Why am I still here?

Changes

2009-06-23T17:51:00.003-05:00

Today, I drove home from work post-call, crying. I had a busy, largely sleepless night, with the lovely addition of the onset of a head cold. I made it through the call shift, made it through my work shift in the morning, then headed to a feedback session with one of my course directors. The course was "Empathy" and involved interns listening to comments made by patients on tape, then delivering empathic responses back.

Most of us had a hard time with this.

One intern said she felt like she couldn't respond to the happy patient because she only sees suffering or she assumes the patient is manic or borderline--she didn't know how to treat someone who was just happy. My responses felt to me like I was still using them as questions to extract more information, instead of just interjections to let the patient know I was listening and perceiving what they said.

My course director said I had done a good job, and that I had "a practical, pragmatic approach" that she felt would become less self-conscious and improve over time. I started to say something in response and instead tears welled up (I've cried in front of her before, so I doubt she was shocked).

I told her I felt like I used to be better at empathy, at understanding where patients come from and what they're going through, and trying to connect, and that I've lost something this year. That I used to enjoy trying to connect with patients, and now I find it difficult (I didn't tell her that often, I don't bother trying).

As I drove home, I started to cry again. At first, I couldn't tell what was bothering me. I assumed it was tiredness + being sick. It felt too bad to be that simple, though. When I get really upset, I feel a squeezing pressure in my chest that seems to wring tears from me (yes, I'm aware this is psychosomatic). I tried to think, what was bothering me? Then I realized I was still crying over what I'd lost this year. But why am I so burned out, empty? What have I lost?

I think a combination of forces has dried up my empathy well (maybe it wasn't very deep to begin with?). Call it soul, or humanity, or empathy, or sympathy, or "being with"--whatever--I feel like mine has shriveled a little (or a lot) under the blaze of a ferocious burn out.

(A note about burn out: when high school seniors, or college seniors moan about being "so burned out on school right now", that is not the same. This kind of burn out leaves you feeling hollow and empty. It invades your personal life, your marriage, your quiet time, and your dreams, even when not at work.)

I'll point a finger at chronic sleep deprivation. I've been working around 60-65 hours per week (which is not that much, really, by medicine standards; please, surgeons, don't hit me) and taking 5-6 calls per month for the past 6 months. I don't feel recharged between calls, and I think over time my reserves have gotten lower. I've taken some vacation time and tried to catch up, but it seems to only take one call to flatten me out again (I like my sleep, so sue me).

That's not the whole story, though. Part of it is the patient population I treat. On call, the most memorable patients are the substance-using (usually cocaine or alcohol) homeless narcissists (or antisocials) who are in it to get a free bed. I used to fight this, but I've given in to the system where I work. This system pulls these patients in and suckles them for a while. Aww, did you relapse for the 40th time? Was that placement not nice enough for you? You didn't make any of your follow up appointments (often, despite having benefits, bus passes, or special transportation) and couldn't be bothered to take your meds (given out for free), but that's okay, come here baby, I have a bed and a tray for you. I strongly feel that this system thereby encourages these patients to continue this behavior. There's no need to make choices or take responsibility when there's always a cushy safety net. Just say the magic words ("I'm thinking about hurting myself", but don't have a real plan) and you're in. I don't mean to suggest that all my patients are like this, but enough of them are (and they all seem to come in crisis at 3 am, because they know an intern is on, rather than during the day when the attending will send them to outpatient rehab) to be grating. I said in a previous post that there are few true psych emergencies at 3 am, and I still hold that to be true. There are some, and I'm happy to treat those, but most 3 am consults to the ER are for someone who's crashed off cocaine, feeling suicidal, and completely oblivious to the idea that cocaine could make them feel this bad. They want me to fix their sadness, but don't want to give up the high.

Some few of these patients can be verbally abusive, which makes it oh-so-exciting when I get to call the police or security to escort them out.

I hate the stigma against the mentally ill, even though I recognize some of it within myself. I recently treated a patient with delirium tremens who had a CIWA of 21 on my exam. The reason for consult was "rule out other psychiatric issues". My note politely stated that I would reassess other psych issues after pt was more alert and oriented (not A&O x none like on my exam) and that the primary team should consider increasing the lorazepam drip. Agitated patients who cannot give a clear history of alcohol or benzo use are often shuttled to psych while having withdrawal. I've seen patients not receive appropriate treatment of surgical or medical conditions with no other explanation than "due to psych diagnosis". (I also hate inappropriate medicine consults by psych because someone forgot how to look up the dose on a blood pressure med, so I'm perfectly aware that this is a two-way street).

Of course, when I went to the dentist last week and saw that my chart said (in Magic Marker on the front cover) "depression, nervousness, psych problems", I nearly cried in the dentist's office. I mentioned having a history of depression and anxiety during my intake, but I had no idea it would be proclaimed on the front cover of my chart like that, for all the office staff to see. So I understood my patient last night who told me she had lied to her psychiatrist about her previous suicide attempts because she was too ashamed, so she said she'd never done anything.

I believe a lot of my burn out is related to having been an intern for nearly a full year. Internship and residency are tough (yes, even in psych). I also believe that I would be pretty burned out no matter which specialty I'd chosen.

But a part of this burn out is psych itself. It's the overuse of meds, the overuse of diagnoses, the stigma against psych patients and psych doctors (but man, are you glad to see us when you need us!), the massive pharma scandals (Seroquel, Zyprexa, and Abilify all come to mind), the overmedication of children who need appropriate discipline (and the recent revelation that the data supporting stimulant use was oversold to us), and the overwhelming feeling that I'm not cut out for this like I thought I was. I'm not as good at psych as I thought I could be, which is tough for me, as I'm usually good at clinical work (for pete's sake, I won an award for best clinician of my med school class when I graduated!). I doubt I'd be a terribly skilled therapist, and I believe that therapists should be skilled. I have some sensitivity to what people are feeling and am able to read between their words, but I'm finding that doesn't seem to be enough. In other words, I'd probably be a competent psychiatrist, but not an excellent one, and that's not good enough for me.

So for all these reasons, and one other big one (and maybe a few I forgot), I'm switching residencies to internal medicine. The other big one, obviously, is that I like medicine and miss it. I think I'd be pretty burned out right now if I'd just finished a year of medicine internship, so I'm trying to think pretty realistically (although sometimes I'm so desperate to escape my burn out that I get "grass is greener" syndrome and wish for medicine to fix my problem). I wasn't a fan of medicine as a med student, largely due to a certain attending who tore me a new one and then said I should go into medicine (which is a dumb reason to avoid a whole field, really). I clicked with medicine as an intern, though. I was good at it. I was my usual gets-too-flustered-when-paged, OCPD-I-might-have-missed-something self on medicine just like on psych, but I was better there. I was better able to see the big picture on medicine than I remembered, and less able to see the big picture in psych than I thought.

So there, that's my big announcement. Will switching residencies solve everything, or anything at all? Maybe not. It's not that I hate psych, because I don't, despite all the mean things I just said about her. After all, you have to care about something to get angry about it. There's nothing magical about doing internal medicine now (and many of the same problems exist there as well); I still don't know exactly what my career will look like from here (which makes me nervous), but I realized at some point in the fall that I could no longer see myself as a psychiatrist, and in November I realized I could see myself as an inpatient medicine attending, or supervising residents in a clinic, giving lectures to med students--in short, similar plans to what I had for psych, only now in medicine. I'm doing psych consults this month, which is giving me some closure (which I needed). I'll miss psych, especially during the sweet 3rd and 4th years of psych residency when they work 8-5 M-F and I'll be a ward upper level on medicine. I'll miss the intern class I came in with--they're wonderful people, and it has been a pleasure to watch them learn how to be doctors. The psych department is full of people who are special to me and I will miss them.

Fortunately, I'm staying within the same medical college, so the switch is relatively painless. I'll be a PGY-1.5 for 6 months, then start PGY-2 in January. This will put me 6 months behind for medicine, but 6 months ahead for psych. I still plan on doing a fellowship, so I'll be a trainee for a long time ahead.

I've thought about combining medicine and psych, and I think that's a definite possibility. I could run a primary care clinic for psych patients, for example. My psych program has offered to let me come back in the future if I want to do so; I haven't ruled this out (although I do NOT want to be a trainee for the rest of my life).

So now, on to different things. As of next Wednesday, I will no longer be a Tiny Shrink. As I've already changed the handle on this blog a couple of times, I think I'm going to close the blog out and maybe start a new one. If I do that, I'll post a link. As I struggle to find my identity as a doctor, I'm not sure it's fair to make my blog struggle with me. It's kind of like CSI picking a new lead actor when Gil Grissom's character left (or maybe not). So I think this is goodbye for now. I really appreciate anyone who has read this blog or left a comment (or indeed, made it to the bottom of this circumstantial, rambling mess of a post), and I thank you.

Natural Does Not Equal Healthy

2009-06-16T21:32:00.002-05:00

http://www.cnn.com/2009/HEALTH/06/16/zicam.fda.warning/index.html

In brief, 3 of the nasally-applied Zicam products (which are sold as supplements, and therefore not regulated by the FDA) may be causing people to lose their sense of smell. The FDA has urged patients to stop taking the products, and has notified the manufacturer that they will not be allowed to market these products without FDA approval.

My favorite part of this article:

On its Web site, however, Matrixx says the allegations are "unfounded and misleading."
The company contends that "there is no known causal link between the use of Zicam Cold Remedy nasal gel and impairment of smell. No well-controlled scientific study has demonstrated a potential cause-and-effect relationship between the use of Zicam and diminished smell function. No court cases have revealed any reliable evidence of any causal relationship."

Well, whaddaya know! They know how to play ball! They may not have to do "well-controlled scientific [studies]" to prove that their homeopathic product works, but they want the FDA to produce one to prove it hurts people!

Does Zicam cause anosmia? I have no idea. Matrixx is correct that there is no current proof of a causal relationship. However, if we regulated these supplementary products, at least for safety if not for efficacy, then we'd likely know the answer to this question. Not that it matters, as I've never used the stuff, but as I like to be able to stop and smell the roses (or at least my gardenias), then I will probably avoid Zicam--just to be safe. One fewer day of cold symptoms or a lifetime of not being able to enjoy eating as much... not much of a choice, in my book.

Vacation Part II

2009-05-14T21:58:00.001-05:00

Taking 3 days off to go see my dad and my grandmother. Trying to catch up on my sleep before taking more calls.

Weight Watchers

2009-05-10T20:24:00.001-05:00

The other day, I took off a few hours in the afternoon and went to the gym (then came back to work so the other intern could leave early). I was super proud of myself--look at me, I'm being so healthy! I knew my pants were fitting a little tight, but I used the usual lie (they must have shrunk in the wash) and blew it off.

Until I got to the gym and weighed in.

I was only 1-2 lbs underneath what I'd set as my "maximum" weight. A weight I'd said "I'll join Weight Watchers if I get to that point." While this is only a few lbs above where I'd been a few months ago, it has definitely been creeping upwards. This scared the junk out of me. Often times, I'll see people walking around who are very obese and I'll think "I never want to look like that". I'm well aware that nobody becomes morbidly obese overnight, though; it happens 1-2 lbs at a time, which is why I set a ceiling for myself. Now, I'm almost at that ceiling, and I've decided not to wait.

So, I enrolled in WW online.

My first few days have been very frustrating. I've been trying to use the online tracker to enter in my foods, and have been totally astonished how many calories I've been eating. My denial voice keeps saying "I usually eat okay..." but the sad truth is that obviously, I don't. In 4 days of entering points, I was something like 17 points behind FOR THE WEEK. AFTER ADDING IN MY WORKOUTS AND GARDENING AND DIGGING HOLES FOR TREES. This is a huge wake up call for me, but I'm left going, what do I do? How do I start menu-planning, when I'm frequently on call and at the mercy of the hospital or eating drug-rep food or eating indulgently because I'm on call? I have so many excuses, some good and some not, but it's hard to get started.

My goal is not to lose tons of weight. I could stand to lose 25-30 lbs to really be in the healthy range, but I just don't think I'm ready to do that. Right now, I want to lose 10-15 lbs and be healthier, more aware of what I'm eating. Especially since I do want to have children in a few years, I want to be as healthy as possible before trying to conceive. I also want to pass healthy eating habits on to my children (and I'd be appalled if they ate how I eat now).

But sometimes this seems like an insurmountable task, and I'm standing at the very beginning of this--I can't see very far ahead. I have no idea if I'll make it or not. I don't have a really fixed goal, either--but maybe that's a good thing, because if I just thought "I'll lose these 10 lbs and be done" then I'd probably relapse. Who knows how this will go, because I don't.

The Key to Mental Health

2009-05-03T17:20:00.010-05:00

I've decided that the one of the best ways to be mentally healthy is to garden. By this I mean I'm tired, cranky, burned out, and counting down my remaining calls, but when I drive home, I get out of my car, go into my yard, and just smile. I keep buying more and more plants to plant because it just makes me happy to putz around in the dirt. Yes, my ancestors were farmers, but I've never felt like I was particularly good at growing things until recently. My flowers are blooming, my trees are finally upright and that lovely dark green, and my herbs are tasty (I bought this the other day and it is AWESOME).I'll be making an announcement at some point on here, but I haven't decided how I'm going to do it yet. No, I'm not pregnant, nor did I get pregnant and sneak off to give birth, nor did I adopt a Malawian baby. For now, I'm just going to put up some pictures of my plants:

FREE=MORE (Some Random Thoughts)

2009-04-12T16:04:00.001-05:00

I'm borrowing a line from the Happy Hospitalist because I really appreciated one of his posts today. Go check it out here: http://thehappyhospitalist.blogspot.com/2009/04/land-of-screwed.html. I know not everyone is a huge fan of Dr. Happy, and I don't always agree with him myself (and sometimes when I do agree with him his tone still kind of gets to me), but still, I think the majority of this post is spot on.

We are facing a time in this country (and in some other countries as well) where we are going to face more rationing of care. I say more rationing because we already have some rationing in place. Every time an insurance company, Medicare, or Medicaid chooses not to pay for a claim, that's rationing. Currently, our system of rationing is haphazard and doesn't make much sense. 1) If you have money, you can pay for any test you want. CT scan of the heart to check for coronary artery disease? Sure! That'll be $500 up front. 2) Some insurance plans pay for tests that others don't, and it may have more to do with the negotiations between the insurance company and the hospital than whether the test is necessary or how much it costs. 3) Medicare benefits are not even across the country; recipients in one state may be able to get a test that those in the next state over can't. 4) Medicaid benefits are even more uneven, negotiated by each state. 5) The uninsured receive wildly variable care. If they have cash (the self-employed uninsured) they may receive care. If they go to the county hospital, they may receive care. It varies widely, and they may not be paying anything for it.

I think many people are afraid that "rationed care" is going to apply to them, personally.

Many people with insurance are afraid their care is going to be different, and that they will get less. We expect our MRI's and our expensive back surgeries and our brand name drugs. We expect these things because they're flashy and we're taught they're the best. We resist when we hear they're not the best. PSA testing may not be effective, but by gum I want to know! I think we're basically a nation of hypochondriacs, using our healthcare system to ease our anxieties.

And then some of the medical interventions that really make a long-standing difference--for example, vaccinations, exercise, psychotherapy--get ignored, downplayed, vilified, or are not covered by insurance. We want the quick fix. I was asked by a highly intelligent patient (in seriousness) whether I had a pill that would make him happy. He didn't want the medicine "that didn't make me unhappy but didn't make me happy".

Everyone is afraid of the long lines we hear about in Europe and Canada. Many of the situations I've heard about, though, requiring months of waiting, are for elective procedures. We want our knee replacements NOW. My back hurts NOW. Never mind that herniated disks may or may not be the cause of that pain, it was on my MRI and I want my picture to be prettier NOW.

I don't think there's a single best answer out there; I think all the sides have some truth to them. Patients demand certain things that they shouldn't; doctors prescribe and order willy-nilly because someone else is paying; insurance companies deny legitimate claims to pad their bottom line; government care is fraught with its own perils and problems.

I have to agree with Dr. Happy, though, on one thing: when we removed the payment from the doctor-patient relationship, we added a whole new world of problems. "Insurance" should mean a policy to save for a rainy day. I don't call my car's insurer when I need an oil change or routine maintenance; I don't call my homeowner's company when my house needs to be vacuumed or the lawn mowed; so why do we expect our health insurer to pay for our checkups? We really shouldn't call it "insurance". After all, there's no guarantee you'll get care just because you have insurance. Your claim could be denied for any number of small errors, and then you'll get the whole inflated, padded bill all to yourself.

A healthcare policy for a group of employees, for example, tries to float the costs of the few unhealthy patients on the premiums of the rest of the healthy; the problem is that the healthy think "$10 copay? I have the sniffles, I should go to the doctor." Or they think "My knee hurts; I could take Advil, or I could get the MRI because the insurance is paying for it." The costs go up and up as people utilize more care (and more expensive care).

I guess one of the biggest problems is that so much of the care is unecessary. Back surgeries don't necessarily reduce pain or return you to work. Penicillin for strep may not actually prevent rheumatic fever like we once thought. Cardiac stents don't necessarily work better than taking your aspirin and blood pressure medication, and we don't really have fewer bypass surgeries even though we're doing more stents. PSA testing doesn't save lives; ovarian cancer screening doesn't save lives; and even mammograms are suspect. Giving proton-pump inhibitors in the hospital to prevent rare occurrences of GI bleed may interfere with your Plavix and give you a heart attack. Getting the glucose down to normal in the ICU can kill you. If we truly analyze our diagnostic tests and our medical and surgical treatments according to strict evidence-based criteria, how many would stand up and how many would be no better than "Take two aspirin and call me in the morning"? How much of what we're spending our healthcare billions on is junk?

I also think doctors share a large amount of this blame. If the public expects the MRI, it's probably because a doctor ordered it for their sister, or a doctor went on the local news station to advertise, etc. While I think public expectations need to be better managed, I also think our continuing medical education needs to be revamped. How easy would it be, out in private practice, to pick "fluffy" CME courses paid for by drug companies that come with a free steak, instead of intensive and expensive courses that require real learning? I also think we are not good stewards of the healthcare dollars we help manage. Every time I order a full CBC with differential, I could have saved a significant amount of money. Any time I might think "I'll order this possibly useful test, they have insurance", I need to be swatted.

Doctors and patients are more money-conscious than ever. Both groups are worried about money constantly. But we're not supposed to talk about it with each other. We placed the insurance companies in between us and then were surprised when our discourse became complicated because someone else was taking and making money off our interaction. Seemingly, the insurance companies are the only ones truly benefiting off this interaction, because certainly the doctors and the patients aren't.

Perhaps we could go to some kind of "basic care" model, where our basic checkups and very basic labs are covered by a yearly fee (provided by the healthcare provider themselves), then we have a high deductible policy for true medical emergencies. Patients with long-standing chronic conditions that require the most medications, the most admissions, and the most cost, could be covered by the government; others could be allowed to purchase more care depending on what they think they'd need. Have a kid with asthma? Get a plan with certain types of coverage or a lower deductible. Allow for interstate insurance policies, so that I can shop for insurance in Oregon if they have a better plan than that available to me. Allow for transparency in healthcare interactions: doctors should be able to publish the cost of their office visit on their website (and it should be roughly the same for all comers, whether insured or not; the doctor can then decide to discount if need be) as well as the price of the most commonly used tests. Let patients decide how much elective care they want to pay for, and require emergency coverage (or make it very affordable).

Or do something else entirely, but (in the words of Kenan Thompson from SNL) FIX IT!

Still Here

2009-04-08T20:02:00.002-05:00

Just haven't felt much like posting lately. Back soon. In the meantime, I'll be watching "Lie to Me", my new favorite show.

I Hate Daylight Savings Time

2009-03-10T20:15:00.002-05:00

This whole "spring forward" thing just plain sucks. Chronic sleep deprivation + post call + losing an hour of sleep had me very unhappy this weekend.

Fortunately, the weather has been lovely, so we planted a tree and some azaleas this weekend. Now, I have new flowers, 2 new trees, a few herbs, and re-organized landscaping. There is something healing about planting something.

I'm not a great example of how to keep yourself healthy during internship, but I do my best. I'm averaging 1 workout per week, which isn't great, but it's better than 0 workouts per week (baby steps, people, baby steps). I'm really trying to eat better, making overall healthy choices and not drinking sodas unless I'm on call. I planted some green things in the ground. We're hanging out with our neighbors more often. I actually sat down with a huge stack of NEJM's, JAMA's, and Green Journals a couple of weeks ago and skimmed/read them all (which also got them off my coffee table). We bought a Roomba, which is helping keep the cat hair at bay.

If we could only invent a pill that instantly gave you all the sleep you were missing (without taking away the time to get all that sleep), I'd be set.

Homeless

2009-02-23T19:20:00.003-06:00

In psychiatry, even more than in internal medicine, we treat a lot of patients who are currently or have been homeless. From work I used to do at a clinic for homeless patients, I'm aware that there are different "levels" if you will of homelessness. There are people who stay with family or friends, people who live in motels, people who sleep in their cars, people who live in shelters, and people who sleep on the street. Sometimes whole families are homeless, but most of my patients are single. There are people who are transiently homeless, and people who are chronically without a permanent place to stay. Many are "mentally ill", but this covers a very wide range of possible diagnoses. I've met some patients with chronic psychotic disorders, often untreated, who have no family to look out for them and were homeless. Many of my patients, though, have personality disorders (usually narcissistic, borderline, or antisocial) and/or are chronic drug and/or alcohol abusers.

In psych, we refer to some of the last group as "having poor coping skills." In other words, they don't know how to be "grown-ups" as our culture and society mandates. Especially when substances are involved, their only method of coping with stressful situations may be to pop a pill or drink a bottle. They may come to psychiatric attention because of a suicide attempt or accidental overdose; sometimes they come to the emergency room voluntarily because they "feel suicidal" or "think I'm going to hurt someone". Patients in the latter group sometimes aren't admitted to the hospital, and are discharged back to the streets.

I've noticed that I have a bias against this latter group. Even though psychiatrists (and other physicians) treat substance abuse, many of us seem to think of these disorders as non-psychiatric and non-medical for some reason. It's easier sometimes to make allowances for someone with bipolar or schizophrenia than for someone who's "just drunk" or "just high" or "just a borderline". I think part of it is because there is such a large volitional component to drug use, ie, no one MADE them do the drugs (we assume), whereas no one chooses schizophrenia (although schizophrenics may choose not to take their meds, or may choose to do drugs). It's true that there is a heritable component to addiction, and also true that many patients start using substances as young teenagers (13-14 years old) before they're able to fully appreciate the consequences of their actions.

So why the bias? Why do I feel like I have a hard time treating these patients? (For that matter, I think many doctors have a hard time treating such patients). Part of it is the volition thing. Part of it is that there's a narcissism involved with substance abuse--people who are addicted care mostly about their addiction, and often (at least the ones who come to the psych ER) can be less than friendly. Some become outright abusive. Part of it is what some of these patients do to feed their habit--I've had some say they prostitute themselves, some who beg, and some who steal, and these are just the ones who talk about it. Some are on disability, which is frustrating to someone who works hard; why should they get their $3000 check per month and get to spend it all on crack?

It would also be different if these patients were asking for help with their addiction when I see them. Instead, many of them seem to be saying "the right words" to get admitted to the psych hospital because it's cold outside, or raining, and have no intention of quitting their drug of choice. This irritates me. It's a hospital, not a free hotel. If I admit all of these patients, then there's no room for the acutely psychotic patients wandering off from home or the manic who hijacked a bus.

One of my patients said something profound to me the other day. This person had been homeless in the past, and was facing discharge to the streets. The quote: "I've been homeless before, man, I've slept on the streets before. Man, when you're out there, it's like you're not a person anymore, it's like you're not a human being."

So how to balance humanity with doing the right thing, which often means denying these patients admission? I'll be honest, this is hard for me. I find this emotional balance to be very tiring. I guess just like the paging etiquette thing, I just have to keep trying. I don't have an actual solution, at least not yet.

I'm a Big Kid Now!

2009-02-18T23:35:00.001-06:00

There comes a time in every young doctor's life when they realize that they are now an adult. Eight years (in the US) beyond high school, the medical resident has put off true adulthood for perpetual studenthood for a long time, especially if they did not take time off and work or pursue an alternate career. For some residents, it's the time they put on the long white coat; it may be the first code attended, the first time they signed an order as "X Y, MD"; the first time a nurse asked "What should we do, Doctor?" All of these experiences have happened to me, and they made me feel a little bit grown-up, but this one really takes the cake. This one says I'm really an adult and there is NO GOING BACK. This cat is out of the bag.

Friends, I got a jury duty summons the other day, and I CAN NO LONGER JUST TELL THEM I'M A STUDENT SO I DON'T HAVE TO GO!

So here soon, I will present myself to a court house and go through whatever jury duty entails. Somehow I doubt I'll actually get picked for anything, so I predict I'll show up and waste a lot of time and then get to go home $15 richer. Or, just my luck, I'll get seated for a really long trial and be sequestered in a motel surviving on bad sandwiches--it'll be just like a John Grisham novel, except half as exciting.

Adulthood--not all it's cracked up to be? Although the shopping part is pretty fabulous, as well as being over the legal drinking age, and getting to do what I want to do... I guess you have to earn that part somehow, so jury duty, here I come!

Say What?

2009-02-17T20:03:00.002-06:00

[Homeless patient receiving disability payments from the government, angry with me for not admitting him to the hospital to protect him from homelessness]: "I pay your salary, did you know that?"

[Sleepy, cranky me on call]: "...?"

[Well-rested co-intern the next day, upon hearing the story]: "Actually, my tax dollars pay for your health care AND my salary."

_________________________________________

More Truisms from Psych Call:

1. The "urgency" of the patient in the emergency room is indirectly correlated with how late it is.

2. If you get angry and yell at me for being "racist" because I won't admit you to the hospital, it isn't going to make me relent--it's going to make me call security to escort you from the ER.

3. The potential dangerousness of the patient is indirectly correlated to the likelihood that the nurses will actually have changed him/her out of their street clothes, put them in a gown, and removed their belongings from the room. We've seen bottles of alcohol and sometimes weapons.

4. If you come to the ER with a wussy overdose attempt, like, taking a couple extra antipsychotic or antidepressant pills (barely over the therapeutic limit, and not a drug like lithium or a tricyclic), it is entirely possible that the ER doc will have the nurse place an NG tube and do a gastric lavage. No, I will not pull it out of your nose for you. Actions --> consequences.

5. The "urgency" of the patient in the emergency room is indirectly correlated to the likelihood they caught an ambulance to come to the ER. This holds true in most areas of medicine, not just psych.

6. The corollary to #5: the urgency of the patient is entirely unrelated to whether the police brought them in. Sometimes the police bring in the really outraged, psychotic, agitated patients who were swinging an axe at traffic; sometimes the police bring in the chronically suicidal "I called 911 and said I wanted to kill myself and no it has nothing to do with how much wine I drank tonight".

7. The lateness of the ER consult is directly correlated to my level of crankiness and indirectly correlated to my level of "give-a-shit"ness.

Sorry for the rant, but psych call is mentally stressful and involves dealing with a lot of manipulative people trying to angle their way into the hospital. I hope that venting like this will help me not burn out and be able to keep showing up for call. /crankiness

Paging Etiquette

2009-02-08T15:14:00.003-06:00

Rules for Paging Properly:

1) If you are going to be allowed to page me incessantly, then you should be required to wear a pager so I can return the favor.

2) If you page me, please wait 5-10 minutes for a response before paging back. Heaven forbid I be answering another page, seeing to an emergency, walking in a hallway without a phone, or sitting on the john. I am very conscientious about returning pages and really try hard not to make you wait, but sometimes it's unavoidable.

3) Please attempt to coordinate your pages. Having 2 different nurses page me about the same patient within 30 seconds of each other (indeed, I received page #2 while I was on the phone with nurse #1) is a little annoying. Especially when said patient isn't actually dying of a heart attack or writhing in severe pain, but "just wanted to talk to the doctor."

4) I know mistakes happen, but please attempt to look through the medications before paging me to say Ms. so-and-so needs a sleeping pill. If I stop what I'm doing and pull up the chart only to find Ambien in their list of meds, it's a little irritating.

5) Blood pressure of 135/anything does not excite me and I do not need to be paged for this, unless it was 220/190 5 minutes ago (in which case, why are they on a psych floor?).

6) The primary team arrives around 8 am M-F. I do not need to be paged at 7:20 (while I'm trying to check out and leave) for 2-day long sore throats or potassium of 3.2 drawn 4 days ago. I appreciate your incentive and that you are trying to help care for your patient, but it can wait.

7) When possible, please page me to an extension you'll be easily reached at. If you page me and I call you right back, only to reach someone who puts me on hold "while I find out who paged you", I get a little irritated, especially when this happens frequently.

