God-Awful

My husband was talking to a non-medical friend at a party the other night, and he referred to internship as being "god-awful." I immediately turned to him and corrected him.

I do not think internship is god-awful.

In fact, I have been fairly happy lately.

Yes, I have been really stressed out. I have cussed out loud while getting gang-paged and dropping the call pager into a cup of coffee. I have been (unintentionally) surly to nurses who have paged me for 2 am constipation. I have had months where I've been very sleep deprived and cranky. My house is filthy. I almost never cook dinner. I've put weight back on because I am often too tired or busy to go to the gym. Sometimes I snap at my husband out of stress and anxiety.

It's also true that I've been to 2 excellent rock concerts and 1 symphony concert since starting residency. I've gone to visit my sister. I've made friends with some of my neighbors, who are awesome people (and closed my garage door for me last night, since I left it open by accident). I've kept up with friends nearby and seen 2 friends who moved cross-country for residency. I've read a few non-medical books and played a lot of Rock Band (II was my birthday present!) Thus far, I've kept up my blog, and my reading of multiple blogs (thank you, Google Reader!). We put up our tiny Christmas tree and some really puny Christmas lights, which somehow makes me really happy. My husband remains incredibly supportive through all of this and still spoils me rotten.

In residency, I've almost finished 6 months at several different hospitals, some inpatient, some outpatient. I've taken some call and learned a ton. I've learned a lot about teaching med students and giving on-the-spot feedback (although I'm definitely still a beginner). I found out I really liked internal medicine as a resident, which surprised me (I really didn't like it as a student). In fact, I liked IM so much, I have concerns about how much I'll like psych when I start in January. I'm studying for Step 3 and it's astonishing how much I've learned, how much I've forgotten, and just how much there is that I've never learned about.

Now obviously, I'm not a general surgery intern, or even a medicine intern. Psych internship is relatively cush compared to what many interns endure. I could imagine that other interns are way less happy. Overall, though, when I look at my current lot in life, I'm pretty satisfied, and look forward to where this is all going. So no, residency is not god-awful.

And now, Merry Christmas (or whatever holiday you celebrate)!

Public Persona

There is a post over at Shrink Rap this week regarding an article in the Psychiatric Times, written by a psychiatry resident. The article got posted to several weblogs, and suddenly the author's email address ended up posted in the comments section. Now, you have an article that was written for an audience of psychiatrists, therapists, and other health care professionals. I really doubt that the author intended for this article to get posted to the internet for all the world to read.

The problem is, now this article is out there. The article featured the author's name and school affiliation. While I'm sure she changed some identifying characteristics, there's still a potentially recognizable patient in this article. As someone pointed out to me, if this patient felt the urge to Google his former therapist's name (which is not uncommon--who hasn't Googled themselves? Um, I mean, not me) then he'd find this article very easily. Chances are, this patient may identify himself in this article, especially since the therapist's name is attached. It's unclear from the article whether the patient gave his permission to have his story used in this manner, but given the tone of the article it seems unlikely.

How is this better than an anonymous blog with patient identification removed and characteristics changed?

Yet, some residencies will allow, even encourage their residents to publish in magazines and journals like Psychiatric Times, yet have policies forbidding residents to write blogs or post to message boards. I feel that policies regarding internet writing should be more reasonable and take into account the level of anonymity of the blog. It's one thing to post publicly "I'm a resident at XX school and my name is YY and I worked 95 hours last week and I think this affected my patient outcomes"--which seems to be what residency programs are afraid of, and what lawyers may look for in litigation. It's entirely another to post anonymously, take careful precautions with patient identification, and be deliberately vague.

One argument I could foresee regarding the difference in regulation is that an article in a journal or industry magazine is published with the intent to educate, whereas a blog post may be more for entertainment. I disagree, however--I rely on multiple blogs to help with my every day medical education. I know much more about recent Medicare legislation, new medical studies, and interactions between drug companies and medicine because of reading blogs than I do from my standard education. I receive 3-4 journals a week at my house, and I quickly get overwhelmed trying to read them all. Reading small amounts of blog posts daily, however, is much more feasible, and usually feature links to the actual articles so I can read them for myself.

Publishing case studies is a long-honored tradition in medicine. New diseases and therapies come to attention through case studies--reports of one or a few patients with a given syndrome or receiving a specific treatment. I do not have a problem with the article in Psych Times; in fact I found it enlightening. I simply feel that blog writing should be given the same consideration, given the crossover between internet publication and traditional academic journal.

