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

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

Doctor Drug Rep

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

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

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

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

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

While I'm Not Studying

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

Happy Thanksgiving!

Eat turkey!

Psych and Medicine

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

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

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

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

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

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

Isn't it Ironic?

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

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

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

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

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

Denouement

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

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

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