8) Perhaps most importantly, when I call you back, please introduce yourself and state the patient's name clearly (perhaps even spell it) before rushing into the story of how the patient has an urgent foot rash. I have some hearing problems--not your fault--and I will have to interrupt your story to ask you to repeat the name, spell it, and wait while I access that patient's chart in the computer before you get going again. Also, if you have a non-American accent, it is going to be difficult for me to understand you over the phone, especially if you speak rapidly.

9) On my end, I promise to keep trying to answer pages promptly, identifying myself clearly when I call back, being really nice (or at least non-snarky) when I answer, and trying to educate the people paging me about appropriate paging. (Hey, I said "trying", didn't I? Stop looking at me, swan!) I know I fail at this frequently, but I really do try, I swear. I don't like paging people only to get yelled at, so I don't want to be the person yelling.

True Story from the Psych Unit

2009-01-26T21:04:00.003-06:00

I'm taking psych call this month at a large hospital. Call duties include consults from the ER, consults from the med/surg floors (rare, since they're after hours or on weekends), "behavioral emergencies" throughout the hospital, and covering the inpatient psych unit, which houses 40-50 patients. I would just like to throw in there that my psych calls are nearly as stressful as my medicine float shifts--psych call is not easy.

A couple of weeks ago, my urology elective experience suddenly and unexpectedly came in handy.

(If you're squeamish, stop here.)

I had just returned a page from the nurse in the emergency room and was hearing about a patient I had to see (the usual "super urgent" med refill type) when I received 2 pages in about 1 minute from the floor. GODDAMN, dude, I'm on the phone with the emergency room! I'm sorry, but people need to learn some pager etiquette!

Ahem.

I returned the page with a slightly snarky "Did someone page Dr. TS TWICE? Can I help you?"

A slightly panicked male nurse answered "Yes, doctor, patient so-and-so has gotten his, ah, his penis caught in his zipper."

WTF???

"Uh, is it, uh, is it still stuck? Is it bleeding?" (I was stuttering and nearly speechless)

He assured me that it was not bleeding, but was still stuck. Holy Christ! I called the ER and told them I had a medical emergency to deal with on the floor (at which point I was "reminded" that there's a policy to see ER patients within 20 minutes of arrival--Eff You, guidelines! The nurse actually asked me why the floor nurses couldn't just "deal with it" themselves. Um, it's not YOUR junk caught in a zipper, but if it were I doubt you could wait an hour while I deal with Ms. "I didn't know how to operate the automatic refill telephone number"). I raced upstairs.

The patient was lying on his bed so calmly I didn't realize it was the right man, until I saw his fly hanging open. It seemed to be an accidental injury (although I'm sure weirder things have happened). I donned gloves and did a quick inspection--whoo-ee, that skin was really wrapped in the zipper. (I warned you about the squeamish thing!) I left the room and paged urology.

"Um, hi, this is the psych intern. I have a patient with his penis caught in his zipper. What do I do?"

Uro: "You pull."

WTF??? ARE YOU KIDDING ME???

He wasn't kidding. I went in and attempted to pull on the zipper, but the patient freaked out (naturally) and wasn't going to tolerate it. I paged urology back and explained the situation.

Uro: "I can come up there if you want, but I'm just going to pull harder."

WTF???????????????

The nurse on duty wouldn't let me take the patient down to the emergency room, since "this is a hospital up here, there's no reason a patient can't get treatment up here just like anywhere else." I had no choice. I asked for a bottle of lidocaine, a syringe, and some wound dressing materials. We got the patient into the treatment room, I did a little local anesthesia, gave him a Vicodin, donned my gloves again, and PULLED.

It didn't budge (but at least this time the patient didn't feel a thing).

We found a suture removal kit with a pair of forceps, which I used to try to get a grip on the zipper. This time when I pulled, it moved a teensy bit. I had the male nurse try to pull, I tried to pull, but we made almost no headway. I carry trauma shears in my pocket (you never know when these bad boys will come in handy) so we tried cutting the zipper off the pants and then cutting the zipper in half. Now, we were left with even worse leverage. I was beginning to freak out, thinking OMG WTF I JUST RUINED THIS MAN'S PENIS!

The patient started talking to us at that point. He said he'd had this problem before (WTF???) and had seen a doctor with similar complaints before. He then reached down, grabbed hold of the zipper, PULLED, and the zipper broke in half; he PULLED again and it came off his skin. I nearly fell over with shock, amazement, relief, and nausea; the male nurse had turned around and was unable to watch.

True, he had several lacerations that I cleaned with iodine and dressed with ointment. I put him on some antibiotics (his hygiene wasn't so great, and god only knows what was on that zipper), and we found him some sweatpants and some briefs. I also lectured the patient on a) wearing underwear and b) tucking it back while zipping up his pants. Honest to god, this was a grown man. I actually told him "Dude, you only have one of these, TAKE BETTER CARE OF IT."

One of the highlights of the evening: I wrote an order in the chart to this effect: "Patient to wear briefs and non-zippered pants while injury heals."

Not exactly what I had in mind when I signed up for this (but certainly a great story!)

He's Fantastic (As Usual)

2009-01-24T15:25:00.003-06:00

If you have a few minutes and want to read about the history of nationalized medicine in England, France, and Switzerland, as well as the history of how the American health care system came to be, and even the American telephone system(?!), go read this article by Atul Gawande in The New Yorker. Go, now.

I found the link at Kevin, MD. Congrats on Best Medical Blog of the Year!

Evidence-Based Medicine

2009-01-23T14:20:00.002-06:00

I've long admired the attendings who really know EBM. I have aspirations to be one someday: have an office filled with articles to print out for residents, know which trial said what, who conducted the important trials, be able to read articles critically and pick up on subtle clues that the research was or wasn't great.

I initially said "always" instead of "long" in that first sentence, but I changed it. My first experiences with EBM were pretty pointless. In our first year of med school, we took a mini-class in statistics, where we had to memorize the "ABCD" tables and what sensitivity/specificity meant. It didn't make much sense to any of us, and everyone groused through the course. That summer, I had to do a project for my preceptorship that involved "PICO" questions. They're ridiculously easy to write, so I couldn't figure out why I had to do so many. I was told that I needed to learn how to search Pubmed properly, so I had to have a good question. Later, I had more lectures on how to search Pubmed well. Seriously, people, most med students now are pretty familiar with Google or other search engines and know how to conduct a quick internet-based search to get what they want. Sitting through stifling lectures about "boolean operators" and learning the difference between searching with AND and with OR... Shoot me.

I think med students may get turned off by the statistics and the uselessness of learning how to search the internet and lose sight of why EBM overall actually matters. It has very little to do with PICO questions, after all.

The way I see it, EBM has several points. First, doctors should know how to critically appraise an article, so when the drug rep hands you the article about linezolid vs vancomycin you aren't blindsided by the pretty graphics. Second, doctors should know how to search the literature to find answers to clinical questions--this is where PICO comes in, but it isn't always necessary to go through that whole process. Still, if you want to read the actual study that UpToDate based their guidelines on, you should have an idea of where to find it. Third, all of this critical appraisal *should* lead to evidence-based guidelines for treatment. I know many doctors get upset at the idea of "cookbook medicine", but I'm all for some standardization (with final discretion always with the doctor and the patient, of course). If the literature said Drug X is very good in diabetes, but not Drug Y, then I think a doctor who wants to prescribe Drug Y to a diabetic should have a really good reason for doing so.

So what are the downsides to EBM? Why isn't everyone doing it? I think there are several potential problems:

First, while the randomized controlled trial is the gold standard for testing therapies (new drugs, new imaging, new surgical techniques & devices, etc), not everything can feasibly have an RCT. Pregnant women and children are often overlooked for studies, because who wants to have their fetus or small child experimented upon? The elderly are often excluded from studies, as are the really ill patients. Thus, RCT's often ignore whole populations that may need a treatment, so then we have to try to extrapolate the results to an untested population (or, if you're a purist, just say "there's no evidence for X in pregnant women" and don't treat). Diseases with very small numbers of patients may be studied in fantastic trials that can't reach statistical significance due to lack of power. And sometimes, you just can't randomize people to have a certain condition--see the satirical "Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials" from the BMJ.

Second, there's often a disconnect between study data and clinical practice guidelines. You don't usually base guidelines on the results of one study, but sometimes that happens--see the WHI hoopla. A treatment may become standard of care based on one study (like using steroids for spinal cord injury) and then even when later studies debunk it you can't change the standard of care (defensive medicine, anyone?). Other times, it takes years and multiple studies to "prove" something works or doesn't work, meaning at any given time the guideliness available are many years behind the evidence. Also, guidelines are written by "panels of experts", so sometimes it's difficult to tell what's truly EBM and what's "expert opinion".

Which brings me to my third problem: we in medicine haven't done a good job of selling the public on EBM. Patients don't really know about sensitivity and specificity, false positives and false negatives, statistical likelihood of disease, number needed to treat, etc. How many people would take Lipitor if they knew that between 100-250 people have to take it to prevent one MI? How many people would clamor for increased HIV testing in the ER if they were the patient with the false positive who had to go through the extra testing and fear of having HIV? Even worse, one may still be sued successfully for following EBM practices when it results in a poor outcome.

Fourth, there's a wide disparity of practices between patients with money and good insurance and patients who do not, or even between geographic areas. In a rural area, if you have stable angina, you're likely to get nitro; in an urban area, you're likely to get a cath. Do people in urban areas live longer? (I don't know, but I haven't seen the evidence). I feel like one goal of EBM *should* be to reduce some of these types of disparities, but it hasn't really happened. The growth of medical technology outpaces the body of literature.

Finally, what do we do when there is no evidence? Many of us are not comfortable doing nothing, and many patients are not comfortable doing nothing. For example, when a patient has viral bronchitis, we know the evidence says DO NOT GIVE ANTIBIOTICS. Yet, patients still come to the doctor with cough and runny nose. There's no evidence for giving cough syrup or inhalers, yet I think many of us do so, simply for the sake of doing something (and to get the patient off our backs about the freaking antibiotics, the answer was NO).

So why do I heart EBM? I feel that it's the best system out there for keeping abreast of the unbelievable amount of medical knowledge available. Sure, it's got flaws, and perhaps in the future a new system will come along and wipe EBM off the map, but until then we should use what we have.

You can wake up now, I'm done.

Another New DSM-V Diagnosis

2009-01-19T21:25:00.003-06:00

Pager PTSD

Criteria for diagnosis:

1) Exposure to a constantly blaring pager; correlation has been found between an increased number of re-pages within 3 minutes (because the person wearing the pager was in a hallway with no phones, so the person paging felt the need to "try again") and severity of symptoms

2) Persistent reexperience; patient may have illusions of the pager going off or nightmares of missing pages

3) Persistent avoidance of stimuli associated with the pager trauma, ie, turning the pager off when not on call

4) Persistent symptoms of increased arousal, ie, sleeping with the call room light on so as not to sleep through a page, anger and cursing when the pager goes off, constant checking and rechecking of the pager when it is NOT going off to be sure the battery is intact

5) Duration of symptoms lasts longer than the exposure to the pager; patient may experience resurgence in anxiety when other people's pagers go off or may fumble for an imaginary pager when hearing the sound of another's pager

6) Significant impairment in occupational functioning such as cursing in front of patients when the pager goes off, snapping at auxiliary staff for paging incessantly, crying at work

Often comorbid with or must be differentiated from the following potential new DSM-V diagnoses:

1) Pager phobia--avoidance of pagers with increase in anxiety when the patient sees or hears a pager, reluctance to touch or wear a pager, patient must know symptoms are excessive

2) Pager OCD--compulsions of constant checking and rechecking of the battery; patient may even test-page him or herself to rest assured that the pager is working; obsessive thoughts of the pager not working or of beating it to a pulp Office Space style

3) Generalized call anxiety--anxiety and worries not just about the pager, but about the 40+ patients the intern on call is responsible for, interferes with sleep and appetite on call, patient may experience fatigue and muscle tension associated with call room bed and overweighted white coat pockets

Loaded Statement

2009-01-12T06:39:00.003-06:00

This dude gave a quote for a smoking-related article on CNN that I think is a) dumb and b) illustrates a point about paying for healthcare.

Retired radio broadcaster and iReporter Gerald Dimmitt, 65, has smoked since he was 14.
"I've always smoked a pipe," he said. "I have successfully quit about 40 times." But, he says, he always restarted, because "it calms me down."
Dimmitt has even more incentive to quit now, since developing lesions and irritation in his mouth. After speaking to his doctor, he received a prescription for Chantix, a pill to aid with smoking cessation. But when he went to pick up his prescription at the pharmacy, he was charged $139 (because it's not generic) for two weeks worth. Outraged, he left the Chantix behind.
"If smoking is so dangerous ... why then do they want to charge $139 to make me stop? There is something very wrong with that. I guess they would rather pay to take care of lung cancer," he said.

So, $139 is too much to pay to quit smoking (when apparently everything else this guy has tried has failed)--fine. But to imply that "they" would rather pay for lung cancer... when the treatment would involve some combination of surgery, radiation, and/or chemotherapy, along with hospital stays, and medication, and would cost THOUSANDS of dollars, that makes $139 seem more like a bargain. Essentially, this guy is saying that $139 out of his pocket is intolerable, so he'd rather make his insurance/Medicare/Medicaid (or whatever health coverage he has) pay for lung cancer instead--because clearly, if $139 is too much for this guy, then thousands is beyond his reach.

I'm largely a supporter of some form of universal health care (although not single-payer), but I'm still torn on some issues, and this is one of them. This guy is going to deliberately forego a treatment that could help him stop smoking and save himself and his health insurance (or Medicare/Medicaid, I don't know what he has) thousands of dollars because he doesn't want to pay out of pocket. Essentially, his insurer is now going to pay for his poor judgment that he's acknowledging publicly on CNN.com.

Now, is the answer to subsidize anti-smoking therapy? Maybe that's not a bad idea, if we're going to suggest banning smoking on federal property and such--use penalties on one side and rewards on the other, give a little extra incentive. Is the answer to penalize such people who are deliberately NOT trying treatment which may be effective in quitting who are deliberately placing an extra burden on the health care system? Maybe--in the private insurance world, these people may already pay a higher deductible, and I'm okay with that. I think that even with a universal health plan, people should be required to pay for part of their health care. ER visits should cost money. Prescriptions should cost money, especially brand-new brand-name meds like Chantix (although I'll admit, $139 for 2 weeks does seem steep).

I just hope his insurer read his little "comment". I guess it's less "dumb" than I initially thought, because if his insurer will pay for his lung cancer why should he pay to quit smoking? Oh, I don't know, unless he'd like to LIVE without CANCER. Because lung cancer kills you. People (myself included) need to take some freaking responsibility with their own health.

Now I'm all riled up to start my Monday. Grrr.

You Need to Be in the Hospital

2009-01-09T14:56:00.004-06:00

I'm learning the ropes in psychiatry, and one issue that comes up is "commitment". Why is it that you can "commit" a patient to the hospital for their schizophrenia, but not for their myocardial infarction? What is the difference? How are the procedures different for each? What if the patient wants to leave AMA? I think there's a lot of fear and misinformation surrounding this topic, so I'd like to delve briefly into how a medical hospital stay is similar to and different from a psychiatric hospital stay.

If Mr. X walks into the emergency room with chief complaint of "chest pain", he gets triaged to the medical ER. Likely within a few minutes he'll have an EKG and cardiac enzymes done. If the EKG shows massive ST elevation and the troponin is elevated, the doctor will say "Mr. X, you are having a heart attack. You need to come stay in the hospital to have treatment."

Mr. X has two options at that point: say "sure doc" or "no way". If he says yes, he signs the consent form and is off to the cath lab. If he says "no way", it's a little more complicated. Is he delirious? Is he drunk? In other words, is he in his right mind and able to make this decision? Is he unconscious without family around--if so, you treat emergently and let the consent work itself out later. If he is not delirious, you assess him for capacity to refuse treatment: does he know what a heart attack is, does he know what the treatment is, does he know he could die without treatment, does he know he could live with the treatment? If he meets capacity and says "doc, I know I could die if I leave, but I do not want treatment" then he signs a paper stating that he is leaving Against Medical Advice (AMA) and walks out the door. The procedure is the same if he's already on the floor and decides to leave.

What if Mr. X is delirious? What if his brain is deoxygenated and he's agitated and trying to leave, but only yesterday he told his wife "absolutely treat me if I have a heart attack?" In this situation, you can obtain consent from his wife (or next of kin) for treatment and pursue treatment. If you document that the patient does not have the capacity to refuse, and you feel that the benefits of treatment likely outweigh the risks, and that they are "not themselves" (disoriented, delirious, etc), then you now have the ability to use restraints against this patient if you need to do so. Ever see the patients tied down in the ICU so they won't pull out the vent tube? A patient who is septic, hypotensive, and delirious may try to pull out a tube--they're uncomfortable--and clearly doesn't know that what they're doing can kill them. That patient is at that moment being held and treated against their will, so this is not something you take lightly. Restraints usually have to be assessed every few hours by a doctor, and patients may need to be sedated so they don't a) have discomfort that led them to try to pull the tube out in the first place and b) fight against the restraints so hard they have rhabdomyolysis.

Therefore, not everyone in the medical hospital is there with their consent. An adult with capacity may consent to or refuse treatment and this should be honored. An adult without capacity to consent to or refuse life-saving treatment may be restrained in certain situations. The family may provide consent for treatment if the patient is incapacitated (which is how we end up with so many demented patients in the ICU--another issue altogether).

So how is it different in psychiatry?

If Mr. Y walks into the same emergency room with chief complaint of "I want to kill myself", he gets triaged to the psychiatric ER. Shortly thereafter a doctor or "mental health professional" (maybe social worker or PA) will assess the patient and perform a mental status exam. If the patient is very depressed, still says he will kill himself, and states that he keeps a loaded gun at home just for this purpose, the doctor will say "Mr. Y, I'm concerned for your safety. You need to come stay in the hospital to have treatment."

Mr. Y has two options at that point: say "sure doc" or "no way". If he says "sure doc" then he signs a consent for mental health treatment and is admitted to the psych unit (after some basic labs to be sure there's nothing major medically wrong at that moment). If he says "no way", then it gets tougher. If his risk of committing suicide seems very high, as in he is an elderly Caucasian male, feels hopeless, has no family, lives alone, has a firm plan for death, is in dire financial straits, and it's the anniversary of his wife's death, then you may make the argument that he is in imminent danger of harming himself and should be admitted to the hospital. (If his risk is low, he's a "frequent flyer" in the ER who uses this line to get a warm bed because the shelter was full and his check is spent, etc, then "Sayonara!") You may also argue that the patient's severe depression is preventing him from making rational decisions or having full capacity to refuse treatment.

For psychiatry, instead of having the family sign the patient in when they refuse but lack capacity, you file paperwork with the court--legal "commitment". This varies from state to state, but usually involves some manner of stating that the patient is in imminent danger of harming himself or others, lacks capacity to refuse due to mental illness, and will acutely decompensate and/or likely kill himself if allowed to leave without treatment. The patient will be brought to a locked psych unit and will remain until treatment is completed. Patients who are on "involuntary" status don't necessarily stay longer than "voluntary" patients; it simply means that they must stay until a physician releases them or the court determines that they may be released.

Now, if Mr. Y signs himself in voluntarily, but 4 hours later decides he wants to leave, what do you do? On the medical floor, the patient asks to sign out AMA. In the psych unit, they ask for essentially the same thing. Different states have a different procedure for doing this, but the patient must ask for a document stating that they want to leave (essentially AMA). A doctor must come examine them within a certain period of time to determine whether the patient has capacity to leave. Mr. Y in our example above told us 4 hours ago he wanted to kill himself and has a gun. If the doctor examines him and he says "doc, I want to leave so I can go kill myself", then the doctor is going to have to file paperwork to commit him to the hospital--after he's already there. If the patient is stable, and doesn't meet criteria for legal commitment, then you must let them leave AMA after they request it.

We often err on the side of having patients sign in voluntarily so that the patient isn't forced to be committed legally, but sometimes that leads to a double standard (in my opinion)--we're saying the patient has capacity to accept treatment (which we want), but not to refuse (which we don't want). I think one reason we do this is because we want to use the commitment process as infrequently as possible. Once a patient has been committed, this becomes a matter of public record with the court, where if they sign in voluntarily this is covered by HIPAA.

Legally, it's all very complicated. Due to some abuse of commitment in the past (in this country and others) a very complicated set of rules must be followed. The patient must meet criteria for admission (usually reserved for acutely suicidal, acutely psychotic, acutely manic, etc) and be either about to commit suicide, about to hurt someone, or be completely unable to take care of themselves (the manic patient wearing their undies in the snow to preach the gospel in the middle of the street, for example) to the point that they cannot practice basic safety. Once you file paperwork with the court stating that you've examined them and they should be committed, they'll be assigned a court date. After around 72 hours, a second exam must continue to document that patient still requires involuntary hospitalization. The case will go before a judge at some point who will either confirm the commitment until a doctor says they may be released or will deny the commitment and order the release of the patient.

You can also order emergency medication. After his heart attack, Mr. X became hypotensive and was acutely bleeding, and was unconscious so he couldn't sign the consent for blood products; he will still be transfused. After his admission, Mr. Y became acutely psychotic and agitated, tried to throw tables at the staff, tried to punch through a glass window, and refused to take his meds; if he refused to take an oral med, he would likely get a shot of something sedating (usually haldol 5 mg + Ativan 2 mg) to calm him down. If Mr. Y continues to refuse to take his meds, continues to be agitated and dangerous, you can petition the court to order medication.

Some people would argue that the two aren't the same at all. After all, the patient with the MI who is bleeding is going to die; as my med student put it yesterday "well, psych stuff isn't life-threatening." It depends. Even patients in locked psych units can commit suicide if they're determined enough; they can commit homicide, they can attack other patients or staff. A condition called "agitated delirium" or "excited delirium" can actually cause a patient who is so overstimulated by their psychosis (and often by drugs) to suddenly drop dead. Maybe it's not as clear cut as the MI situation, but psychiatric patients can die from their disorders or related complications. Speaking for myself and the people I work with, we wouldn't put someone in the hospital against their will and medicate them against their will if it didn't seem vitally important to that patient's ability to survive.

Legal commitment remains controversial; just look at the wikipedia page. Obviously, there is some overlap with this and medical treatment, but some striking differences as well. I think we should continue to work very hard only to use involuntary hospitalization and forced medication when absolutely necessary. Judicial oversight helps keep the process honest, but I'm sure mistakes are made. It does help to compare it to what happens in the regular hospital; if you're out of your right mind and lack capacity you're not leaving, whether it's post-MI or the aliens infiltrating the TV set. If you need emergency IV fluids or emergency sedation, it's an emergency, period. This is a rather awesome power doctors wield, and I'm kinda glad there's a judge looking over this process.

First Post of the New Year

2009-01-04T21:43:00.002-06:00

And it's a lame one. I've been busy, blah blah blah, vacation/work/learning psych call. All the same old excuses, and largely the same ones I use when I don't go to the gym. Hmm, methinks I need some new excuses! (Or I need to get my fat butt to the gym--I gained at least 5lb on that cruise, but at least the food was amazing!)

Happy New Year to you and yours!

And for the love of god, if it's not too late, try not to take your first disability check of the year and go celebrate by snorting/shooting up/smoking >$100 of cocaine. Try to pace yourself, or you're going to end up in a psych ER seeing and hearing Satan telling you to kill yourself, and that's just not pleasant.

God-Awful

2008-12-22T19:30:00.002-06:00

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

2008-12-20T20:20:00.002-06:00

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*

2008-12-14T19:56:00.003-06:00

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

2008-12-10T18:49:00.000-06:00

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

2008-12-09T17:16:00.003-06:00

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

2008-12-02T19:17:00.002-06:00

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!

Let's Talk About Death

2008-11-27T06:13:00.008-06:00

We were talking about code status last night, and how it's really terrible that families get forced to make decisions about life or death. I know it's not a cheerful Thanksgiving Day topic, but as usual it tied in to some patients I treated whose families made them "full code" at 90 years old with advanced dementia, diabetes, heart disease, emphysema, strokes, etc (and usually all of the above). It's too late at that point to ask the patient what they want, so we rely on the families to help us. Unfortunately, I think it's human nature for families to balk at this, or to balk at withdrawal of care discussions when the loved one got intubated and is now in a persistent vegetative state on the ventilator. Who wants to be the one who "killed" Grandma? Isn't that how we would feel, if we make the decision to pull the tube, or the patient is crashing and doctors ask "should we intubate, or let her go?" (Not in those words, but you get my drift).

How much simpler if patients told us in advance what they wanted?

Having already had this discussion last night, I was surprised to see the One Slide blog rally going on today, and decided to jump on the bandwagon. Go check out their website to learn more, and then have the discussion with someone. They call it "Engage With Grace". It's easy. We fear death so much in America that we forget that life has a 100% mortality rate. Death is not always the worst thing that could happen to us. Tell someone what you want done to you when you can no longer decide for yourself. And then listen to your family when they tell you the same thing. Then, it's no longer your decision--it's the patient's decision, which is where it belongs.

I Had No Idea...

2008-11-23T12:31:00.000-06:00

That I am a Cool Nerd. Who knew?

Grand Rounds

2008-11-18T20:19:00.000-06:00

Today over at Dr. Deb's blog. Check it out!

New DSM Diagnosis

2008-11-13T19:42:00.003-06:00

Post Night-Float Call-Induced Delirium (may also be known as Post-Call Delirium)

Symptom Criteria:

a) disturbance of consciousness--manifested by inability to pay attention during rounds, falling asleep during rounds or morning report (or while driving home), inability to speak coherently while presenting patients, etc

b) a change in cognition or the development of a perceptual disturbance--manifested by forgetting what one was saying in mid-sentence, forgetting to print a copy of one's H&P prior to presenting the patient, not being able to answer simple questions on rounds, delusions of nursing staff conspiring to page q3 minutes while patient is trying to sleep, etc.

c) the disturbance occurs solely on the morning and afternoon after a night of call or night float

d) the disturbance is not better accounted for by an underlying dementia, substance (must rule out caffeine intoxication), or general medical condition

Etiology: directly related to the quantity, frequency, and quality of pages received overnight during the call or float shift. Direct correlation between repeat pages for Vicodin in a patient with "knee injury" that is not addressed in primary team's notes (and primary team d/c'ed the Vicodin) or pages to give detailed prognostic information to a family member after normal hours when the primary team had several discussions with them during the day, and the severity of the patient's symptoms.

Prognosis: good. Encourage night/day orientation (give patient bright light in the day and full darkness at night), re-orient them frequently ("You're presenting Ms. X, remember?"), withhold further caffeination, encourage proper nutrition (donuts and leftover pizza don't count), TURN OFF THEIR PAGER AND ALERT OTHER SERVICES THAT THE PERSON IS NO LONGER RESPONSIBLE FOR EVERY MEDICAL PATIENT IN THE HOSPITAL AS OF 0700, ensure that the patient makes it home safely and does not fall asleep while driving, and encourage a refreshing post-call nap.

I'll be submitting my findings to the DSM-V committee soon.

Addendum: This cracked me up: "It may also be associated with post-call dysphoric disorder, as manifested by irritability and the irrational belief that everything "sucks"."--thanks Midwife With a Knife!

Intern Learning

2008-11-03T19:52:00.003-06:00

At various points in medical training, you go through brief intense phases where you must acquire new knowledge at a tremendous rate. (I would say this is a "steep learning curve", but according to Wikipedia, this is the wrong way to use this phrase. Who knew?) Once you start clinical rotations, usually in the third year, you are constantly getting knocked off balance. In medical school, I rotated in 4 different hospitals and at least 6 different clinics in two years. At the start of every rotation, there's a new place to learn, new medical language (especially on OB), new medical record systems, etc. Every time you start to get into a routine and get comfortable, it's time to move on.

It's just like this as an intern, only even more dramatic, if possible. The first few days of a new rotation are, in technical terminology, guaranteed to suck hardcore.

It's November, and I'm on my 5th rotation, my 3rd hospital, my 3rd electronic medical records system, and my 4th new service. Even though I've been to this hospital before, every unit and service are different, so I'm relearning all the procedures of daily medical business, like how to arrange for discharges (on my last service, we met weekly; on this one, we meet daily). The call schedule is different and complex, with day call, night call, short call, and a ghost team that I don't fully understand. Every day, I have to try to attend morning report at 8 and noon conference (the benefit here is free food), but some days it's grand rounds here and some days it's grand rounds there and others it's simple noon conference in room X.

I have a small book of various call schedules, specialty schedules, and enough phone numbers to make a yellow pages. It takes me 3-4 minutes to find the phone numbers I need every time I want to make a call.

