Sunday, December 30, 2007

Starting to Work on Pictures

It's taking longer than I thought to upload all my pictures onto the computer, then the photo website, but I'm working on it. I'm going to display a few here:

One and a half years ago, my husband and I were married next to this bridge. Obviously, it wasn't snowy then.

View of the valley below while we were climbing on the road to Telluride, CO.
Mountain peaks above Telluride.

All in all, it was a beautiful trip. We're a little sad to be back, which is a place I love but a place where I rarely say "Oh, how lovely!", at least outdoors. We also kind of miss the snow, believe it or not. It's only temporary, though. It is really nice to be back in 65 degree weather, instead of 9.

Thursday, December 27, 2007

Cold and Snowy!

It's 10 degrees here. We're on the eastern slopes of the Rockies now, visiting the hubby's aunt and uncle. We're officially under a "winter storm warning" here, which = snow + wind. It's quite cozy inside, with fires lit and baby blankets to crochet--I'm 1/3 through with the first one of the year. I just got news of a fourth baby on the way! Hubby's cousin and her husband are expecting a baby in the summer, so I get to make another blanket. This makes 1 blue, 1 pink, and 2 yellow/green for this baby season. I'm going to be busy!

I have more good news for today. I received a phone message on my cell earlier from an attending at Top Choice Program, just wishing me a happy New Year and saying that they really liked me, please call us if you have any questions! Nothing can be officially said between either of us outside the match, of course, and I don't know how many other people they might have called, but it's a good sign. Or at least that's how I'm taking it. I guess now we can start looking at houses a little more seriously (although we're still not buying anything until I have papers in hand!)

Snow is so pretty! I'm so glad we got to come up here to visit! I cried a little, leaving my mom's house, because I don't get to see them often since they moved up here to the mountains, but it was so nice to spend Christmas with them. I'm going to go eat chili now, since we're being pressed to "come and eat while it's warm", and then I'll crochet some more. It's so nice and domestic and snuggly and cozy!

*This post brought to you by fourth year of medical school, which generously allows time off for such frivolous pursuits. We're very grateful to our sponsors here at WAISH, so thanks!*

Tuesday, December 25, 2007

Merry Christmas!

We are having a truly white Christmas here on the Western slopes of the Rocky Mountains and San Juan Mountains in western Colorado. It has snowed 11 inches here at my mom's house and it is AWESOME! I have taken tons of pictures, but I don't have the connectors here for my new camera, so I'll have to post them when I get home. Suffice to say, it is totally gorgeous, and we are quite happy to see a white Christmas. I'm sure it's 80 degrees back home, and for right now I don't miss it.

Merry Christmas (or whatever holiday you celebrate)!

Wednesday, December 19, 2007

...Aaaand I'm Spent

My next post will be from Colorado, if all goes well. I'll answer all your burning questions about Step 2 CS/CK, while cuddled with my sweetie and some warm puppy dogs by a fire, enjoying a white Christmas (that's the plan, anyhow). Stay warm!

Gauderio, check your email!!!! Or let me know if you got the item!

Off to Take the Step 2 CK

When I'm done, I'm going to pack, since we're leaving tomorrow for vacation. I'll try to post about the Step 2 CS later, a test surrounded with mists of uncertainty and legend, but for now thanks for all the good luck wishes!

Monday, December 17, 2007

Not Studying

I have absolutely no study ethic any more. After the first two years of med school, and the marathon of studying that went into the end of second year (end of block 4, then finals, then Step 1--it was like 2.5 months of solid studying), I have just been unable to make myself study much. I take the Step 2 CK on Wednesday, and I'm not studying right now; I'm watching my cat play with a straw on the floor. Yes, a drinking straw. They are his favorite toys; he'll play with them for hours, jumping on and off furniture, flicking them out of his mouth and chasing them, burying them under the rug, or bringing them proudly into bed with us. If I ever figure out how to use my new digital camera (Christmas and birthday gift), I'll try to get a picture or video of this, because it's pretty funny. But now, I'm writing about watching my cat play with a drinking straw, instead of studying. I should probably get dressed, so I can walk the dog instead of study, go to the gym instead of study, go buy more Christmas cards, fill them out, label, and mail them instead of study, etc. It's a good thing Step 2 CK doesn't really matter for my future.

Speaking of that, I had a funny conversation with my father about the Step 2 the other day.

Dad: What are you up to this month? Are you doing another rotation?

Me: No, I'm off this month for interviews and so I can take the Step 2.

Dad: Are you studying hard?

Me: Nah, these scores probably won't even come in before the match. Even if they did, I probably won't share them with a program unless they absolutely rock. Therefore, the score I get on this test really doesn't matter [so long as I pass].

Dad: Well, now, you should always try to do your best.

Me: It really doesn't matter. I'm sure I'll pass.

Dad: Well, you should always aim for the highest, and that way you'll always do well!

I told my husband about it as soon as I saw him: see, honey, there's a REASON I'm like this! My family wanted me to be a type A, compulsive perfectionist! Ha! I have proof now!

Time to go find another way to avoid studying!

Tuesday, December 11, 2007

An Excellent Question

"TS - are you only interviewing at 5 schools? Do you think that's going to limit your match? ... is it worthwhile to interview at other schools as well, as "safe" backups? (or is that too undergrad application process-y?)"

Thanks for the question, Rach. I chose to answer it here because other people might have a similar question later. The short answer is that it varies widely from specialty to specialty and from person to person.

I am interviewing at 6 schools total. I applied to 10 and canceled/didn't schedule 4 interviews. I'm taking advantage of the fact that psychiatry is a non-competitive specialty. In psychiatry, 6 is kind of an intermediate number. I've had residents tell me they interviewed at only 3 schools, but I met an applicant yesterday who had scheduled 15+ interviews. Since I am "geographically limited", I limited the number of applications and interviews. Also, I need to go where my husband can get a job, so I'm only applying in one state.

I have friends entering psychiatry who wish to move to the East or West Coast, which would require many more applications and interviews (and often an away rotation to seal the deal). They may apply to around 20-30 programs.

I have a friend entering neurology (a low to intermediate-ly competitive specialty) who applied to 30+ programs because she wishes to escape the Gulf Coast and go to the East Coast. Another friend is applying to anesthesia and is applying wherever she can; she applied to 40-50 programs, ranging from state public to East Coast Ivy League.

If you are entering a very competitive specialty, you will be advised by most people to apply widely. When I was entering urology, the AUA said the average candidate applied to ~40 programs. Derm Guy applied to 75 derm programs. Also, many programs require a transitional or preliminary year in medicine or surgery, which often have to be applied to separately (Derm Guy applied to 10+ prelim programs).

So, why did I only apply to 6? I really need to go to a place where my husband can work. I will probably only rank 3 programs, which are all geographically equivalent for me. Yes, that leaves me the chance of going unmatched, but if that happens I will try to scramble for a prelim medicine spot in that area; if THAT doesn't happen, I'll try to get a research position or work at McDonald's for a year. In my situation, my first priority is to go there, and my next priority is to get into psychiatry. Other people's priorities are different.

In other words, I took 3 interviews that were "safe backups", if you will. If I chose to rank those programs, it would be as a backup to protect against going unmatched.

There is nothing wrong with applying widely and whittling down your list as the interviews roll in. Do keep in mind, however, that it will start costing you a great deal of money. My 10 programs cost me $110 for the application ($60 for the programs and $50 to release my USMLE transcript). From the ERAS website:

ERAS processing fees are based on the number of programs to which you apply. ERAS fees are: $60 initial application fee (includes up to 10 programs); $8 each for 11-20 programs; $15 each for 21-30 programs; and $25 each for program(s) over 30.

In other words, applying to 20 programs costs $140, 30 programs costs $290, and 75 programs costs $1415 (I think I did that right). Every interview may require all of the following: flight, hotel, rental car, parking, suit dry cleaning, etc. Some derm applicants can spend around $10,000 applying and interviewing; this cost is NOT included in your student loans for fourth year. Fortunately, you get a break when you rank programs (NRMP website):

There is no charge to programs or applicants for entering their rank order lists for the specialty matches. The registration fee covers registration, submission of rank order lists, and access to Match Results.

The NRMP registration fee is $40 so long as you get it paid on time; late is a $50 fee plus $40 to register. There is no extra fee for ranking a zillion programs (but you can only rank those you have applied with).

So, risks of not applying widely enough: going unmatched, or missing out on a great program you never knew about. Risks of applying too widely: $$$$$$$, interview burnout, time away from electives, family, friends, etc.

After this novella of an answer, it still comes down to this: it varies widely from specialty to specialty and from person to person. Hope this helps.

