Perspective

Every now and again, some experience comes along to remind me that I have it pretty good. That I'm lucky to be where I am. That there are those who are struggling with issues that go far beyond whatever I'm dealing with in my life. The last one occurred when I spent a week at the Betty Ford Center and got to hang out with the families of people that were fighting various addictions. I had the opportunity to see how addiction hurt families, destroyed relationships, destroyed lives.

More recently, I followed closely the medical care of a young man with sickle cell anemia. 'TJ' is a young teenager with the most severe form of sickle cell anemia. He was brought to the hospital for his latest flareup, termed a vaso-occlusive crisis (VOC). Some trigger causes the red blood cells to sickle, and these misshapen cells end up blocking up the vasculature, mostly in the long bones. This in turn can result in bone marrow infarction, causing severe pain. TJ is admitted to the Pediatric ward for pain that he rates an '8' on a scale of '10' in his arms, knees, and lower back. A number of things can causes these crises, among them dehydration or just cold weather. Many of these patients experience three to four hospitalizations per year on average. TJ has also come in with a little shortness of breath. While he's in the hospital, we'll also watch him closely in case he develops acute chest syndrome (ACS).

The first time I enter his room, TJ really doesn't interact much with me. I try asking him the standard medical workup questions, but don't get much out of him. Perhaps he's sick and tired of being in the hospital, and the last thing he wants is to answer the same damn questions from yet another person. Perhaps it's because he's in so much pain that any movement, whether it's turning his head to look at me, or breathing, causes him so much pain. Maybe it's because he's hooked up to a morphine drip and the painkiller is making him too groggy. I suspect it's a combination of all of these things. The only thing he manages to convey to me is that the hot packs on his legs have gone cold, and he needs a fresh batch. At least I'm able to do that for him.

Later, I try to ask him more about his illness. We like to ask the kids what they want to be when they grow up. Most of them say they want to be a doctor, which, of course, is the right answer when they're in the hospital. TJ can't articulate any dreams to me. He ends the interview abruptly, as he has to go to the bathroom. He's still in too much pain to get himself out of bed, so he grabs the hospital urine bottle. He's a pro, handling his business with amazing proficiency (if it were me, I'd probably get some in the bottle and most of the rest would end up on my bedsheets). I walk out of the room and take a couple of moments to think about TJ - 'sicklers' have a life expectancy of 42 years. What kind of dreams do you hold when you're not expected to make it much past middle age? I find it disconcerting that TJ has so much expertise at hospital life. He shouldn't be gifted in the nuances of life in the hospital, administering himself morphine 10 times an hour with the PCA. We shouldn't have to be giving him laxatives to counter some of the more embarrassing side effects of morphine. He should be out running around getting into trouble with his friends or on the basketball court practicing his free throws. He shouldn't be living life with constant 5 out of 10 pain. Every time he comes into the hospital he gets a chest x-ray to watch for development of ACS. It's astonishing to realize how much we've irradiated kids like this.

The truth is that he manages his disease better than anybody else. He lives in a single parent home, and there's been DSS involvement in the past for concerns of neglect. TJ is even able to correct the nurse when she forgets one of his many medications. All we can do for him is try to minimize his pain, keep him hydrated to prevent another VOC, and treat him for ACS when his latest chest x-ray comes back showing new infiltrates in his lungs. Eventually we have to try to wean him off the morphine. He understands that this has to be done if he's ever going to get home. His complacency with this plan frustrates me. Part of me wants him to yell at us, that we're not managing his pain well enough, that we're not doing a good enough job. But no - TJ remains his quiet, stoic self and never lashes out. I feel like I can't connect with him - sometimes I feel like I'm merely annoying him with my constant questions:

How's your pain? Are you short of breath? Were you able to eat? Were you able to go to the bathroom? Do you need any more hot packs?