Anxiety = Psychosis*

That seems wrong, doesn't it? There are plenty of patients who have generalized anxiety disorder who are not psychotic. In fact, I'm not really sure how you'd give someone a diagnosis of schizophrenia and GAD concurrently. To AstraZeneca, however, this difference doesn't matter. They'd like you to give your patients with generalized anxiety disorder an antipsychotic every day, preferably for the rest of their lives.

Confused yet? Don't believe me?

November 2008's American Psychiatry News published an article titled "Study: Quetiapine Monotherapy Works for Generalized Anxiety Disorder" (Vol 1 No 11, p22). The authors discuss data presented on a poster at the meeting of the Anxiety Disorders Association of America, funded, of course, by AstraZeneca, makers of Seroquel XR. The study randomized 234 patients with GAD to receive 50 mg, 150 mg, or 300 mg of extended-release quetiapine versus placebo. The meds were taken for 8 weeks with a 2 week discontinuation taper at the end.

Hamilton Anxiety Rating Scale (HAM-A) scores were used to determine the rate of improvement. Since this isn't the full study, I don't know exactly how anxious the patients were to begin with; this website uses 14-17 for mild symptoms, 18-24 for moderate symptoms, and 25-30 for severe symptoms. The study found that placebo-treated patients improved a mean of 11.1 HAM-A points; 50 mg Seroquel XR patients improved 13.3 points; 150 mg patients improved 13.5 points; and 300 mg patients improved 11.9 points. The 50 mg and 150 mg doses' improvement was statistically significant, p<0.001.>

"The most common adverse events were dry mouth, somnolence, sedation, dizziness, headache and fatigue. During the treatment phase, 15.9% of the patients taking quetiapine XR 50 mg per day withdrew as a result of adverse events, as did 18.1%, 24.4% and 6.4% of those receiving quetiapine XR 150 mg per day, quetiapine XR 300 mg per day and placebo, respectively."

So, the patients taking 50 mg of Seroquel XR improved by 2 extra points on a rating scale, but were 2.5 times as likely to withdraw from the study because they felt the side effects were too severe. That's important here. These patients are saying the improvement in their anxiety was NOT as significant as the addition of the side effects of the medication, given how many of them discontinued the medication.

In the US, you only need to show that your medication is better than a placebo to get FDA approval. Let's ignore the fact that there are multiple good treatments for generalized anxiety disorder, from SSRI's to buspirone to long-acting benzodiazepines to non-pharmacologic therapies like CBT. Let's ignore the fact that AZ is trying to win the approval specifically for Seroquel XR, so if you use plain old Seroquel (expensive enough in its own right) for GAD you'll be using it off-label. Naturally, the drug reps will emphasize the long action and smoothness of XR versus regular (never mind that for most indications, Seroquel can be dosed once daily, which is usually the benefit to using a long-acting form). According to Wikipedia, the Seroquel patent will expire in 2011 in the US, but the XR patent goes until 2017. XR = $$$$$.

*I played a little loose here. The doses of Seroquel XR used in the study were not actually antipsychotic doses (except the 300 mg dose, which was no better than placebo). At 50 and 150 mg doses, you're getting a whole lot of anti-H1, or antihistaminic, effect; some antimuscarinic effect (hence the dry mouth), and probably some anti-serotonergic effect (which likely gives it mood stabilizing properties). No anti-dopaminergic effect. So, using 50 mg Seroquel XR is more akin to using an SSRI + Benadryl than to using Haldol. It's just a LOT more expensive than SSRI + Benadryl. Naturally, we don't have any data to show how Seroquel XR compares to any of our other therapies for GAD, but AZ doesn't have to ascertain this, so they won't. And economically, they shouldn't, if they want to sell shitloads of Seroquel XR.

This is the kind of thing that drives me crazy about psychiatry, medicine, drug companies, etc. There's nothing inherently bad about Seroquel XR; there's nothing wrong with AstraZeneca trying to make money; there's nothing wrong with the article as published, per se. It's just the whole thing put together feels like a huge scam. "Statistically significant" doesn't necessarily mean anything, especially when the clinical effect is small and the side effects were so bothersome that within 2 months 15.9% and 18.1% of patients (at the effective doses) had quit taking the medicine. For those of you who may be in medical school, suffering through evidence-based medicine classes, wondering why in the world do you need to know this crap, THIS IS WHY. So you can be an informed prescriber and consumer of health care dollars and not just take the word of the local drug rep, or even the word of your "Clinical Psychiatrist's News Source".

