On Doctoring

Personal Entry

2006-08-16T14:41:00.000-04:00

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

The Perfect Doctor

2006-08-08T18:58:00.000-04:00

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.

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.
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?
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.
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.
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.

The Perfect Patient

2006-08-05T11:38:00.000-04:00

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:

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.
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.
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.
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.
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.
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."

The Subordinate

2006-07-28T00:10:00.000-04:00

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.

A Textbook Patient: Sepsis

2006-07-20T19:19:00.000-04:00

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.

On Being a Patient

2006-07-17T22:27:00.000-04:00

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.

Flashback: Anesthesiology

2006-07-16T23:30:00.000-04:00

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.

Health News: HIV Triple Drug Cocktail

2006-07-15T14:27:00.000-04:00

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.

You're a Doctor - You Should Know

2006-07-14T15:19:00.000-04:00

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.

Procedure Repellant

2006-07-13T23:37:00.000-04:00

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)

Flashback: Study Habits Part II

2006-07-11T19:00:00.000-04:00

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.

Duped

2006-07-09T20:40:00.000-04:00

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.

The Problem with Choosing a Specialty

2006-07-07T21:11:00.000-04:00

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.

Family Practice versus Internal Medicine

2006-07-05T23:02:00.000-04:00

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.

The Incorrect Answer

2006-07-03T13:27:00.000-04:00

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.

Emergency Room TROLLS

2006-06-29T21:14:00.000-04:00

Category: Clinical Rotations

"28 year old male with possible seizure activity..."
crackled the voice over the radio. The paramedic giving report then proceeded to dutifully give history and vital signs and such, but nobody heard it. All we heard was the first line. We knew who it was.

A troll was coming in to waste our time.

In the brief time I've spent in the ER so far, this made the 2nd or 3rd time this guy came in on my shift, and the regular ER staff sees much more of him..much MUCH more.

He comes in several times a month having "seizures" that are only relieved by Xanax or sometimes Ativan - IV, always IV. Lately he's taken to being nauseated as well, because then he gets to have some Phenergan as a super fun bonus.

Seizure guy has been dealt with in various ways here, from being taken seriously and completely worked up to being pretty much brushed off. One time he was discharged without any of his goodies and he literally threw himself down on the ground, wrapped both arms around a nurse's legs and begged for drugs. "You've been discharged," the nurse had told him. "There's nothing I can give you now. Go on home."

So what did he do? He stormed out of the ER treatment area and into the waiting area, flopped down in a wheelchair, and had a "seizure." He was re-triaged, re-registered, and got his kicks.

So back to today. "He can go to triage," the triage nurse said in a bored voice as the paramedics wheeled him in. It hadn't gotten very busy yet and there were plenty of beds available, but to triage he went. Trolls often use the poor ambulance services just because they know they'll usually go straight to a treatment room instead of the waiting room.

Troll (whining): Don't you have a room open? I don't think I can walk!
Triage nurse: Oh you don't have to walk. We'll take you in a wheelchair.
Troll (whining more): But I might have a seizure, and if I do a wheelchair won't hold me.
Another nurse (curtly): You'll be all right.

Cold, aren't they? Rotten, cynical, hateful nurses! Don't they know they're supposed to be filled with compassion, dripping with sweetness, and always wear ridiculous white hats?

Trolls like that guy make everyone more tired, less loving, less patient, and a lot grouchier. We have some patients that come to the ER with a migraine, for example. And because they know that "chest pain" are the magic words that will move them to the front of the line and perhaps get them some morphine, they claim chest pain, causing us to spend money on a bogus cardiac workup based on a lie.

And what about the prison inmate who bashes his head agains the bars until it splits open, just so he can get out of jail for awhile and come waste our pefectly good oxygen with his presence?

What about the "kidney stone" patient who cuts herself and drips blood into the urine sample she's been asked to give so we'll all be convinced of the excruciating pain she's in? And let's not forget that she's "allergic" to every non-narcotic painkiller ever made.