But I did what I thought I could. On my last day on the Pediatric inpatient service, I walked into TJ's room to say farewell. I told him I hoped I'd never see him in the ward again, and he laughed. He shook my hand and said goodbye.

*******

I suppose working with TJ made me appreciate more the fact that my life is full of choices. Sometimes I bemoan the petty little annoyances like being single, or having unfulfilling relationships with those close to me, or stressing out about climbing the academic ladder. But I can still choose to be content with my life in spite of these things. I've got years ahead of me to chase my dreams, and more than enough time to form new ones. That's something that not everyone has, and shame on me if I ever forget that.

Time Flies in Pediatrics

I. The Write Stuff

You hear so often how little time physicians spend with their patients, and now I'm living it. I get to spend the most time with my patients during their initial workup, which involves taking a comprehensive medical and social history, plus a physical exam (usually focused). If done thoroughly, the history & presentation (H&P) can take over an hour. This is unrealistic no matter the setting - inpatient, outpatient, free clinic, whatever. As a rule of thumb, taking a relevant medical history, performing the physical exam, and composing an assessment and plan should take the clinician about 15 minutes. That doesn't seem like much, does it? Believe me that the medical community tries to optimize their time to enhance patient satisfaction as much as possible. Really. Go to PubMed and type in 'patient satisfaction' and see how many hits turn up. There's a study out there which I've not found yet, that says something to the effect: out of the 15-minute visit, if the patient spends at least 7 of those minutes talking, he or she is more likely to walk out of the doctor's office with more satisfaction. Yeah, I think that level of analysis is pretty cold, too.

Anyway, if we spent more time with our patients we'd never get anything done. And that thing we're doing when we're not interacting with our patients is writing writing writing. We're writing the H&P or writing orders or writing progress notes or writing discharge summaries. And now that I'm a young (stop chortling you out there. Young-ish. I'm at least young-ish) physician-in-training, I'm trying to figure out why this paperwork takes so darn long to write. At any one time, I'm only carrying two or three patients. Last time I was on call, the intern handed me two patients in the early evening in the hopes that I could get cranking on the paperwork and hopefully get out early. But noooooo...I started writing their H&P's around 8pm. I didn't get out of the hospital until 2am. (I got home at 2:30am, trying to decide whether I should risk grabbing some sleep and having to fight waking up, or just pulling the all-nighter. My neighbor was still playing his horrible house music, making the choice easy for me). Anyway, I think the problem is this:

I. Write. Sloooooooooooooooooooooowly.

To those of you who read through my experiences writing my thesis, this comes as absolutely no surprise. Somewhere in the near future I need to draw up some third-year medical student rules a la Fight Club. "The 1st rule of Third Year is....you DO NOT piss off your intern! The 2nd rule of Third Year is....you DO NOT piss off your intern! The 3rd rule of Third Year is....learn to write FAST" and so on.

Same problem, different context - the record keeping in the medical field is crucial when there are multiple caregivers, so you need to write as efficiently as possible - and I really like the narrative to flow smoothly. The patient's hospital course is a story, after all, with a beginning, some mystery in the middle, a conclusion, and the denouement. If the reader is in tears by the end of one of my discharge summaries, then I've done my job.


II. 'Tis the Season for Bronchiolitis...

cough-cough-cough-cough-cough...hack-wheeze-wheeze-cough

I've had the great privilege of taking care of two toddlers who have lower respiratory tract infections, one of them a joyful little guy with diastrophic dysplasia. It's winter, so we get quite a few admissions where we have to closely monitor respiratory function of babies. I'm able to steal a few minutes with the babies just to play with them and get them to smile. I guess I'm 'okay' at this...some med students you just look at and there's this word 'PEDIATRICIAN' in neon lights over their heads. Me, probably not so much, but I'm enjoying this clerkship enough to consider it as part of my residency training.

