Tuesday, January 29, 2008

Last Call!

It's my last call as a med student! My next call will be as an intern, and I'll be signing "Tiny Shrink MD" on my orders and getting paged at 2 am for Colace or to notify me that "we gave the Tylenol that you wrote PRN, we just wanted you to know". It'll be great!

Sunday, January 20, 2008

Saturday Night

Or is it Sunday? I'm getting to the point where I can't tell what day it is anymore. I told a friend last night that I was on call today, when in reality I'm off today--I couldn't tell what day it was. Also, I counted up my calls and realized that I have 3 left--I'd convinced myself I only had 2 left. There's a concert tonight that I'd LOVE to attend--a small band that NEVER comes through here, I've never seen them perform and I love their music--BUT the concert is at 10 pm tonight. I'm in bed by 10 most nights.

Seriously, med school, you're interfering with my social life here. Geez.

But actually, I'm going to be a terrible intern. Just mention "Q4 Call" and I'll be hiding in a corner, rocking back and forth, saying "No, no, make the bad man stop." It won't be pretty.

Tuesday, January 15, 2008

The Rot Slowly Sets In

3 calls down, 4 to go. After only two weeks of q4, I feel like my grip on things is slipping. Out of four days, I'm either on call, post-call, in clinic, or out by 1-2 pm (in that order). Today's clinic unexpectedly lasted till past 5, and I had to tutor at 7, so there was no time to go to the gym. Fortunately, my lovely hubby made dinner, and brought me flowers to boot. He is such an amazing man!

q4 is not the most grueling call schedule possible by far. The schedule I described is not the worst I've ever worked. As the days go on, though, I'm getting progressively more sleep-deprived. I'm getting a few hours on call, so I generally don't sleep post-call until nighttime. I wake up every day around 5 am, and I find it difficult to get to bed before 10 pm. An hour or two of deficit here, an hour or two there, a talk on UTI that couldn't be started till 8 pm, etc etc, and it adds up. Again, it's not the worst I've ever worked, and the rotation is largely easy in terms of the workload (almost ridiculously low), with the exception of clinic requirements (every other day) and mandatory noon conference on post-call days. Maybe I'm just getting softened up by fourth year (very likely), maybe I'm a wuss (very likely), or maybe q4 call is actually somewhat difficult (likely).

Add to all this that my husband and I are working on a large life transition (no, not a baby) that has me all stressed out, and the fact that I was going to have 2 more baby blankets made by now for babies due in February, but I don't (and don't have the time to work on them), and that I just started tutoring this block, yada yada yada, I'm feeling a little stressed and worn out. Fortunately, tomorrow is my day off (I worked all weekend), so I can get a little more sleep, hopefully go to the gym, maybe go get my bangs trimmed, and crochet till my wrist falls off. It actually sounds very nice.

Saturday, January 12, 2008

Silly Mommy

Yesterday in clinic was "Silly Mommy" day.

Case #1: First time young mother has a two week old baby, coming to clinic for newborn checkup and state screen #2. Looking through the chart, we notice that the baby has an ER visit in the chart. What could send a 1 week old baby to the ER? Chief complaint: constipation. When questioned further, mom reported that the baby was constipated after being fed rice cereal. Her ER chart stated very politely that "mom was educated that newborn infants should only be fed breastmilk or formula."

Case #2: Similar to case #1, we had a young first time mother bring her newborn to clinic for a 2-week checkup. Mom said that the baby hadn't pooped in 2 full days, so she'd been giving her water to get her going (see case #1). When I went to examine her, I pulled off her diaper to reveal very thick yellow stool (in other words, normal baby poop). As I was pointing this out to mom, the baby started pooping more, scrunching her face and straining. Then, while her mom was trying to clean her bottom, the baby farted right in her face. She totally freaked out: "Oh my GOD, that is so disGUSTing! Baby, that is TERrible! Oh no you didn't!" I was laughing too hard to be of much help to her.

Case #3: 15-month-old male for well-child checkup. Baby was noted to be so far above the weight scale that he charted onto the height scale, located above the weight chart on the page. When the attending pediatrician came into the room to examine him, his older sister (>2 years) was also in the room. Both children were drinking from bottles when we walked in. The attending flipped her lid. "No es bueno para los ninos usan estos! No no no!" Fortunately a drug rep had left us some sippy cups for kiddos, so both kids left with free cups. We also gave mom some nutrition guidelines for the chunky kid: "El jugo tiene mucho azucar" (Juice has a lot of sugar). Her eyes widened. "El jugo de WIC tambien?" Uh, yes, mom, just because the government paid for it doesn't make it low-calorie, low-fat, low-sugar, and perfect for your child to drink in very large quantities.