The list goes on, each example more pathetic and ridiculous than the one before. But while the nurses in this ER may be jaded and tired of playing ames, they still manage to somehow muster up compassion and kind words for the truly sick. They still manage to at least sometimes give people the benefit of the doubt. I'd like to think I'm like that as well: somewhat suspcious, taking no crap, but being careful not to jump to wrong conclusions or be negligent. Concerning a different troll a couple of weeks ago, one of the ER docs said this: "You know you're wasting your time with this person. But you have to take this seriously as much as is reasonable. They very day you brush off someone as crying wolf or drug seeking will be the very day something really is wrong with them. Don't let that happen to you."

Hitting the Wall

2006-06-28T23:50:00.000-04:00

Category: Clinical Rotations

Around midway through my third year, I hit a wall. I had made a mistake and it was all very unfair. I did not want to do medicine anymore. It was a bad decision. Wrong career choice.

I believe part of it was because my Family Practice and Internal Medicine rotations were all globbed together and there was almost 4 months straight of getting up too early to see hospital patients and dictating large numbers of charts and keeping up with all kinds of details about patients and their lives and their diseases and being on call a lot. Family Practice and Internal Medicine are very broad specialties - there's a lot of information to try to remember. I decided if I had to walk through those hospital doors one more day I would go insane, and do something like poison all my patients, or start rapping over the hospital PA system.

Another factor in my newfound disgust, fatigue, and boredom with the profession I hadn't even begun yet was that I still hadn't found "the love of my life." That's part of the reason we do third and fourth year clinical rotations - to help us figure out what we want to be when we grow up. Several of my friends had already found their niche and were all glowing and in love with some specialty. I suppose it was silly to compare myself with my chums. Just because they had found the love of their lives before I did shouldn't mean I would never find it? Right?

Thankfully I was cured. The following rotation after all that Family Practice and Internal Medicine was Psychiatry. It was a nice change and it was at a different hospital. The psych hospital was 1.5 hours away and I drove it. The driving was tiring but it also gave me some nice down time and I was able to decompress. And then about two months later, I found Pediatrics, which clicked with me like no other rotation had.

So...problem solved, and I was/am grateful. But it left me wondering how long I would have felt all hopeless and whiny and miserable if things hadn't fallen into place the way they did.

Flashback: Anatomy

2006-06-27T22:20:00.000-04:00

Category: Classroom Years

Medical school Anatomy class is a direct creation of Satan - at least it seems that way to the majority of first year students. It takes up an enormous amount of time, effort, energy, blood, guts, sweat, and tears. The volume of material to be learned can be very overwhelming. Anatomy has contributed to students' fatigue, worry, depression, and nervous breakdowns. Below is a list of things I've learned (almost too late) on how to survive.

Find a good study method quickly. I nearly flunked the class because my study technique was terrible. I kept trying to re-adjust and re-do my little methods and they all kept failing because they were all far too detailed, tedious, and time-consuming - which brings me to #2.
Try not to study in a way that involves a lot of re-writing and forced memorization. I tried to do this a lot. It didn't work - there was simply way too much information. Lots of reading and re-reading over and over and drawing out a few things - when I started doing that is when my scores started (finally) going up.
Visit the Anatomy Lab often to review structures. Even if it's a relatively "easy" day in the lab you only have to unearth a few structures, go back and review by the next day at the latest. It's very surprising how much one can forget about those flimsy, tiny, barely-identifable little nerves after just a few hours. Be sure and visit your classmates' cadavars as well as your own; Anatomy practical exams usually make use of every cadavar in the lab. Try to be familiar with them.
Try reading other sources. An old anatomy book from undergad, a hand-me-down anatomy board review book from a 2nd year, your little sister's anatomy coloring book - whatever works. Often a fresh, different approach to the same material can go a long way in making the information stick.
Don't skim over the clinical stuff. This tip is probably way obvious to some of you normal people, but I was exceedingly stupid and did skim over the clinical stuff thinking, "Yeah that's interesting, but I need to focus more on these other million details." Dumb, dumb, dumb. Questions about Colles' fracture, the anatomical snuffbox, and brachial plexus injuries were all over my exams in that class and they popped back up to make an appearance in Part 1 Boards too. Don't ignore it.
Don't neglect your other subjects. However tempting it might be to let your "easier" subjects go abandoned in order to spend more precious time and energy with precious Anatomy - don't do it. Being frustrated and guilt-ridden about forsaking your other classes will just hasten your impending mental collapse. Take a break from Anatomy sometimes. Give the other stuff you're supposed to be learning due attention.