I had two med students over the weekend helping me out (and they're quite good), and today we acquired two more, plus a co-intern, and a new upper level, and an attending I'd never met before, so I'm thanking JCAHO or whomever that we all wear nametags or I wouldn't know who anyone is.

On Saturday, I inherited 7 patients, which is more than I've managed at one time as an intern. One had been in the hospital for 5 months when I picked her up.

Add to this the complexity of actually learning the medicine I'm supposed to learn this month. When my upper level says "replace his K" I usually go "okay, how?" Potassium comes in multiple oral and IV forms and can be administered slow or fast or even hanging upside down for all I know. As a med student, you generally don't learn medication dosing, because you're too busy learning the medicines themselves. Now, I'm trying to learn the dosing, in addition to remembering which calcium channel blocker is a dihydropyridine and which tricyclic antidepressants have the least anticholinergic side effects. Thank god for the PDA (or in my case, the smartphone) that contains the free Epocrates and gives me a starting point to say "should we start metoprolol 50 BID?" (Of course, the answer to most of my dosage offerings is "no, let's start x dose instead", which often seems to be more a matter of personal preference than anything. Or maybe I'm just always wrong.)

I spend half my day (it seems) just looking up the acronyms and abbreviations, because in every place they're different. One service used "HLD" for hyperlipidemia, this one uses "HLP". "MDS" is myelodysplastic syndrome, "SSS" is sick sinus syndrome, "AVR" is aortic valve replacement, and "FUBAR" is how I have felt these past three days. Thank god for Google.

I fully expect that by next week, I'll have my groove down. I'll fly through my notes and know how to replace basic electrolytes and remember the intricacies of acid/base metabolism and how to read an EKG. I'll know the names of the nurses (or at least the main ones) and the social workers (and of course, my team). I'll know my patients backwards and forwards and have their discharge plans in mind shortly after admission (always subject to change, of course). Seven patients will seem like nothing at all (and I'm sure I'll have more soon, as we admit q4).

Those first few days always suck, though. Welcome to internal medicine!

Somatization

2008-10-27T21:09:00.002-05:00

I haven't yet studied the theories of the etiology of somatization, but I'd like to put forth a few ideas of my own.

The term "somatic" simply means "of the body", so what I'm referring to are bodily symptoms that cannot be explained easily by bodily findings. "Psychosomatic" may be more accurate, as nearly all physical symptoms are actually "somatic"--only people with phantom limbs feel pain outside their bodies, for example. Somatoform disorders are those where mental disorders present largely as physical complaints. There are complex syndromes like somatization disorder that require multiple different types of complaints from pain to GI to neurologic, etc; conversion disorder, where neurologic findings don't make anatomical sense and don't have an organic basis that can be found; pain disorder, body dysmorphic disorder, hypochondriasis, and others.

There are people who don't necessarily fit these categories, but just have a lot of "somatic" complaints, especially pain. Patients with lipomas who complain of extreme pain, patients who have a ton of "allergies" to medications (like palpitations from a vaginal metronidazole preparation?), etc. I've seen a few men with small hydroceles/spermatoceles (no redness, no swelling, no pain on palpation during my exam) who complain of severe, disabling pain; a few women with small ovarian cysts, non-ruptured, who complain of the same. Some of these patients have a small physical finding that seems to bother them so much that they have constant pain and disability from a condition which should only rarely be painful. Is it anxiety? I'm not sure.

Sometimes, of course, there's an inciting trauma or injury that induces chronic pain or symptoms. Acute back pain has a pretty high chance of leading to chronic back pain. I've seen multiple patients who had car accidents and end up with years of pain afterward. Why is it that children break their bones all the time and only rarely end up in chronic pain, yet so many adults end up with unending pain?

Is it that having pain for too long leads to chronic pain? The body can become conditioned to things, so perhaps pain leads to more pain. Of course, pain is a poor example, though one of the most common, because pain is neurologically mediated. Other conditions, which have a lot of crossover between "physical" and "mental", such as irritable bowel syndrome, have some reliable clinical findings and may have more organic basis than was originally thought.

Is it possible that some of these syndromes have an organic basis? After all, if thoughts ultimately come from release of neurotransmitters and electrical pulses, then technically everything we think, feel, and do is "organic". The line is pretty hard to see.

Many of these conditions, even if they are ultimately found to have a neurologic basis, are still intimately tied in with psychiatric disorders. Multiple sclerosis patients often have comorbid depression, for example, and experience symptoms when under stress. In my very limited experience, many of these "hypersomatic" individuals, the ones who react badly to most medicine, the ones with chronic vague symptoms and normal physical exams (not the ones looking for drugs, either), often seem unhappy. My life sucks because of this knee pain. I can't work because my back pops because I was tackled at the age of 10. My marriage ended, but now I have 10/10 pain from a bruised finger. Some patients end up on disability, but still aren't happy and have symptoms. One man had vague symptoms every time he walked into his apartment--and then would come to the emergency room for a nosebleed which had stopped, nausea that didn't start until after leaving the apartment (but must be related), etc. He never found it strange that no one else got sick while inside his apartment, even when spending significant time there; he only knew that he felt extremely ill, with widely varying complaints, and his symptoms were not going to stop until he got a new apartment.

Is there a link between unhappiness and somatic complaints? Intuitively, I would say yes. I haven't looked up any data tonight, but I wonder how many happy people suffer from chronic pain or chronic complaints. Or if they have chronic pain, they attempt to go about their life, not spend all their days in the emergency room.

Of course, illness can make you unhappy, which can make your illness worse, and make you more unhappy. Perhaps the answer is just to sing "Don't Worry, Be Happy" all the time. Except that song really doesn't make ME very happy, but oh well.

Hot Topic

2008-10-26T18:38:00.004-05:00

My husband has watched all the political debates, while I only watched a few (and honestly, got bored within 20 minutes and kind of zoned out). It's surprising, though, that neither of us had heard about this until now.

I'm going to try to be politically correct, but I will express my opinion here: I am pro-choice. I do not like abortion. I do not like that there are some women who have multiple abortions because they cannot be bothered with birth control.

But neither do I like that so many women are so incredibly ignorant of their options or about sex in general. And I really don't like the idea of criminalizing a procedure which can actually be performed to save a woman's life.

John McCain has an opinion on this, apparently. He said in the third presidential debate that "health for the mother" has been stretched to mean "almost anything" by the pro-abortion movement in this country.

Is this true?

I not only believe that there are situations when abortion is clinically advised, but I have witnessed situations where a surgical abortion had to be performed for the health of the mother. I am making no statement about how often this occurs, and it is totally possible that this gets exaggerated by some in the pro-choice crowd. McCain may not be totally wrong there.

However, to just write off "health of the mother" as simply a "pro-abortion" tactic is to deny that this procedure exists for a reason.

I watched a woman have to undergo a surgical abortion because she had anhydramnios and a fever at 19 weeks gestation. It was a baby she and her husband really wanted, and she was devastated. To protect her health, wait, to protect her life, she needed the procedure. She had chorioamnionitis and the pregnancy was no longer viable without amniotic fluid. At 16 weeks, there was no way to try to save the fetus (which was not yet deceased), and she could not wait 2 months to viability. A horrible situation with a horrible solution, unfortunately.

Of course, being truly "pro-choice" means that had she chosen to refuse the procedure, we would have had to respect her wishes, even if it meant potential death from sepsis and hemorrhage. Some women would make this choice, and though I don't agree with it I understand why they would make it.

Am I exaggerating this case? No. I didn't make it up for the sake of making a point. Is this a rare case? I certainly hope so--I only saw this one. There are other scenarios where the mother's health would be placed in jeopardy by becoming pregnant, of course; renal failure is one, heart failure another, diabetes, etc. These cases all must be judged on a one-by-one basis between the woman and her doctor (and her partner, ideally). To make a sweeping statement that "all of these cases require abortion" is (to me) as ridiculous as saying "none of these cases could ever require abortion."

Of course, the best way to prevent abortion is to prevent unwanted pregnancy, or to prevent pregnancy in a woman who is at such high risk from becoming pregnant. Still, even wanted, planned pregnancies can have a terrible outcome. To mandate across the board that "health of the mother" doesn't matter (as by leaving it out of the partial-birth abortion ban) is to mandate at a legal level the choice some women are forced to make. Even if this is an extremely rare condition (and I think it is, although I do not have stats on this), it seems to me grossly unfair to have a law which makes the decision that a woman whose health is jeopardized and whose life may be in danger must not terminate her pregnancy.

And if Senator McCain thinks so little of the "health of the mother" then I think I know what side he will ultimately choose to vote for.

No comments on this post, please.

Comment About Comments

2008-10-25T11:08:00.002-05:00

I have rejected a few comments recently because they seemed like they were drug ads, or linked directly to drug company websites. Sorry if I rejected a legitimate comment, but I don't want ads (of any sort, drug or not) on this site, including in the comments.

Carry on.

Paying to Wait?

2008-10-21T20:32:00.003-05:00

http://www.dallasnews.com/sharedcontent/dws/news/localnews/stories/DN-parklandbills_21met.ART0.State.Edition2.4ab5531.html

So, yes, it definitely sucks to wait 19 hours before seeing a doctor. Yes, broken legs hurt. Unfortunately, unless there is cardiovascular compromise, they're not an emergency to the same degree as that of a heart attack, stroke, major trauma, etc. Perhaps $136 is a bit steep to charge the patient, but then again, that helps cover the electronic kiosk where she checked in (equipment, software, and maintenance), the salary of the nurse who evaluated her, the chart that was generated for her (not sure if it was paper or EMR), and the upkeep of the lobby and clinic rooms. I don't know whether $136 is high, low, or appropriate.

Unfortunately, what do you expect in an emergency room that saw over 143,000 patients in 2005? (http://www.parklandhospital.com/medical_services/er.html) And this patient, by declaring her intention not to pay, is just adding to the strain on large public hospitals like Parkland. Did she plan to pay for her xrays and cast?

Waiting 19 hours sucks. Not knowing how long you'll be waiting sucks, but is par for the course in the ER. If you say "20 minutes" or "2 hours" and then a massive MI comes in or a patient codes and takes up all the staff, then the waiting patient gets mad anyway. Lose-lose situation.

Just another example of our imploding healthcare system.

Addendum: an opposing viewpoint from The Happy Hospitalist.

Magic Pills

2008-10-19T20:51:00.002-05:00

I think it's interesting that, while it seems that many patients do not trust doctors, many seem to have absolute faith in what we prescribe. I could do the world's greatest ankle exam, according to the Ottawa Ankle Rules, and determine that it's a mild sprain and just needs an Ace wrap, but until we've given that therapeutic x-ray, many patients don't feel better. The Ottawa Rules are actually to determine who needs an x-ray, and they are very good at ruling out fracture. Yet, most people I've seen (observer bias) would much rather believe the x-ray than me. Then again, that could be wise, since I'm just the intern, but still.

I had a depressed, anxious patient who'd suffered a trauma in the past ask me about "the new medicine that will cure everything, you know, the one on TV. Why did my therapist tell me it would take years?" That one stopped me in my tracks. I'm not sure whether this is the fault of DTC advertising, poor education, denial, or all of the above, but that's an awful lot of faith in a medicine advertised by the people who make money off it.

I had a patient who requested an antibiotic by name for a sore throat. Said throat wasn't even red. Patient was a bit hoarse, and had post-nasal drip, so I made a diagnosis of allergies with post-nasal drip throat irritation and prescribed allergy medicine and over the counter throat spray or lozenges. "But why can't I take antibiotics?" "Because your throat isn't infected." "But it HURTS!" "Antibiotics aren't pain medicine. Use the spray at the store."

There seems to be something magic about that prescription, written on the pad. Writing ibuprofen 800 mg tabs is somehow so much more official than saying "take four Advil or Motrin from the store". Perhaps the reason the antibiotics relieve the pain more is simply because they're written on the prescription pad. After all, the expensive placebo is more effective than the cheap one.

Also, we want pills instead of other forms of medicine. Intranasal steroids sprays are front-line for chronic allergies, but don't seem (observer bias) to be very popular. I personally don't use mine as often as I should. Of course, nasal irrigation with saline is also extremely effective, but very few people do it (of those who even know about it). It's just not very sexy to run salt water through your nose (I did it tonight--I recommend pulling your hair back first), and much less messy to take a pill.

In some ways, I think we over-rely on medicine to cure what ails us. How many patients really try to get their cholesterol down with diet or their blood pressure down by cutting out salt? I think we need to re-think "preventative medicine". True prevention isn't about catching disease early by screening, it's about actually preventing disease. We're so focused on the pills that we forget that the best prevention means not to take any. Preventative medicine should actually be about encouraging exercise and healthy diet, but those aren't very sexy on a prescription pad. They're vital to preventing disease, but how much of our national healthcare budget is spent on exercise? We're doing better at smoking cessation, but of course, there are pills for that.

Preventative Medicine: A Way to Avoid Taking Pills. Will it catch on? I doubt it. We like our pills too much.

Countertransference

2008-10-18T22:22:00.003-05:00

Last month, I worked in a walk-in clinic off the emergency room/department (whatever). A "fast track" if you will, this is the clinic where the not-so-emergent patients get seen. If the chief complaint is "medication refill" or "back pain" or "tooth ache" or "suture removal", they get sent to this clinic. As always, this clinic is a victim of its own success: they take the pressure off the emergency room/department, which allows more patients to be seen, therefore more patients come to the emergency room/department for non-urgent complaints because this clinic exists. Lather, rinse, repeat.

I read several emergency room/department blogs, including WhiteCoat Rants, Ten Out of Ten, and Crass-Pollination, and while I hoped that they were all exaggerating, I had a suspicion they weren't. They're not. I occasionally saw people who really needed help, but more frequently (it seemed) I saw people whose whole existence seems to be about gaming the system for every free thing they can.

One person came in with a list of requests. Not complaints, but requests. He/she wanted pain medicine, refills of all other meds, a cane, free clothes, free food, dentures, and several other things which I can't even remember because the list was so long. I said no, okay, fine, no, no, referral. Since when is the emergency room/department a soup kitchen or the Salvation Army? And I wholeheartedly agree with today's post by Nurse K about the homeless "patient" with the bogus complaint. This same patient with the laundry list was homeless, but was currently NOT sleeping on the street, but instead staying with family. He/she also told me how many beers they drank in a day (the answer was a number >1). So, you have enough money to support your beer habit, but you get angry with me when I won't give you free clothes and insist that you go to a dental clinic to get dentures? Ugh.

Sometimes, it's a family affair. A brother and sister combo came in the other day, one asking for pain medication and a new cane as it had been "destroyed", the other asking for pain medication and a glucometer as it had been "destroyed". It was probably a little passive aggressive of me to document carefully in the chart that this was the patient's third cane in a year. Is there a black market for canes and glucometers?

I'll be totally honest. When I pick up a chart that says "tooth ache" or "back pain", I get put on my guard. I walk in, and make a split-second judgment. If the patient's face is swollen, or they're sitting all tense and not moving, I kind of relax. If they're all relaxed, and smiling as they tell me "doc, I'm doing TERRIBLE", and they have "10/10" pain from a skin rash, I get a little suspicious. One patient was sobbing hysterically when I came in, to the point I could hardly examine them because they wouldn't stop. "OH JESUS DOCTOR I'M HURTIN' DOC PLEASE HELP ME OH DOCTOR HELP ME!" I asked them to calm down, please calm down, TOLD them to calm down, but to no avail. I actually wrote on my physical exam "could not auscultate heart or lungs due to patient's crying". I looked in their mouth, and saw some brown teeth, but nothing red or swollen or infected, so I said "I'll give you the phone number for the dental clinic." "OH JESUS DOCTOR DON'T LET ME LEAVE WITHOUT PULLING MY TEETH OH DOCTOR THANK YOU DOCTOR I'M PRAYING FOR YOU DOCTOR!" This was also, coincidentally, a patient who had been seen previously, given the phone number they needed but failed to call, and somehow needed to call an ambulance to come to the emergency room for this pain.

WTF? So you can call an AMBULANCE for your tooth pain, just to sit in the ER/ED and complain to the nurse that we're wasting your Medicaid by sending you to a different clinic? Oh, the irony. I'm wasting your Medicaid, you're wasting my tax dollars with your ambulance call.

To those of you who may not know, here's a public service announcement: if your tooth is rotten, but not infected, no matter how much it hurts it's not a medical emergency. The emergency room doctors will NOT pull your tooth for free. Spread the word.

I'm being totally honest here because I'm not proud of this response in myself. Why do I feel like every chronic pain patient is scamming me? Why do I care? Seriously, what is it to me if these patients want pain medication? Why does it irritate me?

I could say it's that these patients are difficult, but really, only a few of these patients are actually nasty to me. Sure, it's hard to tell a patient "no" when they ask for Vicodin (by name and dose, and 'nothing else works'), but most of them accept my reasons and whatever I feel like I can give them (usually ibuprofen, sometimes tramadol). It's the few who get nasty who stick in my mind, though, and put my hackles up.

There's also the occasional patient who seems to "dupe" you into feeling sorry for them, or giving them pain medicine because their pain seems genuine, only to find out they were faking, or they start cursing you for taking too long reading their xray, or do something that makes you feel like a huge fool for believing them. This happens to me from time to time, because I really try to believe my patients. I keep trying to fight the cynicism, but it's hard.

A lot of it is in the environment. The attendings I worked with last month would say "Oh my god, another tooth pain? What a waste of time!" It's easy to spread irritation like that. In fact, it seems sometimes that it's easier to spread a bad mood than a good one...

Although not always. One patient had us all laughing hysterically with him (not at him). The attending came out and told me I HAD to go see this 80-year old guy's hand. I walked in, and his thumbnail was hanging off, dangling by a tiny piece of skin; he was totally nonchalant. "WHOA! I've never seen anything like that!" I said. "You've never seen anything like ME!" he said back. He also told us his only allergy was to "women" and that he was "a real tough guy." He was right. We all told his story for days to come, repeating it and laughing, tickled by this patient's attitude. So sometimes the good stories get passed around, too.

I just wish there were more of them, and less frustration. But still, why so much frustration? I haven't found the answer yet. I can totally understand some of the attitudes in the ER/ED blogs, though. There are some NASTY people out there.

A Radical Idea

2008-10-13T21:54:00.003-05:00

I'm working on a post about the health care policies of both candidates, and a thought occurred to me. It all started while watching the second presidential debate the other night. I realized that both men were focused on access to health insurance, but neither fully realized that health insurance is not health care. Obama came near this point when referring to his mother fighting her health insurance company for a "pre-existing condition" in acknowledging that just having health insurance is only part of the battle, but did not encourage access to doctors, just to health insurance.

My thought was, why do we have health insurance?

I own a dog and a cat. I take them to a veterinary chain, where for $25-$50 per month per animal I pay for 2 full checkups per year, including blood work; annual dental work (and biannual for the kitty); required vaccines; and I get a free office visit + 10% discount on any further treatment they need. I can pay for a cheaper plan and get a little less, or a more expensive plan for a little more. I upgraded the dog a few years ago when he started needing dental cleanings, because it was cheaper and easier to pay for it over the course of a year than all up front.

Why don't we have similar plans? Why do we need large insurance companies to be our middle man? It seems like (to be overgeneralized) the insurance companies (and the drug companies, but that's a different story) are the only ones making lots of money here; they squeeze hospitals dry, they squeeze doctors dry, and they cut out coverage for patients with "pre-existing conditions" or for taking Drug X instead of Drug Y to dictate healthcare for their patients. Until insurance companies are run and staffed by doctors and other healthcare professionals, WHY do we let them dictate our care? Why do we have to argue on the phone with a glorified secretary* (who probably makes more $$ than this intern) about why we, the MD, ordered the MRI?

So why do we need health insurance? Or rather, why do we think health insurance has to pay for everything? Why don't we remember that "insurance" is something for a rainy day which we hope not to have to use, but we have it around just like the fire extinguisher under the sink? Since when have we become too cheap to take responsibility for our own bodies and our own health?

I realize that health care is expensive, and even visits to doctor's offices can be out of reach for some patients, but consider how much cheaper the system could be if we largely cut out the insurance companies. Doctors' office staffs could be smaller because they wouldn't spend all day on hold with Blue Cross Aetna UHC arguing over a $10 copay and begging them to cover a visit.

If we got rid of "managed care" entirely, and went to a system of high deductible "rainy day" policies for those people who were healthy, and got rid of the middle men so patients could negotiate care with their own doctor, health care prices would fall as competition evened out the playing field. Patients with chronic health problems or who needed more care would have to pay more under such a system (they do now, too), but even they could still negotiate with a doctor and then purchase insurance to help cover costs they couldn't afford.

Insurance companies get their $$ another way, too, by selling malpractice insurance to physicians, which may cost up to $250,000/year for some specialties. Putting caps on malpractice settlements may help, but does not solve the problem. Perhaps a solution other countries have tried may work: make the plaintiff pay for something if they lose. Or make the plaintiff pay a small court fee (a few hundred to a few thousand or so) in advance, to be refunded if they win. Or make the plaintiff's attorneys (another group making $$$ out of the healthcare pot) pay fines if they sue frivolously, or cover the defense's court costs for fighting the battle. Right now, plaintiffs and plaintiff's attorneys have nothing to lose by filing in court, where doctors have everything to lose just by getting named on the lawsuit. Oh, but what about the poor plaintiffs who can't afford to pay the court costs? Where does it say in our Bill of Rights that we are born with the right to sue?**

Obviously, this scenario leaves out a big player in this business: CMS. The rules would have to change dramatically for CMS, too, because they essentially dictate the amount physicians will be reimbursed for services, and then most insurance companies adjust their reimbursement rates based on Medicare's. I'm fresh out of ideas at the moment as to how to fix Medicare, but my main point is this: there are a lot of fingers in the healthcare pot. A lot of non-physicians are controlling healthcare dollars on behalf of patients, doctors, and hospitals, and currently very few players are winning. The ones who are winning are not the health care providers, the hospitals (at least, the non-profit ones), or the patients. So why are we letting all the wrong people benefit from our trillion dollar healthcare budget?

*I have nothing against secretaries. I am totally inept when it comes to those huge phones with the transfers and hold and multiple lines, gah!
**Lawsuits can occasionally be necessary or justified, including those against physicians and hospitals. I'm not opposed to all lawsuits, I'm opposed to irresponsible suing.
***Written when I was trying to go to sleep but couldn't. Sorry if it rambles or makes no sense.

Thoughts on Belief

2008-10-07T17:02:00.003-05:00

"I think it's better to have ideas. You can change an idea. Changing a belief is trickier." -Dogma

I love that movie. It's so true.

As we prepare for the presidential debate tonight, I've been dusting off my long-standing, ever-evolving "Thoughts on Belief". I started really thinking about this during high school, when I was an evangelical Southern Baptist. I never really liked to proselytize, however. When I pondered why this made me uncomfortable, I eventually realized it was because if I was "witnessing" to someone, I was expecting them to listen to me and potentially change their mind to agree with me and whatever I was saying. However, I acknowledged that I wasn't willing to do the same. In other words, if I was preaching Christianity to a Buddhist, I wasn't necessarily willing to listen with an open mind to what they had to say back to me.

Out of this initial observation, I drew the conclusion that because I believed I was right, it was impossible for me to truly listen to another person's side and consider their (opposing) beliefs as if they were right. Thus, I could debate with them, and talk with them, and have exchange of ideas, but I would still leave convinced that my side was right, because I believed in it strongly. Only if I were able to suspend my own beliefs, or hold them less strongly, would I be able to truly listen to opposing beliefs.

Over the years, I've made many refinements to my initial theory (which, I admit is not original--I'm sure a philosopher probably reached similar conclusions 2000 years ago). Several corollaries emerged.

One: if I hold beliefs strongly, and someone else has starkly opposing beliefs that they hold strongly, and we debate, it is extremely easy to identify the person with their beliefs. You are no longer my friend A who happens to worship at X temple or vote for Y candidate, you are now an Xist or a Yican. If you identify the person with their beliefs, then the argument becomes intensely personal FAST. This is where a lot of internet chatroom nonsense happens, I think. I can't see you on the internet, so if you endorse a political theory I despise, and you think my theory is bunk, then suddenly we're calling each other Nazis and making comments about your mother's marital status when you were conceived.

Two: if I have a strong belief, and you present excellent evidence which directly contradicts my belief, I will make every excuse and rationalization possible against your evidence. It's one thing to argue for my side and present my own evidence, it's another to stand firmly by a belief despite TONS of evidence to the contrary. See the quote at the top. I'm emotionally invested in my belief, so your attack on it feels personal to me. I can't be wrong, because that feels bad, so I'll do everything I can to protect my belief.

Three: I think this is a normal human thought mechanism (forgive me my Freud-level hubris for applying my personal observations to ALL OF MANKIND). If I have opposing thoughts from you, then that implies that there is more than one way to think about that issue. I've made a decision, though, so I need to defend it in order to defend myself. For me to acknowledge that you are right, I have to change my mind, or continue to just be wrong (and who does that? Who says man, those Hindus have the right idea about God and the afterlife, so I'll just continue to be Muslim?) I'll go even farther and say that I think this is where a LOT of wars come about.

Four: I think this goes beyond just random beliefs and applies to things like choosing political candidates. As soon as we pick our candidate, the statements made by the opposing candidate seem completely ludicrous. How could they say that, are they retarded? we yell at the TV during a debate. What we don't usually think is that the opposing team is yelling the same thing at our candidate during that same debate. How many people wear a candidate's pin or sport their bumper sticker, yet will say openly and freely "Their ideas on such and such issue are really not so good" unless they then say "but the other guy's are even worse!"? I usually only hear such talk from people who are lukewarm, not the redhots.

I've never really put these thoughts into written form before, and so I apologize if they are rambling or completely unoriginal--it's just something I've been thinking about for years, including my philosopher days of college.

Now for a public service announcement: Go vote during this presidential election. Whether you vote Republican, Democrat, or third party, I don't care, just do it. I'm not sure if you can still register in some states or not, but if you can go do it.

And try to have a little tolerance for those who vote the other way. After all, whichever candidate wins November 4th, there will be close to half of the country's population who will be very disappointed.

Healthcare Is Not a Right

2008-10-02T19:21:00.002-05:00

Forgive me for just posting a link, but Shadowfax at Movin' Meat has written an amazing blog post which essentially summarizes my thoughts on universal healthcare, only MUCH better written and with a LOT more thought put into it than I usually do. Go check it out.

Oh, and I'll spoil the conclusion he makes: healthcare isn't a right, as we define rights, but an entitlement, and one we should probably extend to all citizens. It's okay if you disagree with this, but it's still a damn fine essay.

Consults

2008-09-28T16:09:00.003-05:00

We were talking about this phenomenon the other day: on very consult service I've ever been on, they whine and complain about the crappy, bogus consults they get, yet when those very same residents are on other services, they make those same bogus consults. One resident felt ardently that you should not call a consult unless you've done most of the workup yourself, ie, if you're calling a consult for altered mental status, then you should probably have actually checked the mental status. Others felt like they would call consults for things their physical exam was lacking, ie, calling an gyn consult to do a pelvic exam, whereas I KNOW the ob/gyn docs whine about those consults ("oh my god, we're all doctors, you learned how to do a freaking pelvic exam in medical school"). So when is it appropriate to consult?

For starters, it helps to have a specific consult question. Your question may be diagnosis (What the eff does this person have??), workup (What kind of tests do I need to run?), management (What do I give this person?), or a combination of the above. You may need to consult a procedural service, such as surgery for belly pain or GI for a colonoscopy. Prognosis is another type of consult question, when the consulting service knows the diagnosis but isn't sure what it means for that particular patient. For C/L psych, the consult question may be "This patient is a pain in the ass", meaning that you may have to deal with the patient, or you may have to deal with the staff (or both).

Don't be vague; if you don't have a clue what's going on then say so, but the more information you can give about the patient, the better. In other words, if you're calling a consult for belly pain, say "66yo WF with DM, HTN, Afib, now with intermittent diffuse abdominal pain worse after eating", not "she says her tummy hurts." If the diagnosis isn't clear to you, then give more information, and tell the consultant that's why you're calling ("Look dude, I don't have a freaking clue" usually works, as does "I'm only an intern.")

Of course, following consult etiquette is also important. It's usually best to actually speak to the consultant (or resident) on the phone to give them the patient's info, previous workup, and of course, the consult question. Most hospitals will let you order a consult in the EMR or the chart, but it's good manners to actually talk to the doctors whose help you are requesting. Be polite, always; after all, you're asking them to do you a favor (a favor which is part of their job, but still, they've got plenty to do without your consult). One bonus to the phone thing is that you can request the "curbside" consult--in other words, if you just had a quick question ("What dose of enalapril would you use in a dude with HTN, DM, and a creatinine of 2.5?"), then it doesn't entail a full consult note, just a quick phone chat. Also, if you call, and the consultant thinks it's a crap consult, they have a chance to turn it down ("Hey, man, don't you have UpToDate? Why are you calling me with this crap!")

