper-level residents rotating through the service who were themselves just starting. We eventually got in touch with one of them who was post-call from his previous rotation and he seemed far from thrilled to hear from us.

“Just meet me on the seventh floor at five tomorrow morning,” he snarled into the phone.

“Ask him if we can do anything today,” suggested my classmate.

“Are you crazy?” I asked as I hung up the phone. “Tomorrow is going to suck, I can feel it. Might as well have one more easy day. I’m going home before somebody changes their mind.”

That’s third year in nutshell. Tomorrow is going to suck, just like today and the day after tomorrow. I think I knew this instinctively.

I went home, moped around the house all day, went to bed early, and five o’clock in the morning found me standing nervously at the nurse’s station on the seventh floor regretting my decision to go to medical school. On the first day of third year you are the most ignorant and purposeless person in the hospital. Everybody else has a job. Even the janitors have an enviable purpose while the newly-minted third-year medical student stands around impotently in his brand-new short white coat trying to stay out of everybody’s way.

We managed to track down our resident who was annoyed that we hadn’t started seeing patients. He threw the census sheet at me and told me to go see the first three patients on the list.

“What am I supposed to do?” I asked innocently. At this point I had only the vaguest notion what vascular surgery was and I had put off researching it ever since I got the schedule. I was too demoralized to study anything about it the night before so I really had no idea what kind of patients we would have.

The resident cursed and made a snide remark at my expense.

“Just go in and see how they’re doing. Jesus, don’t they teach you anything? Take down their dressings and we’ll check on them when we round.”

It was dark in the patient’s room, which was to be expected considering it was only a shade past five AM. I groped for the light switch which glowed at the head of the bed and gaped in the flickering lights at my very first honest-to-God patient as he dove under his sheets and cursed at me for waking him. Later, of course, I would come to realize that if we didn’t wake our patients at all hours and stick them for blood every morning they might come to think they were in a hotel and we would never get rid of them. On that particular morning however, I was mortified and embarrassed to be so rude.

“Um, how are you doing today?”

“Fine, go away.”

I considered beating a retreat but noticed his bandaged left foot sticking out from under the covers. The smell was incredibly bad, like road-kill on a smoldering Louisiana highway. Trying to breath out of my mouth I unwrapped the bandages to reveal a shriveled foot ending in five blackened, gangrenous talons.

“What do ya’ think, Doc?” he asked, “Are ya’ goin’ to cut ’em off?”

“Uh, that would be my guess, sir. Have you passed gas today?” I don’t think this was relevant but at orientation they had said that every surgical patient needed to be asked this so not having anything better to say, I thought I’d buy some time to collect my thoughts.

The rest of the exam pretty much followed that stellar beginning. I pretended to listen to his heart with my brand new stethoscope, pretended to listen to his complaints, and then excused myself to go see the next patient. The other two patients were pretty interchangeable with the first except one only had one leg and the other had gangrenous toes on both feet.

I was beginning to see a pattern, the first of many in my long medical education. Feet need blood or they die.

At about six AM the attending physician showed up and we fell into line behind him as he walked down the hall. He stopped at my first patient’s room and then he and the resident looked at me contemptuously and expectantly.

“Mr. Smith is a 45-year-old man with a history of poorly controlled diabetes and peripheral vascular disease,” I began.

“Never mind that crap,” snapped the attending, “Are his vitals stable and did he have a fever last night.”

I honestly didn’t know.

“Well, Student Doctor, don’t you think it would be nice to know a little bit about your patients before rounds?”

At which point I realized that this guy would probably have his ass kicked every day if he worked in any other place but an academic teaching hospital. This was another pattern I discovered that day, namely that medical schools select for assholes.

The rest of rounds were equally enjoyable. Finally the attending told me to “just shut up” and I followed in humiliated silence. My classmate didn’t do too much better.

“The first case is at eight. Do you think you two can find the OR or do I need to draw you a map?” The resident clearly enjoyed our suffering. I noticed that the attending wasn’t too thrilled with him either.

“Man. This sucks,” said my classmate as we scrambled to write our notes, “I can’t believe we have a month of this shit.”

“Two years, my friend, two years.” The excitement of being a third-year medical student had lasted about ten minutes.

Surgery was awful. I contaminated myself twice while gowning and had to repeat the whole procedure to amuse the scrub nurse while we waited for the attending. “Next time get your own gloves and drop them on the sterile field,” said the circulating nurse. I don’t work for medical students.”

“Stand here, hold this,” was about the extent of the conversation for the entire four hour procedure except when I was asked some piece of medical trivia, the answer to which I invariably did not know. After a while the attending even got tired of that. He was pretty friendly with the nurses but I could tell they knew their place. The procedure was incredibly dull after the initial thrill of seeing somebody’s leg flayed. Harvesting a vein is pretty meticulous work but there’s really not that much to see. I fought to stay awake.

