Serendipity

My hospital is an odd combination of old and new technology, because physicians hand-write orders, but then the nurses enter them in a computer. It's a bit ridiculous, but for some reason some paper pusher somewhere figured it will save money.

Anyway.

Recently I admitted a patient with vague abdominal pain, and since the surgeons decided not to cut him open and the ER attending wouldn't let me send him home, the guy was admitted. (That's another whole story) We gave him a laxative and some Motrin, but figured we'd also try to figure out if anything else was going on, so among other things I wrote for an anti-S. cerevisiae level, as this antibody is elevated in Crohn's. The nurse taking off the orders was new, and unfamiliar with the computer, which will auto-complete the orders as they are written, and instead she sent an Ascaris lumbricoides battery. I've had similar problems with the computer before, and as both of the computer abbreviations for these labs begin "ASC..." it was an easy mistake to make.

Ascaris, for the one or two non-medical readers out there, is a roundworm which is very common in third world countries, but not so much in the yuppie demographic my patient belonged to. I saw the order in the computer later on the night of admission, and went to change it, but the original had already been sent. So we sent the Crohn's lab and thought no more about it.

Flash forward a week. The patient is discharged, and as far as I know still having the vague abdominal pain when his labs start to come back. And though he doesn't have Crohn's, he does have roundworms. It's an easy disease to treat here in America, but we never would have caught it if the nurse had had more training.

To line or not to line?

This month I'm back on the inpatient wards, and for a variety of reasons (not least of which, I flatter myself, is my outward impression of competency) my senior resident has been very hands off in dealing with me. She lets me know if there's a patient in the ER to see, and then swings by about 45 minutes later to see what my plan is. The confidence is good for me, because I'm realizing I actually have learned a lot in the past few years. Pulmonary embolism? I know what to do. Diabetic ketoacidosis? I'm all over that. But only recently have I started standing up for my ideas against those of my seniors.

From my perspective as an intern, desperate for procedures and learning opportunities, it might have been a bad idea. Mrs. Wilkins was a 70-something year old diabetic with renal failure, and the ER was unable to get IV access on her. Normally they would just stick a central line and call us, but we weren't particularly busy and admitted the patient before they had the chance to. Once we got her up to the floor, my senior told me to get consent and then put in a central line. I was fairly excited about the prospect, because I'm getting close to having done enough not to need supervision for this procedure. But I'm trying to be an internist, so I sat back and considered for a minute. Mrs Wilkins didn't need a central line, she needed maybe a little fluid and the occasional lab. Since we hadn't gotten an IV downstairs we didn't have coagulation labs, and for all I knew she had an INR of 4. So instead I grabbed one of the techs from peds and he got a nice peripheral line on the first try. We gave Mrs. Wilkins her fluids, readjusted her insulin regimen, and sent her home two days later.

It's not a particularly moving story, I know. But it stands out to me as one of the first times I went for something less exciting because I was thinking for myself, and for the patient, rather than for a check box in my training. It was a small step on my road from technician to physician. And even if I still need another central line or two, that step was the more important one.

Don't let them change you

The past is the only dead thing that smells sweet,
The only sweet thing that is not also fleet.
I'm bound away for ever,
Away somewhere, away for ever.

The one piece of advice I got sick of hearing when friends/family/people I met on the street found out I was going to medical school was "don't let them change you." I think a lot of people see doctors as a bit disinterested, which is probably why my patients are so pleased when I actually sit down and listen to them. Don't let them change you, I heard, as if staying the same was possible and desirable.

I am finding out it is neither. Even during medical school I found myself picking up on the dark humor of my teachers, my attending, the residents I worked with. But it hasn't been until this last week or so that I've really started understanding it.

I walked into the intern work room yesterday when post call, having been awake and busy with mindless paperwork for the last 18 hours, and awake and seeing patients for 12 hours prior to that, and announced "I'm done even pretending to care any more." There were a few laughs, because we all say similar things occasionally, desperately clinging to humor as a defense against the rising tide of futility and anger and sleeplessness and frustration that is internship. But at that moment, I meant it.

The strain of maintaining insane attention to detail that has never come naturally to me is starting to tell. A few days ago I wrote up the plan for a patient, presented it to my attending, and enacted it. Now the patient is dying, intubated in the ICU, and though a relatively small change in my plan might not have made a difference, it also might have. He is 50 years old. Now despite the fact that it is my attending's responsibility, it is also still my fault. And while my resident was pretty nice in the way he pointed out the mistakes, my attending (perhaps to cover her own insecurities) has not been. I feel bad enough on my own, but her "teaching" of me now takes the tone of an owner-pet relationship. I want to remind her that "you signed off on the plan too, doc" but I value my future in this program.

I've changed, I know. I'm thinking maybe there is a finite amount of things we are able as humans to care about, and in the strain of this environment, having to deeply care about lab values, paperwork, physical exams, paperwork, research, paperwork, interpersonal dynamics, paperwork, the opinions of your superiors, and yes, paperwork, the pain of the patient gets bumped from the list, usually right after you bump your personal life from it as well. It becomes easy to see patients as intentionally causing you more work, even nice 80 old men with funny stories, because they are being admitted to your team for the third time this month. And that's mostly because they like the hospital more than home and are able to convince the ER that they need admission.

Probably part of residency is learning to deal with this strain and busy-ness while maintaining some compassion. But I'm finding that the teaching we got in medical school on implying compassion with body language and listening was some of the most important of all. At the time I thought that would come naturally, since I cared about patients. Now I'm finding that much of medicine is acting. Some patients are easy to like. But no one who is solely human has ever loved all mankind equally. And with tiredness and frustration and a tangible link between whining and hours spent in the hospital, an increasing segment of the population becomes difficult to love.