Of course, not everyone gets buried under the Anatomy Avalanche. There's some who do great in Anatomy from Day #1 and really enjoy it. I never was able to figure out if I liked or disliked Anatomy - I was too busy trying to work out how to study effectively for it. I figured out what worked best for me just in time, and I scraped by, but to this day I'm terrible at Anatomy. I hate pimp questions that require me to know much more than "The heart is the chest," and "The brain is in the head." It's a classic case of "If I knew then what I know now."

The Twelve Types of Medical Students

2006-06-26T21:35:00.000-04:00

Category: Clinical Rotations

This is a comic-strip sort of illustration that shows the twelve types of medical students. Funny and accurate. Follow the link.

The Six Types of Attending Physician

2006-06-26T21:17:00.000-04:00

Category: Clinical Rotations

The Mean Attending. This is the constant berater, the one who changes the rules on you daily, the one who expects the most mind-reading from you, the one who expects perfection in all minutia, and whose greatest joy and delight in life is to see you fail. Thank God I have yet to meet Mean Attending. Doctors like that don't exactly create an atmosphere of learning.
The Vague Attending. As nice as these docs can be, they are infuriatingly vague when it comes to their expectations of students. I have worked with the Vague Attending on a few occasions, and while the rotations weren't too bad, my days were filled with: "Oh you know, whenever you want to be done for the day, just leave." and "You can write directly on the charts or make your own notes - doesn't matter to me." and (after asking if there was anything specific I needed to be studying) "Oh, yes, well - just read about whatever interests you."
The Busy Attending. While you may not learn much content, you'll certainly learn how to effectively see 20 clinic patients in 15 minutes, right after rounding on 1000 hospital patients beginning at 4:30 a.m.
The Buddy. Most of your time is spent shooting the breeze in your doc's office while the patient charts pile up and then you finally follow your attending in to see the patients (since the time you would have taken to see them yourself was spent talking about your attending's children's newest school project). This is fun for about 2 days. Then it gets old.
The Teacher. You will learn. You will have a 15 minute teaching/pimping session after every patient. You will read up-t0-date, hot-off-the-press articles about exciting new breakthroughs in otitis media. You will organize presentations on journal articles to present to your fellow medical students/residents/attendings.
The User. Cinderelly, Cinderelly - all you have to do is make sure all charts are dictated, all forms filled out, all tests ordered, all prescriptions written, all visits coded, while ensuring your attending is well stocked with pens and prescription pads...and by the way, do you have a penlight I could use for awhile? Never mind if you've learned anything.

In reality most attendings are some combination of these. And I'm sure there's a lot more categories that other students can think of. I do appreciate the attendings I've had so far - most of them have been smart, likeable, laid back doctors who did a pretty decent job at teaching. But it's still fun to make fun! I encourage related comments and trackbacks on this entry. I find this type of thing very entertaining.

Flashback: Radiology

2006-06-25T22:48:00.000-04:00

Category: Clinical Rotations

Toward the beginning of my third year, I did 2 weeks of radiology. Even though I have no desire to be a radiologist, I still found the experience useful. The radiology department here acts like it wishes medical students didn't exist, but sometimes I caught a radiologist on a good day and actually learned some things. And I studied quite a bit on my own. For people that don't care anything about radiology, I still semi-recommend it. A broad and basic knowledge of plain x-ray films is useful and necessary, especially in the Emergency Department. With this in mind, I tried to pay a lot of attention to chest x-rays. A good working knowledge of chest x-rays can be important in primary care, and after my rotation, I felt a lot more comfortable about reading them. I looked at other plain films too, but I didn't seem to retain that information as well. Now, in the ER, I'm only slightly less pathetic at "find the fracture" than I would have been if I hadn't done those two weeks.