The rest of the day passed slowly. I tried to hide in the back of noon conference to avoid having to answer questions. This never works and I only later discovered that if you sit in the first row you almost never get pimped. More surgery in the afternoon followed by a repeat of morning rounds where I knew almost as little about my patients as I had in the morning. We finally got out of there at around seven. I was thankful not to have “trauma call” which we had every sixth day for the entire two months of surgery.

You’re supposed to study on your own for the Shelf exams but this is really hard to do during most of third year. Eventually you learn to carry around a little pocket review book and study a little here and there as time permits. But studying after a fourteen hour day with nothing to look forward to but more of the same was not very appealing at the time. Studying during first and second year is easy because it’s your only job. During third and fourth year (and residency) you have to study on top of having an incredibly strenuous and oftentimes humiliating job.

Third year got better. But not much.

Son of Random Madness

Emergency Medicine, Uncategorized

I Hope This Doesn’t Catch On

Vanilla extract tastes just like schnapps and has almost the same alcohol content, at least according to one of our frequent fliers who finally sobered up enough to tell me why he was shop-lifting the stuff. Not only that but because it’s not considered an alcoholic beverage nobody really watches it in the supermarket. I was incredulous, of course. You’d have to drink twenty or thirty of the little bottles to get a buzz and that many bottles might be hard to steal.

“Nah,” he said, “They sell it in half-pint bottles at Sam’s Club. I almost made it out the door with a gallon of it before security tackled me.”

But obviously not before he had imbibed a huge quantity of the stuff. The room smelled like vanilla and I imagine if he took a crap it would smell like grandma baking cookies.

Sometimes he comes in smelling like almonds and oranges, a couple of other popular extracts. It’s quite pleasant, really, especially compared to the usual urine and vomit smell of the less creative drunks.

What Do You Expect From Us?

Empathy training is the latest fad to hit medical school. Large quantities of your time will be wasted on this sort of thing. I didn’t dislike empathy training. In fact, because it is so non-rigorous and intellectually vaccuous it provided a pleasant distraction from the usual boring lectures. What’s not to like about sitting in a circle listening to some idiot drone on about the wonderful things you are going to do for your patients once you learn to relate to them? It was even more entertaining to listen to the small minority of students who take this kind of thing seriously and wax orgasmic about making a difference and touching the lives of patients.

In medical school they make a big deal about empathy, doing things like throwing you into incredibly unrealistic standardized patient exercises where you have a careful conversation that touches all of the patient’s socioeconomic and psychosocial high points. You will never do this in the real world unless you are a psychiatrist. You don’t have time. Even in Family Medicine, the paragon of empathy, you will only have 10 or 15 minutes with your patient, barely enough time to address the chief complaint.

Why is it important that you care, anyways? I spend my day providing high quality medical service that is indistinguishable from the service provided by somebody whose heart bleeds for their patients. You can get into a deep meaningful conversation with your welfare mothers on how hard she has it are but how is that going to change your treatment? Are you going to find her a better job? Are you going to follow her home and protect her from her abusive boyfriend? Will you snatch the cigarettes from her purse and shame her into eschewing the things forever?

Of course not. This is why all the empathy crap (and “community medicine” for that matter) is so useless. You can feel everybody’s pain and give your patients a shoulder on which to cry but at the end of the visit they are still as fat, unemployed, lazy, ignorant, drug-addicted, and hopeless as they ever were. If you’re lucky you will have at least addressed their chief complaint and they will go home with a UTI on the way to being cured.

When you try ot whip some empathy on them by pretending to care, they may decide to take you up on your caring and then you’re stuck. You can either back-peddle and admit that they’re on their own or you can spend half your day trying to get them food stamps, disability, or whatever they feel entitled too including your time.

What you’re going to do is give them their Ciprofloxacin, look sad and wise, and say, “Thanks for coming, if it still burns when you pee come back and see me.” That’s what all of that idiotic empathy and “caring” indoctrination shoved down your throat in medical school comes down to. You simply don’t have the time to be a social worker unless you are willing to work for nothing. I have worked in clinics giving services primarlily to the poor and even the shiny, happy doctors who make this kind of thing their life’s work can’t do much more than a hoary old conservative like me. And they grow to despise many of their patients, something I don’t because I don’t have as much emotionally invested in them.

A good rule of thumb is to never order a test or ask a question if you are not prepared to deal with what you find out. If you inadvertantly ask a patient if he has chest pain and he says he does, you must either work it up or find some legitimate reason to exlude a cardiac etiology even if the guy only came in with a case of the clap. The same should apply to psychosocial issues. If you can’t help the patient find a job or get her boyfriend to pay his child support then it’s none of your business and asking about it sets up a false expectation in your patient. If all you want to do is offer some sympathy then you are being incredibly selfish by trying to win admiration for your caring without actually doing anything to help.