Where it gets crappy for everyone is in the gray area around the above questions. Sometimes, an attending or upper-level resident may ask the intern to call a consult on a patient they're unfamiliar with, so that when you call, you don't have pertinent patient information. Bad situation. Sometimes, your team will have a plan, but will call a consult "just to get Heme/Renal/Neuro 'on board'". This may or may not be appropriate, so just keep in mind that getting so-and-so "on board" requires them to come write notes, perhaps daily, and it may not be an urgent inpatient matter. Psych patient who is psychotic in the hospital? Sure! Psych patient with a remote hx of depression, not on meds, doing fine, in the hospital for something else? Probably not.

Sometimes, you disagree with your upper level or attending about the appropriateness of the consult, but you have to call anyway. This sucks. However, you just have to suck it up and do it. If the consultant says "Okay, I'll come", then great. If they say "Uh, no, that's a crappy consult", then you shouldn't really say "Oh, yeah, I thought so, but my attending wanted it..." I think it's okay to say "My attending requested that I call you," but badmouthing your attending is never a good idea, unless you're home with your non-medical spouse and you're sure no one else is within a 50-mile radius.

Other than the basic rules, just keep in mind when you're on a consult service that no one else in the hospital has the expertise that your team does in your subject. Sure, you think "Well, we all went to med school, they should know such-and-such," but that's not always the case. Also, teams are busy, and may not have or want to take the time to research a topic they're unfamiliar with. So instead of thinking "OMFG, not another consult for Bell's palsy/remote psych hx/benign tachycardia/delirium/benign colonization of urine with a Foley," try to think of it as an opportunity to teach. Or, if you prefer, a time to feel really smart compared to someone else. And just remember, when you're on your next rotation, to kiss up a little when you call your old team for a crappy, bogus consult.

Busy, Sorry

2008-09-20T09:55:00.004-05:00

Inpatient rotation with q4 call = busy TS. Sorry for the lack of posts. It will probably be next week sometime before I can start posting with regularity (sounds like something you take Dulcolax for, doesn't it?) Anyhow, I'll be back soon!

A Strong Statement

2008-09-14T22:19:00.004-05:00

To those people who chose not to evacuate when placed under mandatory evacuation during Hurricane Ike:

Your decision not to evacuate, despite being warned of storm surge threats and of the threat of the hurricane, has placed hundreds of rescue workers in danger. In addition to having to rescue people who could not leave (those who tried to call 211 and could not obtain help, or those without means or were ill), or those who were in areas without evacuation who experienced flooding or fire, they have to come rescue those of you who said, "well, the last hurricane didn't hit us, so we didn't think this one would hit us, either". I'm sorry your house was flooded, and I'm sorry that you suffered, and fortunately you are still going to get rescued. Unfortunately, though, you are increasing the burden on rescue workers, hospitals, law enforcement, etc, and it's entirely through your own choice. If you have children and didn't evacuate those children, then shame on you for putting them at risk when you were TOLD to leave.

It's akin to a severe diabetic not taking insulin and eating cheeseburgers despite warnings that they could lose their heart, brain, kidneys, and extremities. We will still come fix you, but if you had helped yourself then we'd all be in a much better place.

To everyone in the areas affected by Ike, my thoughts go out to you. I hope everyone is okay.

The Almighty Defibrillator

2008-09-08T19:53:00.003-05:00

And now, to change the subject just a wee bit...

I've run across some misinformation amongst some of my family members recently, regarding the use of defibrillators. Articles like this one from February indicate that they're not the only ones who may not understand. So what is a defibrillator, and what is it good for?
We'll start with the heart. It beats between 60-90 beats per minute (normally) in all of us who are alive to read this. The heart beats because inside the heart the "pacemaker", or sinoatrial node, generates an electric signal that courses through the heart muscle, which causes the muscles to contract, forcing blood up and out.

When the rhythm of the heart beat is normal, we call it "normal sinus rhythm". It looks like this:
Sometimes, the electrical system of the heart gets screwed up. It starts to fire in an abnormal fashion, causing the heart beat to become abnormal. We call this an arrhythmia. There are many types of arrhythmias. You can start with slow versus fast patterns. The thing to remember is there are MANY TYPES. Since there are many types of arrhythmias, it makes sense to think that patients have many types of reactions to their arrhythmias. Some patients with a benign arrhythmia may have no symptoms or may have severe symptoms. Some have a potentially lethal pattern and may have severe symptoms or no symptoms.

Now, what do you see on TV? Patient says "I can't breathe!", grasps their chest, and keels over; someone slaps the paddles together, yells "CLEAR!", then you hear BOOM! and the patient sits straight up, fit as a fiddle.

Not exactly.

In real life, the paddles only come out when a) the patient is sick enough and b) the rhythm is shockable. On airplanes and in school gyms, automated external defibrillators may be used instead of the big fancy paddles. Someone goes down, isn't breathing, and they look bad. Bystander grabs the AED, slaps on the pads, and the machine starts to analyze the patient. It has two options: shockable rhythm or non-shockable rhythm. That's it. The machine doesn't know if the patient is breathing, or conscious, or has no blood pressure; the machine simply knows whether it should deliver a strong shock or not.

So when will the machine deliver a strong shock? Two rhythms only: ventricular tachycardia and ventricular fibrillation. Both of these rhythms can be fatal, as the heart beats too fast to pump blood, so the brain dies, and the heart wears out, so it dies.

Unlike on TV, if someone's heart has stopped completely, or is in asystole, they don't get shocked. In that case, the only thing to do is good old-fashioned CPR: manual chest compressions and mouth-to-mouth (or bagging if you're in a hospital).

Thus, if you strap on an AED, it will not always shock the patient. It shouldn't. Pulseless electrical activity, where the heart has some electricity but isn't pumping blood to the body, does not respond well to shock. Asystole does not respond well to shock. The slow arrhythmias, unless they start having ventricular fibrillation, do not respond to this kind of shock (and require a special pacemaker). The correct thing to do, if the machine says "no shock advised", and the patient still isn't breathing, or has no pulse, is to continue CPR.

AED's can and do save lives--it's true. You can't go wrong by strapping one on someone who's down without a pulse and not breathing. But don't forget the CPR.

So, what was my family's misinformation? They thought that the machine always shocked--and therefore always saved. Not true. And unfortunately, if there's not a shockable rhythm, and the patient can't get help within minutes, their prognosis is grim, even with the world's greatest CPR (although with CPR is better than without). A patient who goes down may still have a poor prognosis even if the AED delivers a shock, but now they've got a fighting chance. Since you don't know why the patient is down--they may have had a heart attack, or a stroke, or a pulmonary embolus, or a chemical imbalance in their blood, any of which could trigger an arrhythmia--it's good to strap on the machine and do CPR.

Something random and (I think) fascinating: Hands-Only CPR can be just as effective as the regular kind. So, if you're worried about doing mouth-to-mouth, or don't have your barrier device handy, just work on the chest compressions (100 per minute, so faster than 1 per second, and compress the chest 1.5-2 inches in an adult).

--I'm going to use this for my family and other lay people who have questions about CPR and AED's. Let me know if there's something I should fix.

Psychopathology of The Office

2008-09-06T22:41:00.004-05:00

Just for fun, while watching Season 4 of The Office tonight, I started thinking about DSM-IV criteria and the main cast of characters (yes, I'm a huge nerd). Obviously, these personalities are exaggerated for the sake of the show, because nowhere else on earth (except a psych ward or prison) would you see this many personality disorders in one room--they'd all kill each other. See what you think:

1) Michael: dependent personality disorder vs narcissistic personality disorder; manifests splitting, self-destructive behavior, pathological need to be liked, feels entitled, has some somatization, fears of being alone, rushes to new relationship when old one ends

2) Dwight: paranoid personality disorder vs schizotypal personality disorder; feels everyone is out to get him, has hidden weapons in the office, turns down a free drink because it may be poisoned, has some magical beliefs (the computer has free will, the websites are talking to each other to take over the world, the short guy is a Hobbit), ideas of reference, eccentric behavior

3) Angela: obsessive compulsive personality disorder; control-freak, stubborn and rigid, everything has to be done her way, inflexible with rules, perfectionist, devoted to work, reluctant to delegate tasks

4) Toby: avoidant personality disorder (soft call); can't have Pam so is leaving to go to Costa Rica

5) Andy: narcissistic personality disorder; believes he is special, is grandiose, is often jealous of others or thinks others are jealous of him

6) Jan: borderline personality disorder, alcohol abuse; repeated patterns of self-destructive behavior in work and relationships, impulsive, labile mood, fits of rage

7) Meredith: alcohol abuse/dependence--duh

8) Creed: antisocial personality disorder; exploitative, repeated arrests, irresponsible at work, lack of remorse

9) Kevin: pathological gambling--duh

10) Phyllis: personality disorder NOS with features of passive aggressive personality; always knocking stuff off Angela's desk or throwing things at her when she's frustrated

11) Kelly: histrionic personality disorder; OMG LOOK AT ME OH HI RYAN WANT TO GO ON A DATE I'M PREGNANT OH J/K HI DARRYL MMM LET'S MAKE OUT RIGHT NOW HEY PAM YOUR BOYFRIEND IS SOOOOO GOING DOWN

12) Ryan: narcissistic personality disorder vs substance abuse NOS (I'm not sure what but he was definitely on drugs in that club, looked like Ecstasy) vs pyromania*

That leaves Jim, Pam, Oscar, Darryl, Stanley, and Holly without a current diagnosis. Any thoughts?

Obviously, this is satire, and I just made this all up. This information is not intended to diagnose or treat any condition. I do not think everyone I meet has a personality disorder, I swear. It's just a joke. No, really. Stop looking at me, swan!

Existential Dilemma (With the Usual Windy Discussion)

2008-08-30T21:50:00.003-05:00

The past week or so, I've been experiencing an internal struggle. It's somewhat akin to a loss of faith, if you will, similar to what I experienced at age 19 when I became an agnostic (from Southern Baptist--trust me, that's a big leap). I've felt lost, confused, somewhat abandoned, and angry. While the acute crisis has mostly passed, I'm still feeling the aftermath and haven't decided yet what to do.

What was bothering me so much?

I have been confronted with evidence that a good portion of what we do in psychiatry is based on a) ineffective medication b) bad evidence on medication, sometimes even manipulated by drug companies c) made up as we go along. It just seemed to happen all at once, however, and kind of rocked me: can I "believe" in psychiatry, and practice in this field, if so much of what we "know" we don't actually know?

Some of you are going "WTF?" and some are going "DUH!" I'll try to list examples of what I'm talking about.

1) I've known for some time that the evidence for certain "mood stabilizers" like Depakote isn't very good. In fact, it sucks. In the study linked above, Depakote was no different from placebo in preventing mood episodes. Yet, we put every freaking bipolar patient on Depakote. It does seem to be effective in acute mania, but not quite so much in maintenance. And the whole term "mood stabilizer"? Doesn't it imply that the mood is "stable", or non-fluctuating? Even in trials with relatively good improvement over placebo, like this one with lamotrigine, show that the mean time to intervention for mood episode while on maintenance was 200 days (versus 93 with placebo). So by 6.7 months, the average patient on lamotrigine was going to have another episode. It may have reduced the risk of relapse, or prolonged the time to relapse, which is good, but I'd hardly call that a "stable mood".

2) A recent meta-analysis shows that overall, SSRI's aren't terribly effective in all but the most severe depression. Yet, we're taught in medicine that roughly 2/3 of patients will respond to the first antidepressant you try. It all comes down to your criteria, I suppose; remission vs response vs decrease in symptoms on a clinical scale, etc. Interestingly, the study above re-analyzed ALL the data submitted to the FDA to get these drugs approved, and came up with this answer. Uh, where was the FDA? Aren't they supposed to do that?

What really bothers me about this one, though, is that some of the efficacy data that was used to get these drugs approved in the first place was deliberately manipulated to make these drugs look more effective. After reading "Side Effects" recently, and looking at the study the book discusses, I'm angry. Wading through that study is tough, but you could still come out and think, well, it showed SOME benefit over placebo, and the side effects weren't too bad. Turns out, what was coded as "emotional lability" was actually likely to be suicidal behavior or self-mutilation. AND, several kids' data disappeared from the analysis. AND, the study was ghost-written. AND, GlaxoSmithKline deliberately had the writer word the study to show that "Paroxetine is generally well tolerated and effective for major depression in adolescents" because they knew it would hurt their bottom line to write that it wasn't! (That's not so shocking, really...)

Whether you believe that SSRI's cause/increase/exacerbate suicidal behavior or not (I've seen convincing arguments both ways), it is highly disturbing that the evidence we've been basing therapy on was so deliberately manipulated. Yet, we use this "evidence" all the time. It came directly from a drug company that expected to make millions to BILLIONS of dollars off this medication.

3) People ask me all the time if I'm going to become a child psychiatrist. After all, I love children, and (if I may say so) I'm pretty good at interacting with them. (Maybe I'm just childish?) However, my answer is usually "No." Why? Because I don't like the way we medicalize childhood problems and then medicate them.

Is ADHD a real disease? Sure, why not? I've met kids who were really impaired by their hyperactivity and impulsivity, across settings, with good, appropriately firm parents. I've also met kids who were totally out of control in the doctor's office while mom chats on her cell phone and then looks at me funny when I tell the kid not to hit their sister with the otoscope.

I have seen the number of kids diagnosed with ADHD go up dramatically in my lifetime, and (concurrently) the number of kids getting put on stimulant medication. What happened to behavioral modification? Or family therapy? I've not once seen those prescribed for a patient with ADHD (though my experience is still very small).

And then there's the whole pediatric bipolar debate. Can a 4-year-old kid really be manic? I don't know. But apparently the FDA does, because they're willing to approve medications for use in pediatric bipolar, when even the DSM-IV doesn't have a criteria for it yet, because no one has agreed on what the criteria should be! And apparently Texas knows what it is, because 12% of 0-5 year olds and 2/3 of the teenagers in foster care are taking "psychotropic medication". Twelve percent of kids under 5, and we don't have any idea what these meds might be doing to their developing systems.

So no, I don't think I can be a child psychiatrist, unless I do only therapy, because a) there's very little evidence in kids, because who wants to do studies in kids? b) the studies we have may be flawed c) but we "have to do something" when little Johnny hits his sister, so here's your Risperdal, hope it doesn't zonk you out too much. Oh, it makes you too sleepy in the day? Well, we can try Concerta during the day! Side effects from the Risperdal? Take a Benadryl! We end up with young kids on 3-4 psychiatric medications, and we don't know what any one of them could do to these kids, let alone a combo of multiple.

4) We act like psych patients who are "non-compliant" are constantly wasting our time. I wonder, how many psychiatrists have ever taken, say, an antipsychotic? I've never taken Zyprexa, but I know people who have, and they were complete zombies (who got fat). We act like we're surprised that patients would prefer craziness to weight gain, or sedation, or extrapyramidal symptoms, or (god forbid) tardive dyskinesia. In reality, I think we're asking patients to make a tough choice. Schizophrenics don't get totally well on medication--there is no cure. So, they can have an improvement in their psychosis and mood with a ton of unpleasant side effects, and be quasi-functional, or they can be psychotic and flat and non-functional. This is a tough choice, and we need to appreciate that.
____________________________________________

I guess what's really been bugging me is the huge discrepancy between what we're being taught (in both med school and residency, now) and what is actually out there. We're so "evidence-based"--but so much of our evidence comes from drug-company studies. Or what we "know" is directly in conflict with the "evidence." I don't want to be taught how to dose a medication without knowing the evidence behind it. Is that too high a standard? I don't think so. Would it be any different in medicine or pediatrics? Probably not.

In so many ways, though, I feel like what we do in psych is far behind the rest of medicine. Look at how many options there are for treating hypertension: beta-blockers, calcium-channel blockers, thiazides, loop diuretics, salt restriction, potassium-sparing diuretics... Now look at our options for psychosis: typical or atypical antipsychotics. Possibly group or family therapy; hospitalization for "medical stabilization"; group homes for those whom we can't fix. For bipolar: anti-epileptic drugs, lithium, atypical antipsychotics, maybe SSRI's. When one med doesn't work, we just add more, despite having almost zero studies on combo therapy.

This is not what I wanted. I guess I wanted to feel like I could actually help people. Hopefully, by learning psychotherapy, I still can. I wanted to practice "evidence-based medicine"--how can I, when there's so little good evidence? I guess it's one thing to prescribe Depakote because "it's better than nothing" (although it may not be), because we don't have many better options, but I hate the sales job. Call it a "mood stabilizer" and you believe that it works. Your textbook says "used to prevent recurrence of mood episodes" and you see it as actually preventing episodes, as in all (or most) episodes, not delaying their occurrence by 100 days (like lamotrigine).

I really think basic pharmacology ought to have a segment where they examine (briefly) the best evidence for medications (like second-year med students need more to learn). I think we ought to be exposed to that stuff early. Like, study X showed a number needed to treat of 20 for cholesterol-med Y. Or if second year students can't do that, let's put it into the curriculum for clinical rotations in third year. Or in fourth year when we're lazing around on the beach. Or intern year.

I guess I wish someone had handed me a book that I could reference the actual numbers and studies used to say this drug works on this condition. To the best of my knowledge, no such book exists. Shame on us for not having such a book (and shame on me if there is something but I haven't found it.)

So I'm a little burned out right now. I'm getting plenty of sleep and I just had an easy month, so it's not that. I'm just concerned about my chosen profession and its integrity--scary, huh? And will it be enough for me to just "be with" patients (House of God) in the face of our inability to do much else?

Sign Failure

2008-08-28T20:50:00.002-05:00

At the hospital the other day, there was a flyer posted in the elevator lobby:

"BAKE SALE: Urine Luck!!!"

I read further to see that the bake sale was to benefit the renal group's softball team, but all I could think was, I sure don't want to eat THOSE cupcakes!

I Love Kids...

2008-08-26T22:08:00.003-05:00

In the elevator today, a mom and her adorable little boy stepped in. He looked to be about 4, and he was in a very cheerful mood. I stepped in, and a crusty-looking old doctor stepped in after us.

We arrived at the little boy's floor and his mom said "This is our floor, time to go have your picture taken!"

Little Boy: "Oh boy, I LOVE X-rays!"

*giggles in the elevator*

Crusty Old Doctor: "So do I, it's my department." (I hadn't noticed that his white coat said 'Department of Radiology' on it, and he was old enough, it could BE his department.)

*more giggles in the elevator*

When Your Students Get Bad Grades...

2008-08-20T19:29:00.006-05:00

...why, just lower your grading standards! Which is exactly what the Dallas Independent School District's board has just mandated that all of its teachers do. Dr. Eliu Hinojosa, the superintendent, backs the new rules, which will mandate that teachers accept late homework, give retests for failing tests, and (my favorite) not allow teachers to accept grades on homework that would drop the student's average.

WTF?

So, your average in a class can only go up? What if your average in the class is a 98? Do these people even know how to calculate an average, which includes points both above and BELOW the mean? I guess it wouldn't matter, since these students have zero incentive now to actually DO their homework, anyway, since the teacher can't penalize them for not doing it. Dr. Hinojosa: "We want to make sure that students are mastering the content [of their classes] and not just failing busy work," he said. Oh, so now all homework is busy work? I highly doubt I'd have learned geometry or calculus without practicing at home, and (though I was highly self-motivated) it helped me slog through all those problems knowing I'd get a good grade. I'm sure I wouldn't have been quite so motivated to finish 30+ calculus problems a night if there had been no penalty for not turning it in.

It gets better. Dr. Hinojosa cites research that shows that ninth-graders who are failing 2 or more classes in the first 6-weeks of ninth grade are "doomed" to become dropouts. This is probably accurate, because if you're already failing in the first 6 weeks then clearly the subject matter is over your head or you aren't trying very hard (or both).

Why do I say the subject matter is over your head? The article I linked above goes on to say that teachers are saying the real problem isn't that ninth grade teachers are grading too hard, it's that these kids can't freaking read!

In 2007, 80 percent of them scored below the 40th percentile in reading on the Iowa Test of Educational Development. Yet the promotion rate out of eighth grade for that class was 98 percent. (Dallas Morning News)

So, the majority of these new freshmen read at a below average level for eighth graders. If you can't read well, you can't possibly pass high school courses. Math classes require reading. Science classes require reading. Hell, even drafting, shop, home ec, health, and agricultural classes are bound to require some reading.

This says a TON about the quality of education in the DISD, I think. If 80% of your ninth graders are below average readers, then the quality of your reading program is likely to be--wait for it--BELOW AVERAGE.

So the DISD's answer to their failing freshmen? Lower the standards further. Never mind that nearly 50% of college freshmen from Texas high schools are requiring remedial courses to catch up to their peers. Never mind that the same panel reported that the standards on the TAKS test are so low already that passing this test doesn't reflect that the students are ready for college. Never mind that business leaders are concerned that many Texas high school graduates aren't prepared for the workforce, either.

Let's ignore all of that for a second, and pretend that the problem is that high school is just too hard. Then yes, the answer is to make it easier! If you made a bad grade, we'll just throw that one away!

The real victims, of course, are the students in DISD. Let's take students who are badly prepared by their school to read at a high-school level, and let's give them extra incentives to be lazy. They're going to be told that it's okay not to turn in assignments, okay to make bad grades because they don't count, and then when they hit the "real world" of college or trying to go to work, they're going to be totally stymied. Some of my college classes had 300+ students--do you think that prof gave a crap if I was having a bad day and didn't feel like turning my assignment in on time? And even people who work at McDonald's or a grocery store have to have basic reading skills.

Random data: DISD paid Dr. Hinojosa $327,600 last year. DISD contains 160,000 students currently, 38,586 of whom were in high school in 2007-2008. If 80% read below an eighth grade level (I'm assuming that no further reading instruction was given, so those students reading below the average eighth grader continued to do so through 12th grade), then 30,869 high school students in DISD have poor reading skills and are set up to do badly in high school and beyond. Over the next four years, as those 30,000 students are released on Texas colleges and business as high school graduates (or dropouts), I think we'll see that Hinojosa's rather large salary is a pittance compared to the cost all Texans will pay later for these poorly educated students.

I don't always agree with him, but this time, LawDog has gotten it. Thanks to his site for running this story first.

Grand Rounds

2008-08-20T08:55:00.002-05:00

Go check out this week's medical Grand Rounds at sixuntilme, a blog about all things diabetes from a sufferer of type I. She's organized the posts into a form of the Dewey Decimal system on the advice of an evil card catalog in her nightmare. Just because I find that hilarious does NOT make me a huge nerd. Really.

Weight

2008-08-18T21:39:00.003-05:00

I've been thinking a lot lately about weight, both mine and other people's. I was made very happy last week when this article received a lot of media attention. Basically, the authors looked at data on 5,440 adults over the age of twenty, including their height, weight, and some lab tests. They also used self-reports of smoking and exercise habits. Overall, they found that inactivity, not weight, correlated with heart disease; so did age, smoking and waist circumference. In their study, 51% of overweight patients (BMI 25-29) had normal blood pressure, cholesterol, triglycerides, and blood sugar.

It's not exactly time to go out and rejoice by eating a gallon of Blue Bell, but this makes sense to me. Our BMI scale takes into account 2 things: height and weight. There are an awful lot of other factors that go into a person's build: gender, bone structure, muscle tone, fat density, etc. Just by BMI, many basketball players and other athletes considered to be in excellent physical shape fall into the overweight or obese categories (of course, I'm not referring to 300-lb linebackers here). Other studies have shown the importance of waist circumference in determining cardiovascular risk. I've seen a lot of people with skinny limbs and a big ol' gut.

This study also shows the other end of the spectrum: the unhealthy but skinny person. I'm sure we've all had thin patients with hypertension, hypercholesterolemia, diabetes, and coronary artery disease. I had a friend in high school who was genetically blessed and very thin. Other girls would (jealously) ask her why she worked out or ate salads--"you don't need to, you're so skinny!" We have this perception that only the fat people need to exercise, that the skinny ones have "made it" somehow, they've won the big prize and can eat cookies dipped in butter all day while sitting on the couch.

This study fits nicely into my personal belief, then: healthy people are active, regardless of weight. They probably eat better, too; not necessarily dieting all the time, but eating balanced healthy meals.

Can runners get coronary artery disease? Sure. I think nothing is truly impossible within the span of humanity (except, perhaps, a man who leaves down the toilet seat). Just as there are marathon runners who are fat (rare, but it can happen), I'm sure there are people who could leave me in their dust, only to have a big MI. It's all about adjusting your risk, just like everything we do in medicine.

Now, this study was just a cross-sectional observational study. The authors didn't follow the overweight people to see if that 51% stayed healthy or if they developed problems later on; they just took a snapshot of a group of people at one time. Just as these authors are cautioning that correlation does not equal causation, that obesity may be correlated but may not cause health problems, so might they be reaching the wrong conclusion.

____________________________________________________

I think the heavier you are, the harder it is to be healthy. I can share that I am 5'1" and have weighed as much as 158 lbs, putting me at a BMI of 29.9, which is almost to the obese category. When I couldn't fit into my interview suit from med school to interview for residency, I decided it was time to act, and I hit the gym. I was really appalled at how badly I performed (although I was also having a lot more asthma trouble at that time, too). Still, it's hard to move well with jiggling areas and extra pounds. Every step I took on the treadmill or elliptical, I lifted more weight than a woman my height should (unless she's wearing ankle weights). In other words, my system had to work harder to do the same amount of work as someone with a "normal" weight.

That was around September last year. I worked out and worked out and worked out and eventually noticed I was a little less winded on the elliptical. I'd also lost about 5 lbs, and fit into my interview suit in time, which was my first goal. Over the spring and through my trip to China, I ate a little less, and lost another 5 lbs. This time, I had to buy new pants in a size 10, so now I have a huge motivation not to gain the weight back (if I lose more, I'll have them taken in).

Losing weight is really hard, and I haven't really lost that much. Enough that people noticed; enough that I went down a dress size; enough that my midsection is noticeably smaller (I have an hourglass shape, so most of my weight is on my lower half). I really, really like the way I look now, and I'm having to work hard enough to stay this weight that I'm not sure I'm ready to try to lose more. It's funny, but the first time I weight 148-lbs I felt awful about it. Now, coming down to 148, it feels great. My resting pulse is lower, my blood pressure looks good (it wasn't high, but now it's even better), and my cholesterol looks better (though still a little high).

In other words, if I'm healthy at 148, or a BMI of 28, then that's okay with me. Sure, I'd love to be a size 4, but with the junk I've got in this trunk, it's never going to happen. To get a BMI of 25, back in the "normal" range, I'd have to get down to 132 lbs. I'd really like to get there, but I don't want to end up a yo-yo dieter. I'd rather stay peacefully in one spot than get yanked all over the place. Besides, I really like cookies.

So, I'm really trying to base my personal health assessment on how I feel, what my vitals and cholesterol look like, rather than my BMI. I figure, if I can get on the elliptical for 45 minutes, then walk a mile at a steep incline, and then do a few weights, how bad off can I be? My next goal: to jog a whole mile without stopping or being severely winded. In 26 years, I've never accomplished this; I may never accomplish this, but by god I'm going to try. It would be nice if achieving this goal also got rid of my double chin or made my legs less jiggly, but I'll try not to let that be my only measure of success.

Of course, internship is seriously getting in the way of my personal fitness crusade, but hey, we wouldn't want this to be too easy, now, would we?

JUNK SCIENCE

2008-08-16T09:46:00.002-05:00

Today at Fat Doctor's blog, she has a post about a patient who seems to firmly believe that his high cholesterol will have no impact on his life, and that not only does he refuse treatment but he feels "sorry that [she has] been duped." By clicking on the link on her blog, you can visit the website of a physician who uses the term in the title frequently and always in all caps. I'm not going to put his link here because, frankly, I don't want to give his site any more traffic. If you want to visit, go to FD's blog and click her link. Basically, he promotes not exercising, eating tons of red meat, and pretty much doing whatever you want, so long as you take his "cheap" supplements.

Now, does this patient have the right to believe whatever he wants? Of course. If he wanted to believe that little aliens in his bloodstream were doing battle with the bad cholesterol with argon laser beams, he has that right. Does the patient have the right to refuse intervention? Absolutely. Cholesterol-lowering drugs are not benign therapies. Statins can cause rhabdomyolysis, most cholesterol meds can cause elevated liver transaminases, most (if not all) can cause GI upset, and of course, they all cost money. Without insurance, Lipitor can cost $100 per month (I'm having a hard time finding a good estimate online, so forgive me if that is inaccurate). There will always be patients who don't want what Western medicine offers, and that's okay.