From a pediatrician's point of view, these cases have a few things in common. A) Pediatricians aren't doing a very effective job (at this clinic at [county hospital]) of teaching parents about proper nutrition. B) There is a lot of misinformation out there about what to feed your kid. C) No wonder there's an obesity epidemic when we get 14-kilogram 15-month-olds in clinic.

From a (distant-future) parent's point of view, I feel frustrated for those parents. What will I do to my kids that my pediatrician laughs at? And how much of these teachings are hocus-pocus? Is there solid evidence that babies fed bottles have extra problems with their teeth? How strong a risk is it, really? (I don't know). Is this yet another thing that today we abhor bottles in toddlers, but tomorrow we learn that it causes higher IQ's and less foot fungus so we recommend it? I don't know. I do know that I felt for those moms. Sure, now I know not to give a newborn water (it can actually be quite dangerous, as they can get hyponatremic or have failure to thrive, depending on the amount) but I didn't before I took pediatrics.

Silly mommies or not, I'm sure these kids will grow up to be fine.

Thursday, January 10, 2008

Boring Night on Call

So I read a book. It's a very interesting book, an autobiography written by a young British man with Asperger's syndrome and savant syndrome. I can highly recommend it. He actually sees the world in fields of numbers, only he experiences numbers in terms of textures and colors (he also has pronounced synesthesia). If you've ever thought you were in a minority, imagine this: being autistic (and yet quite intelligent), having epilepsy, AND being gay. I feel positively normal reading this.

...Aaaaaaaaand then, after seeing zero patients before going to bed, I woke up at 5:30 this morning to find that suddenly our team had two new floor patients to work up, two new newborns to work up, and two old babies to see. Before 8 am, when we are required to go to morning report. That's one thing about our pedi program that is bizarre: post-call, residents are required to go to morning report AND noon conference. I fell asleep during noon conference, which was a streamed video of a lecture on "sodium and water balance" and woke up at 1 pm to find I'd drooled all over myself. Awesome.

Now I'm watching "A Baby Story" on TLC (I totally cried during the last one, it's terrible) and trying to stay awake until bedtime tonight. Even when I sleep during call (and I'm not complaining about sleeping during call, trust me), it's just not the same as sleeping at home, and I'm really foggy and stupid for the rest of the day.

I'm finally understanding why the 80-hour rule (and the 36-hour rule, with no new patients after 24-hours) creates such a hassle for residents and programs and why some residents think this rule is a problem. Often, residents take call for one hospital and then spend the day at another or on another service; post-call, they are expected to show up to their other service, but are not technically allowed to care for new patients. The call schedule for the pedi program I'm working with right now is an amazingly intricate, complicated thing. I wonder if, in an attempt to gain meaningful and varied experiences for their residents, that some programs stretch themselves too thin and attempt to cover too many locations, necessitating that someone be on call at all these places.

While I'm all about putting limits on the # of hours that residents work, I can now understand a) how easy it can be for residents to go over 80 or 36 hours; b) why a resident may not want to leave at 36 hours (if there's work to do that won't get done till tomorrow) c) and how well-meaning programs might get in trouble, if residents are on a very busy service and truthfully report their hours (while the program is trying to fix things), while programs that are flagrantly abusing the 80-hour rule can get away with it because their residents do not truthfully report their hours for fear of punishment. It's much more complicated than I initially thought.

I guess it's time to do some post-call laundry now.

Sunday, January 06, 2008


I'm post-call from the first call I've taken since May. God, I love being a fourth year med student. I'm post-call, but it was a really easy call--I only admitted one patient and so got to sleep several hours last night. I may be the "acting intern", but I'm still a med student, which means one important difference: the pager. Yes, I carry a pager, but no one actually pages me on it; nurses don't have the number, and my residents just don't bother (I usually try to stick around the resident or the intern in case there's work to do). Since the floor doesn't have my number, they always page the intern, Jersey Girl, when there's an issue, even on my patients. Sure, I could write out my pager number on everything I write, but I doubt anyone would bother to page me, since it says "MS-IV" next to my name. Fine by me! Therefore, I've decided that "acting internship" is still nothing like actual internship, because it would be hard to give a student the kind of scutwork an intern gets, and because I do get some autonomy with my patients, but as I'm not a pediatrician I rely on my residents heavily. I'm definitely stuck in the middle, a gray area between the MS-III's and the residents, but at least it's a pleasant shade of gray.