The 80 Hour Work Week

This has been a hot point ever since it was introduced several years ago. Recently, it has come to the attention of several prominent bloggers; see here or here or even here. It seems the recent hullabaloo came after the Institute of Medicine released a report on resident duty hours where they recommend decreasing the length of a shift even further, to 16 hours, with more naps, at an estimated cost of $1.7 billion to hire the additional staff necessary to make up the gaps in coverage. All of the above links give excellent, thorough analysis of the situation, including some of the history of the 80-hour work week idea, so I won't repeat it.

As a med student, I didn't log or keep track of my duty hours in any way. I'm reasonably sure that I worked around 80 hours a week on my medicine rotations, and possibly on surgery, but likely no more. I was gung-ho for the cap rules at that time. Many attendings who talked about it gave crappy reasons for hating the 80 hours, like "I went through it, so should you." I never heard a rational, reasoned argument against it in med school. I felt like, 80 hours sucks and is a lot, but it could be worse, so why not?

Then I became an intern.

One of my rotations in the past few months had a night float system for covering patients overnight when your team wasn't on call. It was a terrible system. Essentially, multiple teams would print out 1-page spreadsheets of their patients and then come "check out" to me, usually while I was trying to write notes or admit patients or otherwise do my work. These check out sheets had only the barest of information on them: name, MRN, age, 1-liner about their problem, code status, and anything specifically for me to check up on overnight. Stat electrolytes, stat PTT's for heparin drips, stat H&H for GI bleeders--they'd give me a time, and I'd write down when I should check it. All in all, I estimate that I'd hold about 80 patients' worth of information in my hands by around 6 pm, including my own (the float shift would start after a full day call of admissions, so I'd still be working up my own patients and writing H&P's while taking checkout and seeing float patients).

Then the pages would start. "Mr. so and so is asking for pain meds." I'd go to the proper sheet, look him up, and voila! Absolutely no reason listed for him to have pain. I'd go into the EMR, look him up, no notes documenting pain but "he says he has bursitis in his shoulder and he really wants Vicodin." On principle, I'd try negotiating ("give him ibuprofen first") but usually ended up just writing for PRN Vicodin to save my sanity, as every time the pager would go off for Mr. Bursitis I'd die a little more inside.

Then "Mrs. X's fingerstick reads 'Hi' and I rechecked it twice". Or "Mr. B is having a-fib and his heartrate is 150 and his blood pressure is 90/60." And so on, and so forth. Every time the pager went off, I'd shuffle through a huge stack of papers, trying to figure out who the F the nurse was asking about (and usually trying to decipher the accent), then I'd look them up and try to decide what the hell to do. I had a back-up resident who helped me with anything serious, but still. Being the main doctor overnight for so many patients, almost none of whom you know, is seriously frightening. The potential for error on my part, as I tried desperately to flick through the comptuter for 30 seconds while the nurse waited impatiently on the phone, was huge.

Much has been made recently of the sleep vs handoffs argument. It is true that handoffs can increase the potential for error. I'm not sure if there are any studies that can truly say that handoffs increase the error MORE than working >80 hours (or longer than >30 in a shift)--if there were, the answer would be easy. I will say that after working my first of these night float shifts, I was much less cavalier about checking stuff out to the float. As float, I barely had time to go to the bathroom or examine my own patients, let alone check labs q 1 hour for other peoples' patients.

Obviously, there are programs that have different (and probably better) ways of handling cross-cover. The Day Float resident is a great idea: someone who shows up during post-call rounds, learns all the patients, then stays into the afternoon to finish orders with the attending when the rest of the team leaves around noon. Having a limit to the number of patients allowed per resident on cross-cover might be okay, so long as you can put extra residents on the float shift. Big hospitals will have to have different solutions than small hospitals, where one resident could feasibly cover all of medicine or surgery overnight.