The big myth of Medical School is that you will be some kind of compassion demi-god who will have a significant impact on the lives of your patients.

You know the question we ask a lot in the Emergency Department?

“What do you expect us to do for you today?”

This is usually asked to somebody with a vague, mostly psychosocial complaint. It takes people aback. What they want and expect is for us to cure them of everything that’s wrong with their lives which is impossible to do.

Humility 101

Residency, Uncategorized

Are You a Real Doctor?

They hand you your diploma and you are transformed from a medical student to a physician even though you don’t feel any different and you probably consider yourself to be something of an imposter. I know I did. For months after I graduated I had to suppress laughter whenever somebody called me “Doctor.”

This is natural. You will feel more like a real physician during the end of fourth year than you will at the start of intern year. A fourth year medical student is the dominate predator in his own isolated food chain. You don’t have much real responsibility, your residents take all the heat, and you actually do know a lot of medical trivia, much of which you will forget by the middle of intern year. Not only that but you can look with contempt at the ignorant first and second years running around and justifiably feel that you know a whole heck of a lot more than they do, both practically and philosophically. As an intern, you start with less knowledge than you had in fourth year(because medical facts have a short shelf life) but suddenly you are not only responsible for for patient care but everybody from the nurses to the techs expect you to make decisions.

You do actually exist in a parallel environment with the house staff when you are in medical school. If every medical student called in sick no one would probably notice. If the residents went on strike the hospital would grind to halt. Only the nurses are more important to actual patient care.

In fourth year you also have plenty of free time giving you ample time away from the hospital to imagine what a great doctor you will be. It’s no wonder that you feel pretty good about yourself most of the time. This has a lot to do with it being more enjoyable to pretend to be a doctor rather than being one.

So sometime early in your intern year a patient is going to accuse you of not being a real doctor and this is going to hit mighty close to home. You could lecture them about the validity of your doctorate-level degree which legitimately confers on you the title “doctor.” Deep down, however, you’ll have a suspicion that they are right…that you are some kind of poseur who slacked his way through medical school and is not worthy of the public trust.

The public who are largely ignorant of how doctors are trained fall into three broad categories. One group believed you to be a physician even while you stumbled your way through first year medical school. Parents and relatives fall into this category. My in-laws started asking me for medical advice the day after I was accepted to medical school even though pretty much everything I knew was gleaned from watching ER. They have never stopped asking me for medical advice and I find that the more I know the less I tell them, my typical response to a questions being, “You need to see your doctor.”

I’m more confident in what I know but paradoxically more humble in the realization of what I don’t.

The other group confuse medical students with residents and will never cut you any slack. These are the people who come to the hospital and ask that no residents be involved in their care under the assumption that residents don’t know anything and an attending will be better able to manage their day-to-day care. The attendings find this amusing because one of the reasons they went into academic medicine is to have a team of residents helping them with the more mundane aspects of patient care leaving them more time to devote the big picture. Not to mention that a good upper level resident is at his peak of medical knowledge. There are doctors out there who haven’t read a book or journal article since the Carter administration.

I had a patient insist that only the attending put in her central line even though I have done many of them recently and all relatively effortlessly. The attending hadn’t done one in years. He was eventually able to convince her to let me do it while he supervised.

The third group are largely ignorant of anything to do with medicine and will pour out their chief complaint to the phlebotomist if she’s wearing her white coat. It’s all the same to them. They trust authority to the point that anybody who works for the giant hospital is automatically able to solve their problems. I once walked into a patient’s room and found the patient berating a student volunteer for not writing her a prescription for pain-killers despite his protests that he was just there to get her a pillow.

So stand by. If your self esteem totally depends on what others think then you are in for a rough time. You jsut can’t please everyone. My brother-in-law who has something of a complex where I am concerned will never admit I am a doctor. He keeps moving the goal post and now insists that I will only be a real doctor when I am out of residency, not just licensed.

He’s an ass. The point is not to let this bother you. If you act like a physician, people will treat you like one. This means that you must be confident. But not reckless. If you don’t know something, admit it. It is no crime, for example, to ask the respiratory therapist for his advice. He’ll be happy to give it to you. He will also appreciate if you make a timely decision on his advice, even if it is only to consult with your senior resident or attending and get back to him quickly.

Those of us who are older have a considerable advantage because the grey hair doesn’t hurt. On the other hand I have a friend who looks 16 but has such good bearing that if he told his patients he ran the hospital they’d believe him.

