Action Required....or Not

I feel like I don't know how to end conversations. Or perhaps I'm never sure when a conversation is actually over. Whenever having a conversation over the phone, I always wait until the other person hangs up. The ends of my online chats go something like this:

Mikey: Okay, well...I gotta go eat lunch.
Scooter: Okay, man, eat well.
Mikey: Okay, later.
Scooter: Later.
Mikey: Bye.
Scooter: You're still here?
Mikey: Uh, yeah.
Scooter: Leave, already.
Mikey: Okay.
Scooter: Well?
Mikey: I'm going, I'm going - my computer takes a while to shut down.
Scooter: Sigh. SIGH.
Mikey: Okay, this is for real. Later.
Scooter: GO. AWAY.

This has real world implications now, as I've received several emails from residency programs, some with ambiguous language as to whether they're expecting a reply from me. For example:

I am pleased to confirm and/or reconfirm your interview appointment, scheduled for Monday, Dec. 4, 2006 with the Internal Medicine Categorical Residency Program at the University of ....

Some programs are more concrete and clear, as in the following:

This is a reminder that you are scheduled to interview for a position in the Internal Medicine Residency Program at General Hospital on Friday, December 8, 2006. Please confirm by email that you will/or will not be attending this interview.

See? I like this. Clear directive. No questions as to whether they expect to hear from me or not. The other ones? I'm not so sure. And of course my mind is playing with my head, hinting that these confirmation letters are a test.

Like, what if I answer the ambiguous email but they're not expecting to hear from me? It could look too desperate:

Administrative Assistant: Lookey here. This applicant responded to the confirmation email confirming the confirmation.
Program Director: Why, how redundant. And a waste of internet bandwidth.
AA: And there's drool on the email.
PD: How can you drool on an email? Regardless, he's obviously too desperate to come here. Cancel his hotel reservation, disinvite him from the pre-interview dinner, find out if he has a dog - if so, kick it. And remove him from our rank list.

Or it could be the other way around. Clear communication, after all, is key in medicine:

AA: Mr. Program Director, it's been twenty-seven minutes since I sent the email, and Mikey has still not confirmed that he's coming to the interview.
PD: He's obviously not interested in us. His loss. Cancel his hotel reservation, disinvite him from the pre-interview dinner, leave a brown bag of flaming poo on his doorstep. And remove him from our rank list.

What to do?

No rest for the weary

My sub-internship is now a week ago in the past, and I've the next four weeks off. It's not a relaxing four weeks, as I've holed up in my apartment studying for the next step of the board exams. I really despise studying for these things, as it's memorizing for memorization's sake, and most of us will have flushed about 95% of this information within three months of taking the exam. I get to take frequent breaks, however, preparing for interview season - booking hotel and flight reservations, and once even going clothes shopping for the times when there's a pre-interview dinner planned. My wardrobe has very little in that area between dressy and casual, so I had to enlist some help from Kinjo - no shopping at Brooks Brothers this time!

I have one more week of studying before I start flying around the country. My schedule is pretty exhausting - I might be burned out of the whole travel thing by mid-January, but we'll see.

Medicine Sub-I, Day 28: Finished!

My sub-internship is officially over today. My last day on the wards was actually yesterday, so I bid farewell to my team and my last remaining patient. I had begun the day with three patients on my list, but only managed to discharge two, oh who cares.

It's over!!!

Medicine Sub-I, Day 26

A long-call day for the team. My team gets slammed, and there's nothing that I can to do help. First, my last day with the team is tomorrow. So for me to admit patients today would be inappropriate - new patients should be admitted and worked up by the people that will follow them for a relatively long period of time. It's too much trouble for me to do the initial work then transfer it all to someone else the next day. Second, even though I want to relieve their pain, my choices are so limited. Medical students here can put in orders on patients, but every single one of those orders has to be reviewed and verified by someone with an 'M.D.' after their name. Which is how it should be, but it can really slow the pace of patient care if no M.D. is around to sign the darn orders. So, since I can't write valid orders, I'm really of no use to the team. I could have gone home a half-hour ago, but I'm still waiting for someone on my team to catch a break and help me out over here.

Medicine Sub-I, Day 24: Oh. My. Gawd.

GUH.

Medicine Sub-I, Day 23: Yin-Yang

If you can't say anything nice...

