Wednesday, August 16, 2006

Personal Entry

No posts for probably several more days, at least. Maybe longer. I'm very busy.

Tuesday, August 08, 2006

The Perfect Doctor

Category: General

Now to be fair, doctors are not the only ones who can sometimes have rather unrealistic expectations of other people. According to many patients, doctors should always do the following.
  1. Be perfectly willing at all times to listen to you drone on and on about every ache and pain you've ever had, telling long stories filled with unecessary details about every car wreck you were in, while the other office rooms are filling up with other patients who have real problems.
  2. Call in any prescription at any time. Doctors should never be apprehensive about this. They shouldn't require that you actually come to the office so they can take a look at you. You need to save time and money. Who cares that writing and calling in prescriptions without actually diagnosing you is technically against the rules?
  3. Provide free services and advice. I mean, really, hamburgers and cigarettes and lottery tickets are okay to pay for, but health care? What kind of world is it when doctors get to charge so much for something that everyone ought to be entitled to anyway, right? You wouldn't dream of leaving Wal-Mart or McDonald's without paying for anything, but you don't mind a bit to say the receptionist at the doctor's office, "I'll just have to pay you when I can." Yeah, right.
  4. Have all the answers. Period. The phrases, "I don't know," or "I'm not sure yet" or "I've never seen anything like this before" should never be uttered.
  5. Never be pushy when it comes to health maintenance or general medical compliance. If a doctor is actually dumb enough to quit nagging their patients about those things, the same patient who got angry at being nagged will turn around sue their doctor when they come up with say, prostate cancer, saying, "My doctor never told me this could happen. He/she stopped offering those screening prostate checks and I would have eventually let him/her." But that's okay, that's what malpractice insurance is for, right? Sue away!

And there we have it: aggravation on both sides, doctors and patients playing nice on the surface, but secretly (and sometimes not so secretly) having evil thoughts and unrealistic expectations about the other. I wonder if it's always been that way? My bet is that the answer is yes.

Saturday, August 05, 2006

The Perfect Patient

Category: General

What qualities do doctors think make up "the perfect patient?" Here's a list of things I bet most doctors would love for their patients to do. Patients should:
  1. Wait patiently for their turn in the waiting room - even if their appointment is at 1:00 p.m. and they don't even get to have their vitals taken by the nurse until 4:00 p.m.
  2. Always be graciously understanding and accepting when they are informed by the doctor's office that their appointment has been cancelled and rescheduled. They shouldn't even be irritated just because they made arrangements all around that appointment for work, babysitting, etc.
  3. Be perfectly compliant in every way. If they need to lose 20 pounds, patients need to immediately set up an intense jogging regimen and eat only rabbit food, devoting all their concentration and energy on losing those 20 pounds. They also need to take all medicine prescribed whether it "agrees" with them or not. They should eagerly schedule themselves for all manner of yucky, invasive preventative screening exams such as yearly prostate checks, Pap smears, and colonoscopies.
  4. Be educated and proactive. All patients should at least know what medicines their on, know their dose and frequency, why they're on the medicines and know the basics of all their disease processes. Patients should always know when their most recent tests were performed and what the results were, e.g. mammagrams, stress tests, etc.
  5. Be uneducated and unproactive. Patients need not question everything. They need to shut up and do what they're told all the time. Doctors do not have time to listen to patients go on and on about the side effects of whatever medicine that they printed off Google and brought to the office with them.
  6. Be silent and agreeable when the doctor gives a vague rambling explanation or an explanation filled with fancy medical mumbo jumbo or no explanation at all for anything.

In going through clinical rotations, even medical students come to have unfair expectations of patients. What do we want? Do we want them to shut up, sit down, and do what they're told? That may be nice in a way, but isn't it frustrating sometimes when patients have no idea why you're doing what you're doing, and don't even know why they have to take the medicines they do? And don't care? Don't you want your patient to be at least a little more educated than that? But see, that's no good either, because then they ask too many annoying questions we supposedly don't have time to answer. And really, why can't patients understand that we're asking them to quit smoking for their own good? Don't they know anything? Never mind the fact that we ourselves are waddling down the hall, 20-50 pounds overweight, unable to stop eating ice cream and tsk tsking our patients who can't quit (fill in the blank).