Spectator Medicine

A Day In The Life Of..., Emergency Medicine

Emergency

Mrs. Jones looks like a cadaver. Her bony yellow legs stick out of the bottom of the gown. A pack of relatives clutch at each of her claw-like hands and stare confidently at the monitor over the bed.

“She’s doing better, right?” Her blood pressure had been coming up steadily. A great-grandson reads the numbers to the relatives standing in the hall who nod in relief.

“We’re giving her fluid. She was pretty dry when she came in.” I am not nearly as optimistic.

Mrs. Jones came to the Emergency Department from her nursing home. According to EMS a nurse had noticed that she was looking more cadaver-ish than usual and became alarmed when she couldn’t get a blood pressure.

“Her doctor said not to give her fluids.” The daughter is the spokesman for the relatives. “He said it would flood her lungs.”

Mrs. Jones’ medical history reads like a pathology textbook. Her congestive heart failure is the least of her problems at this point as it’s competing with severe hypovolemia, probably from diarrhea over the past several days.

“Her lungs sound pretty clear. We’re waiting for the chest x-ray but I’m pretty sure she can tolerate a lot more fluid than we’ve given her. We can always take some of the fluid off later but her organs need fluid now.”

The daughter holds up her hand.

“We want to speak to a real doctor. Our doctor told us to keep residents away from her.”

“I am a real doctor,” I say pointing to my ID badge. The family looks suspicious.

“The other doctor who was in here said she didn’t need that,” says the daughter pointing to the small bag of levophed dripping into her central line. “He said it will make her lungs fill with fluid.”

That must have been my medical student. Or maybe one of the janitors. They clearly don’t buy my explanation of the role of pressors in shock. The daughter throws me a dark look. I promise to get a real doctor to answer their questions.

Several hours later and Mrs. Jones still looks like a cadaver. According to the monitor Mrs. Jones is doing fine though she clearly has one foot in the next world. Her daughter who has become adept at reading the numbers is annoyed that we have not stopped the pressors and have not removed the endotracheal tube, something she insists we do immediately. I don’t think she’s going to be very receptive to the discussion of code status once her mother gets up to the ICU but the prognosis for her mother is grim, cheerfully normal vitals notwithstanding. Mrs. Jones is fighting myelodyplastic syndrome which has converted to leukemia, something I only discovered when I browsed through her old records.

“Why does she need to go to the ICU?” asks the daughter.

“Because she’s dying. The only things keeping her alive are the fluids and the ventilator. I hate to be blunt but surely you are familiar with her medical history.”

“Her doctor said she still had at least six months. You’re not even a real doctor. What do you know?” Some of the relatives look embarrassed. The alpha-relatives, however, are clearly not impressed with me and mutter darkly about a second opinion.

“Let’s get her up to the ICU and you can talk to her oncologist in the morning.”

Mrs. Smith has fibromyalgia. I have hardly introduced myself before her husband mentions this twice. My attending laughed when I picked up the chart. Mrs. Smith is well known to the department. A quick check of the computer shows fifteen visits in the last year for similar pain. She writhes in agony on the bed.

“How long have you had the pain,” I ask, grimly determined to think the best of her.

“Since last night…I’m paining real bad…All Over.” By this time she has learned not to point to a specific spot as we have a distressing tendency to take people at their word and order all kinds of inconclusive and painful tests and studies.

“She gets like this a lot,” says her husband, clearly distressed, “You guys never do nothing for her.”

Normal physical exam. Mrs. Smith has still not caught on that when I am listening for bowel sounds I am actually palpating her abdomen with my stethoscope. Sometimes you have to distract the patient. Neither is there anything unusual in the review of systems or the history except for pain.

“What do you take for your pain?” Her old charts record a bewildering array of pain medications. “Let me try you on some Motrin.”

“I want to speak to a real Doctor,” she says.

The nurse mentions to me that “pain lady” was sleeping soundly just minutes before I opened the curtain.

Mr. Simon’s mother hold the basin as he heaves and vomits a large quantity of red-colored fluid, spits to clear his mouth, then lays back in the bed and continues to curse at the nurses. I’d ordinarily be alarmed but the paramedics told us that his neighbor thought he was hypoglycemic and force-fed him a bottle of fruit punch. His vitals are stable and he’s not tachycardic. On the other hand alcoholics are susceptible to upper GI bleeds from ulcers, varices, and esophageal tears. We send a sample of his vomit to be tested for blood and I make sure to order a type and screen but I don’t think he is bleeding. His blood counts come back normal a few minutes later and his vomit is negative for blood.