Sunday, December 09, 2007

Hot on the Interview Trail

Actually, it's effing freezing. I drove up here for an interview, and yesterday I was sweating in 80 degree humid weather. Today, it's been in the 30's all day and sleeting/drizzling. Disgusting. I wasn't able to get the wireless router at my aunt's house to work with my computer (although that probably says more about my computer than her router) so I'm at some random coffee shop/chic eatery populated with law students. Just don't sue me.

This will be my fifth interview, and I'm kinda wondering why I'm taking it. After all, I've pretty much decided I won't rank anywhere outside of the geographic area where we need to go, so even if I love this program I probably won't be coming here. It was a nice excuse to come see my aunt, and I got to see a friend from high school today, which was excellent.

Partly, though, I think it's because I like psych interviews. Everyone is excited about psych there, and they get it. No one makes jokes about "oh, you're going into psych, don't analyze me!" or "oh, you're going into psych, I might need your services!" at psych interviews. Instead, you get to talk about what you like about psych, and what the problems are, and what might be done to fix them. Psych people *tend* to be well-read, which I used to be before med school killed my ability to read. Also, the ladies from the program today are apparently big shoppers, which endeared them to my heart; we compared our favorite shoe brands, and discussed the pros and cons of outdoor shopping malls in cold weather. Always a good sign when the residents have time for shoe shopping!

I haven't decided yet how I will discuss my rank choices here. Suffice to say, I have my rank list in order, and Top Choice Program has emerged as the shining winner. It's hard, though, because I feel like I have to be rather hush-hush about the whole thing. One of the programs I interviewed at was rather aggressive about selling the program, but I know that program has some problems, and so I feel that I have to be careful about how I say things, especially since that will be a program I rank, but not highly. Also, since I've thus far kept this blog relatively anonymous, I have to be very careful how I discuss various programs, or it will be extremely obvious what program I'm talking about. It's all very high school, when you had to gossip behind people's backs cautiously, so they didn't figure out who had started what rumor (even in band, we had this problem).

So, without giving you any information at all, I know what my rank list will be. It will likely be 3 programs long; if I don't match, I'll have to scramble into a prelim medicine year. As everyone tells me, though, it's psych, so that won't happen, silly. I agree, but I still have to know my plan B. Yes, I realize how OCD that makes me. Those nearest and dearest to me just know and accept that I am a little crazy that way, and move on with their lives.

Thursday, December 06, 2007


According to an article at today, that was the rate of cesarean section delivery in the United States in 2005-2006. When I was a second year med student, they told us it was around 25%, and that was still too high.

Interestingly, this number was squeezed in at the end of an article about the teen birth rate rising 3% those same years. While I oppose abstinence-only sex education, I am not too keen to jump on these numbers and say "of course, that's what I expected." After all, the teen birth rate had been dropping every year prior to that one. It will be interesting to see what happens in the next year's data analysis of teen motherhood, as well as what political fodder this will make with the Iowa caucus approaching quickly.

As far as the c-section number, that's 31% of delivering mothers who are exposed to increased risks of bleeding, DVT/PE, wound infection, endometritis, hysterectomy, uterine rupture/placenta accreta in future pregnancies, etc. Of course some of those women required c-section, but many of them did not. How many women would continue to choose c-section if we in the medical community did a better job taking the fear away from labor and delivery? Or if we did a better job of pointing out that the recovery from a c-section takes weeks to months longer than from a vaginal? Or if the lawyers wouldn't ask for millions for a family with a sad outcome by accusing the physician of not doing a cesarean? Even though medical science cannot say when CP happens, even though the rising rate of c-section has not dropped the rate of CP, we continue to do more as we fear the lawsuit. It's a terrible thing.

Friday, November 30, 2007

For Those Days When You Just Can't Take it Anymore

Just hide under the bed! (Look for both tails!)Or kick yourself in the head!
Or just screw it all and take a nap!(I'm going to be one of those parents, aren't I?)

Sunday, November 25, 2007

Doctor Drug Rep

This article in today's New York Times is written by Dr. Carlat, a psychiatrist, who spent a year selling an antidepressant for a major pharmaceutical company. It's a fascinating report of how he suppressed his initial qualms for the easy money, but how over time he felt more and more guilty, eventually quitting. I haven't checked out his website yet, although I'm intrigued by the promise of an "unbiased monthly covering all things psychiatric", which is an enormous claim.

It's a very interesting story. Apparently he was making an extra $30,000 a year doing "drug lunches", talking to primary care physicians about the antidepressant. It's easy to understand, after reading his essay, why doctors get into this kind of thing. It's also rather frightening how much of our "continuing medical education" is actually sponsored by Big Pharma, in that CME doesn't just come in the form of online courses or weekend classes. We continue to evolve our medical practice based in part on the "sponsored" talks, the free lunches with beautiful samples to hand out to patients, and the beautiful, smiling reps, who assure us that "if your patient with X syndrome doesn't improve on our drug, then they've been misdiagnosed."

Also fascinating about this article is his description of how the pharmaceutical companies mine the prescribing information of doctors, aided in part by the AMA's registry of DEA numbers. They then use this information to prod or persuade those doctors who are "heavy prescribers" of certain of their drugs to prescribe more of them--in other words, to dole out medication exactly how the drug company wants them to do so.

Scary. I wonder which company's reps will target me in the future? I wonder what the appropriate stance is to take? I mean, do you reject the free samples that keep some poor patients in their medicine? And who doesn't like free lunch, or shiny new pens? I haven't decided yet how I want to practice, or how much (if any) drug company involvement I want to have. I don't know if I'll go "pharm-free", or if there's a way to compromise without being quite that radical. Or am I compromising my soul that way?

I found this article because Graham at over!my!med!body! found it first. Check it out.

Friday, November 23, 2007

While I'm Not Studying

In case you read her blog and missed it, Michelle over at the underwear drawer was offered a book deal. I am so excited for her!!!! Her blog was the first I ever read. If you don't read her blog, you should. She's also responsible for the 12 Types of Med Students, the 12 Medical Specialty Stereotypes, and several other cute comics over at Scutmonkey. I will definitely be buying her book when it comes out--and so should you!

Thursday, November 22, 2007

Happy Thanksgiving!

Eat turkey!

Tuesday, November 20, 2007

Psych and Medicine

I think it's very important for psychiatrists to be trained in medicine, and vice versa. I have seen many frustrating and complicated psych patients this month at this clinic--in part because the staff knows I'm going into psych, so they'll give me the "special" patients. Joy.

I've seen quite a few patients with severe anxiety, including several with blood pressures >170/100. In my opinion, treating the hypertension alone isn't fully treating the problem, because the anxiety keeps raising the blood pressure. Of course, it's not sufficient to treat the anxiety alone, either, because we know about the acute and chronic complications of hypertension. Fortunately, my attending in this clinic is very understanding about psychiatry, and I feel like he has a great attitude towards all the anxious patients.

On the other hand, it's even more important to know when it's NOT a psychiatric problem. A patient with uncontrolled diabetes and hypertension with a history of anxiety presented with dizziness and slurred speech which resolved over a period of hours. She'd woken up in the middle of the night with symptoms, only a night after having a blood sugar of >500. She'd gone to the ER with the blood sugar only to be told to "follow up with your PCP" and sent home. When her niece called 911 for the slurred speech, the paramedics accused her of being drunk, so she refused the ambulance ride. When I saw her a few days afterward, she looked slowed down, a little confused. When my attending pointed to anxiety in her chart and asked if it was causing her symptoms (that day we'd had two other ladies with anxiety-induced dizziness and hypertension) I adamantly said no. We agreed that she was likely having TIA's and sent her to neurology.

Unfortunately, some patients are written off as being "psych problems" when medical diagnosis fails. Sometimes, there's a medical condition which is undiagnosed, but when doctors can't find what's wrong they politely suggest "maybe it's all in your head." Sometimes, there's a psychiatric condition causing physical symptoms (today, it was panic disorder causing chest pain and shortness of breath), and after the EKG, heart cath, head CT, labwork, upper endoscopy, and chest x-ray are normal, the patient is slipped a prescription for Xanax and Lexapro and told "you must be depressed."

I realize psych patients are complicated and frustrating. I'll admit, the last patient I saw today, with panic attacks and anxiety, who absolutely REFUSED to let go of the idea that some hidden physical condition was causing her anxiety, drove me crazy. I was so upset after I left her that I was having a tension headache of my own (although I did not go to my doctor and demand an MRI, thankyouverymuch). However, telling patients "it's all in your head" is demeaning and somehow suggests that their anxiety isn't real. Then, it becomes even harder to treat these patients, because they mistrust doctors and psychiatric diagnoses; they rebel against being labeled as "psych patients" and demand more physical tests. There are few things more difficult than convincing someone that it's okay that their anxiety is "in their head" and that it is also okay to need treatment for the same.

In other words, I'm very happy to be learning a lot of medicine--I hope to put it to good use over and over again, even in psychiatry. I wish more medicine doctors would learn some psych and put it to good use as well.