Given the choice, when I desperately wanted to go home but I needed to see if Mr. Y had pneumonia or my patients needed morning labs or I needed to check the orders to see if everything was done, I chose every time to stay and do it myself. I'm not bragging about myself in this, because most residents do the same thing. When they slap "MD" on your coat and it suddenly grows a few feet in length, there's an enormous sense of responsibility that falls on you. Suddenly, these are YOUR patients. If something gets overlooked and the patient gets sick in the middle of the night, that's not the float's fault, it's yours. Yes, this is partly the over-exaggerated compulsion and perfectionism that is part of most doctors, but it's partly true. In my current system, no cross-cover will ever take as good of care of my patients as I do (and when I'm the cross-cover, I can't possibly do as well as that patient's team). Having someone hassling me about breaking duty hours just added to my stress. (And to be honest, it really hasn't been too much of an issue--I've gone over 30 just a couple of times, and never averaged more than 80, and have always had my 4 days off per month.)

So, what I'm saying is, the 80 hour rule is kind of a pain in the ass. I agree that going back to q3 call with no restrictions on duty hours is medieval at best, and I'd hate to see that happen. I get tired enough working 70-80 hours per week. However, further restricting the hours without helping programs find manageable solutions to handoffs is not going to make it any better. Balancing patient and resident safety is paramount, and should not be mutually exclusive concerns.

I'd like to make one seemingly tangential comment. I've heard a lot of whining that residents aren't going to noon conference because the 30 hour rule prohibits it. Actually, if you arrive at 7 am, 30 hours is up at 1 pm the next day. If you want residents to come to noon conference post-call, just decree that they are not allowed in the building before 7 am the preceding day. And then tell their attendings not to round for 6 hours post-call, so they can get their work done and make it TO the conference. Ideally, there would be food at this conference, which is my favorite motivator. This is not an impossible situation to solve, people.

What is Wrong with America

I'll admit to occasionally getting sucked into reality TV. I used to watch America's Next Top Model with some girlfriends religiously. I'm not really a fan, but I understand the appeal of mindless entertainment.

Today, while at the gym, one of the TV's was tuned to "A Real Chance of Love", a new reality dating show on VH1. Apparently, these two charming brothers who weren't classy enough for New York were chosen for this show. Their names? "Real" and "Chance", hence the title of the show. (I must say, these were two of the most ghetto-ed out guys on TV). The episode I saw involved 7 of the women (who are largely split into "Real's girls" and "Chance's girls", but there seems to be some overlap) going to a club with the guys, only the guys get into a fight with a dude who has the nerve to hit on one of the (scantily-clad) ladies. The guys are "Pissed!" at this dude, so they talk smack, dude talks smack, dude pushes, brothers take him down. One of them hits dude on the head with a glass bottle. Girls are pushed out the door into their stretch limo by the producers. In the car on the ride home, they hold hands and pray to Jesus for their "boys".

(It gets better)

Upon arrival at their house, the police are waiting. They individually question the girls, on camera of course, as to what they saw. Who hit the dude with the glass bottle? they ask repeatedly. They threaten to make the girls accessories to murder if the guy dies. Some girls cry, some say "so and so did it" and then change their story, one girl flat out says "guy x did it". One girl says "I'm not talking to you" and walks out, and one girl says "I didn't see nuthin', they pushed us out the door." The guy who did the hitting is locked up in cuffs and dragged out.

Surprise! His brother pops up and says it was all a joke, a challenge! The cops come back in and laugh, and dude walks in--he's fine. The brothers wanted a "Ride or Die" kind of girl (which is the title of the episode), the kind of girl who is loyal to the end and will never give up her man. The challenge winners? The one who just didn't say anything and the one who lied and said she didn't see nothing. The other girls were pissed. "I never talked to no cops before! I got no experience with police interrogation! It's not fair!" says one. The girl who told the truth to the cops is angry that they played with her emotions like that, and ends up getting booted off the show at the end of the episode.

My brain almost imploded on itself.

Not a single one of them mentioned anything about the truth or seemed to give a crap that (for all they knew) a guy was dying in the hospital. It's all well and good that the one chick simply refused to talk to the cops--that's her constitutional right. Any one of these girls could have said "I want a lawyer" and I'd have cheered them on. But for all the rest to straight up lie--if they'd been in a real police situation, that would have gotten them in far deeper trouble. After the fact, they were pissed because they'd never had the chance to lie to cops before, it was hard! The one girl who just told the truth was booted out of the house for not being loyal enough. And I just kept thinking, while watching them pray for their boys, that Jesus would want nothing to do with this situation. These ghetto guys, sitting around with their skanky women, got so mad that a guy dared to flirt with one of their ladies (and who would assume that 7 women all belong to 2 men?) that a fight ensued. Yes, it was all staged, but these girls believed it was all real, and they didn't find it weird!