“If you stick me again I’m going to kick your fucking ass,” yells Mr. Simon to the respiratory therapist by way of introduction. Aside from being drunk, diabetic, and high on heroin, Mr. Simon’s immediate medical problem is the inability to maintain his oxygen saturation without supplemental oxygen. When he takes off his mask, his oxygen saturation falls to the high seventies. Mr. Simon is only 29 and a heavy smoker but this is definitely not normal. I want to get an arterial blood gas on him. If he thinks the respiratory therapist is hurting him he’s going to enjoy it even less if I have to stick him.

“Stop cursing at the nurses, Mr. Simon,” I suggest gently, “They’re trying to help you.”

“I’m paying your fucking salary,” screams Mr. Simon. “I don’t need this shit from you.” Mr. Simon is what is optimistically known as “self pay” meaning he wouldn’t pay his medical bills even if he had the money.

According to his mother he went on his current binge after being dropped by his girlfriend. He had stopped taking his insulin a day before and his presenting blood sugar was too high to be read by the glucometer. The complete metabolic panel pegged it at 769 which is pretty high but everything else wasn’t too far out of whack. He also had a normal anion gap which was unexpected as the assumption was that he had diabetic ketoacidosis. His potassium was normal so we started him on a modest insulin drip.

Mr. Simon is a mystery. A rancid, abusive, tattooed enigma. His chest films are normal, his respiratory rate is normal, and his GCS is a solid 15. His ABG confirms both a mixed metabolic and respiratory acidosis and a low oxygen saturation. Pulmonary embolism? His D-dimer is low so he’s not making it easy for us. Aspiration? My senior resident starts him on clindamycin as a precaution but would he really be so hypoxic so quickly? Physical exam pretty normal too except that he feels clammy.

Maybe it’s cardiac but unfortunately is EKG is normal. Maybe the cardiac enzymes will give us a clue. I ask him about chest pain but as Mr. Simon answers some variation of “fuck you” to every question, the review of systems is probably going to be a little sketchy.

“Yeah my chest fucking hurts,” He says.

Surprise, surprise. “What does the pain feel like, Mr. Simon?”

“Have you ever had your heart chewed up and then spit back into your chest? That’s what that bitch did to me.” (He points to a scruffy looking young lady who has crept into the room and now shirks against the wall.)

“Not recently. Listen, is it some kind of metaphorical pain or does your chest really hurt?”

“Fuck you. I need to take a crap.”

He’s stable for now although it’s a struggle to keep his oxygen mask on. He keeps pulling it off and threatening to leave. While this isn’t a prison, he is drunk and high so I could restrain him if necessary. He definitely needs to be admitted and I ask the unit coordinator to break the good news to the medicine intern

Mr. Simon was admitted but bolted a few hours later before the source of his hypoxia could be identified. I imagine he is in some hole shooting up with his insulin money.

Mrs. Jones died in the ICU that day.

Mrs. Smith got six vicodin and left gravely disappointed.

Dark Side II

Uncategorized

Tolerating the Intolerable

(Just an addendum to the previous post in which we discussed Med School Hell, a subversive anti-medical school blog.)

I am not advocating Brother Stox’s point of view, nor am I condemning it. It’s his point of view and he’s entitled to it. Since I’m not a mind-reader I’m not going to speculate on his motives for going to medical school either. We all have our reasons and there is no wrong one.

But let me reiterate that everything in Stox’s blog is true. I have experienced everything he mentions and most of those things made me just as angry. It’s just that we arrived at different conclusions about the medical profession from the same information. I decided that I liked Emergency Medicine enough to outweigh some of the things I don’t like, Stox didn’t really like anything about clinical medicine and decided to cut his losses rather than make himself miserable to satisfy somebody else’s expectations.

I will say that I have never seen such disregard for other people as I have seen in medical school and during my intern year. As many of you know, I spent many years in the Marines, one of the hardest and most disciplined branches of the military. Unlike medical training where the hierarchy is unofficial and supported by nothing but usage and tradition, in the Marines the hierarchy is absolute law, codified in the Uniform Code of Military Justice and carries severe penalties for those who violate it.

I was a Platoon Sergeant and exercised a level of control over my Marines which most of you can not conceive and would never tolerate for an instant.

And yet, I would have been ashamed to treat my Marines in the casual, oftentimes cavalier way that medical students and residents are treated by their attendings and even other residents. One example of this is the all too common practice of an attending keeping his subordinates waiting without explanation at the end of day when most of us would like to go home. It would seem to be nothing more than common courtesy to at least call the senior resident and inform him of the delay, either allowing his people to go home or giving them a reasonable time when they may expect to round. Apparently it is beneath the dignity of most attendings to stoop to such courtesy.

And yet, my Company Commander, a man with the legal authority to send his Marines to their certain death, regularly passed the word to his subordinates to cut the troops loose for liberty if his staff meeting or other company business would delay his presence at the afternoon formation. This was considered common courtesy and is the the rule, not the exception in the Marines.