Here are some quick tidbits on radiology:

Annual Salary: $276,684
Work hours: 7AM or 8AM to 4PM or 5PM
Call: Radiologists do take call, but often from home. X-rays that have to interpreted quickly can be transmitted from the hospital to the radiologist's house and he/she can give the reading over the phone.
Residency Length: 5 years
Duties: reading lots of films (obviously), taking numerous calls from other physicians with questions, concerns, (or demands) about x-rays they ordered, and doing procedures such as ultrasound-guided biopsies, GU and GI studies, and angiograms.

I could never do radiology because a radiologist's knowledge of anatomy has to be fantabulous and the residencies are very competitive. They get to hang out in darkish rooms and look at pictures all day and they don't have to fool with silly old patients too much. However, they have to hang out in darkish rooms and look at pictures all day and don't get to fool with patients much.

I admire people that can do radiology. I'm glad I'm not one of them.

I'm So Glad You're Sick

2006-06-24T04:08:00.000-04:00

Category: Clinical Rotations

Never forget that it is not a pneumonia, but a pneumonic man who is your patient.
- William Withey Gull

An odd and slightly disconcerting aspect of the clinical 3rd and 4th years is how excited we can get over people's illnesses. And the sicker the better - I don't get terribly excited over "routine" illnesses and I can do those history and physicals or admission orders or whatever while stifling a yawn and wishing I was working on someone with a much more fun disease. Warped, isn't it?

It does feel weird at first when we start drooling over the stories other doctors or fellow medical students tell - stories about a septic patient with ARDS or the OB patient about to give birth to octuplets and so forth. But medical students aren't really sick, sadistic creatures who draw pleasure and energy from the pain of others.

As in all things, there must be a balance. In this case, it's a balance between being compassionate toward our patient and trying to cure him/her, and being secretly pleased that their disease process is severe or unusual and we have the chance to learn to manage them and grow that much more into doctorhood.

Health News: Cleanliness is Next to Godliness?

2006-06-23T03:24:00.000-04:00

Category: Health News

WASHINGTON (AP) — Gritty rats and mice living in sewers and farms seem to have healthier immune systems than their squeaky clean cousins that frolic in cushy antiseptic labs, two studies indicate.

The lesson for humans: Clean living may make us sick.

The studies give more weight to a 17-year-old theory that the sanitized Western world may be partly to blame for soaring rates of human allergy and asthma cases and some autoimmune diseases, such as Type I diabetes and rheumatoid arthritis. The theory, called the hygiene hypothesis, figures that people's immune systems aren't being challenged by disease and dirt early in life, so the body's natural defenses overreact to small irritants such as pollen.

Click here for the full article.

I always did think our society went a little overboard on cleanliness. I'm not saying we should raise our children to eat dead bugs and make pretty sculptures out of animal excrement, but I agree with a little less Clorox and a little more dog hair. As an animal lover, I kind of like the theory that people in developing countries have fewer problems with allergies because they live in such close contact with their animals. I'm all for that.

This nifty picture was swiped from a blog called A Shepherd's Voice. It's a blog totally devoted to sheep. Bet this kid doesn't have any allergies!

Emergency Room

2006-06-22T17:38:00.000-04:00

Category: Clinical Rotations

I'm doing my ER rotation till the end of July. It's going to be one of those rotations where it'll be "what I make of it." I suppose technically all 3rd and 4th year rotations are what you make of them, but it seems like some require more effort than others to get anything out of them.