Tuesday, November 13, 2007

Isn't it Ironic?

Not two days ago, we were out boating with some friends. At one point, the boat hit a sandbar, and we got a little splashed. The $300 digital camera was miraculously spared, but my husband's cell phone got hit. We frantically tried to revive it, but that little splash had already condensed inside the screen, and salt was visible. When we hit land, we went to the cell phone store, and since he was eligible to upgrade, he got a fancy new toy phone, complete with MP3 player and "slider" features (he's been playing with it ever since). There was a shiny new phone there that I really liked, too, but I'm not eligible to upgrade for several months, and I'm thinking about going the smartphone route, so I can get ePocrates and such on my device and ditch the PDA + cell phone combo that weighs down my pockets.

This morning, I had my cell phone in my back pocket while I ran around the house getting ready for clinic. I went into the bathroom and prepared to sit down when I heard a loud THUNK-SPLASH! I jumped back up and sure enough, there was my phone in the toilet bowl. I've come close with my pager, but it always hits the floor; I've never dropped an electronic device into the toilet before. Thank goodness it was prior to sitting down, so to speak, but I still had a drowned phone. I struggled to revive it, but it powered off and hasn't come back on since. I've spoken to the phone company, and with my insurance I will have to pay a $50 deductible, but they will mail me a new phone in the next 2 days. I hate my current phone--it was a hugely hyped model, but mine gets poor reception and crappy battery life. I really didn't want to spend $50 to get the exact same phone, especially when I'm planning to upgrade in a few months, but it's better to spend $50 now and have a working phone until then. We don't have a landline, so as I'm sitting here this afternoon, I have phone calls I need to make, but I can't. Ayo, technology.

It's bizarre that within a matter of days, both of us drowned our cell phones. He definitely got the better end of the deal as far as new phones go, but his Sim card was ruined, too, so he lost all his phone numbers. I'm keeping my fingers crossed that mine was okay, but I did lose a really cute picture of the kitty sleeping in my purse that was on my old phone.

It's also kind of funny how every time I get to feeling like I am doing pretty well for myself, I do something totally idiotic, just to remind myself that I'm a doofus. Big heads get burst around here, I promise.

One good thing came out of this morning, I suppose. The kitty was watching as the phone took its dive, and he was totally amused. After all, he is totally obsessed with the toilet, and shiny plastic/metal objects, so the combination of the two was almost more than he could handle. I had to yank him out of the way to grab the phone out of the water. As I was wiping the phone down, he was perched on the side of the potty, staring with fascination into the bowl. Weird cat.

Monday, November 12, 2007


Yes, friends, I have finally heard from Top Choice Program. I actually called this morning, to "put my name out there", so to speak. I just told the coordinator who I was, and that I was trying to finalize travel plans, so I just wanted to let TCP know that I was still interested. Turned out, she was in the middle of typing my interview letter. *was very sheepish* So we scheduled my interview. Now, I've heard from all 10 programs to which I applied. I've turned down two, and I may cancel a few, so I'll probably end up interviewing at 5 or 6 programs.

I vented some frustration a few weeks ago, on my blog, regarding the delay in getting my application complete. Yes, I was very frustrated. However, all of my letters came in, and I met all deadlines. Therefore, all my letter writers came through and did me a huge favor. From this side of the deadline, I feel really badly that I was so frustrated and anxious. After all, I got what I wanted--a letter, and an important interview. Also, if I had been more on the ball, I might have found that deadline sooner, saving all of us some anxiety. I've thanked all my letter-writers profusely, and they all deserve it. I, however, need to not be so damn anxious. To anyone who is still reading, I apologize to you, too, for all the whining.

It's an almost anti-climactic feeling at this point. After two months of obsessing and freaking out, now everything is settled and done. All my interviews are scheduled; it's all up to me now. We'll just see how I do!

Comment Moderation

I turned on comment moderation a while ago, after the prairie dog incident. Since turning it on, I think I've deleted 3 comments--two related to the prairie dog thing, and one that was racially vitriolic. This is my blog, and I reserve the right to delete comments, but I prefer to do it only when the comment is particularly vicious, especially when the commenter feels the need to hide behind the "Anonymous" title.

So why did I just allow this comment, on an old post, to be posted? So I could make fun of it.

"If this ding bat that is typing this blog wants to go into psychiatry she has better get used to seeing the same TEN DSM IV’s and I hope she does not wet her pants when she has to consult with a psycologist."

This is priceless entertainment; many thanks to Anonymous. I have copied it in, errors and all. Let's examine this, shall we?

"ding bat that is typing this blog"--how dumb IS a ding bat, actually? Can bats type? If ding bats are ordinarily stupid, and I'm smart enough to learn how to type, then I must actually be ahead of the pack.

"she has better get used"--I'm sure it's a typo, but it still gives this comment that whole "Your base are belong to us" feel which makes it even funnier.

"seeing the same TEN DSM IV's"--As in, I'll see the same TEN books of the DSM IV? Or the same TEN DSM IV diagnoses (which is probably what Anon meant)? I'm sure there is an element of repetition to psychiatry, just as there is with family practice (which is what the post was about), but I personally prefer the repetition of psych to FP. It doesn't offend me if you want to deal with hypertension, diabetes, and dyslipidemia forever, but I choose not to do so, as I find it stifling.

"and I hope she does not wet her pants when she has to consult with a psycologist."--This is my favorite part, not least of which is due to the misspelling of "psychologist", especially as this person appears to be defending the psychologist. Have I ever disparaged psychologists on this blog? If I have, I apologize, and I will correct that post with an apology. I have a bachelor's degree in psychology, and I recognize that practicing psychologists have to have at least a master's degree, if not a PhD. They have a graduate-level education, and then do an internship, before they go into practice. Their training is not so different from mine, then, at least in length. They may be better at things like neuropsychiatric testing, psychotherapy, etc., but I will (hopefully) be better trained in psychopharmacology, neurology, and somatic medicine. I see nothing wrong with MD's and PhD's working together for the benefit of their patients. If I've ever said otherwise, you have my most sincere apologies.

But other than that, why bring this up? If you're poking fun at the potential repetitiveness of psychiatry (compared to FP, like the post), why bring up the idea of me being offended at consulting with a "psycologist?" Where did that come from? This is a brilliant example of a loose association--the first idea has nothing to do with the second. Perhaps our friend Anonymous was trying to demonstrate a formal thought disorder for us, in which case I should thank him or her.

So, I left this comment up. I'm not sure why a post written in February has suddenly drawn such ire, but that's the way it is. I dislike deleting comments, and I will do so with care, but I will continue to do so, if I find them offensive. I might, however, mock them before I delete them. To all the anonymous commenters out there, trolling away, you've been forewarned.

Saturday, November 10, 2007

Kitty Therapy

A patient yesterday told me "I didn't get depressed when I was diagnosed with [chronic condition]. I got a cat." I can totally understand. Don't get me wrong, dogs are great, too, and we like ours a lot.
That green blanket behind the dog is HIS personal (dog-gonal?) blanket up on our bed. He has a perfectly comfy dog bed on the floor, with a fleece blanket, but after we're asleep he jumps up on our bed, and if we don't give him his own blanket, he steals our covers and will nip at our feet. Of course, he's not the only one who steals covers:There is something special, though, I must admit, about being owned by a cat. (He is clearly the boss.) Even with the nipping my ankles, or gnawing on my hands, and the CONSTANT knocking stuff over, I am still captivated by this cat. Although if he doesn't stop knocking glasses of water over, or pulling picture frames off the wall, or trying to tip over the hubby's flat panel television, he may still end up free to a good home (or at least that's what I tell him).But he has this totally endearing way of jumping into your lap and demanding to be petted right away, followed by a loud purr when you scratch his ears. He also poses for the greatest pictures--it's like he's a little model, always looking for a photo op.Yes, that is my husband's backpack. He climbed in, stuck his head out, and took a nap. If you've ever met my cat, you'll know that we couldn't have posed him for any of this stuff, since a) he never listens to us, b) he's the boss, and c) he wouldn't sit still anyway, unless he put himself there.Note how the kitty has ahold of the dog's soft, squeaky bone. He will grab ahold of the dog's plushie bones, bite down, and then KICK with his back legs while lying on his side. It looks totally goofy.

So, allergies, asthma (it's getting better), knocked over and destroyed belongings, cat hair and all, it looks like this crazy feline is staying. And trust me, he is a BASKET CASE!Thank you, thank you, I'll be here all evening.

Friday, November 09, 2007

Clinic, or How I Became a Drug Dealer

I'm doing a required rotation this month at an internal medicine clinic, and boy, is it cush. This place fascinates me. We work from 9:30 till 12:30 or 1, then eat (drug-rep) lunch, then patients from 2 till around 4 or 4:30. Wednesdays are half days, so we leave after morning clinic is over. One of the attendings only works half-time in the mornings, and on days when my attending cancels his clinic I work with her, which is nice.