Additionally, in the Marines it is all right to dislike the Marines. Nobody ever questions your motives, acts hurt if you don’t pretend to like everything, or expects you to kiss up and be happy and enthusiastic all the time. It is enough that you do your job, carry your own pack, and look after your Marines. This is not the case in medical school. I’m sure Brother Stox had a difficult time with his attendings and faculty, many of whom probably disliked his honesty.

As you know, like Brother Stox, I also intensely dislike call, long hours, and the expectation that we need to devote our entire lives to medical training. I’m sure I’ve made this clear many times. I think call is ridiculous as it is usually just an excuse to use the residents as cheap labor. Blah blah blah. I know all of the counter-arguments about education and “patient care coming first” but this is all nonsense. We need to be on duty at all hours to admit and take care of patients. No question about it. But the way to do it is by having a shift system, not the inhumane practice of making residents miss one night of sleep out of every four or worse.

And I don’t care a bit for the 80-hour work week either. It’s better than 120 hours, of course, but it doesn’t go far enough. If residents knew how much money their hospitals get for their service, and if they weren’t also terrified of losing their jobs by stepping out of line, they wouldn’t tolerate for one minute both the long hours and the crappy pay. We only do because, frankly, the residency programs have us by the balls and they know it. It’s the same with medical school where as long as their are people willing (hell, begging) to be abused nothing is ever going to change.

Now, I like my new residency program a lot. The hours are decent, our attendings are fantastic, and the education is first rate. I also like nasty, smelly, dripping crack whores and other disgusting patients which Stox does not. I’m sure there are plenty of benign residency programs out there where the residents are as happy as is possible for the pitiful salary they earn. But there are also a lot of truly malignant organizations so you need to be careful, if quality of life is important to you, both of where and into what you match.

Take a Trip To The Dark Side

Uncategorized

Dead to Rights

I invite all of you to visit a very interesting blog called “Med School Hell,” the link for which you will find on the right. It is the diary of a disgruntled medical student who decided not pursue further training after medical school. I must warn you that his blog is not for the faint of heart or the easily offended. Those of you who are not yet in medical school will find most of your cherished beliefs about medical education not just challenged but assaulted, bayoneted, and left to die a lingering death with their entrails cooking on the hot sand.

It is, in short, very well written, extremely entertaining, and as thoroughly subversive a manifesto as you will find anywhere. And it’s all true. Every line of it. There is nothing he mentions that I have not either experienced myself or witnessed on many occasions as it was inflicted on others.

I recommend his blog to all of you contemplating a medical career, not to discourage you but only so you know what to expect.

Random Madness I

Residency, Uncategorized

Free Chow

Free food. Just another thing to consider when selecting a residency program. I’m not saying this should be one of the top three factors guiding your ranking decisions but if you have no other way to differentiate programs, I’d go with the place where you can eat for free. If you think about it, you have the potential to drop some serious money on food during almost any residency. Not to mention that it is more convenient to grab a bite at the cafeteria than to brown bag two or three meals a day.

I eat most meals at the hospital. I didn’t last year because the administration at Duke are cheap bastards and the most they could cough up was a paltry six buck on-call meal allowance at their over-priced cafeteria.

I also drink a lot of Cherry Diet Coke (the official soft drink of Panda Bear, MD), probably six or seven a day, which could otherwise be a very expensive habit if I wasn’t getting them for free.

So don’t be embarrassed to ask about this when you interview. If the cafeteria has Starbucks or equivalent coffee then you have hit the jackpot.

Call Schedules

Should you ask about call schedules when you interview or is this a sign of weakness?

Definitely ask, but ask the right people, preferably the residents and preferably at the pre-interview social event. Maybe you don’t want to seem pre-occupied with your free time when talking to the program director but, and trust me on this, by the first week of intern year almost every resident has lost whatever idealism they may have salvaged from medical school and they will perfectly understand your aversion to call and long hours.

Your call schedule will vary over the year. A standard call schedule is what is called “Q4” or every fourth night overnight call. “Q3” is not unheard of but it is difficult to stay in compliance on your hours with this kind of schedule. The surgery interns I worked with at duke were on “Q2” which meant that they did 24 hours on, 24 hours hours off. This doesn’t seem too bad but it will wear you out pretty quickly. Some more enlightened programs have Q5 or even Q6 call.

Intern year in most specialties is pretty standard as far as call is concerned. You will have a lot of call. Be sure to ask how many call months you have in the year. When I was at Duke last year I had eight months where I took call, mostly Q4. How much call you do as a PGY-2 and beyond is highly specialty dependent. Pathology, derm, and urology to name a few hardly do any in-house call after intern year and if they do, it is usually pretty benign. Medicine and Surgery, on the other hand, are call heavy for most of residency. Medicine call especially blows no matter what level resident you are.