The problem is that this guy claims to be a kind of maverick doctor hero, set against the pseudo-science of mainstream medicine, offering treatments that only he knows about. For example, he claims that only low cholesterol is unhealthy and that even the American Heart Association agrees. He says that patients with low cholesterol can be just as prone to heart disease as those with high. You know what? I don't have exact numbers, but it's true that patients with low cholesterol and no known, accepted risk factors can have heart attacks. It's also true that people with high cholesterol may never have a heart attack. Finally, it is true that other factors are involved that we don't know much (or anything) about. Homocysteine is one; the "pattern" of LDL is another; apolipoprotein subtype ratio is yet another. Cholesterol level is not the only predictor of heart disease.

Yet, total cholesterol, LDL and HDL levels are all well-correlated with cardiovascular disease in multiple, multiple studies. There may be a lot to this picture we don't fully understand, but we do widely accept that elevated total cholesterol and LDL and/or a low HDL level puts you at risk for heart disease. We do have good study data that shows that lowering LDL and raising HDL reduces risk of heart attack and death even in those who had a previous heart attack. It's a risk reduction, not a guarantee, not a promise of no future heart attacks, but a better chance for not having another one. And, though I cannot get the AHA website to load for me today, I'm pretty sure their guidelines for cholesterol have not changed since last month when I was on neurology and we followed their guidelines for lowering cholesterol.

One problem with evidence-based medicine (of which I am only a novice at best) is that we can only say what the evidence tells us. If we don't have a study, then we can't say yea or nay. When the Women's Health Initiative shocked everyone a few years ago by showing increased cardiovascular events in women on hormone replacement therapy, the best available evidence at the time was to stop all HRT. Now, the picture is much muddier, as more and more studies try to tease apart the risks and benefits of HRT. What does the evidence tell us? It's really hard to say. All I know conclusively is that HRT lowers symptoms of menopause. So, ob/gyns prescribe it for that. Who knows about the increased risk breast cancer or heart disease or DVT or decreased risk of colon cancer? Is it worth it to increase the risk of breast cancer to decrease the risk of colon? Who knows? (I'm obviously no expert in HRT, and I will leave a more detailed discussion to those who are).

Another problem with evidence-based medicine relates to the studies. One study says that drinking 1 glass of alcohol daily lowers your risk of heart attacks, so the media gets excited and tells people to drink. Then, the next study says it's red wine, not just alcohol. The next says the level is 2 drinks for men. The next says it's so many per week, and if you don't drink that much, then just don't bother. Some studies don't show a benefit to drinking at all, or point out the liver toxicity and risk for dependence. We have different studies that advocate, in turn, low-fat, high-fat, Mediterranean, Atkins, South Beach, low-salt, low-meat, high-meat, low-carb, high-carb, low-protein, high-protein diets. Everyone was shocked recently that the Atkins diet wasn't shown to increase cholesterol. A Mediterranean diet (lots of olive oil) has been shown to be more favorable than the tradition low-fat AHA diet in some studies.

But I digress.

This guy's website is a hodgepodge of truth, incorrect facts, and flat-out lies. Truth: drinking 8 glasses of water per day is a healthcare myth. In terms of hydration, you can get enough water from food and other liquids (even coffee, tea, and soda) to keep you hydrated. Lies & half-truths: the AHA warns that low cholesterol can lead to the deadliest kind of stroke known as the "massive stroke". First, I don't remember learning about the "massive stroke" when they taught us about ischemic versus hemorrhagic, cardioembolic versus large-vessel, etc. Second, is he referring to total cholesterol, or to HDL?

My final problem with this guy's site, before I quit reading it because I was so angry, was right at the top. Next to his link "Find Out What Your Doctor's Not Telling You" is a link "Recommended Products". Here's the key to this guy: he's selling all the supplements he recommends. It's his website that the link goes to. His proprietary "NATURAL HORMONE THERAPY" will only cost you $29.95 for one month, the same price for his "ULTIMATE DAILY SUPPORT". I'm sure he would argue that this is no different than any other doctor prescribing Lipitor, because everything costs money. Sorry, bud, but Pfizer wasn't knocking on my door to give me a big paycheck every time I wrote a script for atorvastatin on neurology (and often, we used the generic simvastatin unless there was a reason to use Lipitor specifically). $0 in my pocket versus $30 in his from the sale of his supplement. (Of course, there are doctors who are getting $$$ from drug companies to hawk products, and shame on them, too).

There's a pretty fine line between a "physician" and a "quack". Those who do their best, slog away learning the best available data, try to read a JAMA or two at the gym, go to CME conferences, and generally try to stay afloat the most recent data represent the current ideal of American medicine. Western medicine doesn't have all the answers. Some of our treatments don't work, and others will be outdated in 5 years. It could be that in 20 years we'll look back and laugh at our current understanding of cholesterol metabolism and atherogenesis. I'm hoping that our knowledge in medicine will be much more personalized by then, so we can more accurately assess a person's risk for bad outcome from a disease and tailor a therapy just to them. For example, the recent PSA outcry has people wondering, how can we tell which men have a favorable, non-lethal tumor, and which have an aggressive tumor which needs removal?

But there's still a difference between trying to keep abreast of the best medical advice, and making up your own "science" in order to sell a vitamin supplement. When drug companies do this, we cry foul, and many patients are wise to this scheme. Unfortunately, when doctors do this, patients may be unaware. It's one thing to buck traditional medical science and point out its many flaws; it's another entirely to just start making stuff up on your own so you can sell books and pills.

And yet, I'm still bothered. I guess I need to believe that in medicine, we're not perfect, but we're doing the best we can. Guys like this exploit the weak points of medicine and rub it in our faces by using inflammatory language. It's rather like a schoolyard bully singing "nyah, nyah, nyah-nyaaaaah, nyah". You can look at it for what it is, you can cover your ears and say "go away!", you can know fully that it's just a stupid song, "a tale told by an idiot, full of sound and fury, signifying nothing"--and yet that song still gets under your skin. Sometimes, when I acknowledge just how much we don't know, and how limited science actually is, I feel like there are fewer differences between "physicians" and "quacks" than I would like to admit.

I just hope that as our science gets better, the gap between the two gets wider.

It's Genetic, I Swear...

2008-08-14T21:05:00.002-05:00

Email from my dad this morning:

"So if the Russians invaded Georgia, is Alabama next?"

Email response I sent back:

"It's Shermanov's March."

I couldn't help it.

Wow

2008-08-11T18:53:00.002-05:00

I would just like to say that I didn't expect all the positive comments. I'm afraid if I get anymore, my head will get so big it will actually explode, which would be messy. Seriously, many thanks for the support.

I haven't quite figured out what I'm going to do. I feel like I'm probably going to do a little blogging about residency and what I'm doing, since (as Midwife with a Knife pointed out), the First Amendment still applies to me. I will try to avoid writing about patients as much as possible, though, since I'd hate to violate someone's privacy. Writing about other people, particularly patients, brings a whole other level of complexity to this equation.

It puts me in a bit of an awkward situation at work, though. I'd like to participate in some kind of discussion about blogging, but just by doing so it threatens my anonymity at work. Right now, the only person at work who knows I blog is an upper-level resident whom I confided in, so now I'm in a weird spot, since he's the one who forwarded the email to me about blogging. If I continue blogging about work, and he's the one who told me the policy is not to do so, then in essence I'm lying to him, or at least betraying his trust. As ridiculous as it may seem, I've considered contacting a lawyer (or at least, a friend who happens to be one) to get legal advice on this issue. After all, this is my current job and future career that could be at stake.

I really would miss blogging terribly, though. I love having a reason to write. I've never been good at keeping a diary or journal, but I've managed to write a little bit in this for nearly 3 years now. That's something to be proud of, no matter how poor the writing is sometimes (or most of the time), or how many times I simply degenerate into curse words. And all joking aside, I was really moved by all the positive comments. Thank you, thank you, thank you.

Quote of the Day

2008-08-05T20:22:00.003-05:00

"Tropical Storm Edouard? Spelled with three vowels, O-U-A? Oh my god, how gay can you get???" --said a gay friend of mine today

In no way related to the sexual preference implied by the name Edouard, this was one wussy tropical storm, IMHO. A friend in Houston called and said they only got 2 inches of rain. Where are the broken trees, the blown-off roof tiles? The videos of guys riding their bikes through flooded streets saying "This ain't so bad"? Geez!

Changing It Up

2008-08-03T18:36:00.003-05:00

I suspected that this day would come, but even so I wasn't entirely prepared for it. In discussions with my chief resident about how I was dealing with my patient's death, I blurted out "Oh, I blogged a little bit about how I felt about it, which seemed to help."

Big, huge mistake.

Apparently, the organization where I'm doing my residency sent out a "cease and desist" email last year to resident bloggers, asking/telling them to immediately stop blogging about anything to do with patients or residency. I was forwarded a copy of this email. It would seem that the reason they are concerned is that a blog could be used in court as a medico-legal document. I'd say that is ludicrous, but most of us still remember what happened to Flea.

So now I'm trying to figure out what to do.

I think I'll leave up previous posts written during residency, as they were all written before I'd gotten the word. If you notice something you feel is a HIPAA violation (keeping in mind I try to change personal details and deliberately keep things vague), shoot me an email at tinyshrink77@gmail.com so we can talk about it. I'm afraid I'm going to have to quit writing this blog, though, as I really don't have much of a life outside of residency. Even if I never posted anything about a patient, ever, the email specifically says "and residency". If I were a great cook, or could write discerning article reviews in psychiatry weekly, or had something else interesting to say, it would be different, but I don't.

Partly, though, it made me a little angry. Another resident told me he writes fiction and non-fiction (I'm assuming with the intention of publishing), and he takes similar precautions to change patient data, so if his book were published how is that different from my blog? It could still be used in court, right? Even a diary, if its existence is known, can be admissible in certain cases, so how is that any different? Could a draft of a manuscript be admissible? I think the program took the "just stop it now" step with the intention of examining its policy later, but it doesn't seem that any actual discussion has taken place. If it had, surely they would have made this an official policy instead of just an email, sent out before I joined the organization.

Ugh. I haven't posted since I found out because I didn't know what to say. I'm not in any trouble with my program, and I'd like to keep it that way.

New York Times

2008-07-24T19:51:00.002-05:00

Excellent article about patients dying and how we rush around, not allowing ourselves to react. Sorry about all the death talk, but I'm sure you can understand why this is on my mind. Although, as my fellow psych intern said yesterday, why didn't everyone get upset when my patient died? It's normal to be upset, normal to cry, so why do we push it down so much? I'm so glad she's on the service with me--it would be a lot worse if I had no one there who knows exactly what it's like to be a 3-week intern on a busy neurology service where everyone else has had at least 1 year of medicine.

Everyone Should...

2008-07-24T19:28:00.002-05:00

...go see Batman. Now. Seriously. Heath Ledger was unbelievably amazing--he owned that whole freaking movie. Well worth seeing in the theater, if you haven't already. I hadn't even seen Batman Begins, actually, and I still really, really enjoyed this movie. Sometimes you need a little escape from reality, and this was a good one.

Really Rough

2008-07-22T17:48:00.002-05:00

I didn't blog about all this when it happened because I didn't know what to say. I'm also working very hard to maintain anonymity (for me) and confidentiality (for my patients) on here, so it's difficult to write about things. But here goes. (Read at your own risk--this is not happy).

Friends, I thought I had killed a patient the other day.

It was a totally bizarre situation. I was just thinking to myself that she'd been in the hospital too long, and had been working with case management to get him "placed" out of there. I get nervous when I look at the roster and see that a patient's been in the hospital longer than a week, because complications go up exponentially after a certain period of time (for example, I think the UTI rate with an indwelling Foley is nearly 100% by one week). On the neuro floor, a UTI is not the benign thing it may be in other places, like an outpatient OB/Gyn clinic. On the neuro ward, a UTI can present with altered mental status or even concurrently with stroke, and can lead to sepsis before we even know the patient has a UTI, because often they can't tell us it burns when they pee, because they've had a stroke or they have diabetes and don't feel it or they have a Foley and it hurts all the time anyway.

Anyway, I'd started working on things to get her out, and then I was off part of that weekend, so someone else rounded on her. And I picked her back up Sunday, and none of us noticed that one of her medications had disappeared after Friday. I continued to say in my notes "DVT prophylaxis with subq heparin" without noticing that my med list, which is imported from the actual med list in the computer, did not show heparin. I did not have her on TED hose and SCD's simply because I didn't know you could gain benefit from using those together with heparin (heparin as opposed to LMWH because my attending likes it.) We were working hard to get her out, and we'd found a good place for rehab...

And then one morning I came in to find out there had been errors overnight. She had a vital sign in the range of "notify house officer" that wasn't reported. Cursing that morning, I ordered lab tests and x-rays, but at least she looked okay on exam, in fact slightly better than the day before.

And then her father called us in, because "she didn't look right". I went in, and indeed she did not, breathing fast and sweaty, but still awake, still trying to talk. She was tachypneic and tachycardic, so I ran to get my chief. "She's on heparin, right?" he asked me. "Of course she is, we ordered it," was my reply. Famous last words, as we looked through the med list and caught the omission. I asked the nurses, who called the pharmacy, who finally told us that heparin orders expire automatically 7 days after admission. WTF? No one knew that this was the policy, and I hadn't received a notice in my computer system, nor did the medicine show up in my "expired orders" list. It just vanished.

We got her a dose right away and started workup for PE, but not long afterwards she coded and died. I helped with the code (although I did NOT run it--I left that to a third-year medicine resident, and I did chest compressions like a good little intern), and then left to write some orders for another patient. Sitting there, out of the melee, I burst into tears. It was all my fault! I'd killed her, I was a terrible doctor, only a few weeks into my training! It was the most bone-squeezing gut-wrenching hot burning guilt I've ever experienced. It was totally intense. My attending asked some probing questions about what happened, and I told him about the heparin error. Even though we weren't sure why the patient had coded, as we had no direct evidence of PE, it loomed large in all our minds.

All night, I was miserable. The next day, I went into the autopsy I'd had to request from the parents, and was greeted with some sweet words: "there's no saddle embolus." In fact, there was no PE at all. We are still waiting on a cause of death, but it seems that my error had nothing to do with it.

Now, I'm trying to figure out how to get past this. I check and double-check everyone's DVT prophylaxis orders, and the hospital is going to revise their DVT protocol and oversight. Still, I feel some guilt, as well as just sadness and trauma from the sudden death of a patient I'd seen for over a week, who was supposed to be on her way home.

I spoke to my psych chief resident today, and I just have to say that they are super wonderful. I'll be meeting with them a couple of times to talk about the death, and they helped me with something I need to talk to my neuro chief about--namely, that I haven't been getting proper backup when I'm on call, despite all the rules about doing so. The chief just kept saying "we want you to feel supported through this" and I was so touched I cried (I know, it's shocking, I never cry). I just reread House of God, and Chuck's line at the end has always stuck out to me: "How can we care for patients if'n nobody cares for us?" I'm not sure if it's just my program, or others, but I feel very cared for right now, and really, really glad I'll be switching to psychiatry in January and leaving this crap behind. (Not that patients don't die on psychiatry, but I'll be getting a lot more sleep, that's for sure!)

Who Can Explain It?

2008-07-21T19:17:00.003-05:00

What I want to know is this: why, when you're watching a really boring lecture or Grand Rounds, does the lecturer insist on referring to their boring, overly detailed, under-colored picture/diagram as a "cartoon"? Oddly, the more boring and complicated the slide, the more likely it is to be called a cartoon, as opposed to a diagram, a picture, a schematic, or anything else. It's an inverse proportion.

Seriously, a diagram of a transposon in a lecture about epigenetics? NOT A CARTOON. Unless your diagram is labelled "Transposon? That's what SHE said!", it's NOT A CARTOON. If you need to know what a cartoon looks like, I suggest you look here.

This message is brought to you by the letter "I fell asleep in Grand Rounds today", I mean "A".

What is Call?

2008-07-16T20:12:00.003-05:00

Some clarifications, based on a question I received in comments. Call is defined differently depending on what program you're in, what rotation you're on, and possibly by what country you're in.

Currently, when I say "call" I mean "long call" or "overnight call". I get to my regular weekday shift between 6 and 7 am (right now, usually around 7--we round kinda late). If I'm on call that night, I start carrying the call pager at 4 pm, and I take in all calls for patients in the ER to admit, or consults on medicine patients who have neuro problems, until 7 am. During the week, responsibility for admissions and consults goes to the consult resident; we admit every day on this rotation. On weekends, call starts at 7 am and goes to 7 am the next day.

After I quit taking new consults or admissions at 7 am, I finish any H&P's that aren't complete, write notes for the day, and get ready for morning rounds. We only round on newly admitted or consulted patients, but rounds still take awhile, as both attendings like to lecture--so where's the lesion? What tract of the white matter? What piece of the trigeminal ganglia is affected?

After rounds, I try to finish my notes, put in orders, and be out by noon. The latest I've stayed this month is 12:45 post-call; we didn't finish rounding/lecturing till 11:30 and I still had notes to finish and residents to page about their patients.

The rule is 30 hours straight: 24 hours of taking new patients, and 6 hours to finish up with those patients, but not take on any new patient duties. In actuality, this turns into "the 30 hour rule." If I get to work by 7 am, I should be gone by 1 pm the next day. Thus far, I've been "in compliance" with this rule. (I've also worked 79 hours, which keeps me "in compliance" with the 80 hour rule. No one has asked me to misreport hours, and thus far it hasn't been a problem.)

What different kinds of call are there? I know there are night float situations, long call/short call situations, even a "rolling call" deal on medicine at my program, which I will experience in November, but I have no idea how that works. Any thoughts on different kinds of call? How long are people working? My colleagues in general surgery, who are taking q3 call, have to be working at least 90 hours per week.

Grand Rounds

2008-07-16T20:03:00.002-05:00

Go check out the very entertaining Grand Rounds at Unprotected Text. Of course, it's awesome that my post was included, but it's just well-done over all. Check it out!

Serious Inefficiency

2008-07-14T19:15:00.002-05:00

Last night was a seriously screwy call night, and I only had 4 patients.

What made it so bad?
1) One of my patients was seriously sick. Big, bad stroke, initially not seen to be so large on the CT scan (which aren't very sensitive for acute ischemia, but are mostly used to rule out hemorrhage); after obtaining MRI/MRA and seeing how big it was, and the occluded carotid that likely caused it, we had to transfer him from the neuro floor to the ICU. This was a lot of work and worry, as I was afraid this guy was going to code on my floor with only a few nurses and me to save him. Fortunately, he's still doing okay.
2) Another patient had the possibility of going to medicine or neurology. In order to determine where she'd go, we obtained a stat study. And then I had to help wheel her to the study, wait with her while the contrast went in, wheel her back to the ER, and wait for the radiologist to give me a prelim report. I couldn't get started on her note because I wasn't sure it would require an H&P-titled note or an Inpatient Note-titled note. This makes a difference in the template used in the computer, and it's not terribly easy to cut and paste between the two.
3) Medication reconciliations are impossible to do when the patient doesn't have a list, doesn't have the meds, and does not have the stuff in the computer. Yet, I have violated the "rules" by not completing it until this morning, and could receive another lecture about "being in noncompliance."
4) I had one patient whom I called "my pager magnet". Literally, every time I'd go into his room, my pager would go off. I cleared out 18 pages about halfway through the night, and had received another 5 more before morning. This doesn't count all the repeat pages from my upper level, the neuro floor, and the ER. I'm really not that surprised that his H&P took over 6 hours to complete, as I never received more than about 5 minutes of consecutive exam time.
5) Doing things on the weekend made all of this much more miserable. I needed STAT carotid and vertebral imaging on my big stroke patient. Unfortunately, he was unable to have a CT Angiogram with contrast dye, which is usually the study of choice on the weekend or at night. I attempted for an hour to get him a STAT carotid ultrasound, but was told that a) radiology doesn't do them on the weekend, vascular does and b) vascular had no idea what the hell radiology was talking about. The ultrasound tech from radiology was actually present while I was doing all this futile calling, and could have run the study in less than 30 minuts.
6) Fortunately, the MRI tech came in from home to run a STAT MRI/MRA for us. I had to be present for this study as well, since the tech was by herself.
7) The rest of my night was mostly spent at the phone: returning pages from my anxious upper-level ("do you have that read yet??? I know you said you'd page when you got it, but you haven't paged in 30 minutes!"), returning pages from radiology, me PAGING the poor radiology resident (who was also new), fielding floor pages, consult pages, pages pages all I saw were pages.

I really miss having a text pager. It would be so much nicer if I could receive a text page with "Mr. Y has arrived on the floor" than have to go through the whole interrupting the patient interview I'm doing to find a phone and call back, not knowing whether the page I'm returning is vitally important or totally banal. The pager shows no mercy.

4 down, 2 more to go. Next call is Thursday, and I didn't realize I was still q4 until yesterday. It was awfully hard to keep going yesterday. Thank goodness I'm done with weekend call and will have two full days off this week.

Functioning at the Level of an Intern

2008-07-10T17:54:00.003-05:00

A few of my med student rotation evals commented that I was "functioning at the level of an intern." Now that I'm an intern, I'm calling bullshit. There's just no comparison between being a medical student doing an inpatient rotation or a subinternship and actually being an intern. I predicted back in January that I really had no idea what it was going to be like, and I'm learning that I was entirely correct (and I called this, too).

As a medical student, I carried a pager, but I received fewer than 3 pages per day on average. Often, they were just from other med students, telling me we were rounding or asking if there was food.
As an intern, I am currently carrying 2 pagers (and I haven't yet been assigned a personal pager, but I'm trying to put that off as long as possible). When one goes off, I often can't tell which pager is beeping, so I usually check them both. One week in, and I hate being paged more going to the dentist. I'm developing a visible twitch and am prone to cursing outbursts when I get paged with my hands full or in the bathroom--perhaps I have Tourette's.
As a medical student, I was able to see all my patients, write beautiful H&P's and progress notes, keep track of my patients' to do lists, help my residents, and even read up on issues (gasp--learning!). Without sounding too conceited (I hope), I can say that I was a pretty good medical student.
As an intern, I feel like I barely have time to see my patients and put in their notes. When I get them in, I find myself making errors that I would have pointed out as a student. Patient A didn't get put on DVT prophylaxis. Patient B is on a zillion anti-cholinergic meds and is confused (not ordered by me, but not discovered initially). In completing Patient C's negative workup for stroke, we discovered a past medical history totally unknown to me (and indeed, the rest of the team) that actually explains his symptoms better. I forgot to order Patient D's nebs, until I listened to their chest this morning and thought Oh geez, they sound like junk. The errors are multifactorial: I'm new, the team is new, I don't know the computer system, half the time I didn't admit the patients and the error began in their admit orders, I just didn't catch it, I'm exhausted, etc. I feel responsible for it all, though, which I have to watch out for. It's useful to be responsible for my patients and be thorough, and learn from my mistakes; it's not useful to get so upset about minor things that I get flustered and forget big things.
As a medical student, I could get the history and physical and defer all questions of workup or treatment to the doctors.
As an intern, I AM one of the doctors, and it sounds weirder to say I'll have to go talk to the OTHER doctors first. It's like I'm saying, I'll go talk to your REAL doctor. I'm only pretending.

Other weird things:

I often find myself prescribing things to patients I don't know when I'm on call. I field questions like Mr. G has constipation, Mr. X has nasal allergies, Mr. Y is on heparin drip and has a PTT of 75, should I bolus? It's totally bizarre to me. If my husband asked me for medication for allergies, he can go to the medicine cabinet or the store and get it himself. In the hospital, we take that away from patients, and they're totally dependent upon those of us with those magical "MD" initials that give us control of their allergy medicine, Tylenol or Advil for headache, and the all-important constipation meds.

I gripe about the constipation thing, but actually, every patient in the hospital is likely to have trouble going poo. Hospital food isn't well-known for its high fiber and whole grain content, we put patients in bed and restrict their fluid intake, and tell them they can't get up to walk without assistance, lest they fall and break a hip. All of these factors = no poo. Honestly, if I were doing a better job of prevention with stool softeners and ambulation orders, I might have fewer problems with this. What I just find truly odd is that these pages are so frequently timed at 2-3 am. Seriously, I have never been so constipated that it woke me from sleep in the middle of the night. (Now, if they have insomnia, AND coincidentally feel constipated, that I can fix). I can give medication for constipation, but unless I write for an enema it's not going to magically produce poop within minutes. I still think that unless the patient is having pain, or is post-op from belly surgery, there's no reason for the 3 am constipation page, so long as the patient is clinically fine.

Also, this morning I got a page at 6:30 am for ordering air mattresses for two patients. Again, this was for patients whom I didn't know, and the page came in on the call pager, causing me a brief heart attack as I woke up and imagined a tPA candidate in the ER. I helped take care of it, and I was as nice as I can be when I'm awakened (I would have been getting up within about 5 minutes anyway), but I just have to wonder--isn't this an issue that is better taken care of during the day? It's not like the air mattress people are going to arrive any earlier than 8 or 9 am to examine their consult requests. No, I'm not bitter. At all.

I told my dad earlier, being an intern is a very odd combination of having supreme responsibility and having no responsibility (where being a med student, you really have few responsibilities). On the one hand, all my plans come straight from an upper level. I don't know diddly squat, other than to say "uh, stroke labs and an MRI?" On the other hand, I get paged about heparin drips and people seizing and I'm responsible for making spur of the moment treatment decisions, often with no warning. Do I give Ativan to the guy seizing in the EMU, even though his seizure is over and he's off his seizure meds so that they might record his seizures? Do we give the heparin bolus prescribed by the protocol, or do we leave it alone on the drip? I make these decisions all night and I have no idea if I've made the right decision. I just try to use common sense (what little I have).

I'm down 3 calls, 3 left to go. I'm so glad that after Sunday, my calls start spacing out further, because I'm effing tired. In fact, I'm going to bed.

Sanity vs Insanity, Part II

2008-07-08T20:24:00.003-05:00

During our lecture today, we spent a long time discussing the paper I wrote about yesterday. It was a great discussion, led by an instructor who's obviously used this paper to teach his points for years. I'll see if I can recap a few of the different views I now have about the paper.

1) (This analogy was given by the instructor) If you were to walk into a neurologist's office and complain of crushing, throbbing unilateral headaches accompanied by photophobia and phonophobia, and you were to be admitted to a hospital for workup, at the end of which they found nothing wrong with you, and you had no headaches in the hospital (and indeed, never had headaches), wouldn't their diagnosis still be migraine? And if they found you out to be lying in the first place, wouldn't their diagnosis be malingering? So, if you come to a psych ward and lie about your symptoms to get in, then have no more symptoms inside, you are actually technically meet a diagnosis of malingering. Therefore, instead of "sanity versus insanity", what we're actually having a tough time diagnosing is "psychosis versus malingering", which apparently is true. It's pretty easy to fake psychiatric symptoms (Oh, I'm hearing the voices now!) and then when you get what you want, not hear them anymore. I worked on a "forensic unit" in a psych hospital, which accepted patients from the local jail. It was amazing how many of them heard voices in jail, but not in the hospital, at least not until the night before they were to be discharged.

2) The study really isn't very rigorously scientific. It is, however, a fascinating social experiment, which I think still renders it valid. It also gives us fascinating insights into the treatment of patients within a psych hospital, which were some of the most appalling points of the paper.

3) Today, you would not likely be admitted just for saying "I hear voices." 35 years ago, the diagnostic criteria for schizophrenia were much broader. I'm still not sure why that symptom alone was enough to get all these people admitted--a patient needs to be unable to take care of themselves, or decompensating rapidly, or a danger to self or others usually to be admitted like that. Maybe that's a difference with time? I'm not sure.

4) The author's claim that the pseudopatients acted "normal" in the psych ward wasn't entirely true. They never told the doctors they'd lied, they never told anyone they were in an experiment, etc. As far as the doctors and staff knew, these patients had honestly heard voices (eg, exhibited psychotic symptoms) and were currently asymptomatic. The doctors weren't given all the information, and certainly psychotic patients can hear voices one day and not the next.

5) Finally, the author's conclusion was essentially that the category of insanity is bogus because we can't reliably tell it apart from sanity (although he really meant we can't tell psychotic from non-psychotic). Is hypertension a bogus diagnosis, even though you might get a reading that is 135/85 and some books say "normal" and others say "pre-hypertension" and others say "hypertension", and some authorities urge you to treat it and others say don't worry? (I exaggerate in this example, but you get the point.) I personally think, and thought yesterday, that he's throwing the baby out with the bathwater, so to speak. Perhaps it's easier to recognize abnormal, maladaptive behavior in the "sane" world than vice versa, but this is the world most of us live in, where such behavior gets us in trouble.