It does have its quirks, however.

  1. I have never worked in a place with so many drug reps. There is a constant stream of young, very attractive, well-dressed men and women in fancy shoes wheeling suitcases in and out of the clinic delivering samples of all the newest, most expensive brand-name medication. They buy us lunch almost every day, and they have several happy hours scheduled for the month. I think a drug rep is even bringing a pre-Thanksgiving lunch. We load our patients up with little sackfuls of whatever they may need.
  2. It is apparently possible to work in private practice, internal medicine, with very few procedures, and still make a very handsome living. I'm not really sure how this works.
  3. I like my attending, but he is a leetle bit crazy. He will sit in his patients' rooms and discuss every aspect of his life, and theirs, and they love him for it. I've been told by the nursing staff that it is my job to try to "hurry him up" and to chart for him. His handwriting is unbelievably bad--we've all heard the jokes about doctors' writing, but this is so bad I can't decipher it at all. Also, he'll document a clinic visit with only a few scribbles, maybe even just one "word", so even though he remembers every detail of their previous visits, I have no idea what the hell I'm getting into unless I find a note from a previous med student. Fortunately, I'm a talker, too, so he likes me.
  4. This is the first time in my life I've ever seen a script written to switch a patient FROM Klonopin (long-acting benzodiazepine) TO Xanax (short-acting, highly addictive benzo). As a future psychiatrist, this move offended my very soul; I made the nurse write the script, as I just couldn't do it. Seriously, when the patient comes in asking for Xanax "because it just makes me feel so wonderful, the Klonopin just doesn't do it", it's probably not so wise to actually switch them to Xanax. Especially when the same patient then walks through to the lab asking (loudly and publicly) "Are you going to do drug testing? Just don't test for THC, okay? I smoked some pot the other day." While yes, Xanax is good for treating a panic attack while it's happening, taking it CONSTANTLY, throughout the day, is not really indicated. It would be like being drunk all day, actually.
  5. For that matter, today I wrote the wildest script, all on one piece of paper: "Xanax 0.5 mg TID PRN #20, Vicodin 5/500 1 tab q4 hours PRN #20, Lunesta 3 mg 1 tab qhs PRN, Buspar 15 mg daily." Oddly enough, the patient was in too big a hurry to actually get his labwork. He also was very reluctant to take ANY kind of anti-depressant, even for his anxiety or for smoking cessation.
  6. Since I've been in this clinic, I've seen more scripts for Xanax, Soma, Flexeril, Vicodin, and antibiotics for viral URI than I've ever seen in my life. We also prescribe a lot of Cipro for prostatism (urinary frequency, nocturia, incomplete emptying), even though there is no evidence that most of the patients who present with symptoms of BPH have any form of infectious prostatitis.

However, an amazing thing happened today. I met a quiet, unassuming man, in for a simple check-up. When I went to present his case, my attending asked, "Did that guy tell you who he used to know?" Uh, no. Didn't get around to asking that in my ROS, sorry. We went in and the patient was pressed to tell me who he used to "run around with." It turns out that my patient marched with Dr. Martin Luther King, Jr. WOW! He talked about being hosed out of a sit-in, and how hard they had all fought, and how he hears racism coming from both sides even now. I was just totally in awe. Sure, all of us now say racism is bad, racial equality, no discrimination, etc., but it is entirely another thing to march when the forces of the state are aligned against you, people are going to jail, being beaten, humiliated, and even dying. Would I have the guts to be Rosa Parks? I doubt it--I'd probably have said "yes, sir" and gone to the back. It was such an honor to talk to this man, like hearing a piece of history, that I certainly did not "hurry up" the attending in that interview.

Wednesday, November 07, 2007

"The Great Uncircumcision Debate"

An interesting article here on about men who felt that their circumcisions left them with sexual dysfunction, so they have invented or purchased products to stretch their foreskins back out, thereby "uncircumcising" themselves.

An interesting take on the "I want my son to look like his daddy" argument--as more boys are left intact, there are actually some daddies who want to look like their sons!

Thursday, November 01, 2007

Death in the Family

While we were going to bed, my husband's phone rang. It was his uncle, calling to let us know that his grandmother had a stroke today and passed away. This news is somewhat shocking and unexpected, as we just saw her a month ago and she was in fairly good health. Also, his grandfather is in very poor health, so this wasn't quite the news we were expecting. If we may find any silver lining here, she passed away quickly and painlessly, after eighty-three years of good life. She had lots of family who loved her and who knew she loved them. MK, we will miss you.

This situation is very like what I faced last year, when my grandfather passed suddenly while my grandmother was battling cancer. Everyone, go hug your grandmother and grandfather. Our time with them is short.

Medical Student Lore

My ICU rotation ended with a bang on Wednesday. Patient rolled in from the floor, respiratory distress, status post intubation for same. She had a history of breast cancer and sigmoid colon cancer, and for months had been complaining of constipation. Now in the ICU on the vent, she still looked pretty ill.

Her chest x-ray was a thing of beauty. This thing will be published somewhere, I can almost guarantee it (in fact, I wish I could write it up). The diaphragms were grossly elevated, probably 4 inches higher than they should be. Below you see tons of air with some haustra. Basically, the diaphragms are elevated because of massive colon gas. On a plain abdominal film, all you see is colon gas and stool, distending the abdomen in every direction. On exam, she looked pregnant, and her abdomen was tense and hard.

Upon viewing her films, my attending turned to our group and said "This looks like a job for a medical student."

Yes, friends, she meant manual disimpaction.

I looked at my two fellow med students, then quickly looked away. I knew if I went in there, I would vomit--I am sensitive to smells like that. There was no way in hell I was volunteering for this job. Finally, the other two students, Derm Guy and Medicine Guy, volunteered to go in. I gave a huge sigh of relief and ran to help grab equipment.

They donned scrub gowns, double gloves, masks with face shields, and scrub hats. They went in, with the attending and the resident, and I sat outside, occasionally giggling and thanking my very lucky stars. Eventually they emerged from the room shaking their heads. Their efforts were only modestly successful, and the patient remained "FOS". Medicine Guy admitted to getting queasy at one point, even though Derm Guy had done the actual deed.

At lunch that day, we presented her chest x-ray to the rest of the teams. One attending joked about the "life-saving procedure" that the medical student had performed--"you saved her by relieving that impaction!"

After lunch, our team was called to the patient's bedside. Crash carts were brought, as her pressures had dropped and they feared a code was near. Another patient came to our team from the OR, so I left the scene to go handle the new patient. I figured there were enough people to handle the code (at least 20 people usually show up), and I wasn't really looking forward to performing chest compressions on my last day.

Half an hour later, I came back to check on the situation. My teammates were standing outside the room, and there didn't seem to be a code running. As I approached and started to ask, "What happened?", I inhaled too deeply and shut up fast. Easily 15 feet from the patient's door, I knew exactly what had happened. My teammate, Medicine Guy, elaborated.

"We were in there, and she was crashing, and the attending looked over and said, 'Guys, you've got to try again.' Her belly was hard as a rock--she said it was like compartment syndrome of the abdomen. So we went and gowned up, and I went a little bit slower, so Derm Guy went in there, and there it was, just hanging out, so he reached in and grabbed this huge thing, and yanked, and all hell broke loose--her belly just deflated with the world's longest fart. I kept thinking she was going to groan and say 'Thank God, that feels so much better.' And yes, I almost vomited AGAIN! It was amazing, though--she didn't code! Her blood pressure came back up and she started breathing better! Derm Guy saved her life with his finger!"

So many people complained about the smell on that unit that the nurses had to order orange oil from central supply and spray down the whole unit. The attending let Derm Guy go home early after his "life-saving procedure", number two. So to speak. For the rest of the day, every time Medicine Guy and I looked at each other we'd burst into giggles.

And thus ends my ICU rotation. On to internal medicine clinic!

Sunday, October 28, 2007

Getting Busy

...with my fourth year to-do list. (I know what you were thinking! Naughty!) Here's what I have on my plate thus far:

  1. Ambulatory Medicine rotation in November--location TBD
  2. Step 2 CS on November 5
  3. December: Interviews on the 3rd, 4th, 7th, 10th; Step 2 CK the 19th, interview in Colorado on the 21st, so we're spending Christmas up there with various family afterwards
  4. Sub-internship in pediatrics in January--location TBD (could be county hospital, which will be asthma, or big hospital, which will be peak-RSV season with no patient caps and HELL)
  5. Submitting rank list in January
  6. Elective in February--currently Infectious Disease, but as my senioritis increases, I will probably switch to something like Diagnostic Radiology, where the hours are more like 9-noon.
  7. March--Required senior stuff, Jurisprudence exam, MATCH DAY!!!, etc.
  8. April--CHINA!
  9. May--sitting on a beach drinking. Or possibly moving, if we have a house by then.