So a good question to ask is how many call months you will take as an upper level resident. Personally, I would rank the programs highest that had the least call but that’s just me.

Also ask about night float. You want to go to a program that has night float as this usually means that the program has decided to make residency more pleasant by curtailing call, or at least making it less onerous. Generally, the night float is a resident who comes in after normal quitting time and leaves in the morning. It is a quasi-shift system as there may still be somebody on call. The night float, however, is supposed to do most of the admissions and handle most of the floor calls only waking up the on-call resident if things get really busy.

While doing cardiology at Duke, we had one week of the month on night float where we came in at seven PM and left at seven AM. Generally the on-call person got to sleep after midnight and the night float took care of business. The advantages of being on night float are legion and I would volunteer for it for all of intern year if I could. Some people don’t like it but I’ll trade vampire hours for not having to round, not having to present patients like a trained monkey, and not hanging around the hospital unsure of whether you can go home. The night float comes in, is relaxed and rested, does his job, and goes home in the morning. It is usually high quality training as you spend the night admitting patients, the key difference between this and being on call is that you are not too tired to give a rat’s ass.

A special warning about family practice residency training and something about which you should ask. Is family medicine more benign from a call point of view than, for example, medicine? Probably. But keep in mind two things. First of all, your program will likely have an inpatient service and you will pull call to admit and cover the Family Medicine patients who come to the hospital. The Family Medicine service is usually not as busy as the medicine service (unless you are at an unopposed program in which case you are the de facto medicine service) as they usually only takes bona fide family medicine patients who belong to your outpatient clinic.

I had a census of about 25 at any given time while doing pulmonary last month. The family medicine service has four or five.

A medicine service generally admits anybody from anywhere with various services taking their turn as “no doc” for the uninsured or unassigned patients.

Small or dying Family Medicine programs either have no inpatient service in which case you will spend a lot more time rotating on medicine services than you probably want to or they have home call where you can sleep at home, only coming in to admit patients. The medicine interns are usually called for overnight problems with these patients, either by formal arrangement or because the nurses know that it sometimes takes a Papal Bull to get a family medicine resident to come in. Some hospitals also don’t let Family Medicine admit or manage ICU patients which is probably another thing you need to ask about.

You will also have obstetric patients as family medicine resident and the custom is to call you in when your patient is in labor. This throws a whole new level of unpredictability into your life as you can be called in at any time to deliver one of your mothers. You will either be excited about this or you won’t but you’ve got to do it. You will also have to come in to admit your obstetric patients for other reasons besides labor. I like to think of it as having forty or fifty ticking time-bombs hidden around town any one of which can go off and ruin your weekend.

You know, sometimes when you’re managing real problems on the floor or admitting interesting and complex patients, call can almost be fun. Usually, however, it is just a grind. After you admit your fifteenth COPD exacerbation the thrill will be gone. So think about it before you rank programs.

Pulmonary Consult

A Day In The Life Of..., Articles You Must Read, Futile Care

Breathe

“I’m a difficult patient,” declaims Mrs. Olafsen proudly around a mouthful of Whopper with cheese. “Nobody knows what’s wrong with me.”

“Really? It certainly looks like that from your chart.” Mrs. Olafsen is gigantic. It took four nurses to get her from the stretcher to her bed. Her legs, like two scaly tree-trunks, encircle a greasy fast food sack which was supplied by one of her skinny daughters.

“I’m Dr. Bear, one of the Emergency Medicine residents working with the pulmonary service. Your doctor asked us to come take a look at you.”

There is a lot of Mrs. Olafsen to look at.

“They tell me you had some trouble breathing.”

“Oh yeah.” She carefully shifts her enormous body and gestures for her daughter to hand her the vat of soda resting on the night stand. “I couldn’t hardly breath when I came in. Isn’t that right?”

Her daughters nods furiously.

The chart does not do Mrs. Olafsen justice. Asthma, COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), NIDDM (Non-Inuslin Dependent Diabetes mellitus), PVD (Peripheral Vascular Disease)…all the usual abbreviations. Everything about her is larger than life. She actually looks and sounds pretty good, all things considered.

“I’ve had the flu or something for the last two weeks. I just couldn’t breath at all this morning and my daughter called the ambulance.” She roots in the bag for the greasy debris and finishes her drink with an exuberant slurp.

No kidding. She presented a few hours earlier in Status Asthmaticus, a sometimes fatal exacerbation of asthma which is refractory to the usual treatments. Imagine every small airway in your lungs clamping down tight. I read with interest on her chart that the use of heliox (a low-density mixture of oxygen and helium that results in less airway resistance) was contemplated but not used because she got better.