The important take home points of the article, according to the instructor (and I touched on this briefly yesterday, but not in a very organized fashion):

1) It's very important to have reliable categories of diagnostic criteria that lead to valid predictors of outcome (which was the point of the lecture).

2) The second experiment, where the doctors rated whom they believed to be pseudopatients, likely shows either a high rate of malingering patients or a high rate of very high-functioning patients (or both) who weren't particularly bothered by their symptoms, although that begs the question why were they in a psych hospital.

3) The way patients were treated by staff was a valid observation by the pseudopatients. They were able to take detailed notes without anyone caring, because they were believed to be crazy. They were able to document abuse by staff of some of the patients, when said abuse would stop when physicians entered the unit, because they were not "credible witnesses"--after all, who'd believe a psych patient? They also experienced the depersonalization that happens on a psych ward--there's little to do but watch TV and wait for meals, you're not in your own clothes, you can't go to the bathroom in peace because there's often no door, you can't have your own belongings with you, and your room and personal items may be searched at any time. Also, the segregation of staff and patients holds true today, for sure. Most of us get a little prickle of fear the first time we walk into a locked psych ward. After all, if we lock them in, these guys must be dangerous! But how, then, do we strike a balance between keeping the patients safe (and keeping those few patients who are dangerous safe) and allowing personal freedom and rights?

It may sound like a non sequitur, but I'd like to conclude with an observation I made in China in a locked psych ward. The air was fresh, because small windows were open to allow air circulation. I'm not sure if the building had central air conditioning, as the majority of buildings in Beijing did not. It was just so refreshing to enter various hospitals and find open windows allowing in fresh air. In America, I doubt there's more than a handful of psych hospitals that have windows which open. As a result, the air quality on most psych wards is ridiculously stale--rather like the jail I worked in last year on OB. The air in this Beijing psych ward was fresh (or as fresh as air in Beijing ever is!) Perhaps one small difference we could make for our patients is a little fresh air. After all, they're not inmates (usually), they're just people with problems that they wear on the outside where everyone can see them, as opposed to inside.

Sane in Insane Places

2008-07-07T20:36:00.003-05:00

I have my first set of psychiatry didactics tomorrow, called "seminars" at this institution. I've been having trouble with my email, so today I finally received the reading material for tomorrow's talks. Some of it was pretty dry, but buried in the PDF's was an article which I'd imagine is required reading for all psychiatry residents (and if it's not, it should be):

On Being Sane in Insane Places
D. L. Rosenhan
[Science 1973;179:250–258]

35 years ago, this author posed the question, would psychiatrists recognize normal? We all think we can recognize abnormal out in the land of the normal, but would we see normal in the land of the abnormal? To answer his question, he and seven other volunteers became "pseudopatients": they "snuck" into psychiatric hospitals, using the key phrase "I'm hearing voices", and then tried to convince the staff they were sane to be let out. Other than the voices, none of the 8 fabricated symptoms or history; they told their own stories. (None of the pseudoopatients had any psychiatric diagnoses, and all were highly educated, high-functioning members of society). Once inside, they said "I'm fine, I have no symptoms anymore" and behaved as they would in any other situation.

So what happened to the pseudopatients? Did psychiatry recognize normal?

It turns out, some people were very good at detecting the sane: the insane. Or at least, the hospitalized patients in the psychiatric hospitals. Pseudopatients were often questioned as to whether they were journalists or professors (they took notes on the wards), but only by patients. Psychiatrists, nurses, and staff never questioned the admitting diagnosis of schizophrenia; even behavior that was normal was seen as pathological. If the patient was seen writing, it was "patient is engaging in writing behavior". When patients were discharged, they were diagnosed with "schizophrenia, in remission".

One hospital, hearing of the results, took offense. That could never happen here, they said. So a second experiment was arranged. The hospital was warned that in the next 3 months, one or more pseudopatients would be sent to try to gain admission. Psychiatrists and staff were asked to evaluate every patient on the ward and presented for admission, to see whether they might be faking their symptoms. Of 193 patients evaluated, 41 were suspected strongly by 1 psychiatrist of being fakers; 19 were suspected by 1 psychiatrist AND 1 staff. In fact, the author did not send any pseudopatients within the three months.

The author hypothesizes that barriers to recognizing sanity were multiple. 1) In medicine we prefer false positives to false negatives; it's better to overdiagnose cancer than underdiagnose it. He believes that this should not be true in psychiatry, because 2) Psychiatric diagnoses carry stigma, even among mental health professionals. He presented multiple studies of people treating others very differently in the psych ward than out in public. 3) The multi-tiered structure on the psych ward keeps psychiatrists, with the most training, furthest from the patients, and staff, with the least training, closest to patients. 4) All staff is somewhat segregated from the patient populations, hiding out in glass "cages" (in other hospitals I've been in, they're called the "control towers"). Interaction with patients is limited. 5) Not many mental health professionals recognize the dehumanizing forces at play within a psych ward. He makes the obvious next step: if these "sane" people went undetected, then how many "sane" people are even now locked into psych wards, saddled with diagnoses that will keep them labelled for life?

I had many feelings about this article. First, I was rather amused that the author pulled this off, and showed up the doubting hospital. Second, I was horrified that this used to happen. Third, I was appalled that this probably still happens every day. Fourth, I vowed to reread this article frequently during my training, lest I forget.

I will say that in my experience last year, we admitted several patients to the pediatric ward at the insistence of parents/law enforcement, etc, only to discharge them the next day or within 2 days because they were fine. Often our history at admission was from the parent or other family; even when it conflicted with the patient's words, sometimes the kid would get admitted anyway (especially if a warrant was involved). Then, with the parents out of the room, we could usually get a good story of what was going on. So, why did we believe the parents more than the kid? Was it the fact that a kid is a minor, and the parent is in charge? Or was it that the kid was accused of being a psych patient, and therefore we didn't trust their story initially? I'm not sure.

This article is over 30 years old, and I hope that things have improved dramatically. I also hope I can help things continue to improve. I'm a little unsettled, though, which is an odd place to be the night before I start attending lectures in this field. I will take hope from the fact that I'll be receiving lectures from an attending discerning enough to have us read this article in the first place.

Added 7/8 at 2054: I just posted a sequel to this post, written after my lecture today on this article. Check it out here.

Fifth of July

2008-07-06T15:38:00.004-05:00

Last night, I had a moderately bad call night. I say moderately, because it could have been worse (that's the mantra for this rotation--it could always be worse.) All day, I was slammed with pages for consults from the ER and the floor, and was trying to wade through them with the help of the team's chief. He's a little ADHD, so when I try to ask him about management it is often a few minutes before he remembers that I asked a question in the first place.

Add to this the craziness that is the Fifth of July in the ER. Everyone gets sick on the Fourth, but no one wants to miss out on the barbecue and fireworks, so they wait to come in on the Fifth. Every service was slammed--medicine had a ton of MI's and rule-out-MI's, one of my fellow psych interns was totally overloaded with people driven crazy by fireworks, booze, and other substances external and internal, and neurology had the joy of receiving consults from a totally worthless PA. Seriously, dude, "sleepy" or "drowsy" does not equal "stroke" or "other neurologic condition." Especially when you ask me to see the patient BEFORE obtaining any labs to rule out metabolic or pharmacologic causes of drowsiness/confusion. Now, if you don't know HOW to work up drowsiness, then fine, make that your consult question, but don't just say "well, it might be neurological" when you don't even know whether the patient is high as a kite, dehydrated from the fine jungle summer weather, has a raging sepsis, or is just drunk. GRR!

Other than that, we were just plain busy. We had patients with dizziness, we had patients with sleepiness, we had seizures and strokes and hallucination/seizure/nightmare/flashbacks-induced-by-loud-fireworks. I'd staggered to the call room praying for some sleep, but received a page probably 30 minutes after falling asleep, so I was extra-groggy for that one. And immediately after writing down that first mid-night consult, I got a page for another. And a page from the floor for a fever, could I write the patient some PR Tylenol instead of PO? I dragged myself downstairs to see the patients, anticipating the long neurological exams I'd have to conduct and dreading them (I just don't enjoy the neuro exam).

This morning, after handing off the call pager, I would start twitching every time it went off, forgetting I wasn't wearing it anymore. I'm going to join my PTSD patients before long. Not to mention I was having word-finding difficulties, left-right confusion, memory loss, and disorientation to place (couldn't find elevator) this morning, putting me right on par with most of my stroke patients.

But the thing that made it all suck, the thing that nearly broke me last night...

THE VENDING MACHINES ONLY CARRY PEPSI PRODUCTS.

No Coke, no Dr. Pepper, only Pepsi. I tried to buy a bottle of water from several machines, but they were all broken. I gave in and tried to buy a can of Pepsi, but the machine was "sold out" and refused to give me back my $0.75, so I ended up drinking Mountain Dew. Which I hate, but it was better than root beer (which I despise). It gave me tachycardia, which made it hard to sleep even when I went to bed. (I could have just gone thirsty, but I was really, really thirsty. Trust me.)

I'm a southern girl. I use the word "Coke" to describe all soft drinks in general, and then name the specific drink I want. Not "soda", not "soft drink", not "cola", but "Coke." It is just not right that every single freaking vending machine in this hospital is Pepsi.

This morning, bleary-eyed, I poked my head in the back door of the cafeteria. The lady said they didn't open till 8, and I nearly cried I was so tired. (Not drinking coffee is not so handy sometimes.) She took pity on me and let me sneak in and pay her cash for a Coke from the fountain.

It was delicious.

Primer Noctem

2008-07-03T16:50:00.003-05:00

So last night was my first call as an intern. I survived, and it really wasn't that bad, thank god.

Things that happened overnight:

At one point, my upper-level gave me a pack of "brownie bites". I was walking down the hallway with the pack, and at some point I realized that it was not closed, like I thought it was. I was dropping little brown squares, like a trail of bread crumbs, from the ER back to the neuro callroom. And from a distance, they did not look like brownies. Heh.
Raise your hand if you've ever in your whole life been so constipated that at 3 am you feel the need to call out for help. Anyone who wasn't a post-op abdominal surgery patient? Anyone? Anyone? Bueller? Yes, I got that page at 3 am. The nurse had tried to use the PRN meds ordered, but the patient refused. He wanted some "lemon-tasting stuff" he'd had in the past. The nurse decided that equalled mag citrate and asked me to order it in the computer. I complied, and figured that he probably knew what he was in for, or at least hoped I wouldn't get called to clean up the mess.
I got paged in the ER while I was on the phone trying to call someone else. As I was trying to juggle the phone and check the pager, the pager slipped out of my hands and fell straight into a styrofoam cup of coffee on the counter. Ker-Splash! Coffee went everywhere, including my brand new white coat, the phone, and a nursing note. A nurse grabbed a towel and started mopping it all up while I was still trying to talk to the doctor on the phone. The call pager ended up smelling pleasantly of coffee for the rest of the night. Sadly, it continued to work.
After dropping the pager, I cursed (after I hung up the phone). The nurse next to me started to laugh, because my patient's wife was standing not too far away (I didn't know who she was) and SHE started to laugh. I apologized to her repeatedly for my unprofessional behavior--I make it a point not to cuss in front of patients, and I was more than a little embarrassed. She thought it was hilarious.
It is possible to have close to 5 hours' sleep on call (or at least, that's how long I was in the call room) and still feel exhausted in the morning. I'm not complaining about getting sleep on call--the girl on the night before didn't even get to go FIND the call room--but there's something less than refreshing about sleeping in your dirty scrubs with 4 different alarms set (I'm notorious for sleeping in) and getting paged all night.
I ran into a fellow psych intern who was taking psych call. She had been having a slow evening, but was praying the suicide pager wouldn't go off. I'd forgotten that in 6 months, I'll have to carry that same pager, and I'll absolutely pray it never goes off. Or that whomever it goes off for is not ACTUALLY committing suicide, but just needs someone to talk to. *shudder*
I discovered that there is a wireless internet connection (or is it Bluetooth?) between my pager and my ass. As in, the moment my ass connected with a toilet seat, the pager went off.
Finally, I'm only one call into the month (5 more to go) and I'm convinced that pagers are the spawn of the devil. They are truly instruments of pure evil and must be destroyed.

I'm on call again Saturday, because we swapped some stuff on the schedule. It makes the next few days suck, but my last call will be nearly 2 weeks before the end of the rotation. Thank goodness I'm off for the Fourth! Have a happy holiday!

I Almost Forgot

2008-07-02T05:20:00.002-05:00

Two tales from yesterday.

1) We went in a patient's room and needed to turn off the TV so we could hear ourselves talk. The TV's are mounted on the wall right up by the ceiling. I looked up and figured I wouldn't be able to reach it, but then my attending looked over at me and asked me to turn it off. I stood on my tiptoes and pressed the button with a pen held in my hand--it was that high for me. The attending busted out laughing, laced his hands together, and offered to give me a boost.

2) That first order I signed yesterday? The social worker walked me through every step and dictated to me what I should write. I also signed an order for a wheelchair that PT put in the computer for me. Really, I did very little on my own yesterday, which was kind of a relief.

First Day

2008-07-01T20:01:00.003-05:00

First off, I think everyone should read this post at Mothers in Medicine: "Cry". As a person who cries very easily, with pretty much every major emotion (happy/sad/mad), I can really relate to this post. I have come to see my teariness as just a part of me, not a weakness or a problem. It can be inconvenient, like when my patient died on ICU and after I'd done compressions and been relieved of duty, I found myself with nothing to distract me, so I ended up crying in the bathroom. And then rounding for the rest of the day with the pathognomonic red eyes and nose.

_________________________________________

Today was my first day as "Dr. TS." I actually answered a phone that way once, and I did not refer to myself as a med student all day (although I did look up when someone else said "Students?"). I totally freaked out when I wrote my first order in the computer; it popped up, I signed it electronically, and it showed up with MY name on it as provider. OMG!!!!!!! I turned bright red and announced to the room, "That was my first order!" I have hereby saved the world, people, because my first order was a referral to outpatient physical rehabilitation. WHOA!

Seriously, I flipped out.

A third year med student looked at me with envy. "I can't wait to do that! Is it awesome to wear a long white coat?"

I told him the truth: "It's scary as hell."

And I kept looking down at my legs all day, wondering what the hell was flapping against my shins?

It was totally bizarre, I must admit. Tomorrow night: First Call!

Good luck to all my fellow new interns, whether they've started already or are still waiting. We'll get to the good stuff eventually. For now, it's learning how to write Colace orders.

Finally Got My Call Schedule

2008-06-28T20:27:00.002-05:00

Yes, I just got the schedule today, Saturday, and the rotation starts on Tuesday. What? That's not normal?

Fortunately, it's not such a bad call schedule. I'm on call the first time Wednesday, July 2, so if you're having a stroke and you come see me, please ask me to call my upper-level resident STAT. After that, I get the long weekend off (WOO!), and I have one Sunday and one Saturday call in the month, with the rest of the weekends off. All in all, 6 calls for July, which is better than the q4 I was anticipating.

My friends and I have been sending each other emails about what we're up to now. Most everyone else has already started their various rotations. One is in a clinic where an attending told him to "just do the usual for the patients, you know, write your assessment, write the prescriptions, here's my sticker". He's in his first week of real doctoring. Another is in a cardiac care unit, where he has already learned how to deny morphine to the "chest pain" patient who has ruled out for MI (and had other signs they were seeking). Still another is doing a medicine rotation and had to call a code on a patient the other night when they were pulseless and apneic (the patient, not the intern). A life was saved, so that the patient might go back to taking cocaine (which likely caused the MI in the first place).

In other words, they're out there in the big world of American medicine. Take pity on your young-looking doctors these next few months. If they're nervous, tell them to relax. If you're the patient, and you're nervous, remember that these fresh interns are heavily observed (usually) by the more-experienced.

And if you see a very small intern on a neurology service, and she says "Hi, I'm TS, your medical student, I mean your doctor", well, you still might want to be a little nervous. Because I hate neuro.

Disorienting Orientation

2008-06-25T21:03:00.002-05:00

Is it just me, or is the word "orientation" completely abused nowadays? It seems like it should be applied to a process which helps you know where you are, keeps you from getting lost, puts your head back on your shoulders and find your way around. Right?

The problem is this: has anyone EVER been actually oriented during a session called "orientation"?

Yesterday, I went to the program's session, where we received a very thick binder full of papers. During the course of the morning, various people filed in and added even MORE papers, including some we'd already been emailed (and so, of course, your OCD-highness here had already printed them out). Statements in the binder conflicted with the verbal statements of the program directors on very important subjects, like parking, so much time was lost in working out the nitty gritty details of parking at multiple different clinical sites (how much does it cost per day? per month? will I be reimbursed? how far will I have to walk to the site?--etc.)

Today's was far worse. We arrived at the Very Large Hospital and eventually found the conference room (helpfully titled "6B-183", but located on the 6C wing), only to find that none of the people orienting us were present (and I was 10 minutes late, due to an alarm clock malfunction and lack of parking spots). We spent awhile filling out paperwork, then were led to a 3 hour computer orientation on the very-complicated EMR system. (On the way to the computer lab, our leader, who WORKS IN THIS HOSPITAL, got lost. And when she asked for directions, two different employees had no idea what she was asking about. This does not bode well for me--I have zero sense of direction indoors). The computer session was awful. The woman leading it had a mild speech impediment, yet spoke rapidly. I would look at my screen for 5 seconds, look up, and she'd be on a whole new window, but I'd have no idea what she'd clicked to get there. About an hour and a half in, I gave up and surfed the Web (conveniently NOT restricted on that computer) until it was over.

Lunch was yet another boxed sandwich meal. I don't mind them, but honestly, why would you put tuna and chicken salad sandwiches on a catering menu? You know those sandwiches were delivered up to an hour or so before we got to eat them, and who knows how hot the delivery driver's car was (it was in the 90's here today). I ate warm chicken salad until I couldn't stand it (it also had pineapples or somesuch in it--yech), and then survived on potato chips and a granola bar until dinner. Nothing like a little warm mayonnaise to breed a little staph food poisoning.

After lunch, the real crap started. The lady led four of us to Human Resources to get our badges. We signed in and proceeded to wait. Eventually, the rest of the group came into HR, but we original four were still waiting. Now there were 15 or so of our group, plus other new residents who were there before us, all crammed into a tiny waiting room with about 6 chairs. They started calling us out one at a time. I went, and found that one woman, by herself, had to verify ID, fill out the form, take my fingerprints (twice), take my picture, upload the picture, copy my documents, and lead me to the exit. It took her about 10 minutes to complete my paperwork (and she wasn't lollygagging, either). I then had to go to another office where they actually printed my badge; the whole thing took me an hour, and I was the first done. They scheduled our group to finish this in 2 hours.

After waiting for another hour, our lady came in with some forms to sign and get notarized, and then we waited some more. I tried to go get my parking decal, but the office closed at 3:30 (we went at 3:39). Eventually, our last (and reasonably important) lecture started late and ran long (naturally), and I spent what was probably the most important time of the day trying not to fall asleep or let my stomach growl too loud.

Tomorrow, I have stuff in the morning, then a break of several hours, then more stuff from 3:30 pm on. Our schedule says "dinner" (another box, from the looks of it), with no end time given, so for all I know I'll be in the Very Large Hospital all night. I'll have to try to go get my PPD read, since the occupational health people aren't going to take my word for it that it's flat without erythema. One of my classmates said "Well you know, MD, you need that LVN to read that PPD." (My med school's clinic just let us call in with the results if it was negative, hence the confusion).

At this point, I have one ID badge (out of 3 I need), 0 passwords/logins (out of 3 I need), 0 pagers (out of 1 needed--I'm not in a hurry for this) and I have not seen my call schedule for July because apparently the neuro department is known for not getting it done until 2-3 days before the month starts.

So now I've finished my little temper tantrum, and I've finished compulsively typing in the entire year's lecture schedule into Outlook, so I think it's time for bed. I'm still reading The Devil in the White City, which is really interesting and more than a little creepy. Nighty night from a tired, cranky TS.

Shrink Rap Grand Rounds

2008-06-24T16:29:00.004-05:00

I think everyone should go to Shrink Rap and read their amazing Grand Rounds right now. Or at least, go over there and look at their awesome rendition of the new iPhone 3G. They even put my icon on there!

My Grand Rounds post is here.

The image above is from the Apple website and is their property.

Windows Vista Sucks

2008-06-23T23:09:00.003-05:00

I have gotten that error message "Windows Explorer is not responding" twice today, which necessitates either restarting Windows Explorer or just turning off and turning on the computer. Also, I have plugged in a printer so I could print orientation materials. At first, it worked very well. Later, I tried to print a Word document, and it wouldn't print. The little print icon told me that it was printing, but it wasn't. I tried to cancel the document and resend it--nothing. Eventually, I turned off the computer, and turned it back on, and the document printed twice (great).

I just tried to print another document for tomorrow--nothing. Then, when I tried to close the document folder it was located in--"Windows Explorer is not responding."

GOOD GRIEF! I'm not playing large PC games, I'm not listening to music, I'm not doing ANYTHING but surfing the web on Firefox and trying to print a friggin' Word document! That's it! What the hell is wrong with the computer and/or this OS? This is a BRAND NEW LAPTOP. IT SHOULD NOT BE RUNNING WORSE THAN THE 4-YEAR-OLD LAPTOP IT REPLACED.

I miss XP.

Dilettante

2008-06-22T12:59:00.002-05:00

From Merriam Webster:
"Main Entry: dil·et·tante
Pronunciation: \ˈdi-lə-ˌtänt, -ˌtant; ˌdi-lə-ˈ\
Function: noun

1 : an admirer or lover of the arts
2 : a person having a superficial interest in an art or a branch of knowledge : dabbler"

And that second definition fits me like a glove. In my personal life, I have many hobbies and/or things I like to do, but I am a jack-of-all-trades and am truly a master of none. I got to thinking about this the other day and I made a list of all my various hobbies/interests. I was astonished at how long it was.

Singing: I haven't had any instruction in singing since I started college and quit going to church. Looking back, choir was the only part of church that I truly enjoyed all the time. Now, my only singing is in the car or while playing Rock Band. I'd love to take voice lessons and maybe find a choral group to join, because I miss singing with a passion.
Playing trumpet: I haven't played my trumpet since second year of med school. At this point, I couldn't join a group, it's been so long since I played. Sad.
Playing Rock Band (drums and vocals): I do love me some Rock Band. Unfortunately, I don't play often enough to actually be any good at the drums, despite my occasional daydreams of becoming a drum goddess and touring with Metallica.
Dancing: I took ballet, tap, and jazz lessons for most of my childhood (nine years, in fact). I had to quit when I started band, because of time and money constraints. I miss it. I've picked up a little salsa here and there, but it's a rather useless skill if I'm out dancing with my hubby, because he doesn't really know how. (Well, he can do the merengue, if he counts...) I don't really know how to teach him, and whenever we dance I end up leading (and counting for him). I'd really like to take salsa or ballroom lessons with him, or even take tap lessons again. Now, though, I have my own time and money constraints.
Working out: I was working out like a fiend toward the end of fourth year, and lost 10 lbs, which made me extremely happy. Even better, I found myself able to jog a bit on the treadmill WITHOUT a heartrate of 200+, blue lips, or painful gasping breaths. My total cholesterol was down in the 170's last time I checked it. I was seeing results. And then I graduated, and had to turn in my student ID that got me in the gym. Now, I'm debating whether to pay for a membership for a gym near the hospital (cheaper), or a gym near my house (more expensive), and so for the past month my butt has grown roots into the couch. I've kept the 10 lbs off for now by mowing the yard and Krav, but I'm deathly afraid it's going to come back.
Krav Maga: I had started taking Krav lessons with my husband after I came back from China. It's a form of martial arts started by the Israelis. I'm not great at it, but I'm a rank n00b. However, it costs $90/month and we get too busy to go NOW. I'm cancelling my membership after June, because there's no way I'm going to be LESS busy while taking q4 call and working ("no more than") 80 hours per week.
Biking: My husband and I just bought nice road/hybrid bicycles. I'd love to be a good rider, and I also like to use it to make small grocery runs when I don't want to take the car. Now if I could just find the time to ride, and if only it weren't 100 degrees & 90% humidity outside...
Crochet: I learned how to do this when I was eight and bored at daycare. I can still make the occasional baby blanket (oh geez, I have several to make!), but it hurts my wrist unless I wear a brace. This is one skill I am actually pretty good at, without any further instruction needed.
Painting: This is not something I am good at, but I decided I wanted to paint some "wall art" for our new house. It's... interesting. I'm sure someone will make a comment about their three-year-old's fingerpainting when they view it. However, I've barely done one, and I have several to go.
Making jewelry: Something I randomly picked up third year for no apparent reason. And really haven't done since.
Gardening: I haven't planted anything new at our house, because the front was already landscaped and everything else was sod. However, I plan to have an herb and vegetable garden in the future. If my thumb isn't so black anymore, that is.
Cooking: When I want to cook, have time to cook, and have bought the ingredients, I'm not a bad cook. I make a mean lasagna, for example. I'm always buying new spices or ingredients to try out, that then languish in my pantry. We eat out a lot. But just when I think "I'm not so bad a cook", I read TBTAM, and her recipes make me cringe with fear, because they are so complicated. I want to be able to throw together a lovely, tasty meal in 10 minutes using only what I have on hand, no more than 5 ingredients, and have it be low-fat, low-cal, and amazing. Oh, and I want the dishes to do themselves. Is that too much to ask?
Reading: Another skill I don't need more practice at. I am an extremely fast reader, probably a) genetically and b) because I read all the time. My med school colleagues (at least those in my half of the alphabet) used to get really hacked at me because I'd finish exams so fast. I didn't usually tell them I'd gone through it twice before I left. I finished Genghis Khan and am now reading The Devil in the White City, as well as having read (entirely) several new blogs.
Blogging: Heh. I want to be a super-blogger, one with thousands of readers. But when I read the super-blogs, I get really discouraged. I don't write often enough (or well enough, let's be honest) to be one of the big boys. I'm not sure how so many busy physicians and residents find the time to write so much, but I'm just not that good. I'm happy that I've kept writing here, because I've saved memories in these pages for myself. I also love writing (I was once told I was good at that, too--you'd never think it to read the drivel I post here). I may just have to become a super-blog-reader, and leave it at that.

So why am I worried about this now? I'm trying to figure out why I'm spread in so many different directions, and what I can do about it. I think I just want to do too much stuff. I feel the rush of getting ready to start residency (oops, orientation starts tomorrow), and feel like I have to do everything NOW. Of course, that usually ends with me on my bum on the couch reading medblogs, which is marginally better than curled up in a closet in fetal position sucking my thumb. I also feel intense pressure to be a whole person, a good person, outside of medicine. Medicine is my calling, and I'm passionate about it, but I don't want to be that person all the time. It's only part of who I am, and I'm a little ashamed that the rest of me is so splintered and unfocused. I'd like to be really good at something other than medicine. I'm not sure which of my little hobbies (if any) will provide what I need, so I guess I'm afraid to commit fully to any of them.

I use the "I have no time" excuse a lot, especially when I'm working hard. Well, guess what? I'm NEVER going to be totally "unbusy", now that this month is gone. And look what I did with a month off--not a damn thing. It's time to buckle down and pick something to do and spend some time doing it, even if it's only a little bit. Money is going to be less of an issue now that we're going to be a two-income household, so long as I don't go totally nuts (or make my new hobby shopping--I do too much of that as it is).

But what'll I do? I'm not sure yet which of my little hobbies is worth my precious time outside of the hospital on a q4 call month. I guess we'll find out soon enough.

EP Has Done It Again

2008-06-19T09:45:00.009-05:00

Today's Empowered Patient on CNN.com has really "chapped my hide" (as an old salsa commercial used to say). Today, she has gone for the vaccines. She even titles the article with a question: "Should I Vaccinate My Baby?" LIKE IT'S REALLY AN OPTION!

Ahem. Must... not... throttle... aweraerfd... must try to write rationally...

Okay, so here's what I think of her article: it sucks. It teeters on the edge of inflammatory journalism to bring bad information to worried parents. AND, she never actually answers the question she poses in the title.

As always, we start off with a story. The worried parent who wants to change up the vaccine schedule for her kiddoes, even though her first child received them all on time and was fine. Did you read that right? Yes, her first child was fine, and didn't die of measles and wasn't crippled by polio. Yet, she decided she wanted to change it up for kids #2 and #3.

Then, a quote from the enemy: the doctor. He says he'll work with a parent to change up a vaccine schedule, even if he disagrees. He then says "I share with them what I know, but ultimately, it's the parent's decision." In other words, he shares the science of vaccines with them, and they still choose to go against. Sadly, this is not the point Ms. Cohen is trying to make.

Then, she lists five changes that some pediatricians and families might be making (right now!) to the vaccine schedule. She even specifically says she is not going to address the pros and cons to each approach, or touch the autism/vaccine debate. In other words, this is what people are doing, but we have no idea why.