So yes, I've changed. Some of the compassion is acting. But the acting allows me to do my job, to be more dispassionate, to view a patient and their disease as I have to to treat it. Because I'm thinking maybe if I liked that guy less, he wouldn't be dying. But maybe I just need a vacation.

West Indian Girl - 4th and Wall

This was unexpected. I've written before about being surprised how popular, in terms of comments and email, my music reviews have been, but I definitely did not expect to have music recommended to me by promoters on the basis of my reviews. When, therefore, just such a person recommended this album to me, I was skeptical. However, I gave the promotional track a listen, and was interested enough to check out the whole album.

Electronica and rock have enjoyed tenuous relationships in the past. I'm not exactly a music historian though, so in order to avoid doing any research, I'll just say that a long creative thread runs at least from Emerson, Lake, and Palmer through Madonna's "Ray of Light." It is a genre I enjoy, and though I no longer fall asleep to the Future Sounds of London, the formation of sound and art through digital means still speaks to this 21st century soul.

If in my last review I was complaining about how often mimicry passes as artistry, this album stands as a lesson to aspiring artists. You can work in a given style, but you need your own twist. Putting a twist on an old style for the sake of the twist is obnoxious (like Jet pretending to be the Rolling Stones), but when you do it as part of a coherent vision, like West Indian Girl is doing, it becomes worthwhile. While listening, I was trying to make comparisons, but winding up with absurdities in the process. Folksy Pink Floyd. The Shins meet U2. Perhaps it is best I am paid to be a doctor, and not a music reviewer. But it is true that I have not heard anything exactly like this crew before.

"To Die in LA," opens this album with a distant flute sound, but rapidly picks up, adding drums and synth until the singers (in their first clear words on the track) voice the listeners' own thoughts with a chorus of "here it comes." I'm not certain the lyrics on this particular track are meaningful. They aren't particularly important, as in most trip-hop, but they do get the album off to a fast paced start with a few cool vagaries. Even if I was rocking with the album, I wasn't truly impressed until the track "Solar Eyes," where electronic beeps and an acoustic guitar trade off without jarring the listener. It sounds impossible, but they manage to do it. Throughout the album, with transitions like that, the confidence with which the disparate sounds were melded struck me. Also, I admit (though it is no surprise to anyone familiar with my defense of Keane's first album) that I like songs with a tune. That's why X&Y didn't really do anything for me. But the tracks here are all hummable.

It's not a perfect album. The band struggles with ending their songs, dragging the otherwise strong "Sofia" on at least a minute more than truly necessary. And the lazy, psychedelic "All my Friends" will never rank in my favorite track list. Of course, the Goa-trance meets folk marriage here (there I go again) is bound to have some distinctive offspring, some more palatable than others. Still, there is quite enough to enjoy here, and this one is going to be the soundtrack to my commute for a while yet.

Just another call day, or good nurse, bad nurse II

Me imperturbe, standing at ease in nature,
Master of all or mistress of all, aplomb in the midst of irrational things

Eleven am. I walk into the hospital, change into scrubs, and within ten minutes I'm admitting my first patient of the day. By mid afternoon, I'm collecting signouts from the other teams, and by 6pm I am responsible for the medical care of some fifty patients overnight.

At about 9 pm Mrs. Stone really lost it. She was frustrated with the primary team's treatment of her husband, and utterly convinced that IV antibiotics were better than oral. So she and her husband decided that was a great time to page me, the night call resident, and demand IV antibiotics. I remained as calm as possible while explaining to her that the particular fluoroquinolone her husband was on had exactly the same bioavailability in either IV or oral form, and that a UTI was not, in this instance, life threatening, but she was having none of it. Her concern I could understand. Her manner I could not, and as her voice reached a level which was probably audible from several adjacent floors in the hospital, as she denounced my ability to have compassion, my intelligence, my understanding of medicine, and virtually every person connected with her husband's hospitalization, the charge nurse (blessings on her and her children) came in and interrupted by saying that visiting hours were over, and that if Mrs. Stone did not remember the way to the exit, the security guards would be more than happy to show her the way out.

Three am, and I am awakened from my one hour of sleep by a nurse who feels that this is a great time to pass on to the night float doctor the results of several perfectly normal, non-emergent tests performed over the course of the day. The sorts of test which will not, by any stretch of the imagination, change the management of the patient in the next three hours before the primary team comes back in.

Eleven am. I am now in the step-down unit, dealing with my patient who has developed mental status changes. I am very suspicious that these changes are due to the fact that he has bad COPD and has been off his oxygen. I need an ABG, quickly, to determine whether the oxygen I'm about to start is going to fix the problem, or whether I need to keep looking for a cause. The patient's nurse has decided that it is far more important to gossip about another doctor to one of the other nurses than to actually draw a lab that might help her patient. I try telling her nicely, but she will not be interrupted. So, exasperated, I draw the lab myself and make a note to write up an incident report.

Four pm. The bed manager finds out, and pages me about, the fact that one of my patients has been off telemetry monitoring for most of the day, because the nurses can't find the tele pack. They've only now decided this is worth passing on. Another twenty minutes of work. That will teach me to think of getting out of the hospital early post call.

Five pm, sign out complete, my patients passed off, my pager off, I drive home. And in just under twelve hours, I'll be right here, headed the other direction, starting all over again.

Back to the ward

As the title suggests, I've gone back to the inpatient wards. It's a welcome change in ways, since I now feeling like a doctor again, making treatment decisions and actually taking care of patients. However that also means I'm on call, missing sleep, and since I had a month off essentially, I've lost a lot of the good habits I had. My first night back on call was rocky, and it was fortunate that we had a phenomenally light call, or I would have been completely hosed. Now I'm two days in, and getting back into stride.

Of course, that entails sacrifice. I had made plans to go to a play with a new friend of mine this afternoon, but as I was heading out the door, I got a page about one of my patients who was crashing. Two hours later he was safe in the MICU, but the play had already started. Still, that's the kind of medicine that excites me, making actual helpful changes in patient care, rather than the combination social worker-slave-clinician stuff that usually compromises a medicine intern's life.