The oxygen going to her small tracheostomy hisses and bubbles in the humidifier. I see that she is at her baseline oxygen requirement and is “satting” in the upper nineties. Vitals suprisingly good. Her blood pressure is better than mine and she is the most alert and engaged patient I have seen all day.

Mrs. Olafson. Viking fertility godess surrounded by her pretty, reverential daughters. Nothing much to do, really, except write the usual admission orders and the standard prose on the admission HPI. (“46-year-old woman with a history of asthma presented to the Emergency Department in staus asthmaticus…etc. etc.”) However, If there’s one thing I’ve learned this month it’s that everybody can have a pulmonary embolus and Mrs. Olafson is a set-up for one. The D-dimer was equivocal so I order a doppler ultrasound of her massive lower extremities.

The ultrasound lab pages me an hour later.

“You’ve got to be kidding.”, says the tech, “It’ll take three of us just to lift her pannus out of the way.”

“Just do the best you can. I don’t think she’ll fit in the CT scanner.” I know it’s asthma but we’ve had a bad experience recently with a pulmonary embolus (PE) so the service is a little spooked. I examine my logic for ordering the ultrasound. A negative scan, by itself, does not rule out a pulmonary embolus which can only be confirmed or excluded by a CT 0f the pulmonary artery and it’s branches. A low D-dimer would have done it but it is high…but not that high. Why not just skip the ultrasound? We’re going to start DVT prophylaxis anyways.

“When will I get a bed,” asks Mrs. Olafson clearly tired of repeating her story to another guy in a white coat.”

“I don’t know. But we’ll get you upstairs eventually.” The moon will not set before I see Mrs. Olafson safely transferred and slumbering in semi-upright splendor. She seems melted in the flickering light of the television.

The Fresh Prince of Bel Air. I swear, it’s the only thing on at 3 AM.

Mr. Bomagard has died. An hour ago, the ICU informs me.

“Who?” I’ve never heard of him. I’m cross-covering.

“You know, the guy we coded for half an hour yesterday.”

Oh. That guy. I was at the code but it was very well-attended so I didn’t do much. An elderly and demented gentleman who checked out several months ago but whose body had been preserved as a museum to our arrogance and folly.

Mr. Bomagard actually died yesterday. He was in asystole for close to ten minutes before his heart was coaxed back into sputtering life. That was the best CPR I have ever seen. His arterial line measured optimistically normal blood pressure during compressions but trickled away to nothing when they were stopped. And he had the oxygen saturation of a teenager. He came back in stages. From asystole to ventricular-fibrillation at which point he was shocked, the response becoming more dramatic as the current was dialed up. He was finally stabilized in a tenuous sinus rythm on a continuous infusion of amiodarone. And three different pressors to keep his blood pressure up.

What were we doing to you, Mr. Bomagard? You have been in a nursing home for the last three years and haven’t spoken or moved in nine months. This was your fourth ICU visit in the last year. Maybe when you’re being fed through a tube, breathe through a tube, defecate and urinate through a tube…maybe it’s time to let you go. It’s not even a question of your dignity because we’ve taken that away from you. Your shrivelled naked body bounced to the rythms of chest compressions under the bright flourescent lights for ten minutes while your children looked on from just outside the door. Another minute and we would have called it off.

We should have let him go a year ago but families lie. The patient always perks up for them. He knows they’re in the room. It’s not much of a quality of life but we’ll take it. Please don’t let him die. We still see the man we knew in the contracted husk with the tubes and wires sticking out of him. You didn’t see him when he held his first grandchild or on our honeymoon before he shipped out for the Pacific. He’s still in there, somewhere.

He has to be.

“It’s not like they held a gun to my head and made me smoke,” says Mrs. Needlebacker between coughs. “I knew it was bad but I still did it.”

“Don’t beat yourself up, Mary,” I say, “We all have bad habits.”

“Do you, young man?”

“Well, I used to drink but my wife made me quit.”

Mrs. Needlbacker laughs then coughs. I didn’t really drink that much but what can I say? She is 65-years-old and lung cancer has got her in its death grip. When, in her 150 pack-year history of smoking did she realize it was kiling her? When she became short of breath working at her job as a cashier? When her need for supplemental oxygen finally overlapped into her entire day?

She has been coughing up blood. I write “hemoptysis” on my daily note.

“Can I do anything for you, Mary?”

“Yeah, let me out to smoke.” She laughs but she’s serious.

“You’re on oxygen. Your hair might explode.” If it was in my power I’d wheel her downstairs myself and let her smoke as much as she could stand. “Besides, those things will kill you.”

More laughter, more coughing. “No, you’re killing me.” We make the same jokes every day.

I will be off the service on Monday. We are transferring her to hospice in the morning.