I've ended up working way too much with a doctor who used to do surgery. And he mined coal. And he was in the army. And he had a degree in engineering. And I'm sure he's probably the inventor of plastic or something. I have to sit through endless stories about his adventures in vascular surgery and how brilliant he was/is.

Another doctor I work with doesn't care if you learn at all, as long as you do his paperwork. Still another stares at God-knows-what on Google and grunts and mutters while I try to present patients to him.

There is a really good one, though. This guy listens to my whole presentation, asks what I'd like to do, often listens to my suggestions, asks good pimp questions, teaches me stuff, and then I get to follow the patient all the way to discharge or admission. That's become kind of important to me. There was a couple of days when I was trying to be a hotshot machine and see patient after patient. I really was just trying to be efficient, but it ended up being a stupid thing to do. I was so busy trying to hurry and see patients that I never followed the patients I'd already seen to conclusion and I might have missed something cool.

It's a small hospital with a lack of many specialties, and a small ER, so I'm not working in a knife and gun club. Instead, I'm seeing a bunch of patients who use the ER as their primary care. Here's a few things I've gotten to see so far:

A guy who waited to till 1:00 a.m. to come get treated for his poison ivy
Several minor injuries
People with migraine headaches who just so happen to be allergic to every non-narcotic pain medicine on the market
Large numbers of complaints of chest pain and shortness of breath (there's lots of coronary artery disease and COPD in this area)
Several pukers - there's been a GI virus going around.
A really good case of rhabdomylosis, complete with acute renal failure. He also had a nasty UTI, was septic, dehydrated, and had mental status changes. He was admitted to the ICU.
An idiot mother who brought her 14 year old to the ER over a zit. I'm not kidding.
A possible real trauma - she was in a 4-wheeler accident. All her plain x-rays were negative at cursory glance. Her lab work showed blood in the urine and slightly elevated liver enzymes. She was pretty tender and hard the left upper quadrant of her abdomen, where the spleen is. Unfortunately my shift ended before she had her CT of the abdomen and pelvis. I was tempted to stay and follow her some more, but I was dog tired. I hate night shift.

One good thing about night shift in this ER is that sometimes things do eventually slow down enough to where I can get some reading in or kick back for a few minutes.

So until the end of July I'll be griping about the trolls that come in wasting my time, and glowing over the truly sick patients that make me think. I'll put up with a variety of ER doctors and their stupid quirks and pet peeves and pet lab tests and pet medications. I will then periodically chide myself for being such a whiny baby and go back to "making the best of it."

All We Ever Talk About

2006-06-21T15:16:00.000-04:00

Category: General

It usually happens just a few weeks into the first year of medical school. You begin discussing religion, politics, and the after-exam party while cheerfully (or angrily) hacking away at your poor cadavar in Anatomy Lab. You use the words "medial," "lateral," "distal," and "proximal" when you're giving directions to your house. You understand stupid medical jokes that normal people don't get - and what's worse is that you think they're funny.

Medicine takes us over, and finds its way into our everyday lives to take a firm hold. And to the distress of many, nearly every conversation is dominated by medicine and we say, "Good grief! All we ever talk about is medicine! This is ridiculous!!" And there's truth to this. For the first two years we commiserate about classes and exams. And for the next year we commiserate about call schedules and mean residents, and swap stories and patient anecdotes.

But is it really ridiculous? Why do we act like we're the only group of people to whom this happens? Take your average stay-at-home mom raising 3 little kids. Surely she says to herself, "All I talk about is my kids! My non-parent friends must hate me!" Even people with "regular" jobs talk about their work a lot. Why? Because our work/school is such a large part of our lives, it's only natural that it become a large part of our conversation. Whether you work at Wal-Mart or go to medical school or raise a bunch of kids, you're going to have a lot to say about the thing you do the most.

I believe if we would take a closer look at our conversations, we would probably find that we really do talk about other things, even if it's only here and there. I've decided that if I'm in a conversation and it happens to be about medicine, I'm not to going to kill myself trying to change the subject just because medicine is "all I ever talk about."