In other news, Mrs. Roman got that surgery, oddly enough because someone told her exactly the story Judy mentioned in the comments.

Faith healing

Mrs. Roman needs her lung removed. It has become severely damaged, is chronically infected, does not aerate her blood, and is spilling bacteria into her good lung, causing life threatening pneumonia. However, she will not undergo the lung resection surgery because she believes God told her he will heal her. So she lays in her ICU bed, trusting that God (plus antibiotics) will cure abscess and empyema.

This is (to put it mildly) ill-advised. So much so that it makes me angry to think about it. Without realizing it, I have become the person I feared.

Back in medical school, we had a class on the "human context of medicine." It was our first year, we were still figuring out how to do the whole medical school thing, and for three hours every Thursday morning we sat in small groups and discussed the papers we had been required to write about a variety of topics. Death, end of life care, sexuality, culture, religion. Pretty much we talked about everything your mother told you was bad manners to discuss with strangers. The teacher for this class, who gave us weekly lectures on top of our discussion, was a militantly atheist Reform Jew, and one of his pet projects was to ensure we all kept our religious convictions out of our practice of medicine. At the time, I thought this impossible. I resented his depiction of a strictly empirical physician, admitting the presence of more than flesh and blood only when necessary to gain the trust of a patient. It was an odd, soulless compassion he taught.

But I realized today, standing next to Mrs. Roman's bed, that I have become more like that person than I knew. Through the next three years of medical school, and the first few months of internship, I have come to believe in the power of medicine. I've seen medicine heal the sick and make the lame walk. If we haven't made the blind see yet, we're working on it. More effective than any lecture or any crazy triple-board certified medical school teacher was merely living this life. And standing by that bedside, my first reaction was anger, or at least irritation, that this woman held to a ridiculous conviction that is going to kill her. I was angry that this pleasantly deluded woman didn't share my near-religious conviction in the power of medicine.

At the same time, I share her convictions, at least in part. I am a Christian, but I've never been the "let go and let God" type. I'm more a "praise the Lord and pass the ammunition" type. I figure that no matter what you think about the controversial questions in life, God has given us all a brain and hands, which we ought to put to good use. Because of faith, I allow that God could heal her. But I believe in medicine the way I believe in gravity: it just works. Of course, it works based on principles which are either impossibly serendipitous or intentionally designed, but then that truly is the religious question. Whatever the answer, it is not germane to Mrs. Roman's condition. She is waiting for a miracle, and if she does get better, that's what she'll call it, but I'm intensely skeptical of miracle claims. Remissions happen in many diseases, and we don't always have an explanation for them. It is only when they happen to religious people that they are called miracles.

So the focus on pathology and on biology has made me a skeptic and maybe a bit of an empiricist. Where that breaks down, and where I retain my faith and humanity, is in the big picture. Certainly, the only way Mrs. Roman is going to be cured is with cold steel. But if there is any point in curing her, it is more than molecular; she is more than a broken machine, and the only way to understand that is not found in Robbin's Pathology.

Said the Whale - Taking Abalonia

So I admit it, I first heard about these guys from perezhilton.com. Perhaps I shouldn't admit frequenting such places, but I figure if you haven't checked that site at least once, you aren't doing your part to be the "Great Satan" that Ahmadinejad sees in the world. Anyway, whatever I think about the color scheme and the content, Perez occasionally has good music taste, and this wasn't a disappointment.

The first song I heard from this album was "This Winter I Retire" which is the most distinctive track on the album. Check their Myspace page to get a taste here. I like upbeat songs with a minor feel, so musically I was predisposed to like it, though the lyrics are nothing spectacular. As I listened to the rest of the album, I was lured into just listening, and forgetting to be critical. But a few listens have me somewhat less enthralled. That first track is still distinctive, but the balance of the tracks are derivative sounding, with the most egregious being the second "Live Off Lamb" which James Mercer could probably sue for plagiarism over. The Shins, the Strokes, the Decemberists...an alert listener can place all of them in this album. None of which says that this is a bad album. It's not. But it mostly sounds like B-sides of bands you already like.

In short, there's potential here, coming out particularly in "Plans for the Future" and the already mentioned lead off track. But the potential has yet to be realized, I feel.

Return to Psychiatry

If I thought ENT was a step back in time, psychiatry is worse. Don't get me wrong, I loved psychiatry as a med student, but here I'm not even supposed to talk to the patients. My whole experience is to "shadow" a psychiatrist, basically pretending I am a hole in the wall. So clinic was pretty boring this morning, with the only bright spot occurring when I stood behind the front desk looking out. On the back of the desk is a row of photos of people who have made credible death threats against staff in this psychiatry group, along with a short description of last known whereabouts and any other useful bits of information. One guy had the terse line "an FBI investigation is ongoing" beneath his description.

Next month, when I return to the wards, I don't think I'll complain too much about COPD exacerbation patients. At least none of them have ever tried to kill me.

This is a pretty informal rotation, so I ditched the clinic in the afternoon. I joined up with the Consult-Liaison team instead, and had a much better time. C/L psych is something I could enjoy, plus the specialists in it seem to be the sarcastic, screwball humor, polymath types that I enjoy so much in any specialty. We didn't have too many patients, so the attending launched into an impromptu discussion of paraphilias, which is apparently his research interest. Think Doctor George Huang from Law and Order: SVU, only an older white guy and you've got a pretty good idea what this doctor is like. Both entertaining and informative.