Self-assessment in Pediatrics:

• Play-fu: 6/10
• Tickle-fu: 9/10
• Cooing-fu: 0/10. SUUUUUUUUUUUUUUUUUUUUUUCKS!!!! I attribute this to the fact that I have two sisters, neither of whom has been considerate enough to provide me with nieces and/or nephews to practice on. Come on people what are you waiting for????

Oh, The Totality!

So...'They' totalled my car. 'They' being the insurance company on the advice of the latest appraiser to take a peak at my car. Mind you, it's a bit of a 'soft' total, as my car is still drivable with a little touch-up paint here and there (plus a brand new front bumper and engine hood).

Apparently I have two options:

1. Accept the loss and accept the $4.53 for the value of the car, or
2. Convince the insurance company to 'untotal' the car and let my mechanic get to work.

Well, since I have:
a) not enough money to even think about buying a new/used car,
b) even less time to even think about going car-shopping,
I'm hoping for option #2.

It's been three weeks since the accident, and my car is still sitting in some lot, rusting into nothingness. God, this rental car is costing me a fortune.

Kids

Orientation for Pediatrics was on Monday. The orientation lasted about 8 hours - some of which was useful, a lot of which was a waste of time. One particular funny moment (funny as in 'uncomfortable' rather than 'humorous') was during the Introduction to Pediatrics video, which explained to us that the physical exam on young patients can sometimes be difficult. They tend to perceive medical instruments as invasive and will react accordingly. It's easy to see how the otoscope can be scary, but the stethoscope itself can apparently evoke screams of horror. In the video, one pediatrician said that it was almost impossible to properly examine the oropharynx of the pediatric patient without the use of a tongue blade (I prefer to use the term "tongue depressor", but to each his own). "It is essential for you to master the proper use of the tongue blade," she said. "First, slide the blade down the gumline. Now twist...and now....GAG!" (emphasis, mine). We look askance at one another - "Did she just say what I think she said?"

Then, they brought in a lawyer. I snuck a picture:

Just kidding, Kinjo (serves you right for punking me). The lawyer was actually there to explain to us our role in looking for signs of neglect or abuse in the pediatric population. It can be a bit stressful, I suppose, because the way she put it was: "If you miss it, you're liable for malpractice" or something like that. But, she then pointed out all the resources that were available for us to contact if - no, when - we suspect that something is amiss. I'll refer you to Kinjo's blog, which has some links to organizations which deal with child protection. Pretty depressing stuff.

But, to make it all better, they handed us toys!!!!

Unfortunately, the toys are for our patients. Dang. Anyway, I hit the toy store and got some more toys to hand out. I'm thinking I'm going to enjoy this rotation.

*******

I start off on the Pediatric Inpatient Wards - I'm not just looking at ear infections and sore throats here. Here are two of the first two patients I hear about - I'll just give vague details to give you an idea of what I'm talking about, while protecting the kids from any sort of identification:

1. 2-year old boy with failure-to-thrive - DSS is trying to get custody, but can't find his mom to let her know when the hearing is scheduled. He's bounced around several foster homes, and he sleeps in a strange position. There may be bruises on his back. In contrast to the other beds and cribs on the ward, there are no balloons or toys or candy - his crib is bare. He's scared of all of these older people staring at him. We order a full skeletal survey to check for old fractures. It's nice to hear the attending physician tell the nurse to dig through some of the Christmas toy donations to see if there's anything that the boy would play with. Trust me that this kid was treated like a superstar while he was on the wards.
2. A 4-day old girl with a broken arm. It's not uncommon that arms can be dislocated or broken during birth. But the radiologist has never seen a fracture like this in his 50 years of practice from such a circumstance. X-ray shows a compound fracture in the middle of the arm - one may imagine how stress fractures or microfractures could occur, but how this break occurred is unfathomable. The case has now been labeled with "NAT." (I'm seeing too many "NAT's" on my patient list.) DSS refuses to let her parents in to see her unless they themselves are supervised.