I may cancel some of those December interviews, especially if I hear from Top Choice Program. If somehow my letters don't make it in, or I don't get an interview with them anyway, then I'll keep most of those interviews. I had planned on picking from three potential local programs; I may have to choose from the two I've already heard from. This would not be the end of the world, and if I end up in a program where I'm really unhappy I can always try to transfer next year.

My hubby and I had "The Talk" the other day. I laid it out: should I rank programs outside our geographic region, and risk matching elsewhere, which would mean long-distance relationship and hubby finding new job? Or should I only rank programs in the geographic region and risk going unmatched, which means I'd have to scramble for a PGY-1 preliminary Medicine (or Surgery, shudder) year? After some consideration, he decided that it would be difficult for him to find a job elsewhere, and likely it would not be as good a job as he currently has. Neither of us wants to do long-distance again (2.5 years was enough!), so I think the verdict is that I will only rank programs in our region (and possibly Colorado).

When I expressed my slight discomfort at the idea of only ranking 2-4 programs, he laughed at me. What I see as a risk--going unmatched--he doesn't see. It's nice that he has such faith in me, but I can't turn off the anxiety that easily. Nor can I just assume that "well, of course I'll match within those programs! Who wouldn't want me?" Thank goodness psych isn't terribly competitive, so my chances are actually pretty good of matching; faced with the same decision in urology, I was sweating bullets from about January to July. It's not the reason I switched, but it's certainly a bonus.

It is nice to make the decision, and even nicer that we could make the decision together. Look out, world, in only 7 months it'll be TS, MD!

Thursday, October 25, 2007


I requested three letters of recommendation back in July and August of this year. One is from a psych attending at my school whom I've worked with twice; one from a psych attending on my away rotation; and one from a pedi attending I worked with last fall. I made sure they all had the ERAS cover letter (where I waive the right to read it, yada yada yada, and the address to my school is on it), my CV, and my personal statement.

By September 1, I still had no letters in ERAS, but I turned it in anyway. Interview offers started almost right away; I've now heard from 9 of the 10 programs I applied at, and all 9 offered me an interview. Several of my offers came in without any letters of recommendation.

By October 1, I started to panic a bit. After all, my first interview was October 19, and generally you are supposed to have all of your letters in before interviewing--I had none. My school sent out an email saying that several letter-writers had called to say that their letters had been returned, so to check with our letter-writers if letters hadn't arrived. I dutifully forwarded that letter to all three attendings.

One attending, the pediatrician, called me that very afternoon, confused. She'd prepared my letter in August, shortly after I asked her, and had confirmed with her secretary that it had been sent. Was I saying it hadn't arrived? Yes!, I said with great relief. I faxed her secretary a new ERAS cover letter, and she had someone walk it to the dean's office the next day. One down! TS 1: letters 0.

Emboldened by my success, I called the away rotation attending. I asked if she had any trouble sending my letter, as another one hadn't arrived properly. She hesitated, then said well, I hadn't gotten around to sending it yet, so sorry. Oh, uh, that's no problem, I stammered, fully feeling like an idiot. She promised to send it soon. TS 1: letters 1.

Two weeks later, still with only one letter in ERAS, I grew desperate and called the third attending; I left a message for her. She emailed me that night--I'm super busy, the letter is done, but I've misplaced the ERAS cover letter. I promptly faxed her another. That was a week ago. TS 1: letters 2.

This week, as I continue to check my email and ERAS obsessively (like, every 10 minutes when I can), I realized that I can't keep that up forever. Therefore, I decided to give them another couple of weeks, and try to contact the attendings mid-November, in order to get things moving before my December interviews.

The last program that I haven't heard from is my top choice program (pre-interview). While perusing their website and FREIDA tonight, I got startling news: their deadline for completed applications is November 1, 2007 (the date the dean's letter is released). Now, I'm in full-on panic mode, totally freaking out, chewing my fingers, etc. I just emailed the two attendings in question and laid it out for them. Look, I need my letter, do I need to come get it from you in a sealed envelope? Do you need another ERAS cover letter? WHAT IN THE NAME OF GOD DO YOU NEED I WILL DO ANYTHING BUT YOU ARE COSTING ME MY TOP CHOICE PROGRAM!!!!!!!!!!!!!!!

*is trying not to hyperventilate and seriously considering drinking wine tonight to calm down*

So, I have 6 days to get 2 letters scanned into ERAS or I'll never get an interview at this place. This effing sucks, people. For pete's sake, if someone asks you for a letter of recommendation, please do not take 3 months to get it turned in! If you can't do it, just say no!

*Author's Note: Please see the follow-up post here, where I apologize for being so whiny and continue to thank my letter writers for helping me out, despite my being a whiny, anxious little whiner.

Saturday, October 20, 2007

The Mating Ritual

I sat there nervously, twirling my hair on my fingers surreptitiously. I was nervous, meeting someone new. I just knew he was going to ask me tough questions. How should I respond?

I'd dressed carefully, styling my hair, applying makeup, pulling on pantyhose and heels. Naturally, though, my hair had frizzed out, and I felt sweaty after walking in from my car. Our meal had been delicious Tex-Mex, but I could feel the beginnings of heartburn above my tight-waisted skirt. Was I shaking? Did I have a run in my hose? Were there any stray pet hairs on my outfit? Any lip gloss on my teeth?

He didn't really look nervous. He'd dressed up, too, but somehow it felt as though I were the one on the spot here, not him, even though I was here to interview him as much as he was me. I could see my photo on the table--ugh, what a terrible picture, why didn't I submit a better one? I wished he'd put it away.

We talked, asking each other careful questions, eyeing each other closely. What was he thinking? Could he tell I was so nervous? Was that the answer he was looking for? Am I asking intelligent questions?

Finally, it ended--only I knew I had 5 more people to see before I could leave. It was rather like speed-dating, residency interview style. Somehow I made it through all 6 interviews yesterday. Over all, the day went well. I believe I was able to convince all of them that I belong in psychiatry, even after we discussed the whole crazy "urology" thing. By the final interview, I felt like my brain had melted and run out my ears. Had I answered that question? What did she ask me? Could I possibly think of one more question to ask when pressed to do so? After the ending tour, I staggered to my car, found a fast food restaurant, changed clothes, ate dinner, and began the 5 hour drive home.

As of now, I have 5 interviews scheduled, one more to schedule and one I turned down. I have two programs yet to respond with an interview offer (or rejection); unfortunately, one of them is my top choice program. I still only have one letter in ERAS. I've mailed Thank You's, emailed, and called the two letter writers who are procrastinating, and I don't really know what else to do on that end. Pray, I guess.

Breaking News!

Dumbledore was gay.

Thursday, October 18, 2007

Shout Out to All the First Year Med Students

Inspired by comments to this post at TruMed, I felt the need to drag out some advice to any first year med students who might need a little reassurance right about now:

Take some time out and BREATHE, now. Stat.

Hear me out: What you do in your first two years of medical school will not necessarily determine the rest of your life. Your job is to survive, and pass your exams. That's it.

But, TS, the speaker at the surgery interest group said I should make the best grades possible in order to be a surgeon! And my buddy is a super ultra gunner who told me that we'll never get into residency with any high pass grades! Help!

Seriously, breathe, and think logically.

1) If you are a med student in the US who plans to practice in the US, you are automatically ahead of the thousands of people who graduated from programs outside the US who are applying here. I'm not saying FMG's are stupid, or poorly educated, but the reality is that most US programs will accept a US grad over an FMG who is similarly qualified. Therefore, you already have an advantage.

2) If you are able to achieve passing grades in your classes, you are ahead of those people who don't. This sounds lame, but there are always people who fail classes for various reasons. Guess what? There are residency spots available for people who failed first year biochemistry, or for people who needed extra time for basic sciences.

3) The majority of med students have "average" grades. It's a simple bell curve, right? So the majority of the class falls somewhere in the middle. If there were no residency spots for people with average grades, then med school classes would be a hell of a lot smaller. In other words, most of your attendings made "average" grades, and now they're attendings. Conversely, the majority of your attendings did not make AOA, and they're still attendings.

4) Check out this article at Student Doctor Network. Residency directors care FAR more about your clinical rotation grades than about basic science grades (or USMLE scores). It's more important to show them you can think and act like a doctor than like a college student. This even applied to residency directors in ophthalmology, a highly competitive specialty.

5) Whether you know exactly what specialty you'd like to pursue, or have no idea, don't worry about it. Many people change their minds, even if they were sure at the beginning. So long as you are passing your basic science courses, you have a shot at most specialties.