He reminded me, at first, why I thought psych was so cool, but after a while he began to remind me why I couldn't end up doing it. Psychiatry can be pretty creepy, and while some of the discussion was interesting, after a while, frank discussion of deviancy gets old, and then painful to discuss. I have been relieved before when a lecturer (usually a pulmonologist) ended a talk, but the end here was a very different sort of relief. That's more of an "awakening from sleep" relief. This was more a "coming out of a haunted house" relief. We'll see tomorrow what a full day in the haunted house is like.

ENT

One of the more inscrutable whims of whoever it is that determines the requirements for internal medicine residency this year has been to require a "subspecialty month" in which we see a week of clinic in ENT, Ortho, Ophtho, and Psych. This week has been ENT clinic for me, and it's beeen a leap back in time.

What I mean is, I am basically functioning as a fourth year medical student. I don't know any of the surgery, so I can't really contribute there, and my idea of a clinic visit is at least 30 minutes long, so I'm not fast enough for surgery. These guys have are double and triple booked in twenty minute time slots, and they are rarely behind. On the plus side, I've seen a lot of scopes and procedures that I probably won't ever again, unless I go into general internal medicine, get really fancy in my own practice, and decide a nasopharyngeal scope is a worthwhile investment.

I've survived though and today was actually fun, even for an internist. Just when I was about to slide into the quick, only-the-highlights ENT exam on a patient, I figured out she had something more serious than just hoarseness wrong with her, and we ended up needing a fairly involved thyroid workup. That's something I know how to do. And then one of the later patients needed to be scheduled for surgery, and the ENT doc I was working with wanted to do it tomorrow. He looked at me and said "with this guy's cardiac history, anesthesia is never going to take my word on a physical so seriously that they'll approve surgery on this short notice. Can you do the H&P and write 'internal medicine resident' next to your name? They'll take that, I'm sure." So I did, and I don't think the surgeons minded my 25 minute exam, because it meant one more case on the schedule for tomorrow. It was nice to be recognized for expertise in my field, even if it is considerably premature.

Sigh...

I usually love clinic, even now that the patients I see call me doctor, and I have to have a plan pretty much figured out within half an hour of seeing them. What I don't like is patients like Mrs. Fortnight.

Mrs. F showed up in clinic to be seen for hospital follow up. See my hospital has a policy that every patient is seen in follow up within a month by the intern who admitted them. No matter how complicated, or how many other medical problems they may have. I admitted Mrs. F about a month ago because she was dehydrated and low on magnesium, but of course, this being internal medicine, she also has heart failure, an obscure and ill-characterized propensity to lose electrolytes, chronic diarrhea, Parkinson's, depression, and diabetes. She's the kind of patient who can make almost anyone wish they had picked another specialty.

So she shows up in clinic, and right away the complications start. The triage nurse checks her blood pressure and gets a value of 90/30. This is not good. However, blood pressure machines are not infallible, and any abnormal value they give you should be rechecked. So the triage nurse duly rechecked the pressure three times, getting the same value, but still using the machine. When I came out to see what was holding up my clinic, I found they had not checked the pressure manually. I did so and got a completely normal value. Meanwhile, the nurse had checked a blood sugar and found a value of 232. This is also bad. Especially since my patient hadn't eaten since the night before.

Things never really went uphill from there. She had stopped the magnesium I had started, which necessitated a stat magnesium check. She hadn't rescheduled two appointments with specialists that she missed (and needed.) She hasn't ever written down her blood sugar when she checks it, and neither she nor her husband can tell me where it usually is. She was surprised when I told her she should check it with every meal. 90 minutes later I am an hour behind on clinic with two patients yet to see in the morning session. Goodbye lunch.

I felt bad for her, but there's only so much I can do, and I'm only supposed to be seeing her for her dehydration follow up. She has a regular doctor who should be taking care of all these other complications. But evidently he's doing a poor job. Maybe though, she's just minimally adherent to her regimen from him, like she was from me. So, schedule follow up with her doc, get her a glucose level diary, counsel on foot care, schedule follow up with subspecialties, refill Sinemet, smile, bid goodbye.

Next patient, rinse and repeat.

Please, dear reader, bear this in mind the next time your doctor is late for an appointment.

On the positive side, I finished my infectious disease rotation, and my attending was singularly complimentary in my evaluation. He asked me to consider applying for fellowship in his department in two years too, so we'll see. I did love it, but the siren song of cardiology is still ringing in my ears.

More jokes

My attending is just non stop with this kind of thing. So today he was telling us how he modeled coccidiomycosis in mice...

"So we gave the mice some barbiturates to sedate them, a little 'mouse roofie,' if you will, stuck a tube in their noses, sprayed the cocci down there and pulled it out. Then the mice woke up, called the cops, and claimed they'd been violated. All in the name of science."

Unusual stories

I love old people. That's a huge reason why I'm internal medicine, but even with the exposure I've gotten so far, I am occasionally startled by the stories they tell. So I was when talking to a recent patient the infectious disease team was consulted on. He's a 90 year old guy who fought in WWII, starting in North Africa with the original American landing and going through with Patton to Italy and then landing on D Day in Normandy. The reason we were consulted was because of a positive VDRL test and concern for neurosyphilis, and while asking this guy about it, he told us "yes sah, I knows when I got the syphilis. It was in Italy. We was mostly worried about the gonorrhea, you know, 'the clap' we called it. But the syphilis...it was worth it." Straight out of Hemingway. I actually thought of Papa's story "One Reader Writes" while hearing Nick's side from that hospital bed.

It reminded me of another patient I recently saw too, a very sweet 87 year old woman, who when I saw her was having some adhesive bandages pulled off. The nurse joked to her as she winced that "it's a bit like a wax job, right ma'am?" Miss Elsie (as she insisted we call her) looked seriously at her and said "I used to wax. *pause* When the sailors came to town." She then smiled a look of mischief at all of us as she settled back on her pillow.