After a patient encounter of significance last night, I came home to find this running debate between Graham at Over!My!Med!Body! and Panda Bear, MD about social justice vs. free-loaders. It was particularly apropos, because I've been pondering what I think the right answer is in this situation:

Mother brings her 15-month-old toddler to clinic for a weight check. His weight continues to be well below the 5th percentile, so he is admitted from clinic to the hospital with a diagnosis of "failure to thrive". A lengthy series of lab tests is ordered: blood counts, celiac disease autoantibodies, stool studies, calorie counts, etc. We ordered all these tests even though we knew why this kid was so thin. During the history, mom gave a constantly changing account of how when she/her dying mother/her 6-year-old son would feed the child, he didn't really take solid foods. She also said the family's only sources of income are food stamps and WIC, which must feed herself and three children; citing "health problems", mom said she left the children with their grandmother 4 days a week, but couldn't really tell us where she herself went on those days. We observed the child eating solids, and he was a finicky eater--as is fairly normal at 15 months of age. As my attending put it, "this is the age where they throw the food on the floor--someone has to sit there and feed the kid and it can take 30 minutes at a time."

We knew why this kid was so thin: nobody was feeding him. Sure, someone throws him a bottle from time to time, but no one is sitting down and feeding this child good foods--meats, vegetables, breads, etc. How well do you think a 6-year-old boy can feed a toddler? (The answer is: not very.) In this case, it's an issue of time and money. Mom doesn't have time to make sure the kid is properly fed (which takes more work at 15 months than as a newborn), nor does she have the money to make sure the kid gets good food. Between Medicaid, WIC, and food stamps, this family is living entirely off the government (mom denies any welfare benefits). Apparently, that wasn't enough, and that's how a 15-month-old is the size of a 6-month-old.

My dilemma is this: what do we do? What do we do for the children of those parents who won't do for them? This kid isn't quite neglected enough to call CPS, and even if we called CPS there's no guarantee they'd intervene. On a national scale, how often does this happen? Pretty often, apparently: eMedicine estimates the prevalence at up to 10% of kids in primary care. In the United States, "non-organic" failure to thrive, aka kid doesn't eat enough without a truly physical problem, is more common; we do the workup for organic causes because they'd be devastating if they continued, but more often than not the kid isn't eating enough. Another common cause of FTT is "over-mixing": mom can't afford formula, so she mixes it half as strong as it says to. Eventually the kid will get skinny and/or have seizures from hyponatremia if this continues. Sometimes, the food stamps aren't enough, and the family runs out of food by the end of the month.

What do we do? What should we do? Should we do anything?

If we do nothing, and say that her kid is her responsibility, what happens to that kid? The kind of poverty I'm describing can only lead to further insults to the child: crappy schools, crappy neighborhood, possibly with drugs, etc. I'm stereotyping/over-generalizing on purpose, but the kind of poverty that won't allow a small child enough food to eat tends to be associated with other things that promote a poor outcome. The more obstacles we stack in front of this kid, the harder it will be for this kid to become anything but another burden to the system.

But are we responsible for her kid? How do we intervene? I'm pretty sure this mom is going to give this baby as much food as she can now, as well as high-calorie supplement, but what happens to the older kids? Is food really so tight in this house? It can happen that feeding all the high-calorie foods to the baby takes them away from the older kids. What do we do when food stamps and WIC aren't enough?

Panda tends to see most of these moms as system-abusing freeloaders, the ones who will never work because the government keeps them just well-fed enough so that they can go out and support their crack habit and have carloads of welfare babies. Graham tends to sympathize with the poor, and sees (most of) them as hard-working, too busy to even get healthcare. Sure, the truth is somewhere in between. Is it worth feeding these children if it encourages mom to go have more children she can't support because she doesn't work? If we don't feed them, will she have more babies anyway, and will their blood be on our hands?

I'm emotionally involved here, because I love children and I personally think that if we give our children better early nutrition, education, and healthcare, there is evidence that this promotes better outcomes. I also think that our society in general will benefit from having more children nurtured in this way. 7 years ago, if you'd asked me this same question, I'd have answered very differently. People are responsible for themselves, and I'm not responsible for them; if she wants to raise her kids to be beholden to the government for survival that's her problem (although I didn't think the government should be involved at all).