6) There are ways to bolster a CV, even if your grades aren't as high as you'd like them. Want to do dermatology, but can't quite honor gross anatomy? Think about doing some research in the department. Kick ass on the Step 1. Can't handle standardized tests? Rock your clinical rotations. Do some volunteer work. It's not all about the grades, after all.

7) Lastly, whether you are a super ultra gunner type, and insist on making honors in everything, or a "P=MD" type, you should also insist on having a life. Sure, you're studying a LOT, and your apartment is filthy for a month before exams, but that doesn't mean you shouldn't take some time for yourself somewhere. Work out, or go out with your friends, or spend time with your significant other--whatever it is, take some time for yourself outside of medical school.

Remember, those two years will eventually be over, just like mine were (and I really didn't think they'd ever end), and you can get on with the rest of your life.

Thank goodness I'm not a first year anymore!

Wednesday, October 17, 2007

Shock Media

"U.S. Deaths From Staph Surpass AIDS" says the AP. The first line of the article reads "About 18,700 people die in this country each year from drug-resistant staph infections, according to a federal study released Tuesday — more deaths than the United States sees from AIDS annually." This number comes from a CDC study on MRSA published in today's JAMA (JAMA 2007;298:1763-1771). Using the number of yearly AIDS deaths in the US cited in the Chronicle article, 17,000, then 1,700 more people die in the US every year from MRSA.

When reading the actual study, though, I get a slightly different feel.

Basically, the authors used a CDC surveillance procedure, monitoring 9 large urban areas for cases of MRSA, then obtaining medical records for each patient. Outcomes--death or discharge--were taken from the medical record.

Here's the thing, though: they never stated explicitly that the cause of death was MRSA. It's easy to imagine that a person with an invasive MRSA bacteremia would be critically ill, but how does one determine that the MRSA killed them, or the kidney failure which had them requiring dialysis which led to them getting MRSA in the first place? Or if someone is recovering from MRSA sepsis with DIC, then throws a massive pulmonary embolism and dies from being in the ICU for weeks, is the cause of death MRSA? It's also possible that a patient had a positive MRSA culture from a cellulitis, but died of something entirely unrelated, like an MI or CHF. They never stated that the cause of death was MRSA, only that these people a) had an invasive MRSA infection and b) died. If MRSA wasn't the direct cause of death in all of these patients, then the rate of death due to MRSA would be lower than they predicted.

Also, the only record of death came from the medical record for patients who died in the hospital. It's feasible to imagine that some patients died at home or in nursing homes from MRSA or its complications who weren't included. This would mean the rate could be higher than they estimated. Lastly, we're assuming that these 9 regions represent the US as a whole, but in reality bacterial populations vary by geographical regions. One of the sites studied, Baltimore, was left out of incidence calculations because it had much higher rates than the other 8 sites.

The point of the article was really to show that the rate of invasive MRSA infections is higher than previously supposed, and that a substantial amount of these infections came from the community. The majority of infections and deaths came from the healthcare-associated disease--patients who have been hospitalized recently, or have indwelling catheters and lines, or dialysis, or live in nursing homes, etc. Healthcare-associated infections also tended to be a more dangerous strain, USA100, with more multi-drug resistance, compared to community-acquired infections. Interestingly, although they gathered the data about the strain and presented it in the results section, they give it only a few sentences in the conclusion, as if the incidence data is so much more interesting.

Much of what got quoted in the Associated Press was an editorial about the study, also in today's JAMA (2007;298:1803-1804).
This is where the comparison to AIDS comes from and some of the other quotes used in various articles about this study today.

Naturally, MRSA is a huge problem. Isolates at one hospital I work at have developed alarming tolerance of vancomycin--not high enough to be considered vancomycin-resistant, but high enough that the concentration of vancomycin required for treatment is reaching dangerous levels. This hospital is considering a policy change to make linezolid the first choice antibiotic for MRSA. We're one step closer to VMRSA, a much scarier beast.

Most hospitals are not required to report MRSA rates (or any other drug-resistant bacteria) to authorities. Some hospitals have started nasal swab policies to identify MRSA carriers upon admission to isolate them sooner and prevent the spread to other patients. Hand washing policies are effective against the spread of nosocomial infections, but are sadly under-enforced.

I'm always a little amused by what the popular media will choose for their headlines, however. I guess they made their point: everyone knows about and fears AIDS, but few people know about MRSA.

Tuesday, October 16, 2007

Emotional Rollercoaster, or The Power of Denial

We've all heard the term "denial". It has several meanings:

  1. A refusal to comply with or satisfy a request.
    1. A refusal to grant the truth of a statement or allegation; a contradiction.
    2. Law The opposing by a defendant of an allegation of the plaintiff.
    3. A refusal to accept or believe something, such as a doctrine or belief.
    4. Psychology An unconscious defense mechanism characterized by refusal to acknowledge painful realities, thoughts, or feelings.
    1. A refusal to accept or believe something, such as a doctrine or belief.
    2. Psychology An unconscious defense mechanism characterized by refusal to acknowledge painful realities, thoughts, or feelings.
  2. The act of disowning or disavowing; repudiation.
  3. Abstinence; self-denial. (

Definition 3b is the one most people think about when they hear the word "denial". It's a Freudian term which has made it into popular English. It's a pretty self-explanatory term, after all; a person is "in denial" when they refuse to acknowledge the truth of a (usually negative) situation. Denial is necessarily an unconscious defense mechanism; in order to protect the mind from a painful truth, it's pushed aside. Your mind cannot be allowed to consider the truth, whatever it may be, so instead you think "Well, that just can't be true."

It's a term that is far overused, in my opinion, just like many other Freudian terms (Oedipus complex, anyone?) It can be part of the stages of grief, but it tends to be temporary. After all, most of us eventually cave in when we're shown hard evidence of what we fear. A rational person can only deny a situation for so long before the truth becomes indisputable.

For the past week, I've had a patient in my care who has diffusely metastatic cancer. He's got enough life-threatening issues that he has to stay in the ICU, but there's nothing super-acute. If I had to give my totally accurate, super-informed, expert opinion, I'd give him a few weeks to months to live. His kidneys have failed, but he can get dialysis for that; his gut has failed, but he can get TPN for that; his lungs are stable, and his mind is clear. The dialysis makes him hypotensive, and so do the drugs we give him to cure his arrhythmias, so he's still on pressors. Despite all this, it's not unimaginable that he could leave the ICU, go to rehab, and possibly even home for a brief time. Sadly, this will only be brief. His tumor burden is extensive, and chemo left him without kidneys. It's unlikely that oncologists will resume chemotherapy which was only for palliation after such a dreadful reaction.

One of the hardest parts of seeing my patient every day is having to deal with his wife. Last week, she accused all of us of being totally incompetent, of not communicating with each other at all, and of not doing the things medically necessary for her husband. She accused me of not giving her all the information available when I told her that my team would evaluate the chest x-ray on rounds, and that until then I didn't have an official report to give her. She tries to pin us down on specific times for procedures over which we have no control: "So, in a couple of hours? Then if it's seven now, it'll be done by nine?" Only, after a week in the ICU, she still tries to do these things, even after we've done our best to explain why it might take more or less time to obtain even a simple chest x-ray.

She has accused the oncology team of not explaining her husband's prognosis, even though they have spent hours discussing his disease. She then accused them of hiding from her that chemotherapy can cause immunosuppression and kidney failure, even though the chemo consent form clearly documents these risks. She accused us of not performing dialysis quickly enough over the weekend, even when we explained that he hadn't qualified for dialysis over the weekend. What about drug X, my friend works in a pharmacy and he suggested it? Why didn't you perform this [palliative, symptomatic-only procedure] as soon as he got here, we've been asking for it for WEEKS? Why aren't you feeding him [even though he's vomiting bile and obstructed], he hasn't eaten for so long and oh, you just don't think it's imPORtant?

In turn, she has yelled at and offended all of her nurses, every consulting team, the oncologist, every ICU attending, etc. We never know what we might say that will set her off. All of us have spent great lengths of time explaining things to her in great detail, only for her to fixate on one tiny point and perseverate for the next few days. I dread going to see them every morning, because I can't escape with generalities with her, but I never know what I might say that will make her angry and anxious, or what I might have to spend fifteen minutes retracting. She makes it hard for me to do my job, basically.

Now, I've vented all this from my point of view. To me, this is a woman who is interfering with her husband's care. She is so argumentative and demanding that sometimes, the teams cave in to her and give treatment that we were hesitant to give. She makes her husband anxious. There's a flavor of borderline personality to her; she yelled at my attending yesterday for DARING to suggest that a dialysis catheter be placed in the femoral position, but today she told me how much she preferred the same attending to all the others.