#1. "Delaying the first hepatitis B shot". Since the first Hep B is given prior to discharge from the hospital, some doctors find this ludicrous, as babies aren't having unprotected sex or injecting drugs, so they'll delay this shot till the baby is two months old. Since, according to the CDC vaccine schedule, the child is supposed to receive the second Hep B at 2 months, I'm not sure when they'll then receive dose 2.

Also, kids who are household contacts of people infected with Hep B are also at risk. Just because mom didn't have it doesn't mean someone else couldn't. I'm really not opposed to Hep B at birth.

#2. "Not doing some shots at all". Since some diseases aren't as scary as others, some parents opt out of certain shots. The parent interviewed in the article opted out of the rotavirus vaccine and the chicken pox vaccine. Now, I've heard the argument for skipping the chicken pox vaccine before--"well, I had it, and I was fine." True. I had chicken pox at 3 years old and I did fine. However, there are currently several problems with this scheme. First, it's harder to find kids who have the chicken pox in order to get your kid exposed to get it. Therefore, your kid is going to be older when they get it, and the older you are the sicker you get with Varicella. Second, Varicella is a required vaccine for school now, so if your kid didn't get this shot you're going to have to go through the vaccine exemption form.

As far as rotavirus goes, it's a brand new vaccine and a lot of kids end up missing it anyway (at least in the clinic I was in), because it has to be given at 2, 4, and 6 months. There is no catch-up for that vaccine, so if you miss it, it's done. In the United States, infectious diarrhea is not a leading cause of infant mortality, so I guess this one is really up to you.

#3. "Checking for 'titers' before giving booster shots". First off, I like how 'titers' gets quotation marks. It's like they're not even real! Sorry. So now she suggests that you can get titers drawn before booster shots to see if the booster is necessary. She does at least have the decency to add that this procedure will not be covered by the majority of insurance, so if you want this you'll pay out of pocket (depending on how many titers you want, this might be over $100 or so--I couldn't find an accurate price online.) I don't think there's anything wrong with this approach, so long as you use it appropriately. Just remember, though, for those parents whose main objection to vaccines is the number of pokes for your kid: it's a lot easier to give a tiny little shot than it is to draw blood from a baby. I'm just sayin'.

#4. "Spreading the vaccines out over a longer period of time". Here's where it gets funny again. She provides a link to the Sears Schedule, "an alternative vaccine schedule developed by pediatrician Dr. Robert Sears. Sears' patients bring their babies in for shots seven times between the ages of 2 to 9 months, never receiving more than two shots at each visit." Unfortunately, if you click on her link, it takes you to an ad on Sears' website for his book on vaccines. If you want all his magic information on what's really in your vaccines, and how to spread them out, you have to buy his book (it's only $11.19, come on!). I've looked up on Pubmed "Sears vaccine schedule" and the answer was "No items found." Nor does Robert Sears appear to be a published author on PubMed. Neither Cohen nor Sears gives a really convincing argument for stretching the vaccines out like this, although I'm sure Sears' business manager likes getting kids in 7 times instead of just 3, as they can bill for each visit (at least as a nurse visit). Note that if your kid is on most Medicaid plans, this will not work, as you get visits at 2, 4, and 6 months or when the child is sick. That's it.

#5. "Splitting up combined shots". I reread this section several times and I cannot find any reason behind why you would want to do this. Sears' website states that some of the combo vaccines have a less favorable ingredient profile, but to find out why you'll have to buy his book. (one more bitch about Sears' website: below this is a link to "Find a vaccine-friendly doctor near you." Um, I'm sorry, isn't every doctor who gives vaccines "vaccine-friendly"? Oh, I'm sorry, you must have meant "vaccine-suspicious" doctor, like you.)

She concludes the article with "another consideration: what's best for your child." Now, she tells the story of Hannah Poling, the child whose autism was found to have been exacerbated by her childhood vaccines by the "vaccine court." Here's a review article in NEJM, but watch out--the author holds the patent on Rotateq, the rotavirus vaccine. Apparently, Hannah Poling had a rare mitochrondrial disorder and had been susceptible to infection prior to receiving the shots.

By throwing in this anecdote, and then getting a pediatrics professor to endorse recommending a change in vaccine schedule for any family history of autistic spectrum disorders, now Cohen has added credence to this faulty theory. Of course, if Poling received those five shots at 19 months old, she was way behind the schedule anyway (why?) and probably shouldn't have received at least a few of the shots she was given--she was too old. (Not that I think that's what caused her problem, but still--something else was not right here).

So, there we have it. The Empowered Patient strikes again, telling nervous parents that doctors don't know what we're doing, that it's a fight between us for your health (and now your child's health), and that making unproven changes in the vaccine schedule are fine. Good job! So when the next round of children goes unvaccinated, and gets measles or polio, or has necrotic varicella, I think we should send them to Ms. Cohen's house--she clearly knows more than we doctors do, anyway.

*** I will go on the record here to say that I'm not at all concerned about vaccines and autism. I've seen the data, over and over again. It's not the vaccine MMR itself, OR the thimerosal (which has been removed*). That said, I know perfectly intelligent people who have become parents and start worrying about this. Of course they do, it's their kid! I'm not making light of people who worry about this. I think vaccines are great, but I do have concerns about how many we give at a time. However, without seeing any evidence that it's causing health problems, that's all they are--my concerns. Of course, if you'll pay me $11 for a book, perhaps I'll write a book of junk science, too, and then we'll both be happy.***

*I meant that the thimerosal has been removed from MMR (in 2001). It's true that 2 influenza vaccines contain measurable (though small) amounts, 1 contains trace, and 1 DTaP vaccine contains trace (<1 microgram per dose. There are 2 flu shots without thimerosal: FluZone and Flumist [nasal]). If you are still concerned about thimerosal, here's one study to check out: JAMA 2003 Oct 1;290(13):1763-6, which showed no difference between children who got thimerosal-containing versus thimerosal-free vaccines (in terms of ASD), AND failed to show a dose-response relationship between thimerosal and ASD. That said, I'm not opposed to removing it from vaccines, so long as you can find a suitable means of keeping the vaccine bacteria-free for injection. Thanks to Sweet Mama for the correction.

Fun With HIPAA

2008-06-18T14:10:00.004-05:00

In my extensive perusing of medical blogs recently, I came across an article at The Happy Hospitalist which asked whether HIPAA applied to the deceased. This comes in the wake of health information we've received via the media about Tim Russert. It's not surprising that in the comments section, no one knew the answer to this question. In every HIPAA training session I've attended thus far, we're basically given a brochure, told to take the test, and told the page number at the back where the answers may be found. In one HIPAA session I took as an undergrad (to work as a medic on campus), we were shown a video about "Protected Health Information" but not really expected to listen, as "it's really boring." Great. In the wake of all this HIPAA misinformation, even amongst health professionals, I decided to *try* to read through the actual rules and come up with some answers.

First, I'd like to clarify that it is "HIPAA", which stands for Health Information Portability and Accountability Act. It is NOT spelled "HIPPA", which I see all the time and makes my inner spelling bee demon ANGRY.

1) Does HIPAA apply to the dead? There are layers here (it's like an onion): First, if you are getting this info because it might apply to your own healthcare, then you can get it, as HIPAA allows release of information for treatment, "even the treatment of another individual." Second, if you are the legal executor of the estate of the deceased, then you can have access to information. Third, hospitals may release records to medical examiners or funeral directors as needed.

This was very important when I worked in the ME's office, because usually what happened at the hospital before death was vitally important (ha) to the autopsy results. If the patient grabbed their chest and said "OW" before passing out, and an EEG lead showed ST elevation MI, then V fib and asystole, then when the body goes to autopsy and even a small coronary plaque is found (but minus large ischemic tissue because it was too sudden), tada, "Hypertensive Atherosclerotic Coronary Artery Disease" is your answer.

The next part of this is that autopsy results are a matter of public record. Many public medical examiners' offices websites have a formal process for request of public records. (Note that you have to know a good bit about the decedent in question; you can't just write in and say "send me reports".

2) Can I have access to my own health care information? YES. I see this all the time. Patients ask for a copy of their health care records (maybe a copy of a radiology report, or a lab value) and are told "we can't do that, it's a HIPAA violation." That's crap. Fine, make them sign the waiver, cover your bottom, but it's their information, not yours (be you the hospital or clinic, doctor or nurse).

3) If my husband is in the hospital, can they notify me? YES. I pulled this straight from the HIPAA FAQ page. They do add the caveat that if the patient is awake and can consent, or at least not object, the hospital can do this. In other words, try to tell the patient this is what you're doing, which is basically like asking them politely anyway (or should be). They then clearly state that if the patient cannot consent, the "covered entity" (health care provider) can still notify family or close friends of their "location, general condition, or death." In other words, if you call the hospital, identify yourself as family and ask where is my loved one? and how are they?, the hospital is not being truthful if they say "we can't tell you, it's a HIPAA violation." (They may have other reasons for not telling you; they might like to see ID first, to make sure you're not a reporter or someone else who doesn't need to know).

4) Can I pick up my husband's prescriptions at the pharmacy? Yes.

5) Can I see my kid's medical records? So long as your parental rights haven't been terminated, you didn't sign an agreement with the doctor to allow the records to remain confidential, or it was a situation where the kid didn't need permission to consent (like for birth control or STD testing), then yes, you may see your child's medical records. If it was an emergency, and the child received treatment before you got there, you may see the records unless the hospital/doctor decides there's a reason you shouldn't (like, the kid has a strange set of fractures with a bad story to go with it).

6) What are the consequences of violating HIPAA? In civil court, you may be fined $100 per incidence, or in criminal court, up to $50,000 and up to a year in jail, depending on how you violated it (ie, failure to provide privacy notice versus deliberately leaking public health information to the press). This, friends, is why everyone misinterprets HIPAA and why everyone is so afraid of this law. This is why you will sign a release form to receive a copy of your own medical records, or why some doctors won't fax records for fear of a HIPAA violation (by the way, that's a load of crap.)

More can be found here: HIPAA Frequent Questions.

So what does this mean about Tim Russert? I think there are several issues at play here.

First, his autopsy records are a matter of public record, and therefore available to the media.

Second, for his physician to be talking publicly about his treatment of Mr. Russert, I'd assume that family had to have given permission for him to do so. If they hadn't given him permission, and he went on Larry King, he could be prosecuted under the HIPAA laws and/or sued in civil court. His physician can reveal all the information he wants to the ME, or to the family representative, but Larry King doesn't count.

And there you have it. Funny how a law that was intended to make health information "portable" has instead hampered my own ability to see my records or my doctors to talk to each other, but I guess that's politics for you.

Blog Work

2008-06-18T00:04:00.005-05:00

I've been reading a ton of medical blogs lately. It's one way of getting me ready for what's coming to me in 14 days (or 13 days, 5 hours, and 50 minutes, according to my handy counter on Facebook). I've added some blogs to the drop-down menu on the right, in addition to changing my template. I may keep it, I may not--who knows? Does anyone have an opinion as to whether the drop down menu is better, or should I just list out all my blogs down the page? These are tough questions here, people!

I have to reboot my computer now, which is why I only made a few small changes to the olde blog here. It seems that "Windows Explorer is not responding" and quit doing so at 7:50 PM (that's the time still showing on the laptop as of now--it's now after midnight). Fortunately, Firefox kept working, so I was able to indulge in medical blogs all night (tasty), but I couldn't maneuver between windows. This is a brand-new laptop, good brand, purchased towards the end of May, and already I think I've crashed Windows Vista 3 times. I'm averaging around 1 crash per week. I don't do anything very exciting--mostly play around on Firefox, use Outlook, or play Spider Solitaire. I'm not sure why this is just too much to handle for this new super-duper fancy OS. I've never really considered going Mac because they're just so friggin' expensive, not to mention I'm used to Windows, but with all the changes they put into Vista to make it look more like OS X I'm not as familiar with it as I was, and with all these crashes god forbid I try to do something important on this computer! (Otherwise, it's a lovely computer, very shiny; I just wish it had come with XP). GRRRR!

While I'm soliciting advice here, does anyone use a particular feed reader to read blogs? I've never used one before, because I always just click the links from my bookmarks or from my own blog. However, I think that if I contain them within a reader, it will make catching up easier from the hospital. I've put stuff into Google Reader, but is this a good one? Any tips for using it?

I really will try to post more. I realize I'm not a prolific blogger (just wordy when I do write), and I probably won't become one, but surely I can do better than this. At least until July 1, when all bets are off. GAH, I just got that cold feeling in my guts and my heart rate just accelerated like 40 bpm JUST THINKING ABOUT IT! It's a good thing I haven't had a real medical rotation since my AI in January on pedi, and I haven't done neuro since the January before that one, so I'll be just super prepared. It'll be great!

Yes, I Said That

2008-06-13T11:00:00.004-05:00

The other night, I wanted to make my husband laugh, so I decided I would tell him a funny story.

"Honey," I said, "I have a confession to make."

"Oh? What's that?"

"Well, you know who Warren Buffett is, right? CEO of Berkshire Hathaway, one of the richest men in the country?"

"Uh, yeah?"

"Well, I have to confess that for a very long time, until very recently, I didn't know that he and Jimmy Buffett were two different people. I thought they were the same person."

**speechless hubby bursts into laughter**

"Yeah, I couldn't figure out why that stupid song would have gotten him to be the second richest man in America. I hate that freaking song, but everyone in college loved it."

**he's still laughing**

"Sadly, it was only very recently, like within the past few months, that I read a US News article on Berkshire Hathaway that I realized my mistake. I guess I'd just heard 'Buffett' and never really looked farther than that."

At this point, my easily amused husband is nearly crying with laughter as I sung snatches of "Margaritaville" to him. He has since relayed this story to many of his friends.

Well, apparently Warren Buffett heard about this.

Yesterday in the mail, I received an envelope (addressed to me) that said "Exclusive financial advice from Mr. Warren Buffett." The return address was from a local furniture store. Inside was a card, advising me that "Warren Buffett, CEO, Berkshire Hathaway" says "There's never been a better time to buy furniture" (I found a copy online--look, there's even a video message). In tiny print, it reveals that BH is the parent company of this furniture chain (they're not even near us, I'm not sure why they sent us a flyer). On the back, there's a "$100 dividend check" (good for purchases of $499 or more in tiny print), and a registration form to win "one 'B' share of Berkshire Hathaway stock valued at over $4000".

So apparently, the "Oracle of Omaha" has spoken directly to me. He said I need to go buy furniture I don't need with "no down payment and no finance charges til 2010" and if I provide him with my name and email address, I might just win 1 share of his stock. In other words, he's going to remain the second richest man in America so long as people take his advice and go buy furniture (in a time of rising gas and food prices).

I guess I should apologize. I didn't mean it, Mr. B! I would never hold you responsible for that stupid song! It was all a misunderstanding! There's no need to insult my intelligence with a really bad furniture offer! I promise, I'm smarter than that now! Or at least, until I go to my friend's wedding tonight, where I might just be "wasting away again in Margaritaville." Woo!

Reading

2008-06-10T21:00:00.003-05:00

Since I have nothing medical to blog about for the next three weeks, until they unleash me upon an unsuspecting neurology service, I'll blog about what I've been doing recently, and that is reading.

It's such a simple thing, reading, yet it was so hard for me to do until I went to China. Ever since I learned how to read, I've always had my nose in a book. I used to read through dinner, in the car, while everyone else watched TV, in the bathroom or even in the shower (this amazes my husband). In fact, I used to get in trouble for reading so much when I'd visit my dad's house as a kid. "Put your book down and come join the family" was a refrain I heard often. At my mom's house, the punishment that worked the best (until I had a car) was to ground me from reading (unless it was for school, of course).

Sometimes, I'd have two or three books going at a time--one for school, maybe, and one I'd read before, and sometimes a third. I used to get in trouble with Mom because I'd leave them lying face down, bending the spines. I still do that, but I own the books, so it's not such a big deal. I read all through high school and through college. I laughed at a professor who told me I'd eventually get too busy to read. To me, reading was like breathing. I read extremely fast (as does my mother and hers), so I often reread books that I've enjoyed and gain new insight into them every time(as opposed to my father, who reads extremely slow, but retains everything perfectly, so he only reads a book once, ever).

Then, I hit medical school. And I'm not sure when the reading stopped. There were 1,000 page syllabi (per class) to read, as well as textbooks and reviews and such, and frankly, my brain was tired. Then, on the wards, I'd be so busy and exhausted and full of what was going on with my patients and studying for the shelf that I was all used up. For a long time, I didn't even want to watch movies--I didn't have the ability to concentrate on two hours' worth of material. Television shows became the limit of my concentration--one hour max. (This change also coincided with moving to an apartment that offered free cable, which didn't help.)

My aunt sent me three books to read in China. I packed them, unsure if I was wasting the room in my backpack. After all, surely I'd be too busy to read much. I mostly did Sudoku on the flight over, and it was at some point later that I picked up the first book. I proceeded to read all three of my books, one of A's books, three of B's books, one of C's books (on the flight home; she didn't want to have to pack it) and a book I bought at the Bookworm in Beijing. It was like rediscovering breathing, I felt so refreshed. Since I came home, I've been off, and I've made several trips to Half Price Books. My shelves are stacked with new books that I've been cramming down, bingeing on the new reading material. I'll list off a bit of what I've been reading lately (during and since the trip):

Suite Francoise by Irene Nemirovsky (lovely reading about WWII in occupied France)
The Glass Castle by Jeannette Walls (memoir about a very dysfunctional family)
The Memory Keeper's Daughter by Kim Edwards (girl with Down's is taken away, mother is told she's dead)
The Time Traveler's Wife by Audrey Niffenberger (a new favorite, this book is amazing)
Remember Me? by Sophie Kinsella (beach fluff but fun)
The World According to Garp by John Irving (very odd, and book really has no theme or message)
Salt: A World History by Mark Kurlansky (a little dry, but interesting nonetheless)
Spook: Science Tackles the Afterlife by Mary Roach (not as good as Stiff, but still fun)
Coyote Blue by Christopher Moore (read in China, was fascinated by Moore's work)
Fluke, or I Know Why the Winged Whale Sings by Christopher Moore
Lamb: The Gospel According to Biff, Christ's Childhood Pal by Christopher Moore (well-written and not as blasphemous as it sounds)
You Suck: A Love Story by Christopher Moore (vampire love story)
Prairie Gothic: The Story of a West Texas Family by John R. Erickson (interesting West Texas history; I've been looking into genealogy lately so this was fun)
Goodbye to a River by John Graves (quoted often by Erickson so I had to read it)
The Liars' Club: A Memoir by Mary Karr (found in Texana section at HPB, also a memoir of a very dysfunctional family)

China books:

Iron and Silk by Mark Salzman (read prior to trip)
The Rape of Nanking by Iris Chang (read prior to trip, heart-breaking history)
Red China Blues: My Long March From Mao to Now by Jan Wong (fascinating)
Tiananmen Diary: 13 Days in June by Harrison E. Salisbury (great account of Tiananmen student protests in 1989, compare to Red China Blues account)
Falling Leaves: The True Story of an Unwanted Chinese Daughter by Adeline Yen Mah (very sad memoir)
Genghis Khan and the Making of the Modern World by Jack Weatherford (currently reading, just started; written by researcher who helped translate the long-lost writings of the Mongols)

I have quite a few more books to try to get through before my break is over. And hang curtains. And hem curtains prior to hanging. And paint wall art for dining room and guest bath. And write more China stories before I forget. And try to organize office a little more. And talk to county extension master gardeners about our oak trees being planted too close together. And... We'll see how much I actually accomplish in between riding my new bike, reading all my new books, and catching up on medical blogs (I just started reading The Blog that Ate Manhattan, and it makes me so hungry!). But, because I like reading and procrastinating more than doing chores...

Anyone read any other good books lately?

Introducing Doctor TS

2008-06-04T11:49:00.003-05:00

We graduated this past weekend. I walked across the stage, picked up my diploma, received my hood, and took the Hippocratic Oath. For the rest of the day, anytime someone said "Dr. TS", I giggled. It doesn't feel real, despite working for the past four years to get here (and in reality, the past 10 or so, because I've been planning this for a long time). My mom was laughing at all of us with our "shit-eating grins" (her words); we were just walking around calling each other "Doctor" after the ceremony was over.

I felt pretty good all weekend, but today I got my PGY-1 schedule and I will be starting on neurology. We all know how I feel about neuro, so add my fear of being the intern in charge + fear of being the intern on neuro = rather scared TS. I do hope that I can learn to enjoy neuro more--I think part of the reason I don't like it is the way our school went about it. But who knows? I'm going into psychiatry, not neurology, and while I hope to learn what I need to get by in the overlapped area, I'll never be a neurologist. That job is my friend newly-Dr. B's job, who is now moving to the East Coast. At least some of my other newly Dr. buddies will be staying here, at least for their intern year, before moving far away. It's bittersweet at this point--I'm so proud of my friends, but sad that they're leaving. And sad I only get 2 weeks off, so I can't possibly visit everyone. Oh well.

Thank you for the comments on the post about not being a nurse. It really isn't that big a deal, but for some reason it gets to me. If the roles were reversed, and I'd just finished four brutal years of nursing school, I'd be offended if someone called me "Doctor". Or maybe not, who knows?

Just so it will be in writing somewhere, it took a village to get me through medical school. Or at least a very loving husband. He has put up with me when I was cranky, brought me food when I was exhausted, and snuggled with me even when I was post-call scuzzy. The rest of my family has also been very supportive through all this. Also, I have great friends, both in and out of medicine. Of course, entering residency won't be very relaxing, either, so I will continue to rely heavily upon them, but at least I can take a minute to thank them all for helping me get this far. To all y'all, you know who you are; thank you, and I love you.

No, I'm Not a Nurse

2008-05-21T20:05:00.003-05:00

Salesguy: Do you need a new suit?

Me: No, thanks, I don't need one if I wear my white coat.

Salesguy: Oh, are you a nurse?

Me (politely): No, I'm a doctor.

Salesguy: Ohhhh.

I know every one of my female classmates has dealt with this, and I'm sure we're not alone. There are worse things to call me, of course, than "nurse". Nurses do a ton of work that I don't have to. I don't have to change sheets, clean bedpans, draw blood, or answer the call button all night (although I will get to answer my pager if the call button was pushed for me).

So why, then, does it irritate me when people assume that if you're a female in a health profession, you have to be a nurse? And conversely, if you're male, that you're a doctor? There are male nurses out there, more than ever, and women now make up at least half of current medical school classes (mine had a female majority). Is it so shocking that I'm a doctor (or about to be--I'm trying to get used to saying it, as it will be true in ten days)?

I know that most people don't mean any harm by this, and the guy didn't mean to offend me, but every once in a while I get sensitive about this. Does this mean that I am somehow superior to a nurse, or that I feel superior to them? I hope not. However, I have worked awfully hard to get to this point (hence my defensiveness). I want some acknowledgment that this took eight years to get here. I don't want everyone to call me "Doctor", but I am proud to be able to call myself one.

And I'm awfully tickled that, from now on, formal invitations addressed to us will read "Dr. Tiny Shrink and Mr. Husband Of". I find this totally amusing.

Okay, I'm probably a little overly proud of this, and maybe even a bit conceited, but it'll be rubbed out of me soon enough. I'm sure there will be times during intern year when I'll wish I could say "I'm just the medical student, let me get the doctor for you." In fact, I think that is highly likely. Ack, less than 1.5 months to go!

Chinese Medicine

2008-05-18T18:24:00.003-05:00

This is the essay I turned in to complete my China rotation. It's a little long, and wordy, but hey, that's me.

I really didn’t know what to expect of the Chinese medical system. Consciously, I didn’t think much about it; I was more concerned with what I needed to pack for a month overseas than what I would actually do when I got there. Subconsciously, however, I think I had more stereotyped ideas. China is a Communist country, and that brought up sensations of drab ugliness, poverty, dirtiness, and an inability to change. After all, I was raised during the Reagan era by Republican parents, and I think I internalized some of those expectations. I know I carried some of those stereotypes to China because I felt surprise when I entered the first few hospitals; even though I thought I hadn’t expected anything, they weren’t what I expected. During the month, we saw so many hospitals in so many specialties that I not only changed my expectations, but I can actually compare my experience in China with my American medical education and draw some conclusions.

The first hospital we visited, T, was known for neurosurgery. Our first morning at T we visited the operating rooms. I was surprised that the inside of the OR looked like any OR in the States. The CT and MRI films on the wall were high resolution; the anesthesia cart looked familiar, and the surgical equipment was advanced. In fact, the only shocking thing in the OR was the appearance of OR sandals (we were all given pairs ourselves), which seemed dangerous (OSHA would have thrown a fit).

In the afternoon, we visited the wards, where the difference was much more striking. Each room held eight to ten patients, plus several family members for each patient. There were no curtains or privacy walls, and the restrooms were down the hall for the use of the entire floor. They appeared to be less than sanitary. Each patient had a water jar or a baby bottle at the bedside; I assumed the baby bottles were for patients who were bedridden and couldn’t sit up. Each patient had a folder at the foot of their bed containing their films, which we could go pull out and examine at the bedside. Patient privacy laws must be less stringent than HIPAA, because we would discuss the case in the room in front of all the other patients and all the families.

The next day at T we visited the ICU. The ICU attending was very interested in American end-of-life ethics, and we talked for quite a while. We gathered that there are a limited number of ICU beds in a Chinese hospital, like ours, but they don’t seem to have LTACs or other places to send patients needing high-level care, so those patients simply remain in the ICU. Then, the family takes ultimate precedence over what happens with the patient. Thus, if a physician wants to transfer the patient out of the ICU (I assume because care is futile), the family may request that the patient stay. Every bed was full while we were there, and he seemed upset that families may request a patient to remain in the ICU even while other patients need that bed more. This is a situation that is at least similar to ones most of us have faced in the States, as there are never enough ICU beds for everyone who needs them (or so it seems). It did seem, from speaking to that attending, that few Chinese have any kind of DNR or Power of Attorney paperwork (or family discussion), which complicates the situation.

The most interesting difference is that they recognize brain death, but it is not a legal criteria of death. Therefore, if a patient is brain dead, they still have to convince the family to remove life support, whereas in the States (at least in those states that recognize brain death without qualifications) once those criteria have been met, that patient is legally deceased. Life support is withdrawn because the patient is not alive; it is a different situation for us than a patient in a vegetative state where life support is withdrawn from a patient who would continue living on it. I remember how much relief the brain death standard gave to the physicians when I was on neurology, because there were no tough decisions to make at that point; the patient was brain dead, therefore they were dead. It was much harder if the patient retained one brain stem reflex but otherwise had no cortical function, because then the family must make a terrible decision. All in all, the situations doctors face in ICUs regarding end-of-life are fairly similar in China and the United States.

At F Hospital two weeks later, another interesting situation arose. We were rounding on general surgery patients, and we met a patient who had arrived at the hospital with a small bowel obstruction. A CT of her abdomen showed a large sigmoid tumor which had caused her obstruction. As we took her history (translated through the resident), we asked if she knew her diagnosis (since we’d seen her case presentation before examining her). The resident explained that she had not been told, as most patients with cancer did not want to know. We were all shocked. Then who makes decisions? The resident replied that her family would be told of the diagnosis, and they would make decisions in her case. This was totally foreign to us, and several students were made very uncomfortable by this situation. Next, we examined two women with very large breast masses (in front of the other seven patients in their room), one of whom had large palpable nodes in the axilla. We asked the resident if these women knew their diagnoses. He replied yes, because it is “more obvious” when the problem is in the breast. All of us in that group have read the case in ethics where the family requests that the patient not be told her diagnosis, and the correct answer is of course to ask the patient how much they want to be told. When we asked the Chinese residents about this, they were puzzled; why would the patient want to know? I think they were easily as confused by our views as we were by theirs.

The biggest difference between our health care systems took the majority of the trip to elicit. We asked this question at every hospital, of every resident and attending, and received varying answers. Finally, at A Hospital at the end of our third week, a cardiology attending answered our question in a startingly truthful manner: what happens if the patient doesn’t have insurance and can’t pay? Answer: they don’t receive treatment. She was incredibly honest with us. She told us that even acute patients having a STEMI come to the emergency room and are required to pay for their stent before receiving it. If they do not, most hospitals can/will do nothing, so that patient simply does not receive treatment. If the patient has no means, the family will be pressed; this might work better in China than here because the family structure is very tight. As one might imagine, demanding cash up front delays the time before the patient goes to the cath lab, which had been confirmed in studies this attending had helped conduct. Now, in the States, money is a huge issue in our medical system, and I have watched many back-boarded, c-collared patients in the ER trying to sign insurance forms held above their heads while they lie flat on their backs. However, because of the EMTALA law, if a patient is in need of emergency care, they will receive it (at any hospital which receives Medicare funds). A truly private American hospital might refuse to stent an uninsured patient, or deliver their baby, but most hospitals are bound by EMTALA. China does not seem to have such a law. The hospitals we visited in China were all public hospitals (there are some private hospitals), and surely a public hospital should be required to treat the public (at least in my understanding of the word).