What changed for me? I saw more working poor people; the kind who do grueling work 80+ hours/week to put food on the table. I saw the effects of neglect and malnutrition on innocent children, in one of the world's wealthiest countries. I did become more liberal as I saw more in medicine. Some of my classmates have become more liberal with me; others have become more conservative, as they encounter more of the "welfare queen" type patients, or those who use food stamps so their income goes to their drug habit, or the Medicaid recipient who is an ER frequent flier because "it's free." I see those things, and they annoy me, but I guess I'm more of an "err on the side of caution" type. Better to feed the kids of the crack whore than to allow the kids to starve.

Fortunately, in our kid's case, the mom really is concerned for her baby; she keeps her pedi clinic appointments and tries to follow instructions. She was neglectful, but I think after all the education (and a little tough love) we've given her, she'll improve. The kid seems okay developmentally, so hopefully we've caught this in time. Even good parents make mistakes, after all, and even bad parents have redeeming qualities.

But I'm stuck in a gray area here, too. I'm too liberal to be a Republican and too conservative to be a Democrat (although I'm probably left of center). I want this mom to take responsibility for herself and her kids, "pull herself up by her bootstraps", but at the same time I don't want her kids to suffer for her mistakes. What to do, what to do.

This is some awfully deep thinking for post-call, no? Too bad I didn't reach any actual conclusions. I guess I'm better at identifying problems than reaching solutions, which in the long run is not terribly helpful. Oh well, what the hell.

Tuesday, January 01, 2008


One requirement to graduate from most US allopathic medical schools is to take and/or pass the USMLE Step 2. In 2004-2005, the Clinical Skills portion of the exam, or the "CS", was added. The purpose of this piece of the exam is to have students demonstrate their ability to interact with patients and perform a focused physical exam in a standardized fashion. After all, many medical students never perform a history and physical in front of an attending physician. I've conducted H&P's in front of an attending only on psychiatry, really; most attendings rely on your presentation of your findings to gauge what questions you asked and what exam maneuvers you performed.

In reality, though, the test is (IMHO) complete and total BS. There are only 5 test centers in the United States: Philadelphia, Atlanta, Chicago, Houston, and Los Angeles. This year, it cost me $1005 to take the BS, and $470 to take the CK (Clinical Knowledge) portion. Most of us have to pay to travel to a city with a test center.

I spent the night in a motel, then on the morning of the test, I drove to the test center, which is not in a fantastic part of town; the neighborhood is nicknamed "Gunspoint" if that helps. You have to arrive promptly at 8 am, or they threaten not to let you take the test. I arrived and was told to strip off my watch, tape over my name on my stethoscope, put only my ID in my pocket, and put everything else in a locker. I was thus armed with an unlabeled white coat (if you have a badge or patch sewn on, they'll tape over it for you), a stethoscope, and my ID. They gave me a clipboard and two pens--we weren't even allowed to have our own pens, because god forbid that you cheat with your own pen. They put tags on our chests and left shoulders with our number for the day--I was number 1 of 26. Trying to be cute, the test staff repeatedly called us "doctors" as they ordered us to march to a different holding cell where we watched a video about how to conduct the encounters and played with the model room equipment. Finally, we were marched out to a long corridor with 13 rooms opening off either side and 13 computer desks against either side wall. We were lined up, warned strictly against "unauthorized or irregular behavior", and told to wait for the voice to tell us to start.

At the sound of the voice, you flip over the sheet on the door to learn about Patient X, a 26-year-old man in the clinic with a complaint of cough and vitals of X, Y, and Z. You knock, go in, introduce yourself, and it begins. The complaints are usually vague enough that several diseases could fit the description; our patient could have pneumonia, bronchitis, influenza, lung cancer, asthma, or GERD. The point of the exercise is not to narrow the differential, really, but to ask "the right questions". Don't forget to wash your hands in the freezing rooms before you touch any patient! There will probably be at least one encounter where either you have to talk to the SP over the phone, or see a "parent" while their imaginary kid is "getting his vitals taken by the nurse".

The fun thing is that each patient has their "tough question" to ask you. "Doctor, do you think I have cancer?" "Doctor, will I be able to go back to work [as a schoolteacher who has symptoms very consistent with mononucleosis]?" "Doctor, do you think I waited too long to bring my son in to see you? I feel so guilty! [Kid had a mild fever x 1 day with no other symptoms]" "Doctor, I can't be sick, I have to take care of my wife! Do you think it's serious?" These questions are designed to test your ability to quickly think of soothing BS--we can't rule out cancer, but I think it's unlikely; let's see what you might have, but there's a possibility you will need to stay home from work; your son appears to be okay, but I'm glad you brought him in today, you did the right thing; we need to work on taking care of your health so you can care for your wife, as I know that she's your top priority. Don't worry about sounding fake; just let the BS roll off your tongue. Oh, and always assess smokers' willingness to quit, advise promiscuous people to use condoms to protect against STD's, and never assume that the elderly businessman doesn't use tons of cocaine. There is no profiling here!