*******

They don't hand those difficult social cases to third year medical students. I've followed two patients so far, and both they and their families have been wonderful to deal with. Thank goodness.

One for the Thumb

Hallelujah!

Kind of a sloppy game, but the Steelers were able to hold a potentially explosive Seattle team to just 10 points.

Phew!!!! Excuse me while I go over to CVS not for Prozac, but instead several crates of tissues.

* sniff *

Whoopee

I'm published again. Yippee!!!

*******

What I'm listening to now: El Salon Mexico, Aaron Copland

The Day Has Arrived

...and I'm positively sick to my stomach.

I'm trying to figure out why I care so much. I mean, I'm not the type that's going to smash store windows or set cars on fire if my team wins or loses, but I do put my emotional health on the line whenever these championship situations arise (which is, to say, not too often in the last decade). So...if the Steelers win, I'll feel euphoric for about a day, then get on with my life. But...if the Steelers lose, man, I'm going to hit a week-long funk that's going to have me begging CVS for their entire stash of Prozac.

Go Steelers

Tale of the Hood

An update to my car accident story: My faith in humanity is justified. The driver of the other vehicle didn't bother to give the insurance company my information, essentially admitting fault for the accident. My mechanic is surprised. However, there is a hitch (of course). Apparently the latch of my engine hood was damaged when my car's front bumper was hit from the left side. This damage wasn't apparent during the appraisal, and did not make it into the report. While I was driving up to the mechanic, the hood popped open and slammed against my windshield. My car's hood is now somehow inverted the wrong way. Miraculously, my windshield didn't sustain any damage. Perhaps even more miraculously, I didn't get into another car accident despite driving down the road with my vision obscured by my car hood.

Now I'm trying to convince the insurance company that the damaged engine hood should be covered by the same claim. They're open to the idea, but it's going to take some convincing on my part. We'll see....

*******

I'm done with Family Medicine! Three more clerkships until being officially done with third year. You know, this whole idea that 'the third year of medical school is wicked hard' is bunk. I'm having a pretty good time; the only 'hard' part of third year is trying to find enough time to read.

Anyway, I've completed Psychiatry, Internal Medicine (from herein referred to as 'Medicine'), and Family Medicine (referred to as 'Family'). If I had to choose from these three, well, Psychiatry would be last - I enjoyed it, but...it's not a career choice for me. Choosing between Medicine and Family is a bit of a struggle, though. Medicine is almost a default choice - the problem is, it seems like a stepping stone to specializing in something else. Not that one couldn't just do Medicine and become a general practitioner, but if you know you want to be come a generalist, Family would probably be a more logical way to go.

I'm pretty sure I want to be a generalist. I really enjoyed Family - there was no limit to the problems or the population I would see. One day I could be looking at twenty cases of Strep throat, the next day I could be delivering babies. If I chose medicine, I would say goodbye to dealing with the pediatric population, which I would miss (except for the two-year olds). But I feel the pull of Medicine and the allure of training at a large academic center. And I have to wonder WHY? I mean, if you've been reading this blog long enough, you know how I feel about these large academic behemoths and all it takes to keep them running. Perhaps it's out of familiarity - that I've been in the system for so long, I'm a bit scared about getting off the beaten path. Maybe the institutional bias against primary care has been subtly implanted in my head. It's going to be a tough choice.

So - current rankings:

1. Internal Medicine/Family Medicine¹
2. Psychiatry²

*******

¹ I know, it's a copout, but HEY - it's MY blog
² Well, technically it shouldn't even make the list, but I'm a believer that all lists/outlines should have at least two points

That's What I Should Have Said!

Every now and then, when the medical field isn't making us read thousands of pages on the pathophysiology and treatment of a zebra disease like pheochromocytoma, they try to make a point about how one appropriately relates to the patient. Apparently some of us have forgotten how to relate to people, but this advice is well appreciated - stuff like, "Always remain at eye level with the patient" and "Let the patient address you by your first name." All of this is to dispel the illusion of there being some hierarchy in the doctor-patient relationship, which is important, because we try to promote the team aspect of achieving the best results in the patient's health.