Sometimes no matter what, you're a target. Just a white coat with a big-ass BULLSEYE on the back. I was sitting down, writing a progress note, when one of my patients sauntered up to me with one of her family members in tow. Said family member began to growl at me, at the quality of medical care in general, and also complaining that the patient was unhappy with the quality of care, which was news to me. I asked if she could be more specific. She couldn't, and proceeded to tell me that one doctor told her one thing, then another told her another thing. Again, I asked, could she be more specific, then maybe I could better address her concerns. She couldn't, then asked me if I was a 'real' doctor or an 'intern' doctor. Neither, I replied, I'm a sub-intern, but I'm the most heavily involved in the patient's care. At which point she told me that she didn't want to talk to me but then proceeded to bitch and moan at me some more, anyway.

Without being more specific (and thus violating health privacy laws), all I can say is...it's really hard not to hate people sometimes.


Every dog has its day...

Evaluation day for me, as my attending is leaving the service. So we spent some time talking about my performance during the sub-internship. I'm pleased with the evaluation. Again, same old same old with the constructive criticism - I'm the quiet type, I could pipe up more. Whatever. I'll move on to residency and strike a blow for all the quiet types out there.

Medicine Sub-I, Day 20

A long-call day. Nice that it is on a weekend, though, so we can concentrate on doing the work that needs to be done, uninterrupted by lectures. I picked up two new patients.

One is admitted with chest pain. A nice fellow, he's in a jolly mood answering my questions while eating dinner. I lay out the plan, and he's on board waiting for the test results as we do the 'Rule Out M.I.' Dance. A few hours later, he goes all bipolar on us, yelling at the nurses, yelling at me, ripping out his IV, and leaving the hospital against medical advice. It could have been worse, I suppose - while the scene wasn't particularly pretty, none of us felt physically threatened at any time. I did my duty as best I could trying to convince him to stay, but in the end he was dead set on leaving. Thankfully none of us are especially convinced that he was having a heart attack anyway.

My resident asks me if I feel like I've learned anything during the sub-I. "I've learned how to 'rule out' an M.I." I answer, "but I have no idea what to do next if someone is ever 'ruled in'." He doubles over in laughter.

Medicine Sub-I, Day 19: Yet Another Day Off

It only seems like yesterday that I was writing about another day I spent not in the hospital. Dang - this is like the slacker sub-intern schedule.

Anyway, the following is a list of errands I ran on this gorgeous day - 65 degrees in late November - only in Boston....

1. Showered, brushed my teeth, and got morning coffee - c'mon, even off days have to start right.
2. Washed my dress shirts - Ring around the collar, ring around the collar...
3. Changed the oil in my car, and the transmission fluid, and the brake fluid, and... - the grinding and clunking coming from my engine is a signal of something...something not right.
4. Grocery shopping - For there is a limit to how long anyone can live on stale whole wheat tortillas and condiments alone.
5. Agonized about travel plans for interview season - yeah, that's right, no movement here, just stressing out.
6. Studied for Boards - zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz

*******

A fun interaction yesterday with my 'interesting patient', the one that mocks me for coming in 'late.'

Patient: I really like your shirt/tie combo today.
Mikey: Hey, thanks. I really can't take credit for it, though. The salesperson at Brooks Brothers picked out the tie.
Patient (mocking/spitting): Brooks Brothers?!?! I figured you a little too young to be shopping there.
Mikey: Well, how old do you have to be before you can start shopping at Brooks Brothers?
Patient: Like...near DEAD. That's an old people's store, Mike. You here me? OLD!!


(Note to self: re-assess state of wardrobe.)

Medicine Sub-I, Day 18

My sub-internship lasts for another week-and-a-half. However, in 3 days, some of the faces on my team will change. One intern rotates over to the hospital across the campus. The resident will move to the MICU¹. The third-year students go who-knows-where? So, as a token of appreciation for the team's work, the attending physician took us all out to dinner before the switch. I arrived at the the restaurant a few minutes later than the rest of the team, and I ended up sitting right next to the attending, I'll call him, oh....'Dr. Stallone'. You should know first that Dr. Stallone is also high up in the Medicine Residency Training program, so I'll most likely be seeing him again when I interview at my own school later next month.

So...what to do when Dr. Stallone is ordering round after round of margaritas?

First round: "Okay, I'll hold myself to one. I have to drive home, after all."
Second round: "Well, it would be rude to refuse a drink from the attending physician."
Third round: "Yes, sir, you're absolutely right, I need another one of these fine concoctions from these very fine people from south of the border."
Fourth round: "Hey! I don't think this floor is made from real volcanic rock². And are those my pants over there? No, really, Dr. Stallone, I'd be a great addition to your residency program."