Yes, patients, a doctor's expectation of you can be quite unfair, but there's a flip side to everything. Stay tuned for the next post entitled, "The Perfect Doctor."

Friday, July 28, 2006

The Subordinate

Category: Clinical Rotations

I'm tired of trying to be impressive and wonderful. I'm tired of being bossed around by interns, residents, and attendings.

I know that I still have a few years to go of trying to be impressive and brilliant. I have a few years of being bossed around, though the number of "bosses" I have will slowly diminish as I ascend the ranks and finally achieve the title of Almighty Attending Physician. I realize that even then I will have to do things I don't want to do, that some silly rules will always be hanging over my head that I have to follow, but I'm not talking about those types of things. I'm talking about always having to arrange my notes the way the someone else likes them, use drugs that someone else prefers, run tests that other people think are necessary. Oh, I realize that I'm still in the learning process - sometimes I have no idea what drug to use or what test to run or what course of action to take. Thank God for my "bosses" who know what they're doing, because there are times when I certainly do not. But as I progress, I do learn. I'm learning how I like to document things, and which medicines I think work well, and which tests and procedures I think are necessary. I know I don't know everything, but I am gaining confidence in some capacity, and sometimes I wish I could skip right to the end and be the boss.

I doubt I'm alone in this feeling, but it certainly didn't come quickly. I spent most of my third year feeling very dumb. But now as a fourth year I'm feeling much smarter. In internship I'm sure I'll be feeling dumber than ever again. Maybe that's the magical cure for Fourth Year Boss Syndrome.

Thursday, July 20, 2006

A Textbook Patient: Sepsis

Category: Clinical Rotations

Isn't it great when patients follow all the rules? And by that I don't mean patient compliance, like taking their medicine properly or quitting smoking or following a good diet. I mean when their disease process presents in a classic textbook fashion. Take today for example....

Our patient in the ER was a 21 year old female with left flank pain, back pain, vomiting and fever. No interesting past medical history except for a couple previous bladder infections and some ovarian cysts that weren't really givng her a problem. No surgical history at all, no medicines, no allergies.

Criteria for SIRS (Systemic Inflammatory Response Syndrome)
(1) Temperature >38 C or <36>
(2) heart rate > 90
(3) Respiratory rate > 20 or PaCO2 <>
(4) WBC count > 12,000 or <> 10% bands

If a patient meets any two of the above criteria, they have SIRS. Sepsis is SIRS plus a documented source of infection, usually bacterial. Our patient had:

1) Temperature of 38.6 C
(2) Heart rate of 136
(3) Respiratory rate of 24
(4) WBC count of 17,000

So not only did she meet all four criteria for SIRS, her urine came back all nasty and positive for infection, thus putting her in the sepsis category.

Now why can't all our patients be that way? It was extremely satisfying to watch all those factors neatly come into place and to see the diagnosis fall gently out of the sky and into our hands with such little effort.

But isn't there more to doctoring than that? Of course there is. The real challenge, the real test of a diagnostician is when patients bodies' do not read the textbooks. It's when patients present with all the symptoms of a certain illness, but their actual illness is something else, manifesting in an unusual way, causing physicians to go down bunny trails, misdiagnose, pull their hair out, frantically consult various specialists, and maybe even get sued.

A patient like today's is certainly gratifying, and I'm glad I can spot the obvious. That's step one. Step two is to have the ability to look beyond the normal, to spot the not-so-obvious, to think outside the box and (gasp) be creative. I hope that somehow I'm developing that ability as I bumble along.

Monday, July 17, 2006

On Being a Patient

Category: General

It's different going to the doctor now that I'm so much closer to being a doctor. I've often wondered how other medical students feel/act when they have to go see a doctor: any different? proud? knowledgable? less nervous? more nervous?

During first year, I believe we're still more on the level of a layperson as far as medical knowledge goes, but sometime during the second year, after a bit of pathology and pharmacology, we start to semi-understand the unnecessarily complicated vocubulary of the medical world.