After you've examined your "patient" and addressed their "concerns", you will quickly recap everything you talked about and go over the plan: you'll need a chest x-ray/pelvic exam/rectal exam/antibiotics/biopsy/CT scan/blood work/immediate surgery, say goodbye, and exit. Unfortunately, I didn't always have time at the end, as I ran out of time in several encounters. Since I knew this would be a problem, I tried to include this info throughout the exam. This portion of each encounter is 10 minutes long.

After you leave the room, the fun part begins. On your desk is a computer and a blank H&P form. Choose one and begin to document furiously. I did one written note and 12 computer notes because that was easiest for me. You can do either one. You write up the H&P, including any pertinent family history/social history/medications/PMH/PSH, etc. At the bottom of the page, you are to come up with "up to" 5 differential diagnoses and "up to" 5 potential next steps. For some, this is easy: the 25-year-old female with belly pain, fever, skipped period, and pain at McBurney's point could easily have ectopic pregnancy, appendicitis, ovarian torsion, PID, IBD, etc. Try limiting yourself to 5 tests for her: she needs a pelvic exam, pap smear, rectal exam, fecal occult blood, urine pregnancy test, abdominal ultrasound, and CBC for starters. I squeezed multiple answers onto one line sometimes, but it wasn't really clear how this would be scored. Eh. You have 5 minutes for this section.

After 5 patient encounters, you are fed lunch and can go to the bathroom; after another 4, another short break; then the final 3, a short survey (where, conveniently, you can't give them your actual opinion, only the numbers 1-5 in response to their questions), and you're HOME! (Or at least off to the airport).

The day I took the exam, I think there were maybe 5 of us who were US medical graduates, out of 26. The BS is widely regarded as a substitute English proficiency exam designed for FMG's to US grads, and though I've known many good FMG's, there were several present during my test who couldn't follow directions like "leave your stethoscope on the table during the break" or "stand in front of the door, don't sit in the chair". Oy.

The whole thing just felt so forced and fake. I've had standardized patient encounters at my school which were better than others, but there's always that feeling of being played in some way, going through the motions. My favorite SP encounters were the ones where we were allowed to practice, and were given immediate feedback. There is hardly any feedback from the BS. I took the exam at the beginning of November, but my score apparently won't be released until the end of January. If you fail, you get a breakdown of the areas you failed in, but if you pass, that's all you find out. The score recheck procedure is somewhat fishy to me:

For Step 2 CS, score rechecks first involve retrieval of the ratings you received from the standardized patients and from the physician note raters. These values are then re-summed and re-converted into final scores in order to confirm that the reported pass/fail outcome was accurate. There is no re-rating of your encounters or of your patient notes; videos of encounters are not reviewed. Videos are used for general quality control and for training purposes and are retained only for a limited period of time. -2007 USMLE Bulletin

In other words, no one checks the standardized patients. They videotape the encounters solely to protect the SP's, not to also protect the students. The recheck process is only going to make sure that your score was added correctly, not to actually re-evaluate your performance. Multiple physicians grade your notes, but 1 SP grades each encounter. Who grades the SP's?

I have no idea whether I passed or not; I was (for no apparent reason) really nervous that day. According to the First Aid for the CS, the pass rate among US medical students is 96%. I'd be interested to see how many of those 4% who failed pass on the second try because they're more used to the format and/or less nervous (versus those who fail simply because they suck). Therefore, I wonder, who are they really weeding out with this test? If it's designed to pass us all, why pay $1000 for this privilege? My school's OSCE, or clinical skills exam, was much more difficult than the CS, and I received very detailed (and somewhat amusing) breakdowns of my performance.

Oh, and I took the CS before the CK because the date was available, and when I switched my schedule I was unable to move it again. You have to schedule it WAY in advance. I doubt I'd have done any better if I took it after the CK, because the studying was very different for the two tests. The CK was a lot like the Step 1: a long day in front of a computer screen.

I'm going shopping now, because tomorrow I start my sub-internship in pediatrics. Strange to think that I haven't really examined a kid in over a year. Yes, I did child psych, but those were mostly adolescents. Looks like the only kid on the unit right now is a toddler with a leg abscess. Let's hope that tomorrow stays slow.