So yes, surprised, though I surely shouldn't be, to realize that my patients were young and foolish and wild once. It adds a depth of humanity to them, and I try to imagine what Miss Elsie looked like at the height of the Jazz age, or whether Private Stone, seeing Europe from the back of an Army truck, thought twice about the Italian girl he left behind. I wonder too, what became of her, and whether she's telling some Italian medical resident about the dashing American who contributed to her own medical history.

The stories are often sad or bittersweet, but I like hearing them, and though I'll never know the details or even the endings, it definitely brightens my day knowing there is more to my patients than penicillin. Perhaps 'brightens' isn't the right word. But humans are a tragic, noble, and foolish kind of creature, and seeing them "warts and all" does more each day to help me appreciate our little world and the kind of sense we all strive to make of it.

Subspecialty musings

While sitting in conference today, I leaned over to one of my fellow interns and mentioned how pleased I was to have had both days off this weekend. He leaned back and whispered "two day weekends are proof of the existence of God."

It takes so little to cheer us now.

That said, my current rotation, infectious disease, is fantastic. Interesting subject matter, a sane patient load, and I'm only in the hospital 12 hours a day, 5 days a week. I could get used to this. Adding to the enjoyment is my attending, with whom I share a rather offbeat sense of humor. While discussing the impossibility of getting a particular lab drawn he quipped "but you might as well follow that order up by writing 'end world hunger' as your second line. The nurses are about as likely to do either." Later he said "that's like writing a progress note with cut out words from a newspaper. You can dream about it, but you probably shouldn't." Oh yes. I am entertained.

A break, for real

I'm finally finished with the wards, which means that after two and a half months, I have two days off in a row. Having one day off a week is fine, it's the biblical model and all, but I've found that it is tough to really do much with it except sleep. That's all I do anyway. But now, with the glorious luxury of having the entire weekend off, I'm left planning hikes, and listening to music, and enjoying life in general a lot more than I was.

Which leads me to an unrelated topic. A while ago I reviewed KT Tunstall's album here, in one of the sporadic music reviews I post. Apparently that got the attention of her promotion company, because I got an email this week which included a video from Tunstall's upcoming album, "Drastic Fantastic," and a number to reach her agent, along with an invitation to interview her. That's not probably something I have time for just now, but it is fun to get an email offering to include me in something besides obscure bank transfers from shady Nigerians who can't spell.

However, if there is anyone out there who really wants to interview Tunstall, I have the contact info for her agent and will pass it along. I can also report that the video is fairly straightforward, with a vague narrative thread and constant flashing between camera angles showing people having a good time. I don't understand why this is now cool, but no matter how much I like a song, I'm not going to spend any of my free time getting aggravated by the apparent epilepsy or ADHD of a video director. The song itself though sounds like her hits from the last album. Quite catchy, and now it's stuck in my head. I'm betting this will do well too when it comes out September 18.

Now I'm off to luxuriate.

First on the scene

Even before I wanted to be a doctor, I used to imagine being the first person to arrive at some great tragedy, saving the day with my Boy Scout first aid skills. I've learned a lot of first aid since then, all the way through ATLS and ACLS, but still, I've never had to use it outside of the hospital. I'd never seriously considered it even, for despite the nature of my job, there was still a division between me at work, being a doctor, and me at home, being a 20-something guy with a cheap car and a nice stereo.

Until last week.

I had the unique opportunity, late one night after dropping a friend off at her apartment, to be the third person on the scene of a rather horrific motorcycle accident. When I pulled over and ran up to the site, I did have a vague idea that "I might do something good here," but it was shattered when I saw the one victim. Even though I'm not a surgeon, it didn't take medical training to realize there was nothing I could do for the dead man, who had hit a retaining wall while traveling maybe 100 miles an hour. (He had passed me moments before, and my last uncharitable thought as he sped over the hill was "he's going to get himself killed driving like that.")

The guy who got there ahead of me was taking a pulse when I ran up, and he looked up at me and said "I'm an ER tech, and I don't think there's anything we can do." I looked at the double amputation, the blood all over the road, and the apparent high neck fracture, and responded "I'm a doctor. And there isn't." We called 911, of course, but there was no bleeding to stop, and the EMS guys called him dead on the scene.

Two things stuck with me from that night. One, I called myself a doctor, claiming a certain level of expertise, intentionally. And I didn't feel inappropriate doing so. I also watched, with part of my mind amazed at the change, as the seven or so bystanders now on the scene seemed to relax. I think they all needed to know that there wasn't anything to do, and they felt bad not doing something, despite the horror of the situation.

Two, even as I called myself "doctor" I felt a bit guilty for not doing anything. This bothered me for quite some time actually, until I realized that it is actually my job to make that kind of call. It is my job to take the information I have about a patient, compare it to the knowledge I have of my abilities and resources, and decide how to proceed. And here I had few resources to use on a patient with two major arteries severed and no longer bleeding, implying he had exsanguinated. I think I made the right call, but it still was painful not doing anything while waiting for EMS to arrive.

The crowd started to drift away, having had their fill of voyeurism. The victim's fellow motorcyclist (who had missed the retaining wall and come back) knelt by the body, nearly hysterical. The guy didn't look more than 18 or so, and I realized, with a bit of a start, that I was moved myself. Oddly reassuring, because, having seen so much death in the MICU and CCU lately, I was beginning to wonder if I was losing the ability to really care about my patients.

There are at least two ways of caring, I think. It is possible to be emotional and tearfully connected to another. But this form of caring does a physician little good in an emergency, and that is where I demonstrated, at least at first, another kind of caring, in bringing my assessment of my talents to bear on the situation. There is time for emotion after all the action has been taken.

I'm not sure what this kind of perspective means to my life as an internist. Internists are supposed (especially by surgeons) to be the hand holding type, remaining emotionally connected with patients always. Perhaps I am that on some level, but I think this is why cardiology, and especially interventional cardiology, appeals to me. It will allow me to apply my internist's mind to an emergent situation like that faced in surgery. And if I go that route with my career, I will need that perspective on caring.