From her point of view, there are tons of doctors coming in and out of her husband's room every day. Sometimes, different doctors and their assistants and the nurses tell her different things, which is confusing to someone with or without a medical background. Her husband can't always speak up for himself, so she has to do it for him.

There's more to it than this, though. One of the first questions she asked me during our first meeting was "what will this do to his chemo schedule? He was supposed to have chemo this week." In reality, the chemo was only to try to reduce his tumor burden for a little while--there was nothing curative about it, and it really didn't matter when he was to receive his next dose. Her concern, though, was my first clue. After that, I started to figure it out. Every one of these things she fixates on--it's like we're denying him the one crucial treatment which would cure him.

When viewed in terms of denial, her behavior makes much more sense. After all, her husband was only recently diagnosed, but was already at a late stage in his disease. Only a few months ago, there was no cancer. Her future with her husband has been stolen from her, and she is furious. She can be angry with us, because we are the incompetent doctors who aren't doing everything for her husband, and because it's easier to be angry with us than to be angry at him. To be angry at him is to acknowledge that he is dying, which she can't do. She can focus on each medication, routine chest x-ray, lab, etc, because it can be controlled, which the cancer cannot.

Eventually, this facade will crack. As his condition deteriorates, and she becomes more frantic, something will break. We called a counselor to see her (at her request) but she refused to speak with her. I doubt she's spoken to anyone willingly about his diagnosis and prognosis. Eventually, it will all come out. I don't want her to lose all her hope, but I also don't want this moment of revelation to come to her after it's too late.

I am a selfish human being, though, and I just want her to quit bugging me so much and let me take care of her husband. Just because I'm going into psychiatry and can try to understand her situation doesn't mean I don't get frustrated, too.

Thursday, October 11, 2007

Where Have All the Blog Posts Gone?

So I keep checking some of my favorite blogs over and over again, because I'm bored, and I'm kinda curious as to why it's been so long since many of these blogs had new posts. Come on, people, what am I supposed to read while I'm not getting interview offers from my #1 school??? I need entertainment, dammit! I DESERVE IT!

Come on, just one little post? Just one? I only need a small one, I swear, just an update on your day or a link description, just a little fix to take the edge off and then I'll be fine...

I'm not really complaining, please don't be offended if you write one of my favorite blogs. It's a compliment to you that I'm so addicted! Really!

Edit: If you write a blog, and you update it a lot, this post doesn't mean you aren't one of my favorites. I promise. I just always seem to need a little more!


I'm a person who has a tough time with balance. I'm not referring to my klutziness (although I could, because sometimes it's amazing that I walk upright). I'm referring to a kind of balance of life that sometimes I feel like everyone else has besides me.

Medicine is certainly not the only career that promotes a skewed life. One can be a workaholic in nearly any profession or job. Both my husband and I have fathers who work 80+ hour weeks (one as an entrepreneur, one as a CPA). There's something about medicine that encourages total devotion, however, and for those who drink that Kool-Aid, there can be no life outside medicine. Since many doctors are socially retarded (extrapolating from classmates who are certainly not going to acquire better social skills between now and graduation), their lives outside the hospital/clinic are not very rewarding. They learn to base all their satisfaction on medicine, and society condones this. After all, medicine is a "meaningful" profession, so it's only right for you to spend all your time doing it.

In my life, I sometimes feel like I can't possibly do everything I want to do. I want to be a good student/doctor, a good wife, a good daughter and sister, and a good friend. I want to get my body in better physical shape, which requires going to the gym, and I want to take better care of my pets, which involves vet$ and food and the pet $tore and the dog park and boarding, etc. I want to be well-rounded, so I try to go to rock concerts, art museums, the symphony (season tickets this year!), and take vacations. I want to have a clean apartment and be a better, more frequent cook. I want to have beautiful plants in my small garden. I want to express myself on this blog in a meaningful way.

In reality, though, every one thing I try to add knocks another thing out. I get easily overwhelmed by fatigue and then lose all desire to try to cook dinner, so we eat out a LOT (especially on rotations like this one, where I'm physically and emotionally drained). This habit doesn't really help with the physical condition issue, of course, and the fatigue doesn't make it easy for me to go to the gym. I've been going to the gym more regularly for a few weeks, but then I'll have an asthma attack and miss a day or two, which is frustrating. If we go out during the weekend, somehow the apartment doesn't get cleaned, and then I spend the next week disgusted by our living conditions. I've killed almost all my plants. Also, I spend so much time at work dealing with everyone else's problems that sometimes it's hard to listen to my husband talk about his day. After all, I spent MY day HELPing people, for goodness' sake, how could anyone else's day matter?

I think part of the problem is that I try to add too much at once. If I'm not going to the gym every day, then obviously I failed. One reason I let this get me so anxious is that I realize that my life is currently going on, sometimes without me. In medicine, we put everything off for the future: we'll make money later, get married later, have children later, talk to our spouse later, and so on. Since you can't make medical school nicer, you can only make your outside life better (that's my theory). I realize that the point of making your life more well-rounded outside of medicine is NOT to get anxious about it, but hey, that's me. As someone pointed out the other day, "that's TS." If I don't have anything to worry about, who am I?

And who would I be without medicine? I have a gift of intelligence which is, for whatever reason, oddly suited to medicine. I have a repertoire of useless medical trivia that don't help me get pimp questions right, but have totally ruined my ability to win Trivia Pursuit on any other subject. I guess part of what I want is to be able to say that I have an identity other than "future doctor", and part of me worries that I don't.

As for medicine being so meaningful, I'm working on a post to address this issue. If I can work it into my schedule, that is.

Monday, October 08, 2007

The ICU Makes Me Sick

The evening after my last post was entirely uneventful. I made frozen pizza for dinner, my hubby and I watched TV, I blogged, I checked many blogs, and then went to bed. I coughed some, but then I can't really stop coughing. (For some unknown reason, my asthma has turned into "moderate persistent", with daily symptoms, for the past month and a half, despite being "mild intermittent" for years. I can't tell if it's a URI or not, and therefore I don't know if I should fill the Z-pack I was given as an "emergency" script or not.) It really wasn't a special evening.

Until I woke up at midnight and re-experienced the frozen pizza.

After a mostly sleepless night, I called in sick, notifying my nurse practitioner ("the boss"), my attending, my course coordinators, and my course director (all at 5 am--impressive!). Then, I slept till noon.

During my third year of med school, I went to work sick several times. It's something of an expectation that third year med students will not miss work. I did call in "sick" (ie, played hookie) once while on family medicine (and agonized about it for DAYS, I'm terrible at that sort of thing).

As a fourth year, I no longer have any qualms about staying home from work when I'm sick. I called in once last month because of the asthma/URI crud that hasn't gone away (it's been a month and a half!) On this occasion, I wasn't sure if I was done with the ickiness, and I figured that a) I didn't need to be around ICU patients and b) ICU patients didn't need to be around me.

When I went back to work, I felt better, but I still had the sniffles and the cough. Since these were noticeable, everyone assumed that this was why I'd stayed home. Since then, most of my ICU team has come down with some form of cough/sore throat/runny nose/sniffles, and they blame me, despite my frequent hand-washing and obsessive use of hand sanitizer. A friend called me "a walking fomite" today.

Never mind that we're surrounded by patients with every drug-resistant bacterium known to man, I get blamed for the creeping URI. Oh, well.

Wednesday, October 03, 2007

They All Have Cancer

...and that pretty much sums up my first few days of my required ICU rotation. I'm in a special cancer ICU, on the "solid tumors" team. As one of our PA's said yesterday, we either have "easy" patients--or not. The easy patients are mostly craniotomies for intracranial tumors--ie, brain cancer. They come to the ICU after their surgery, stay overnight, and generally get transferred to the floor the next day. Thus far, I've only managed this kind of patient, as they're not on a ventilator and have fewer serious issues (although I still write a 2 page progress note, detailing labs, meds, and physical exam for every body system + ID & oncology--they're not easy patients yet for me!)

The other kind of patient, according to my PA, come into the ICU from the floor "crazy sick", get a ton of money spent for a 1-2 day ICU stay, then DNR/DNI/withdrawal of care papers are signed and the patient disappears from the list. I believe she (the PA) was talking about what a waste that is.

The "liquid tumors" team (lymphomas, leukemias, bone marrow transplants, etc.) supposedly has a 30+% mortality rate. One of my friends is following a patient with a total bilirubin of 35; his skin is a strange neon green color. Another patient has a strange bacteria I'd never even heard of before--Stenotrophomonas maltophilia--which is apparently resistant to EVERY SINGLE ANTIBIOTIC TESTED EXCEPT BACTRIM. Still another patient has a virulent varicella pneumonia on top of her end-stage metastatic colon cancer.

I could go on and on and on. But I won't. Suffice it to say that it sucks. Yes, I am taking my antidepressant; otherwise, I don't really think I'd make it through this month.

