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.

Saturday, July 15, 2006

Health News: HIV Triple Drug Cocktail

Category: Health News

WASHINGTON — The federal government on Wednesday approved the first HIV treatment that packs a triple-drug cocktail into a one-a-day pill.

Doctors say the salmon-colored pill will vastly simplify AIDS care and turn what a few years ago was a bothersome regimen of 20 or 30 tablets to one pill taken before bed.
To be sold as Atripla, the pill includes doses of three drugs now sold in the USA by two companies. The drugs are Bristol-Myers Squib's Sustiva and Gilead Pharmaceutical's Truvada, a combo of Viread and Emtriva.

Taking the trio as a single pill makes it less likely that patients will miss doses, which would allow the virus to rebound and become resistant to treatment, doctors say. Keeping the virus in check also helps lower the risk that a patient will infect someone else.

"To me, it achieves the ultimate goal," says AIDS specialist John Bartlett of Johns Hopkins University. "It's a pill you can take without regard to meals, it's about as potent a regimen as we have, and it's relatively free of side effects."

The Food and Drug Administration approved the drug in three months, as part of a fast-track process introduced two years ago, after research showed the pill is equivalent to the drugs taken separately. The wholesale price of a 30-day supply of the pill will be $1,150.88, the same as Truvada and Sustiva purchased separately, Gilead officials say. Atripla is expected to be on sale within four days.

Click here for the full article.

In this area, I've not had any experience with HIV patients. Oh, I'm sure I've probably chatted with them and not even known about it. It's not like people go around wearing a sign that says "I have HIV." But what I mean is that I never saw an HIV infected person as a patient, for the specific purpose of checking up on their HIV status. What little I know about the lifestyle these people have to lead comes mostly from TV and movies and a few lectures in the first two years of medical school, none of which could possibly convey what these people go through.

I think it's fantabulous that they've combined several pills into one. I'm sure that people who have to take these drugs will have at least a somewhat improved quality of life just because of it. But it's still expensive, expensive, expensive. One of the lectures I had in school about HIV/AIDS was actually pretty good. A comment was made that Magic Johnson has had HIV for years and years now, has never converted to full-blown AIDS, has a super low viral load, and may eventually be called "cured". Why? Because he has the money to pay for all the hottest and sexiest new HIV therapy. So, with lots of money and resources, does that mean this virus can be eradicated from someone's body? Does this make HIV a class-based disease then?

But back to the topic: I'm usually all for combining pills. Even in "ordinary" diseases like hypertension, I've seen in the clinic that combined pills really do improve compliance and therefore the health of the patient. I hope HIV patients who take the new cocktail enjoy their newfound freedom from having take 9 billion pills a day, and maybe even keep their CD4 count up for a longer time. If they can afford it.

Friday, July 14, 2006

You're a Doctor - You Should Know

Category: General

It's approximately one month after your very first year of medical school. The overwhelmingness of it all has eased just slightly. You've been through the glorious white coat ceremony. You're feeling a little less uncomfortable in your new surroundings. You've probably survived the first set of exams.

And then the phone call comes. It's Mom (or some variation of), who chats pleasantly and appropriately and ends the conversation with "Oh yes, by the way, your Aunt Virginia (or some variation of) is here and would like to say hello." You groan inwardly and wait patiently for Aunt Virginia to come to the phone. After just a very few seconds of introductory pleasantries, the conversation shifts to something like this.

Aunt Virginia: Honey, I've been having these headaches for about a month now. I've never had a headache before. What do you think they are?
Student: Um, well. There's a lot of things it could be, I guess.
Aunt Virginia: Like what? Do you think it's a tumor?
Student (helplessly): I can't just say whether or not it's a tumor. It could be lots of things.
Aunt Virginia: Like what? Do you think my brain is swelling? It is migraine headaches? After all these years?
Student (exasperated): I really don't know.
Aunt Virginia: Well, why not? You're in medical school! You're a doctor, aren't you?

Yes, friends and neighbors, right as you juuuuussst start getting used to everything, these types of phone calls and conversations come, initiated mostly by friends and relatives who don't quite understand that they still know just about as much about medicine as you do, and maybe more. They can't fathom it. Five seconds after your first classes on your first day, you're supposed to know it all.

So how do you handle such encounters? My first response is/was usually rather curt, but I tried to keep it polite. If the same person did the same thing to me again, I usually got pretty rude.
"I'm not a doctor, yet," I'd snap. "You need to be talking to your doctor about this, anyway." I know it sounds terrible, but enough is enough. Nowadays, as a fourth year, I don't have to do that as much, because I know slightly more about what the heck I'm talking about, but it still doesn't cease to annoy me.

Take heed, fellow doctors-to-be: Patients, friends, and relatives generally sort of gape and act confused and can't understand when you say, "I don't know." And many times, "I don't know" is the most honest and appropriate answer you can give.