Change of pace

Ahhhhhhhh, ward medicine. Q5 call. Knowing that I'll get to sleep through the night on a normal schedule more than twice a week. This next rotation is going to be nice.

Additionally, there are two interns per team here, and I'm coming on to a team with Rick, one of my better friends from the intern class, so we are going to have a blast no matter what happens. And we have a med student, whom Rick worked with on the last rotation and who is apparently pretty strong. Excellent. The funny thing is, Rick has apparently been talking me up as some kind of uber-intense born cardiologist with no patience for incompetence and laziness. Which I guess is mostly true, but I'm a nice guy about it, I hope. Still, I want the med stud to have fun while becoming the best student in his class, so if I'm hard on him, it will be with good reason and with lots of encouragement in the right direction.

The great thing about medical students is that they encourage me, so recently one of them, to study harder to stay ahead of what they know. Which encourages them to study, and keeps the cycle going. I'm already saving up ridiculous pimp questions to try out.

A joke

Maybe this is only funny if you're sleep deprived. But then you have to be a huge nerd too:

Resident: "Dude, I think being on vecuronium sucks."

Intern: "Nah, man, I think it rocks."

*cue general hilarity*

Deprived

One one of the rare occasions I was outside the cage hospital lately, I watched the "Bourne Ultimatum." Partway through the movie, the fearless protagonist is reading a stack of papers describing his own forgotten training and a line flashes across the screen: "subject has been awake for 56 hours." My first thought was "I could do that."

Q3 call is ridiculous. I'm in the hospital for 30 hours straight without sleep every third day. To think, as a medical student I assumed only surgery interns worked hard. At least they roughly keep to the 80 hour work week. And at my hospital anyway, they have call q5 on most rotations. Part of this may be the fact that my hospital is renowned for its medicine program, and the directors feel they have a reputation to keep up. But after two straight months of work in critical care, I'm noting the diminishing marginal utility of this particular learning environment.

Making matters worse is the fact that I am what is known as a "black cloud." Even among physicians, supposedly highly educated and purely scientific minds, there exist strong superstitions. A black cloud is a doctor who, when he is on call, has worse luck than the average. For example, last month, on the cardiac ICU team, my team admitted over twice the number of patients the other team did. And here on the MICU, the story is the similar. A positive side of this is the fact that my attending noticed it, and last time I breezed through presenting nine patients, he said "dude Nathan, you are like Superman."

I feel compelled to add that he's both a)from California and b)about a year out of his fellowship.

But where that was a motivation, and I was pretty energized previously, the flog is taking its toll. My motivation to read (or at least skim) an article or two on each of my patients before rounds has dropped off. Last night I fell asleep sitting up in my chair, in the process of typing a note. Where I was once understanding of being paged for even the dullest questions from nurses, I'm getting dangerously close to snapping out things like "that's exactly what I wrote in the orders, twice, and I just spent 30 whole seconds clarifying it in person."

Everyone is feeling it. One of the nurse managers pulled aside a senior resident the other day and told him he had to be understanding of the nurses aides, because they worked long hours. The guy shot back "You're right, they work four long 12 hour shifts a week, and the stress of filling the rest of their time with boys, alcohol, and sex must be incredible. On second thought, no, I'm not all that understanding. How about you tell them to do their damn job."

It wasn't the best way to remind the nurse of the truth, but I would have been tempted myself in the same position. But I'm greatly looking forward to my two week subspecialty block coming up in a month. No call, just two glorious weeks of sleeping through every night.

And Jane makes five

Jane was a nice woman, scarcely old, who was admitted for sepsis and pneumonia. But it was only after we intubated her that we heard from her oncologist the truly grim prognosis of her disease. We didn't do her any favors with intubation and the family made the decision to transfer to comfort care only. I handled this completely without my resident, getting the morphine set up, making her comfortable, extubating her, pulling all the extraneous lines, stopping the drips. After the nurse and I called the family back in, it wasn't much more than five minutes before I was pronouncing someone dead for the first time.

Two years of clinical rotations in medical school and I never saw anyone die. Now more of my patients are M&M subjects than any other intern's. That's not a particularly uplifting distinction to have. Thankfully, nothing I've done wrong contributed to their demise. But it doesn't do much for a mood already dulled by lack of sleep.

The karma gods are angry

So I realize my last post was all about conciliation, but last night, all I could think about was my anger at the orthopedic surgery team. Orthopedics is a fascinating specialty, I'm sure, but the practice of it trains that tribe to regard anything that cannot be solved with a stainless steel power tool as beneath them. So when, for example, a patient who had a hip fracture repair is semi-stable but has a few co-morbidities that make them nervous, they are quite anxious to transfer her to a medicine team.

Unfortunately, they performed this transfer directly to my staff, without informing me, the guy who would actually get paged to her bedside about an hour later to find a patient I didn't know with new ST depressions of 5mm in all her precordial leads and a tachycardia to the 140s, complaining of chest pain but unable to point to it, because she also developed sudden onset of bilateral paralysis from the neck down. To add beauty to the situation, the patient also had mental status changes and was unable to tell me anything about her history, and the chart was full of worthless surgery notes saying "vital signs stable" and "wound healing without signs of infection" but little else. The nurses were able to tell me that the patient at baseline had left sided paralysis, but that the right was new. And fortunately the orthopedic team had ordered a nephrology consult at some point, so the life-saving nephrology consult note functioned as my understanding of the history long enough for me to get the basic ACLS stuff started and to page my resident with more to say than "please come save me." Even more fortunately, we were able to help the short term things with her. Long term, I have no idea if her apparent stroke will resolve. Probably, even knowing about her wouldn't have stopped all the craziness, but I would have been far more comfortable and would have lost less time.

I'm going to prepare more war paint.