Mind Reading

2006-06-20T13:49:00.000-04:00

Category: Clinical Rotations

When interacting with physicians as a 3rd and 4th year medical student, there's a degree of mind reading that is expected. Here's a scenario experienced by one of my friends on her OB/Gyn rotation:

Doctor: So, how's our post-op hysterectomy doing?
Student: Um, fine I guess - you mean this morning before her surgery?
Doctor: No, I don't mean this morning before her surgery. I mean this afternoon after her surgery. You didn't go check on her?
Student: No, I didn't know you wanted me to.
Doctor: (sighing hugely and rolling her eyes): You have to always remember to go back and check on your patients as soon as possible after surgery. Patient care doesn't end with morning rounds.

Now that probably doesn't seem like such a huge deal but conversations like that can go a long way in making you feel stupid and lazy and incompetent. Wouldn't it have been nice if someone would have told her about that expectation at the beginning of the rotation? Or at least at the beginning of rounds that morning? There are tons more examples I could write about, and I've experienced quite a few myself. Ideally, the attending physician should spend a few minutes (and a few minutes is all it would take - it's not like it would eat hours out of the day) talking to the student at the beginning of the rotation, telling him/her what the expectations and requirements are. Good luck finding an attending who will do that. Before starting 3rd year, it might be best to brush up on your hidden magical psychic powers of mindreading.

Flashback: Study Habits

2006-06-19T00:31:00.000-04:00

Category: Classroom Years

During the first two years of medical school, I was something of a misfit where study habits were concerned. I studied a little differently than most of my other classmates in two ways:

Number 1: I slept

I rarely went without a decent night's sleep (6-10 hours) in years one and two. Why should I deprive myself when all I do all night is panic, stare at the clock and panic some more, wonder if I could just go to sleep and get up really early instead of staying up really late, and read the same paragraph 10 million times and never know what it says? I tried this method in college. Useless.

Number 2: The closer exams came, the less I studied.

This was completely backwards in comparison with my friends. We had exams about every four weeks. For the first two weeks of a block, while everyone else caught up on sleep, drank too much alcohol, visited family, and cleaned their houses/apartments, I was already studying for the next exams. About the time I started slowing down is when everyone else was just getting into the study groove. And then by the time exams were a day or two away, I had pretty much quit studying and most of my friends had pretty much quit eating and sleeping.

The bottom line is that different methods work for different people. It's easy to let yourself feel guilty if you're not a person who can study for 12 hours straight without taking a bathroom break, or one of those nuts who can pull frequent all-nighters. But it's important to let yourself have guilt-free study time, regardless of how backwards, bizarre, or different your study habits may be from everyone else's. If your methods get you the grade you want, then stick with your methods.

One of my friends spent his afternoons after lecture piddling around, and then sleeping. He'd wake up and get started studying at 10:30 or 11:00 p.m. It worked great for him. Another friend re-wrote all her lecture notes - I tried that and it ended in tragedy, but she really benefited from it. Still another was a hard-core marathoner - it irritated her when she had to stop and do ridiculous things like shower, eat, and pee. I figured out that what worked best for me was a lot reading and re-reading over and over again, jotting a few notes here and there, and consulting various textbooks if I needed clarification. I usually couldn't bear to study for more than four hours a day (the exception was Anatomy in my first year). It took me awhile to get over feeling like I should be making better use of my study time. Sometimes I ended up spending all my study time feeling guilty and panicky that I wasn't studying enough. At some point in my second year, I just got it over it. My grades were fine. I accepted the fact that I didn't have to study and learn like everyone else.

I believe there's a right study technique and a right study schedule for everybody. It's just a matter of finding it.

About On Doctoring

2006-06-18T21:32:00.000-04:00

Category: About

The On Doctoring blog will journey through my life in medicine. It begins with the fourth and final year of medical school, but many entries will flash back and include scenes from the first three years as well. The story then continues through residency and beyond.