Well...I'm anticipating a bit of a hangover tomorrow.


¹ Medical Intensive Care Unit
² However, the guacamole was prepared in a genuine molcajete, a mortar made from volcanic rock.

Medicine Sub-I, Day 17

Now this is what I expected my sub-internship to be. A hard day. A long day. Patients getting sick, sitting by the bedside or by the machines that they're hooked up to, and watching and waiting for them to get better or get worse. And feeling like a nervous wreck the entire time, not having time to get work done like writing progress notes or making follow-up appointments for the patients, or even eating. Yet I think I'm still enjoying myself. Wait a minute...whose idea was it for me to go to medical school, anyway?

Medicine Sub-I, Day 16

For the last ten days, my patient greets me in the morning with a mocking, yet cheerful: "You're late." Apparently he wakes up at 5AM and watches television or reads the paper. Plus I'm pretty sure the hospital bed really isn't that comfortable. Anyway, I finally decided to hit him with a comeback:

"A medical student is never late...nor is he early. He arrives precisely when he means to."

He totally didn't get it.

Medicine Sub-I, Day 15

Halfway through, so far so good.

The team is post-long call, so we tried to get out a little earlier today. We tried a Korean restaurant north of the city, who recommended it over the more popular alternative (where Korean natives almost never go). I tried something new...all I can say is, I hope it doesn't hurt as much coming out as it did going down.

Medicine Sub-I, Day 14

It's gorgeous in Boston today. Rare, wispy cirrus clouds streak across the clear blue sky.

And we're stuck on long call, imprisoned in the hospital until at least midnight.

Medicine Sub-I, Day 13

A day off.

I took this opportunity to go interview suit-shopping, accompanied by my sister. She's pretty much around so I don't purchase something like this:

Medicine Sub-I, Day 12

How quickly things change. My 'interesting' patient is getting better. An older gentleman with multi-drug resistant HIV, and a lung nodule suggesting lung cancer, he has come to recognize me as the point man during his stay in the hospital. There's a trust between us, and he seems happy to see me every morning - partly because I'm one of the few people that actually tells him what is going on. Well, trust can be fickle. I walked into his room in the afternoon, and he unleashed a bit of vitriol at me, over a number of petty little things. I suppose that I was a bit hurt by the change in demeanor, but I suppose if I were in his situation, perhaps I would be just as frustrated. This person is seriously ill, and we're nearing the end-game. There are limits to what medicine can do, and I believe he's coming to terms with that.

And I'm coming to terms with the fact that I can seem like God's gift one day, then a total goat the next.

Medicine Sub-I, Day 11: The 'Rule-Out'

Today the team was inundated with patients that were admitted for chest pain. Most of time, chest pain doesn't mean much - a muscle pull, maybe chostochondritis, perhaps they merely forgot that somebody kicked them in the sternum when they were passed out drunk on the pub floor. However, because you never want to miss someone having a heart attack, most people with chest pain are admitted to the hospital for observation - "Rule Out M.I.¹". These admissions are quite annoying - they hardly ever amount to anything, we just sit there waiting for a bunch of blood tests to come back, we spend at least an hour working on the admission, then several hours later, we spend another hour working on the discharge paperwork. Of course, it'd be even more annoying if an M.I. were ever 'ruled-in.'

*******

I'm trying to schedule interviews during the spare minutes I have during the day. I literally have so little time to accomplish so much in the next couple months. It'd be nice if I could group all my Pittsburgh interviews together, then my Chicago interviews another week, and my Ohio interviews another week. But no, it's not going to be that easy, of course. I'm going to be spending quite a bit of moolah on plane tickets and hotel rooms, and lots of time missed from school. That's not going to go over so well.



¹ myocardial infarction

Medicine Sub-I, Day 10: A Bloody Mess

That's right. Ten days into the Sub-I. Which also means that I should have washed my white coat, oh....about nine days ago. This thing could probably stand on its own and walk away right about now. There's a brownish splotch on my left sleeve that I'm certain has formed an imperialistic dictatorship, and I believe they're about to declare war on a small, innocuous blood/ketchup stain on my right lapel.

*******

Sleeping Beauty, my CMO patient, is gone. No, she hasn't passed yet, but is going off to hospice. I had to pull out her femoral line before she left. My resident - Gerhardt - asks me if I want help. No, I answer, how hard could it be? Cut the stitches, pull out the line, and put pressure on the site. No problem! Yeah. No problem. But jeez these femoral lines bleed like a MoFo.