Internecine

Late last month, Sri Lankan police killed 12 members of the Tamil Tigers, a rebel group with which they have been fighting for nearly 25 years. At issue is self determination for two rival groups sharing a small island with limited resources.

It is easy to see how this is like a hospital. Within the four walls (figuratively speaking, since my hospital was built in about 50 different stages and has long since ceased to be rectangular) of this building are numerous warring tribes, calling themselves internists, surgeons, pediatricians, radiologists, and the like. Through the vicious coming of age ceremonies involved with these tribes, they come to identify all outsiders as unclean, beneath their attention, untouchable. What makes this caste system more complicated than the politics behind Alexios I Komnenos' hold on the throne of Byzantium is the fact that no one group recognizes an ultimate ruler, and no one group is treated equally badly.

Surgeons, for example, tend to look down on internists as nitpicking, reactionary types overly concerned about minor lab values, most of whose conclusions need to be regarded with considerable skepticism. Even nice, earnest surgeons can fall into this category at times. Internists, for their part, are generally frustrated with surgeon's apparent disregard for important but small lab values and seeming inability to document more than the most obvious one or two physical findings, usually in cryptic, barely legible acronyms, but we reserve our most earnest hatred for ER physicians.

Surgeons, we reason, have an area of expertise beyond our ken, and we beyond theirs. I, for one, will never presume to take out an appendix or a liver, just as I wouldn't expect a surgeon to handle renal tubular acidosis or manage diabetes. We only step on each other's toes in presuming outside our area of expertise, and both our specialties can complement one another. An ER physician on the other hand, oftentimes appears to be actively involved in undermining our patient's health. For instance, I recently admitted a patient with atrial fibrillation causing a rapid heart beat. The ER physician though, assumed this was due to alcohol withdrawal, so despite reading the patient's old notes, he started the guy on a Versed drip rather than a diltiazem one. As a result, the patient got more and more somnolent and had to be intubated. Fortunately my resident and I got to him in time to start a medication that would actually treat his condition and prevent damage to his heart.

What gets lost in the griping as the tribes head back to camp to prepare more war paint and weapons is the fact that, even if we aren't shooting radiologists like Tamil Tigers, real people can be hurt in these conflicts. The ER, for example, does see acute alcohol withdrawal, and they did a)realize this was a bit atypical and b) call me before it got out of hand. I'm sure many times they would have been right with the Versed. So despite recognizing my growing attachment to my tribe, and my earnest defense of it in the call room, I'm trying to remember also that most of us have the patient in mind, most of the time. Sri Lanka I can't help. Bed five in the ED? I'll be right down, and sure, I'll consider alcohol withdrawal.

In the Zone

Maybe it was the phase of the moon. Or maybe it was the fact that my day on call followed Simon's, and in comparison anyone would look good. But I was on today. By "today" of course, I mean my last thirty hour shift, in which I only say down for about 10 minutes total, and never touched my call room bed.

But despite being crazy busy, and rather stressful at times, everything went well in general. I had to bag ventilate a patient for about an hour and a half (trading off with one of the nurses) but he survived while teaching me much more comfort with mechanical ventilators (and incidentally, which are the good respiratory techs in this hospital). I had to get an arterial line on another patient, and did it perfectly it on the first try. I had 30 minutes of free time at exactly the right stage of the night and managed to look up articles which may positively alter our therapy for two different patients. I looked like a superstar on rounds and the fellow and attending both complimented me on my work and my presentations.

Not that I'm complacent. I know how hard it was to keep myself moving for that long, and how much busier the night could have been. Still, good days should be enjoyed.

Stronger

Growing up means taking responsibility, learning your place in the world, and just occasionally, royally reaming out someone who deserves it.

But this isn't a post about nurses. You know I love you guys.

Or even med students. I was one once.

My program has a rather large array of personalities and capabilities. Most the people are pretty strong, even the ones I don't exactly click with. There is at least one notable exception.

Simon, as I'll call him, is a nice enough guy. Like all of us, his personality is not naturally that of the perfect physician, but unlike most of his classmates, he has not progressed very far down the path of mortifying these traits.

So yesterday, as he was the post-call intern, his job was presenting the new patients and giving a brief update on the old ones. Since this is the MICU, these patients are complicated, and need detailed notes discussing in depth, by system, the problems they have and what we are doing about them.

Rounds got off to a rocky start because (as my friend the senior resident told me) Simon had spent his night on call sleeping rather than working. So when he got up at 6am to round on six patients in the ICU before 8am, he was understandably far behind. He didn't know what had gone on during the night and had, despite the senior waking him up and directing him on what to do, gone back to sleep on several occasions before finishing his work. When I came in at 6:45 to see my one patient, I heard Simon asking his senior to help him with the note writing. He was rightfully rebuffed.

So notes were not finished before rounds. This makes rounding difficult, and what made it more painful (for Simon and the rest of us) was the fact that he had arbitrarily decided that some vital signs were not important on some patients. So, for instance, with one of his patients with acute renal failure and CHF requiring mechanical ventilation, he hadn't written down CVPs, and the blood pressures he had written down weren't the real range, they were what Simon felt were the "normal" ones of the night. Not cool. You can't just cherry pick data to make yourself look good, these are sick people.

There followed possibly the most painful rounding experience I've ever watched, one which demonstrated every mistake I've ever seen a third year med student make. Actually, I haven't ever seen a third year med student refer to his "Gay-dar" in assessing the patient's sexual orientation. Maybe you could get away with that, in the right crowd, with docs you knew and who understood your humor. Not the first day, when you've already floundered through twenty painful minutes.

This was painful, but I was mostly hoping it would be painful enough to make Simon realize his errors and maybe start slouching towards competence to be born. No such luck. Later that afternoon, about 3 hours after he was supposed to have left, I ran into Simon putting a note on a patient's chart. Unfortunately, this was a very short, 10-15 line note, nothing like the three pages you would expect on a complicated patient with decompensating respiratory effort.