I bet there are some of us who are just bursting with pride, just dying for the office staff, nurses, and doctors to be fully aware of our vast array of knowledge. "Oh my," you say, so terribly seriously, "My hemoglobin and hematocrit is low? I wonder if it's a hypochromic microblastic anemia? What is my mean corpuscular volume? You are going to do an anemia panel, aren't you? It's most likely iron-deficiency anemia, you know. It's one of the most common. I'm in medical school so I know these things. I was thinking about being a cardiothoracic surgeon. Go ahead, you can talk me like a colleague. I'm almost a doctor, anyway."

Heh heh - in a perfect world, no medical student would be so full of themselves, so anxious to show the world that they can understand and coverse with the Almighty Doctor in Sacred Medical Language. Of course we know it's not a perfect world. Another variation of show-off student would be I've-already-diagnosed-myself-so-here-are-the-tests-I-want-run student and his close cousin, I've-already-diagnosed-myself-so-here-are-the-prescriptions-I-want-go-ahead-and-call-them-in student. And what about I'm-in-medical-school-so-I-shouldn't-even-have-to-wait-in-the-waiting-room student?

Congratulate yourself on your brilliance silently, okay? Nobody else wants to hear it. Go to the doctor, sign in, sit down, shut up, and wait your turn. When you're called, walk - don't swagger - through the door, go to your little room, sit down, shut up, and wait your turn. When the doctor comes in, and begins the interview, use your knowledge and experience to help him/her instead of showing off. Try to not to babble, stick to the point, give as much information as you can, cooperate with the exam. When he/she is finished, use your knowledge again to ask good, pertinent, focused questions if you really have them - as opposed to just making up questions to provoke the doctor to say, "Wow..you know your stuff! Are you in med school or something?"

Sometimes, when we're feeling particularly competent and clever, it's tempting to strut a bit, throw around some medical lingo, and show the world that we're one of the cool kids in the medical profession. Ultimately, I try not to. One of these days, your doctor you're seeing as a patient might start pimping you worse than the most evil attending and/or professor you've worked with, and you'll end up feeling a whole lot dumber than you'd ever want to. A small degree of humility, friends and neighbors. It'll go a long way.

Sunday, July 16, 2006

Flashback: Anesthesiology


Category: Clinical Rotations

After I did a two week rotation in Radiology, I did a two week rotation in Anesthesiology - and it was a miserable. Why? Because I was terrible. The doctor I worked with set me one major, focused goal: get intubations. I was absolutely the most inept intubater ever. I spent most of my days in the OR feeling clumsy, uncoordinated, and very incompetent. I decided that if anyone ever needed an emergency intubation and I was the only one around, they'd just have to die. I was frustrated, disgusted, and sweaty. I practiced relentlessly on the dummy (whose poor lips were torn to shreds) to no avail it seemed. But the moral here is that persistence is the key. Right in my last two days, for crying out loud, I started getting those stupid intubations. First try. Even in people with teeth. I still didn't get a high enough number to satisfy either me or the doctor, but I had improved pretty drastically. I said to my doc, "I can't believe I'm finally getting these intubations on the last two days. If this were a month long rotation I believe I would have gotten the hang of it." He agreed with me, and I believe he was sincere and not just humoring me, and I felt better.


Besides, I did well on his dumb ol' quizzes and I successfully did a spinal block. I whined and begged to do epidurals but he wouldn't let me. He was pleased with my little anesthesiology pre-rounds and we got along very nicely. He was just as frustrated as I was that I was hopelessly pathetic at first. His responses ranged from, "C'mon, dummy, he doesn't have teeth for God's sake!" to "Is there something I'm doing wrong? Could I be teaching you better?"

But again: all's well that ends well. Finally. Anyway, that was my personal experience with that particular specialty, nightmare as it was. But anesthesiology has become pretty hot in recent years. Here are some stats.

  • Training: 1 transitional year plus 3 residency years for a total of 4 years
  • Average annual salary: $250,000
  • Subspecialties: Critical care, pain management, pediatric anesthesiology
  • Duties: An anesthesiologist is trained to provide pain relief and maintenance, or restoration of a stable condition during and immediately following an operation, an obstetric or diagnostic procedure. The anesthesiologist assesses the risk of the patient's condition prior to, during and after surgery. They provide medical management and consultation in pain management and critical care medicine.
  • Lifestyle: Generally speaking, great hours. Call is shared with other anesthiologists and nurse anesthetists.
  • Residency competetiveness: high

To learn more about anesthesiology, click here.