Thursday, July 13, 2006

Procedure Repellant

Category: Clinical Rotations

Procedures? Not when I'm around, baby. No siree. I'm thinking I emit a sort of pheromone which mysteriously keeps away patients in need of the following: chest tubes, central lines, arterial lines, even stitches for Pete's sake.

But today was different. I got to remove two stitches!! Unbelievable!! Never mind that people remove stitches from their pets and themselves all the time with no trouble at all and no need for a dumb ol' doctor. I had instruments in my hand, today, darnit. And for about two seconds, I did something.

The people at the hospital I'm rotating in are great about letting students get it on procedures. So, it's not like nobody will let us do anything. There's one of my fellow students here in particular that attracts procedures and has gotten to do quite a bit. And I don't stand around and wait for stuff to fall in my lap either. I've tried to be proactive and say things like, "Will you guys call me if you do a [fill in the blank]?" Nothing.

I'm not a procedure-happy gal. I can be pretty clumsy when it comes to even simple things like stitching and injections, so sometimes the prospect of procedures (especially real procedures) makes me nervous. I wonder if maybe I'm avoiding them subconciously? Hmm...no...I really don't think so. I'm getting too irritated about not getting to do anything.

If you ever hear of a doctor who doesn't sew, inject, splint, cut, or stick, it's probably me. (sigh)

Tuesday, July 11, 2006

Flashback: Study Habits Part II

Category: Classroom Years

In my last post about studying, I blathered on about how I finally found a study method that worked for me, and got me decent grades. Now, I want to talk about how that study method is slightly crippling.

In undergrad, lots of the tests were multiple choice, but there were always some that had fill-in-the-blank and/or essay questions. Those questions couldn't be answered very well unless you knew the material pretty well. In medical school, all my tests have been multiple choice (including Boards, obviously). So I don't have to know the material as well. For example, a college exam type question might say "List the 5 deadly causes of chest pain" and you'd have to spout them off from memory. But a medical school exam question goes, "All of the following are deadly causes of chest pain except...." See the difference? No spouting off on medical school exams. It's all recognition, baby.

Now that served me just fine on written exams, but what about now? What about when preceptors ask me pimp questions? I can't just say, "Uh...give me some choices, will you?" And what about when I'm a real doctor and my patients say, "What are some things cause my condition?" I'll shake my head regretfully and say, "Sorry, that's a not a multiple choice question."

All right, maybe I'm exaggerating slightly. And that method will probably be okay for the second board exams I'm getting ready to take. But I'm not thinking it's the best technique for really, really knowing your stuff. I don't feel more miserably incompetent than any of my other classmates - I do generally get some pimp questions right and manage not to look too stupid, but I sometimes I wonder how much more brilliant I'd be if I'd studied the way I did in college. Only, I couldn't really study the way I did in college because there was way too much material to remember.

Shut up, self. You did fine. You're doing fine. Go study for boards.

Sunday, July 09, 2006

Duped

Category: Clinical Rotations

A woman in her early to mid 50's came to the Emergency Room because of an injury to her wrist. She had slipped and fallen, and her wrist was pretty swollen and tender. She seemed to be in discomfort but she wasn't screaming in pain or anything. The woman was very ordinary-looking, medium sized, clean, dressed in very ordinary clothes, pleasant, and sort of soft-spoken.

The x-ray of her wrist showed a possible fracture. We scheduled her for a bone scan for the next day, splinted her wrist and wrote her a prescription for Lortab 5 mg - six pills. The particular ER doctor that was working said he never wrote for more than six. I remember thinking, "Oh good grief - if that's really fractured it probably freakin hurts. He needs to give her more than six! It's not like this lady is some drug-seeker or something." But, of course, I didn't say anything. She thanked us and left, and we went about saving lives and doing good for the world.

About two or three hours after she'd gone, we get a phone call from the pharmacy over an altered prescription. Guess who? Nice, soft-spoken, ordinary, not-seeming-to-be-the-criminal-type wrist lady had turned the number 6 into 16. "What the h?" I thought to myself. "That's just insane! She's not the type!"

I've been told that after a few years of practice, doctors develop an eye for drug seekers. And they try their best not be fooled, but sometimes it happens. "Everyone's going to get duped," one of the ER doctors told me. "It's nothing to fret over, but it does sharpen you for the next time. Besides, there are people with real pain - what can you do?" He shrugged it off and accepted the fact that sometimes we would be fooled. Doctors try to keep the drug seeking to a mimimal by using narcotics contracts and developing personal policies on when to give controlled substances and how much.

I felt slightly stupid - I try my best not make too many assumptions and there I went. "She seemed like such a nice person," I thought. Well, what of it? Lesson for the day: The nicest seeming people can turn out to be the ones that treat you the crappiest, and the ones that seem to be the most troll-like might actually turn out to be truly sick.