Another thing they tell you is to be non-judgmental with the patient. There are so many different cultures and alternative lifestyles out there, it's in both your interests not to come off as condescending. Reasonable. I haven't had a problem with that, as I can be pretty stoic to begin with. Sometimes, though, you struggle to search for the right words because total honesty would be, well, bad.

Let me explain with the following examples:

Patient 1: A 30-something year old woman comes into the voice because she has felt sinus pain and pressure for the past two days. She is a smoker, and her last bout with sinusitis was treated with a course of antibiotics. After taking the appropriate history and performing the relevant physical exam, I present my assessment and plan to the patient. I think she has sinusitis caused by a cold virus. A two-day history of symptoms is really not the time to be prescribing antibiotics, so I tell her we'll probably treat her symptoms - vitamin C, zinc lozenges, honey lemon tea, maybe some echinacea. "WHAT ARE YOU TALKING ABOUT?" she sneers at me. "I'm a pharmacist! I know about drugs! I want something so I can function."

What I say: Okay, that's something we can talk about. You are a smoker, and you have had prior bacterial sinus infections, so a course of antibiotics may be appropriate for you.

Translation: Oh, you're a Pharmacist, huh? Then you must realize that these antibiotics will probably do nothing for you, they'll make you feel like crap for a couple of days, and I'll bet you're back here in 10 days begging for more antibiotics. Add to that the fact that the more you use antibiotics, the more you depend on them and not your own immune system to fight off the buggers. Why people get addicted to feeling nauseous and willingly give themselves a bout of diarrhea is beyond me. And no - acute bacterial sinusitis doesn't require antibiotics if you only have mild to moderate symptoms - but I'm sure you Pharmacists work from better guidelines than I do.

*******

Get my drift? Here's another one.

Patient 2 is an elderly gentleman with chronic obstructive pulmonary disease (COPD). Management of COPD is geared more towards making the patient comfortable and preventing further damage to the patient's lungs. He's in the office for a follow-up visit to see how he's doing on his medication regimen, and - he's clinging to this clipboard. Perhaps it's his list of medications (always a good idea to have on hand when you visit the doctor, folks). Anyway, I start off the interview with the standard: "Hello, Mr. Smith, I'm Mikey, a student at Suchandsuch University, how are you feeling today?"
Mr. Smith has no complaints, except for the fact that he's concerned that Massachusetts is going to become known as the "Gay State" and he's getting as many signatures as he can to prevent that from happening.

What I say: Well, that's certainly interesting. It's always nice to have a cause to feel passionate about. But let's get back to how your breathing is doing. Are the inhalers working for you? Do you need any refills?

Translation: Mr. Smith, you have a serious lung disease. You will be living the rest of your life gasping for breath, and that's when it's pretty well controlled. You're more prone to other diseases such as lung cancer and heart failure. You'll likely be visiting us often for respiratory infections over and over again. And your dying breath is going to sound something like Ricardo Montalban in Star Trek II: Wrath of Khan - "From Hell's heart, I stab at thee. For hate's sake, I spit my last breath at thee." Nice.

*******

And this next one is my favorite, so far.

Patient 3: A 16-year old girl has just given birth to a baby girl. She would rather bottlefeed the baby, because, well, breastfeeding is "icky."

What I say: Certainly there are plenty of options in providing your new baby daughter with the proper nourishment. I'll have the breastfeeding nurse come in to talk to you about all of these in detail, okay?

Translation: Icky? ICKY? Do you remember what you did to make this baby in the first place? I call 'Bullsh*t.' You probably did worse to your boyfriend. And you think breastfeeding is ICKY???

*******

What I'm listening to now: Five Tango Sensations, Astor Piazzolla and Kronos Quartet