The only thing that could make tomorrow more awesome would be if my nurse practitioner, who introduced herself as "the boss", decided to assign the medical students another learning issue. My 2 minute regurgitation of UpToDate on astrocytoma was spectacular, let me tell you.


In happier news...

Interview Count: 6
Letters of Reference in ERAS: 1, scanned in today
Letters of Reference NOT in ERAS: 2
First Interview: October 19
Anxiety Level About Lack of Letters: 10 out of 10

Thursday, September 27, 2007

The Empowered Patient

Today, is featuring an article called "Five commonly misdiagnosed diseases" on their editorial "The Empowered Patient" by Elizabeth Cohen. The article begins with a large picture of John Ritter, mentioning that he died of an aortic dissection; his family later won a malpractice suit alleging that he was misdiagnosed "at least twice." She alleges that "certain diseases are misdiagnosed over and over again. It's worth knowing what they are so you won't be a victim."

The five diseases mentioned: aortic dissection, cancer, coronary artery disease, acute MI, and infection. Three of these (cancer, MI, and infection) are from a study at Harvard by Gandhi TK, et al regarding settled malpractice claims in the outpatient setting (Ann Intern Med. 2006;145:488-496.)

The solution, or "how can you keep yourself from becoming a victim of misdiagnosis?" Here are the five ways given to protect yourself: "Ask for more tests", "Ask 'what else could my illness be?'", "Don't assume no news is good news", "Assume your doctors don't talk to one another", and "Be wary when your doctors work in shifts".

I'll just throw this out here now: I greatly dislike this column. There is a little defensiveness on my part, I'll admit it; doctors do make mistakes, every day, but I don't like the tone of some of the articles. However, let's examine her evidence a bit, and I'll see if I can't give you a reason to question this article as well.

Issues I have with this article:

1) John Ritter: His family did indeed sue the hospital (successfully) for "missed diagnosis". Cases against three doctors are still pending until 2008. Even though he was apparently in emergency surgery within 4 hours of arrival at the ED, he died on the table. See Rangel MD's post on why he thinks the ER docs followed all the right steps, and why the "misdiagnoses" were appropriate steps along the pathway to the correct diagnosis. If you really want a blatantly misdiagnosed aortic dissection, look at Jonathan Larson (author of Rent); he was sent home from two ER's with "flu" or "stress" and died suddenly at his apartment.

2) Aortic dissection in general: For a proximal aortic (acute) dissection, 40% die immediately. Within 24 hours, 70% die. If left untreated, the condition is eventually 100% fatal (or close enough). A proximal dissection is a surgical emergency; if treated, there is a 70% 3-year survival rate. Distal dissection is better managed medically, as the surgical mortality is high. Interestingly, "Overall survival rates at ten years are approximately 5% for untreated patients and 50% for treated patients (49). Operative mortality has decreased to about 20% (57)." (Auer J, et al). In other words, 20% of patients still die in surgery, and 50% of the patients still don't make it 10 years even with good treatment. This is a big, bad disease.

Misdiagnosis is only going to make this worse, of course, because delaying surgery in an acute proximal dissection (Stanford A/Debakey I-II) can be fatal. Unfortunately, a chest X-ray has only 67% sensitivity and low specificity, because a wide mediastinum could be caused by many things. The test of choice is CT angiography, which takes a little longer and requires IV contrast, but has a sensitivity/specificity of 96-100% (See Wikipedia article). In this case, one of the things Ritter's widow alleges is a "simple X-ray" would have given the diagnosis; this is not entirely true.

Moral of the story? Misdiagnosing an (acute proximal) aortic dissection is almost certainly a death sentence, especially if treatment is delayed for days. However, if 4 hours was too long for Mr. Ritter, then I'm not sure he could have been saved (and that's my personal opinion--things take a while in the ER, doing the ABC's and getting the EKG and the chest x-ray and the CTA and calling the OR and the cardiothoracic surgeons and getting an unstable patient to surgery, etc. This stuff takes time. I don't know whether this 4 hours is below the available standard of care at that hospital. In other words, I don't know whether this constitutes a breach of care or not.)

3) Coronary artery disease:
"Sometimes doctors tell patients they're short of breath because they're out of shape, when it's actually coronary artery disease, says Bonow, who's also the chief of cardiology at Northwestern Medical School." This quote is meaningless because a) If you interviewed a pulmonologist instead of a cardiologist, he'd have told you that shortness of breath could be an undiagnosed PE. Pick your specialist, pick your disease and b) There's no references (besides Dr. Bonow) or studies here, so I can't really say how often this occurs.

Basically, you diagnose CAD by visualization at angiography or after the patient has had acute coronary syndrome (angina, MI, etc.). There's no one great screening test for CAD. We approximate by checking risk factors: family history, smoking, cholesterol profile, blood pressure, and diabetes are the biggest ones (of course, there are others). In a patient who fits the picture, we may offer stress testing or other measures. Sadly, not all patients fit the stereotype, and I'd imagine it's a younger, fit person who presents atypically who would be misdiagnosed more frequently (this is just my guess). Patients with no/few risk factors may still have CAD.

While I do think it's negligent to just tell a patient "you're just out of shape" without doing any kind of exam or workup, I could see how a patient might fall through the cracks here. I couldn't find any studies to say how often CAD was misdiagnosed (and I'm referring to asymptomatic CAD, not acute coronary syndrome).

4) "Demand more tests." The example they gave here, of the RN whose endometrial cancer was misdiagnosed for 3 years as "menopause", is probably the one example in the article where if I were that patient, I might have sued. Then again, if I were that worried, I'd have gone to another doctor. Heavy bleeding in a perimenopausal woman should be ruled out for endometrial carcinoma, period (ha!). I'm not sure the "simple ultrasound" she mentions would have done the job (although it can be used as a screening test by the thickness of the endometrial stripe or by ruling out fibroids) but she warranted an endometrial biopsy. If her doctor didn't at least recommend one, he/she was negligent, IMHO.

However, more testing isn't always going to solve your problem. While failure to order a diagnostic test was the most common reason a diagnosis was missed in the Harvard study (55% of the errors studied), that means 45% of the errors were made even with the appropriate testing. Additionally, errors in the testing itself were also common; just because a test is ordered doesn't mean it will be performed or interpreted correctly.

5) "Be wary when your doctors work in shifts." Up until now, the article has mostly dealt with outpatient issues. The Harvard article (which wasn't actually cited, I had to search by "malpractice claims" in PubMed to find it) deals only with outpatient mistakes. Doctors who work shifts are typically inpatient. The article cited here, "Fumbled Handoffs", is a case study by the same Dr. TK Gandhi from Harvard ( Ann Intern Med. 2005;142:352-8.). The error she attributes to "multiple handoffs", however, actually comes from a human error (a wrongful interpretation of a chest x-ray as "normal", written on the chart) which was given in handoff with the patient. She then describes a "diffusion of responsibility" associated with multiple handoffs, ie the receiving resident should have read the chest x-ray himself. I don't think that's an error of the handoff policy, but rather of the resident believing the night float resident's documentation in the chart. Basically, he should have looked it up himself, whether the person speaking to him was the night radiology resident or the float resident. To me, this error had nothing (or little) to do with the float system.

Through a documented series of MULTIPLE errors, in this case study, an elderly man died of TB after his diagnosis was missed on several occasions. Certainly, medical handoff policies can contribute to errors. Here's an abstract of a policy on how to reduce errors with handoffs.

I think it's misleading to include this information in this particular editorial, because a) other data in the article is outpatient, not inpatient; many people reading the article may not understand this distinction, especially since the 2006 study is not actually referenced properly and b) I disagree with Gandhi's emphasis on the multiple handoffs in this patient's misdiagnosis in the case study. I'm not denying that this type of error can occur, but I think a different study would have served better to illustrate it.

Also, as Gandhi points out, studies have shown that "traditional" medical shifts with overnight call also cause error. Look at Landrigan et al, NEJM 2004;
351:1838-1848 for this study of ICU residents working q3 call shifts compared to a reduced schedule of 63 hours/week with no overnight calls; the interns working fewer hours made 35.9% fewer "serious medical errors". My concern is that if we don't clean up the errors in the handoff process, we'll all be working q3 again, which isn't really good for anyone, is it?

Here's my guide to being an empowered patient:

1) Ask your doctor questions. It's his/her job to answer them, even if they're dumb questions.

2) If you disagree with your doctor, and you can't get an answer you think is reasonable, get a second opinion.

3) If you look stuff up on the internet, use something like WebMD or eMedicine. Do not go to Cletus' Sight on Awtism and the Vaccine Devil!, because *gasp*, you won't get balanced information there.

Doctors DO make mistakes, every single day. They can be serious. Inform yourself and ask tons of questions, and if you think a mistake is being made, speak up.