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?)

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.

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!

Happy Thanksgiving!

Eat turkey!

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.

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.

Denouement

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.

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.

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.

"The Great Uncircumcision Debate"

An interesting article here on time.com 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!

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!