Truly, the next great health campaign, in the spirit of "Just Say No to Drugs" from Nancy Reagan, needs to be "Get Rid of Terrible 'Reality' TV". Either that, or I'm going to have to put a condom over the television to protect my eyeballs from that kind of syphilitic programming.

Do Not Be Weird

This advice goes out to all of you who may be interviewing for residency soon. I cannot stress enough, DO NOT BE WEIRD. Do not be weird at any point of the interview process, including the pre-interview dinner/social. At my program, I'm part of the recruitment committee, which means I go to a few of the pre-interview dinners and conduct informal lunch interviews from time to time. I didn't realize last year when I was interviewing that these dinners and lunches are all scrutinized. Let's put it this way: if you think they may be evaluating you, they probably are. And if they're not, you should behave as if they are anyway.

My evaluations of candidates are certainly not the thing that makes or breaks them getting into our program. Rather, groups of evals are piled together to give an overall picture of a candidate. If one resident has an off eval but everyone else loves them, the off eval gets discarded. However, if several residents give off evals, this sends more of a message that this person may be a problem.

Cases in point:

1) Dinner started at 6. Applicant walks in at 6:40 (without calling to say they'd be late), surveys the group, asks "where's the pitcher of beer?", and proceeds to order one from the waiter without asking if anyone else is drinking or wants beer. Don't be an alcoholic at the dinner.

2) At a dinner just prior to the election, an applicant walked in wearing a prominently displayed political button. You simply cannot assume that everyone will agree with you at your interview dinner, and is it worth not getting into a program because someone got offended at your button? (This is a trivial point, for sure, but to me this implies that this person will be so passionate about their politics that they may be difficult to speak to without lengthy political harangues--not that I know anybody like that...)

3) Don't make fun of the male resident's choice of beverage by saying "That's so fruity". Do you know if they're gay? For that matter, do you know them at all? How can you possibly assume that person will not be offended by such a comment (unless you know them well)? (I wish I was making this up)

4) Dinner started at 5, applicant walked in at 5:45, looked at all of us eating, and asked "Oh, did you all get here early?" Awww-kward!

5) Don't spend the whole night talking about how amazing some other program is and how every other program in the country needs to adhere to the same standards as this other program and why doesn't your program do x like that program does?

6) Don't wear a denim jacket covered in fringe. Nuff said.

Actually, these comments were all made about 2 interviewees in some order. Any one of these things would have been okay by themselves--put together, they made most of us uncomfortable at the dinner, and several of us emailed the directors to say so.

Other advice for your interview dinner or interview day:

1) Again, DO NOT BE THE ALCOHOLIC. If people are having drinks, fine. If no one else is drinking and you want one drink, fine. If no one else is drinking and you order a pitcher, that's weird. This is psychiatry, we treat addiction all day--why advertise yours at the dinner? (although, maybe I should thank them for doing so)

2) For your interview, you must have a nice suit. Colored suits or pinstripes are perfectly acceptable within reason--no white, purple, or pink suits, please. The goal of your interview suit is to look nice and blend in, basically. People don't often remember the amazing Chanel suit, but they do remember the girl wearing black stretch pants with a turtleneck, because she sticks out (not even kidding, except that was med school interviews).

3) Tattoos and piercings: depends on the program and the specialty. My program has people who have both, including myself, but I didn't flaunt my tattoo during the interview (it's on my backside, so that would have been difficult). Some interviewers will take offense at dudes with earrings, dudes with long hair, people with pink hair, anyone with nasal piercings, etc. I know some people feel that their raging individualism makes it all worthwhile, and they'd rather die than go to a program where their neck tattoo isn't accepted, but again, I feel that the point of the interview day is to make your appearance NOT STICK OUT. They might remember you if you're amazingly hot, but they'll definitely remember large stretched ear piercings, etc. Why take a chance? Cover it up!

Fortunately, the majority of candidates I've interviewed or met at dinner were very nice, and I don't hesitate to pass on that I think so. I'm sure I'll have more to report back after interview season is over, so stay tuned!