Friday, July 07, 2006

The Problem with Choosing a Specialty

Category: Clinical Rotations

I've already eluded to this in an earlier entry, but I was utterly relieved to finally figure out what I wanted to be when I grow up. I was probably being a drama queen and a big fat baby, but I was convinced I was never going to find the love of my life and that I would be doomed to practice medicine in misery for the rest of my days.

The fact that I've chosen Pediatrics is strange because depending on my mood, when asked whether or not I'd consider it as a specialty, I'd either wrinkle up my nose and say, "Nah...I don't think I'm too interested in that," or "Good Lord no! Are you insane? Nasty, squawling little kids?"
Go figure.

Bu anyway, t the problem I've run into is this: I don't care nearly as much about learning other things now. At least when I didn't have a clue, I went into each rotation with an open mind, wondering if that rotation would be "the one." Thankfully, most of my core rotations are over. I just have to finish ER and I have Surgery in the winter, and the rest of the year is full of electives and subspecialties. So I guess I can say I entered most of my core rotations with an open mind.

I wonder how people who figure out what they want to do early on in their rotations have the discipline to make themselves learn about other stuff? All I want to do now is read Pediatrics so I can look terribly brilliant and impressive and wonderful when I do my electives. Silly, huh? I need to be studying more for boards and trying to get what I can about my ER rotation.

In short, I guess there's something to be said for both sides. Finding your passion early on is probably a great feeling. You can go ahead and look into student electives and residency programs, and have the knowledge you've at least found one thing you like. The downside is that it may be difficult giving 100% in your other rotations. Not figuring out your specialty till late can be so frustrating, but I think it forces you to be more open minded.

I think I'd rather find out early. The not knowing nearly drove me nuts.

Wednesday, July 05, 2006

Family Practice versus Internal Medicine

Category: Clinical Rotations

The difference between FP and IM? I have a better understanding of the differences between the two now than I did before - hopefully my information is at least semi-correct. To tell the truth I sometimes still find the differences blurred and confusing. Actually trying to diligently look up the differences didn't lead me to many answers. Asking around yielded better results.

One of the reasons such confusion exists is that in smaller towns with smaller hospitals, there is barely a difference between the two. Our family practioners here do tons of hospital work, take medicine call, and are nearly identical to the internal medicine attendings. The only exception is that in the clinic, the family practice docs might see a few kids and/or a few women for Pap smears. That's about it.

I've been told that if one lives in a real city with a real hospital, more of a difference between the two does exist. Apparently you'll see more family practioners who have ambulatory only practices(meaning that don't fool with hospital patients).

In addition, IM doctors get paid more. If an FP doctor and an IM doctor did the exact same procedure in a clinic, IM doctors get paid more for that procedure. Family practice residencies include more rotations in Pediatrics and OB/Gyn, and generally have a broader knowledge base. Internal medicine people aren't so broad, but are much more detailed and academic in their training. Supposedly, family practitioners are better-suited to work ER shifts due to their additional training in Peds and OB/Gyn. With internal medicine, you have the chance to subspecialize in cardiology, endocrinology, GI, etc.

For awhile I was considering either family practice or internal medicine, and wasn't quite sure which would be the best choice. If I were going to practice in a small, rural area like the one I live in now, I would probably go with IM since FP docs do the same thing for less pay. If I were going to live in a bigger place, the option of doing clinic only might possibly be attractive, and the differences between the those roles might be more defined.

Monday, July 03, 2006

The Incorrect Answer

Category: Clinical Rotations

Nurse: We have a patient in Room 2 that needs a joint injection. The doctor says you can come watch/do it.
Student: Oh, no thanks. I'm good. (returns to playing on the computer)

Student (to nurse): Could you hole punch these papers for me?
Nurse: There's a hole puncher right over there.
Student: I don't think you understand. You are the nurse. I am the medical student.

Intern: This patient's hemoglobin has dropped considerably. Go in her room and get a hemoccult.
Student: Oh, I don't really need any more experience doing rectal exams. I already know how.

All those answers are incorrect. You'd think medical students would know better wouldn't you? You'd think that even the freshest, greenest, newbie 3rd year would sort of automatically know the following:

  • Volunteer for procedures.
  • Don't turn up your nose at scut work. You're at the bottom of the food chain right now.
  • Remember: nurses can be some of the biggest help, or your biggest enemy.
  • What's appropriate to wear at the beach is usually not appropriate to wear to the hospital/clinic.
  • Try to show some enthusiasm whether or not you care about what's going on.

In other words, work hard and show up on time. I have classmates that don't quite understand these very simple concepts. So while we can probably never answer every single pimp question correctly, we can almost always have the correct answer to the kinds of scenarios listed above. The answer is usually, "No, I don't mind emptying the bedpan," "Yes, I'd love to stay late and be drilled with questions," "Of course I can single-handedly do this heart cath!" Okay..so maybe not the last one.

The point is, you can be the dumbest medical student ever, but hard work and willingness to try can go a long way in making your attending physician happy with you.