The Chinese system is much more capitalist than ours regarding payment for service. Much of the work American hospitals do is unpaid; in China, that hospital must receive a fee for their work. The fees charged are very low by American standards, because we tend to float the unpaid bills off those that are paid. So the price of a blood test is several hundred dollars, because the hospital will not be paid for everyone’s test. In China, the fee is lower, but everyone has paid for their test. In our system, we’re running into escalating costs because of the price of paying for the uninsured (among many other things); in theirs, their population just keeps growing. Rural areas are terribly underserved there (as in America, only worse), so there are always more patients who need the care than there are hospitals or doctors to care for them, but on a scale that most of us could not comprehend. After all, our system administers to 301 million people; theirs, 1.3 billion. Our system is overloaded; theirs must be bursting. Is it any wonder that we saw many paying Chinese patients receiving “extra” tests because those are cash tests? Of course, that kind of thing happens in the States, too, but we call it fraud. There, it was normal.

Overall, I learned many things about the Chinese health care system, and by contrast, many about our own. I saw the differences between Chinese and American medical education, and I am very glad I don’t have to learn medicine in Chinese (but Chinese doctors have to learn medicine in English). I learned a bit about Traditional Chinese Medicine, if only enough to know the terms to look up for patients in the future. I witnessed a living example of an ethical situation that had been only abstract until then. The Chinese system would be an excellent system to study here in America in the near future, when our health care system will be scrutinized and changed after the presidential election. Whoever is elected, I hope they can take some of these lessons to heart, because their system modeled interesting features of both capitalist and socialist health care systems, and in some cases, the worst features of both. Perhaps the most important thing I learned, though, was how similar our systems really are—far more alike than different. I’m much more conscious of my beliefs about the Chinese health care system now, and I’m no longer surprised by what I saw there.

Home Again, Home Again, Jiggety Jog

2008-04-30T20:39:00.005-05:00

My plane arrived home today after an 11 hour overnight train ride from Xi'an to Beijing, an 11 hour flight from Beijing to San Francisco, and a 5 hour flight from San Francisco to the Gulf Coast. It's now 8:39 pm here, but my body kind of thinks it's 9:39 am tomorrow morning in Beijing. I didn't really have jet lag too badly on the way to China, but I'm so confused right now I'm amazed I'm typing. I will shortly go to bed and pass out, and hopefully wake up when tomorrow is truly tomorrow, not some strange half day where the sun sets and rises but the date doesn't change.

It was a great trip. I'm thoroughly sick of Chinese food, and I'm sooooo happy to be back in my house, with my own soft bed, my own clean Western toilet, unlimited toilet paper, clean hand towels, and soap (all luxuries). In the airport, I could actually read all the signs, and understand the directions of the officials guiding me through multiple lines of Customs checks and security searches. You get homesick for little things you didn't even think about.

After leaving the airport, we drove immediately to a mexican restaurant, where I had (in this order) iced tea, a margarita (on the rocks, no salt), chips and salsa and queso, enchiladas (chicken and beef) with refritos and rice, and vanilla bean cheesecake. Every bite was heaven.

I now speak a few words of Mandarin. I can say hello (nihao), thank you (xiexie), how much is it? (duao shao chen?), count to three (ee, er, sun), this and that (jega and nega), doctor (ishung), please (ching), and you're welcome (bu ku chi). (All spellings are TS-ized pinyin and I just made most of them up). It is weird now not to be greeted at a restaurant with Nihao! but I guess I'll get used to it.

Travel is fun, and I really, really loved my month, but I'm so glad to be home.

Feeling Strangely Fine

2008-04-15T18:57:00.001-05:00

Or at least a little better. Nothing puts me in a good mood like a good bookstore. Especially one which has a) books in English b) Kurt Vonnegut and c) books which are currently banned in this country. Rock on, Bookworm!

The Bell Jar

2008-04-14T23:04:00.002-05:00

On the second day of our trip, after giving a brief presentation on neurosyphilis at the neurosurgery hospital, I burst into tears. I'd stuttered a few times in the presentation and then started talking really fast; a person from my class subtly whispered "slow down!" and I tried very hard to do so. Still, afterwards when someone teased me about going so fast, I couldn't bear it. Tears started rolling down my face while I was trying to watch another presentation. I excused myself and found a quiet corner to have it out.

I felt really rotten, but I was still jet-lagged, and quite hormonal and emotional anyway, so I chalked it up to that and went on. "Allergies," I told anyone who took a double take and asked me what was wrong. Since I turn really bright red when I cry, it's usually very apparent for several hours that I was upset. My nose, especially, becomes a shining red beacon, rather like Rudolph.

That weekend, I felt a little better, but starting the next week (last week), I felt things sliding. My self-esteem plummeted. I couldn't get my hair right, and the only clothes I brought were not very attractive, so I felt completely hideous. I felt acutely alone most days, as the majority of my close friends didn't come on the trip. It came to a head on Saturday at the Summer Palace. The group kept leaving me behind (I'd lost my ticket that would allow me into the inner buildings, and kept having to buy more), but I was sure no one noticed my absence. I felt like everyone was making plans around me, but I wasn't included.

I had a really rough time that afternoon upon returning to the dorm. The flood gates broke and every negative emotion I feel about myself came pouring out. I'm stupid, I'm ugly, I have no friends, and why would they want to be with me anyway? I missed my husband, but I hurt too badly to talk to him.

The bell jar has come back down. I always appreciated Plath's metaphor; it fits how I feel. I felt so much better for so long, but over a few weeks to a month or so I've noticed the warning signs. More irritability, more emotionality, tearing up at corny commercials, more negative thinking. Unfortunately, it hit me on this trip, where I have no medication or confidantes. It's always hard to talk about, anyway, because I get so overwhelmed by it. My heart gets squeezed by an iron fist and my throat closes off (so yes, I'm a little somatic, too), and words won't come out. Then, once the pain eases, I'm too embarrassed to talk about it. Will they pity me? Will they be uncomfortable by this pouring out of emotion? I fear the answer, so I try to keep it in. I have always also feared that by revealing the loneliness, the desire to be around people and the pain I feel when I'm not, that I will become their pity friend. Oh, let's invite her, poor thing, she has no one else to be around. I hate that. I hate being alone, but sometimes I prefer it to that other feeling.

I need an outlet, so I'm using this. Now, maybe that I've written this down, I can go wipe my face and put on a smile and get through the rest of my day, until the blackness passes for a few hours and I can smile for real. There's no need for comments. Thanks for reading this far.

Hello From Sunny Beijing

2008-04-07T08:44:00.003-05:00

I've been having Internet difficulties here, but I might be able to sneak in a short post before going to bed. It's 2143 here in Beijing, and 0743 back home, so I'm having a very difficult time getting in touch with my husband. Email is just not satisfying, but even though my cell phone is working here it costs $2.29 per minute to call home. We've just downloaded Skype but haven't had time where we could attempt calling each other. Ai.

I've already done many of the tourist-y things here, like Tianenmen Square, Forbidden City, and Temple of Heaven. This weekend, we might go to the Summer Palace and the Ming Tombs. And, of course, the shopping. Meccas of cheap goods with fake American or European labels for which you have to barter like crazy. These shopworkers are GOOD. I got taken for an enormous ride for my "authentic" North Face jacket, but I did a lot better on my "Seven" jeans and "Max Mara" short red trench. I'd put in pictures, but my internet connection will not let me upload photos to blogspot right now, which sucks.

We've seen a neurosurgical hospital (very impressive) and a psychiatric hospital (nicer than my county one) so far. Thus far, most of the doctors I've talked with are very well-educated, very smart, and eager to learn from us (and we them). One interesting phenomenon is that most of these doctors very much look down on traditional Chinese medicine--they're not taught it in medical school or residency, and aren't really sure what training those practitioners receive. I think we visit a TCM hospital later in the trip, so I'll learn more. I'll also try to discuss the differences between our health care systems further, but I will say that they are probably more same than different, which is surprising to me.

And now, to prepare for bed, adieu. I would say good night in Chinese, but I can't. Adios, then.

Going Green (Baby Steps)

2008-03-27T10:55:00.004-05:00

So recently, I've been thinking more about trying to reduce our impact on the environment. I'm kind of at the level of the typical American consumer, currently, so I'm at a place where some of the changes I'm trying to make are relatively easy. I recycle whatever I can, although unfortunately our curb-side recycling is very limited, so I end up driving to the recycling center fairly often. I will save plastic bottles or soda cans all day in my purse so I can take them home and recycle them; if I don't, I feel terribly guilty.

Part of my concern is for the amount of stuff ending up in landfills. I think eventually I'll start worrying more about the content of what products I use, but for now I'm trying to limit the amount I throw away. And believe me, we throw away a lot of stuff. My husband and I have a serious fast food habit, and combined with my iced tea habit, I use a ton of fast food cups. Most of them are Styrofoam or plastic #6, neither of which are recyclable (at least not here). I've started pondering ways to avoid throwing away so many cups.

What I'd like best doesn't seem to exist in the form I'd like. I want a reusable plastic cup in the same shape as most fast-food to-go cups (so it fits in my car cup holder). It could be a different material--it doesn't have to be plastic--but plastic would be relatively inexpensive. I guess I can start using my Nalgene bottle for this purpose, but as I now do so much driving, trying to unscrew the cap while driving isn't terribly safe. Many other forms of reusable bottles for sale (like these) are built in a similar fashion. A narrow-mouth bottle wouldn't be convenient for filling with ice and water in a fast-food situation; a wide-mouth bottle with only a screw-off lid has no straw for easy drinking. If anyone finds a cup that fits all these requirements, let me know.

We had the little squiggly lightbulbs in our apartment; we haven't had a chance yet to replace all the bulbs here in the house, but it's in the plans. I'm actually thinking about doing a composting experiment in the backyard, too. We have plenty of dog poo to add to the pile, and food which goes to waste, so why not?

I think a lot of what I'm looking at is how wasteful we are. I'm looking at a to-go container for a sandwich I took home yesterday from a restaurant. It's a clear plastic container, made of #6 plastic. This is going straight in a landfill. Most other to-go containers we get are styrofoam, which is also going in a landfill.

I've started using reusable shopping bags, but it's harder than I thought. I never seem to have them on me when I go to the store for large grocery trips; sometimes I have one in my purse for the quick trip, but sometimes I don't. Sometimes the cashier uses plastic bags before I realize what has happened. I still have piles of plastic bags under my sink; fortunately, a local grocery store has a bin for recycling plastic bags. Not everyone is so considerate; there are dumped plastic bags all over the countryside out here.

I'm not quite to this level, though: apparently, they make reusable menstrual pads and "cups". I'm not so sure about this, personally. That's just more gross than I'm currently willing to do.

I'm only taking baby steps here so far. The truly green will probably laugh at some of my efforts, because we're still definitely "consumerists" and will probably remain so. We have to start somewhere, though.

Match Day

2008-03-21T21:59:00.003-05:00

So yesterday, 3/20/08, was Match Day for most fourth year medical students. At my school, we showed up for a class picture at 10:30 am, then were herded to a cramped outdoor location. The dean gave a speech while everyone twitched anxiously. They finally started reading off names and each student would push their way through the crowd, grab their envelope, and drop a dollar into the basket (a raffle for the last name called). I waited with my friends forEVer, then finally bobbed and weaved my way through the crowd to get my envelope. I made it back to my friends and took the required pictures of me with my envelope, then held it up to the sun for another photo op.

Except in my case, I actually was able to read the program name (backwards and upside down) through the envelope. I immediately burst into tears.

It was Top Choice Program.

I had to tear open the envelope with everyone else to be SURE, but it was still there, on the paper. You have matched with TCP. I confirmed that it was my name on the paper, and cried some more. My husband hugged me fiercely, rubbing my head and telling me "I told you so!"--probably the one time in his life when I'd let him say that to me. I squealed with my friends and hugged people and took more pictures and cried some more and eventually called my parents and one of my grandmothers and texted some friends and walked around finding classmates to celebrate with and finally settled down long enough to get some food and eat.

For my class, the news was mostly good, but there were a few people who had to scramble, or matched into a program they're not happy with, etc. At least one couple who tried to couples match ended up on opposite sides of the country. One person tried to match surgery and ended up in pathology. One tried to match OB/Gyn and didn't make it. Several ended up deferred or taking prelim spots to try again next year. For a few, the news wasn't good.

For me and most of my close friends, though, the news was great. It was so awesome to see my friends so happy, to learn where they're going next year (and therefore, where I'll need to go visit), and to congratulate them on their accomplishment. They're all going to be great doctors in their various fields, and I look forward to saying "Why, of course I know a great anesthesiologist/ internist/ neurologist/ OB-Gyn/ pediatrician/ radiologist/ surgeon/ urologist, etc. in X town, I went to school with them."

It was a great day.

I Got Dinged

2008-03-13T16:46:00.003-05:00

A friend dinged me for not posting today. It's true, I haven't been spending much time blogging or reading blogs lately. Somehow, even though my days are fairly easy--only a few hours of lecture a day--the new strains that commuting puts on my time somehow chip away at my time to play around on the internet willy-nilly. So sad.

Last week, I was pondering a great topic to post about. I even told my friends, Hey, I'm going to post about this, I think it would be awesome. And then I promptly forgot what I was going to post about. It was a fascinating, deep topic, and it's gone forever. Actually, it probably wasn't that great, but it still sucks that I forgot.

So instead, I'm going to write about the best lecture we've had so far in our "Transition to Residency" month.

Yesterday during a leisurely lunch outside under the trees, enjoying one of the last months of nice weather here in the jungle, we consulted our schedule to see what useless lecture we'd be attending at 1 pm. The lectures have generally been getting better, but overall they're nothing to call home about. Anyway, we checked our schedule, and we see a lecture titled "Diarrhea". Most of these lectures begin with "Approach to the Patient With...", but not this one. Short but sweet--"Diarrhea." Since I have a five-year-old's sense of humor, I burst into song.

"When you're drivin' in a Chevy, and you feel somethin' heavy, Diarrhea! *clap clap* Diarrhea! *clap clap*"

A few of us took turns recalling verses we knew to the song. Then, lunch hour was over and we walked into the lecture hall, only to find that our lecturer was already present. He was messing with the computer and pulling up his powerpoint presentation. I pulled out my Sudoku book and prepared for the usual, when a friend called for my attention. "Hey--look at the screen!"

I looked up to the screen to see the lecturer had pulled up YouTube and had clicked on a video. A video called "The Diarrhea Song." I didn't even know that this song had been used in this movie, but he played a little clip for us. Throughout his lecture, he'd throw in "favorite phrases" from the song, referenced from this blog: http://diarrheasong.blogspot.com/. Who knew that someone actually created a blog in honor of the Diarrhea Song?

The remainder of his lecture was actually quite good, and he took pity on us for having to be there (he showed us pictures of himself snowboarding as a lazy fourth year med student). My favorite part, though, was definitely the poop jokes.

Just goes to show, 'The real money's in the dick and fart jokes.' Or, med students are five year olds, and we are all still amused by poop. Or maybe it's just me.

*This post brought to you by the Diarrhea Song!*

Coasting on Out

2008-03-05T20:11:00.002-06:00

Today marked the beginning of a month dubbed "Transition to Residency". We had a relatively useless panel of residents talk about why we should be married ("so your wife can help with the stuff at home that needs to get done"--yes, that one was from a surgeon), then an hour break spent at Starbucks chillin', then an hour long lecture on fever. It was supposed to be "Approach to the Patient With Fever", which implies (to me) that there will be some diagnostic workup & treatment involved. Instead, we had an hour long lecture on "The Myths of Fever" from a disgruntled pedi ER attending bitching about stupid parents ("they actually thought that a fever of 104 was harmful! They'll beg you to treat their child!") and a lot of information about rectal vs oral vs axillary thermometers. Gag me. Tomorrow, more of the same, so I'm taking a book and possibly some Sudoku just in case.

All anyone can talk about is THE MATCH. Those few lucky individuals who had to slave to early match are now the envy of everyone else in the room. We've been informed of the plan for what I've called "Matched or Not Day", which is March 17: those persons who are not matched will receive a page at 10:30 am, while we're all in a mandatory lecture together. People who aren't comfortable with this scenario can ask to be on a "Do Not Page" list, so they'll get a phone call at some point during the morning. My group of friends has made a solemn pact not to page or call ANYONE during these hours. Still, though, the poor bastards who have to scramble the next day will be conspicuously absent from the day's mandatory lectures, and it certainly won't be very confidential.

The dynamic is unusual. Everyone who has yet to match is very tense. There are terse jokes about "the walk of shame" if you were to be paged on "MoND", and much discussion about the intricacies of the rank order list system. ("So, if they're my second choice program, and they rank me, and I don't match at my top choice program, but if this other guy ranks them #1, but the program ranks me above that guy, who gets the spot?"--this was an actual conversation earlier). There are also comparisons to others about who has the right to be more anxious: "you shouldn't be worried, your program called you, but I should be worried." Then the other party tries to justify their anxiety: "Yeah, but I only ranked 3 programs, there's always a chance that I won't match and will have to scramble for a prelim medicine spot and try again next year." Everyone is secretly convinced that everyone else has nothing to worry about (we know our friends and how good they are) but that they, personally, will not match and be laughed at. If I weren't caught up in it, I'd be totally amused.

In a "last hurrah", the gossip swirling this month is a hark back to the first two years of medical school, when the rumor mills churned all the time. "Did you hear about that girl who failed the intubation practical? Yeah, she had the blades upside down and kept insisting she was doing it right! Ha!" "Did you hear about this guy who's telling everyone he matched into xxx at yyy? I hear he didn't actually match yet, he still has to interview for it, but he's telling everyone he matched!"

And last, it's good to see everyone one last time. There are women who've gestated babies and delivered them in the time since I saw them last and I didn't even know they were pregnant! It's also nice to hang out with my friends for this time, since most of them will be moving away soon.

Should be a good month--too bad they're ruining it with lectures.

Just So I Don't Forget

2008-03-02T20:26:00.003-06:00

Thanks for the supportive comments, and a special thanks to my friend for allowing me to call and vent last night. I really needed to talk girlie stuff and cry over my stupidity and get some comfort--all of which was given and then some. Thanks.

And yes, I certainly hope that karma catches up with people who feel that it's okay to place international phone calls on someone else's phone, even when that person was idiotic enough to lose it. Is it okay to wish genital herpes on such people? Does that make me vindictive?

Ah, who cares. A plague on both your houses and HSV-2 on both your genitalia.

Cell Phone Saga

2008-03-01T20:46:00.003-06:00

I shouldn't be allowed to own a cell phone, seriously. A few months ago, I famously dropped my cell phone into the toilet prior to sitting down. I had to call the cell phone insurance people to replace my crappy RAZR with another crappy RAZR, since I was a few months shy of being able to replace the phone and get the huge discounts I needed.

The day before Valentine's Day, my cell phone went missing (see my last post). The next day, I was in the middle of calling around to various Lost & Founds when I decided to check my bill online. Lo and behold, someone was using my phone to call Matamoros, Mexico. I promptly called my provider, canceled the phone, and went to the store, where I was able to purchase a new, beautiful PDA phone. It was a little inconvenient, as we were in the middle of moving into our new house, but I was able to get an awesome new phone with the discounts.

The new phone is a bit large, and didn't fit into many of my pockets (girl pockets are small). I spent the past several days researching expensive phone cases on the internet because there is a paucity of accessories for this brand new phone model. I hadn't been able to purchase one yet, though, because the options were limited.

This afternoon, I was out when I realized I didn't have my cell phone on me. I must have left it in the car, I thought, and didn't worry about it. When we got home, I glanced in my car, but there was no phone. It must be on the counter, I thought, but it wasn't on the counter. It wasn't in my purse, it wasn't in the jacket I wore last night, or my pants pockets from last night. Panicking now, I realized the last time I'd seen it was last night when we went to eat, prior to going to Best Buy. I called the restaurant, but no one had turned in a cell phone. I called the phone, but it went straight to my voice mail.

Feeling an awful sense of deja vu, I checked my bill online. No calls to Matamoros today; instead, some asshole has been calling El Salvador with my phone, as well as half of the US.

Q@$#@$!EWAR#@Q$##@@!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

I just sat down and cried for a while. I simultaneously felt stupid, ashamed, sick, furious, and kind of violated. How could this happen twice? How could I be so retarded? What the hell is wrong with these people? Seriously, if I found a cell phone my first instinct would not be to begin placing international phone calls.

The phone has now been canceled again, and a new phone is on its way. Fortunately, the insurance covered this phone, but since they just replaced the toilet phone they're kicking me off the insurance for a year after this. I can't say I blame them--I think I've proven that I'm not a good risk for an insurance company.

The best part of the whole experience: after taking care of everything with the insurance agent on the phone, he says "oh, this phone is Bluetooth capable and we're running a great deal on our Bluetooth headsets--would you be interested in hearing more?" I could only laugh. I just paid upwards of $250 for this new phone and a car charger (I just sent off my rebate paperwork yesterday), I'm now paying a $50 deductible that I wasn't anticipating in order to get YET ANOTHER new freaking phone, and I just spent $45 online to get a nice case to keep it scratch-free + close to me with a wrist strap. Um, I really cannot afford to hear your great offer on the Bluetooth headset, but thanks.

*facepalm*

Yet Another Brazilliant Move

2008-02-28T13:58:00.000-06:00

I absolutely cannot stand when people conduct cell phone conversations in a public bathroom stall. It’s rude—I feel like the sounds I might be making in the bathroom will be transmitted over the phone line to the other end, so it’s like having an even larger audience in the restroom. Plus, it’s just strange to hear someone talking to themselves in a stall and not know whether they’re on the phone or just weird.

Last week or so, I misplaced my cell phone. I looked through my backpack, my purse, my jacket, my car, and my office, but couldn’t find it anywhere. Calling the thing went straight to my voice mail. Soon thereafter, I checked my bill online, and someone was calling Mexico with my phone. I contacted my wireless provider, cancelled the phone, and purchased a new, gorgeous PDA phone (which I’ve wanted for a while—I had a RAZR previously and it was a piece of junk). The problem continued, though, that I had no phone numbers, since my old phone was stolen. My old PDA has most of my numbers in it, but it’s in a box somewhere and I haven’t unpacked it yet.

I’m a bit of a paranoid person, so if I see a person calling me at an unusual time, I’ll answer the phone, because I get worried. “Oh, no, why did Dad call me in the middle of the afternoon? Is my grandmother okay? Did someone die?” You get the picture. Well, now that my phone had no contacts listed, every phone number calling was an unknown. I had no idea who was calling me at any time.

So it came to pass that one afternoon I went to the bathroom at work and had just seated myself when my phone rang. I looked at the screen hopefully but it was a number I didn’t recognize, with a Dallas area code. I made a split second decision to answer it, since I didn’t know who was calling or if it might be an emergency.

It turned out to be my insurance agent with an important question. She needed me to fax her a document, and I had nowhere to write a fax number, as I was still in the bathroom. Now, I made a second split second decision: finish my business and get out of there quickly, so I could run to my office and write down what I needed.

Why didn’t I just call her back? I wasn’t sure the phone number displayed on my phone was the one I’d need to call her at, and I didn’t have anything with which to write a different number if I had to go through multiple extensions. Again, a split second decision.

I stood up and covered the mouthpiece so she wouldn’t hear the toilet flush, then quickly pulled up my scrubs and exited the stall, cell phone tucked between ear and shoulder. As I walked toward the sink, my attending walked in the door.

It could not have been more obvious that I’d just come out of a stall on my cell phone, and there was nothing I could do about it. At all. I just had to go to the sink to quickly wash my hands and attempt to race out of there before anyone else came in.

Trust me, it was awesome.

Happy Valentine's Day, Texas!

2008-02-14T07:10:00.002-06:00

Just in time for Valentine's Day, a federal court has overturned a Texas law banning the sale of "novelty sex toys", aka vibrators. Enjoy your Valentine's celebrations!

A Little M.E. Humor

2008-02-13T15:05:00.002-06:00

*****Rated SG for "slightly gory". May not be suitable for children under 13 or for pets.*****

While out on a scene with a forensic investigator, we were all discussing food and how hungry we were after leaving the decendent. The investigator said she always gets hungry while photographing burn victims (ew). Then, she told us about the tricks she likes to play on rookie police officers on their first death scenes. Act 1: rookie officer is at scene of really gory "decomp", or a body that is being returned to the elements by bacteria. He is turning somewhat green (the rookie), so the investigator starts discussing what food she is going to go consume ravenously after leaving the scene. Act 2: another rookie, another scene. Acting in cue with the senior detective, she asks the rookie to collect a sample from the body. A sample of #2, if you will. As he got more and more upset, the detective told him "the ME said you have to, you better do it."

_______________________________________________

The other day, while discussing yet another "decomp" case to be autopsied, one ME teased another about how stinky she was going to be after doing the case. The ME assigned the decomp shook her head and said "If I'm going to be stinky, I'd just as soon stink to high heaven!"

********This last comment is REALLY GORY, rated RG, read at your own risk!***********

Forensic investigator said she's always wanted to take a photograph of decomposing skin to a paint store and ask if she could get paint in "decomp green" just to see what they'd do.

********RG alert is over*********

Just another day in the ME's office.

Where Have I Been?

2008-02-11T14:40:00.000-06:00

No, I didn't fall into a hole in a corner of the morgue, or become one of my own patients, or accidentally get zipped into a body bag. What has been happening in my life?

It all started with my husband getting a job last year. Suddenly, our household income increased from $nothing to $something. At the same time, we grew tired of constantly saying to each other, "I wish we had a house." We'd gone house-hunting several times, and had narrowed down to a general region where we might want to purchase a home. Still, we would need to wait for me to have a residency match with a proof of salary in order for us to buy a house, right?

Well, we found out almost by accident that we could purchase a house now by doing exactly that. We closed on our house in late January and since then my life has been a whirlwind of painting, buying furniture, picking curtains, painting, fixing the backyard fence (our dog has already escaped once--fortunately he came in the front door), trying to save our grass (who plants sod in January?), and painting. Painting took forever. Notice that I did NOT include "packing" in that list. That's because we have 5 boxes packed at this point, and we're moving this Saturday. Yes, I'm freaking out (but who expected anything different, honestly?).

That's where I've been, and that's what I'll be doing all week--packing and moving. I didn't even check my email all weekend (gasp!) because we were so busy, and yet I feel like we didn't get half of what we needed done.

I hate moving. At least I love my house.

My Patients Can't Talk to Me

2008-02-01T14:14:00.001-06:00

This month, just for a little change of pace, I'm working in the medical examiner's office. This morning I watched my first autopsy. I haven't decided how I'm going to write about this experience, because I'm bound ethically and legally in several ways. One, they made me sign a form stating that I wouldn't reveal personal information about any of the "decedents". Two, it might be easy to inadvertently reveal information that might seem harmless. For example (and I made this up entirely out of my own head), if I were to examine a male who died in a car accident, and I were to say "oh, his tox was positive for alcohol and cocaine", and someone astute went and looked at newspapers and found an accident that seemed similar, well then I've just leaked information about an ongoing investigation. Again, I made that example up. I just wonder about my ability to distort the facts well enough to be HIPAA friendly and ethical, so I probably won't put any autopsy stories on here (or at least, not about the findings).

Also, a friend of mine begged me not to gross her out. Please, she said, don't describe the smell, because I just don't want to know. That got me to thinking, how does one talk about autopsies without being disgusting? Around here, we look at photos of crime scenes, dead bodies, and such right after breakfast, then go work on dead bodies. The view of what is or isn't disgusting is necessarily skewed around here. You may notice that I'm trying to be very tactful here; I don't want to really offend anyone. So, whenever possible this month, I'll have my very squeamish husband read my posts before they go up, or I'll warn you if it gets gory for some reason.

I do want this to be a good month. I'm hoping to go to crime scenes and to court as often as possible. This should hopefully quench any desire I may have had to play Nancy Drew, or Sara Sidle in today's lingo. For this month, I'm doing something I will never, ever do again. I think that is really cool. Albeit kind of disgusting. I predict a LOT of showers this month. I may have to invest in lotion and heavy conditioner from all the washing.

PS: I got my Step 2 CK and CS scores back, and I passed everything, so I just have to pass jurisprudence and in the words of a friend, "not screw up" for 4 months and them I'm DONE!

Last Call!

2008-01-29T21:26:00.000-06:00

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!

Saturday Night

2008-01-20T18:48:00.001-06:00

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.

The Rot Slowly Sets In

2008-01-15T21:33:00.000-06:00

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.