So I called him out.

There followed a very tense, even toned conversation that was, nevertheless, my laying out in very clear language about 85% of what I figure is necessary to be a good doctor. I don't even remember all I said, but I do remember saying things like "this isn't about rules about notes you think are silly, this isn't about work hours, or personality, it is about taking care of patients. And if you don't realize that, you don't belong here. Internship is supposed to be hell, but you have to make it that way. If the pressure doesn't come from within you won't succeed." I added some choice things about needing to write notes, to consider every patient carefully by system because if you don't learn to come up with plans on your own, you'll never be able to. You'll always be an intern, and never a real doctor.

About halfway through this harangue, I realized that the entire nursing staff of that ICU pod, about 20 some odd people, were listening, mostly while pretending not to. I noticed the nurse taking care of the patient in question nodding his head in agreement. I am a bit ashamed to say I enjoyed the audience almost as much as the fact that I finally had an opportunity to maybe, just maybe, work for positive change in this guy's life, and more importantly, in the lives of his patients.

To his very, very great credit, Simon took this correction without offering an excuse for his behavior. He actually wrote a real note, and later, he paged me to thank me for the advice. I wasn't really sure what to say, except "you're welcome."

Heck, I could code in front of that guy some day. And it is nice to know, not just believe, that I have what it takes to give constructive correction. It is also nice to be the strong intern on the intensive care service.

30 hours without sleep? I'm still smiling.

Almost coded

Late this morning, while finishing up the last of my work and hoping for an early exit from the hospital, I rounded a corner of a hallway to have my heart sink within me. For as soon as I rounded that corner, a group of nurses at the other end of the hall turned and said "there's a doctor!"

This is almost never a good thing. But in response to their earnest gesturing, I hurried to the room to see a very pale woman lying on a bed gaping at the ceiling with eyes closed. Meanwhile, in one ear I was hearing "just checked on her, was smiling a minute ago," and in the other I was hearing "there's no pulse on telemetry, just bradyed down and stopped, I think she might be DNR."

I am, in looking back, pleased with my calmness as I said "bring the code cart and her chart, see if she's DNR/DNI." By the time I reached the patient's bedside though, a nurse was standing in the doorway with the chart, telling me this patient was DNR/DNI. The code cart was pushed back to its familiar home and the crowd started to disperse.

I told the nurse to page the resident of the primary team and the staff physician as I felt the carotid for a pulse. Feeling none, and hearing no heartbeat, I realized I had just seen my first death in the hospital. First death ever, actually, which is an odd thing, I think, a sign of our times, a mark of the twenty first century, in which people die in small rooms away from home, attended by a select group of people to whom the experience becomes familiar. And until you join that group, you are insulated from the event, one that comes to us all.

The intern from the primary team drifted in. Though it may not have been the right thing to do, I let him pronounce the death.

"Time of death, July 17, eleven fifty AM."

It would be false to say this affected me greatly. I had never seen the patient before, never spoken with her, never heard her story, except her diagnosis. And I wonder what to make of that. I came into medicine partly because it allowed me to treat people, to be around people, who are dealing with real questions, and to deal with them myself. Somehow the presence of the "unveiled mysteries of life and death" seemed to add profundity to my experiences.

I thought as a medical student. As an intern, I'm harried to the point that thought beyond "what do I need to do now" is difficult. If I'm not moving, there's something wrong. I'm so used to hearing my senior resident say "what aren't you writing this down? You should be writing this down, Nathan" that it has become a bit of a joke. All this action, all this doing, keeps me from thinking.

And so, as I stood in that room, a little nervous, a little relieved that I didn't have to run a code, and a little awestruck by the whole situation, I wasn't really processing. I wasn't having grand thoughts voiced by Longfellow or grim ones by Thomas. I was tired, and after the details were passed on to the primary team, I went to grab lunch before heading back to work.

The beatings will continue until morale improves

So today I presented my first CCU patient, and relearned a host of lessons I had thought were past. ICU patients, of course, are presented in a different format than ward patients, and I was rusty on that format. I was also very far behind in rounding today, and essentially I failed in every quantifiable area of accomplishment where my patient was concerned. Justly, I received some very stern correction for this, culminating in one of the interventional cards guys drifting from "know the patient" to "have a differential diagnosis." This particular lesson was not necessary in my case, but a few others were, so he can be forgiven for going overboard.

He did say that if next year I saw a patient in the ER with severe, tearing chest pain radiating to the back with blood pressure different in each arm and I activated the cath lab, calling him in from a sound sleep at 2am, then "I will throw you off the top floor of the hospital. Which would be tragic. Because the patient would die."

Maybe it's Stockholm syndrome, but I love cardiology.

Obsession

To work at my trade by the dozen and never a trade to know;
To plan like a Chinese puzzle -- fitting and changing so;
To think of a thousand details, each in a thousand ways;
For my own immediate people and a possible love and praise.

I used to think I was obsessive-compulsive. It was my strong point. My concern for minutiae made me a great medical student, as I had all the labs, all the studies, all the details of the patient histories, going back as far as the hospital records would allow.

Then I became an intern. As a medical student, I had charge over one, two, or at most four patients. These were acquired gradually, over a period of days, and I came to know them well. Now, on cardiology, I regularly admit six patients on a call night, and then I have to know them well enough to present the following morning. Gone is the obsession. Or if not gone, I realize that I cannot get information the way I am used to, cannot use the same organization. I must move faster, more thoroughly, more efficiently.

Case in point, one of the patients I admitted last night was only in the hospital because on his more recent discharge, his medication instructions were not clear. This resulted in him not taking a medication he needed. Now I know the intern who wrote those instructions wasn't intentionally trying to harm anyone, and in fact, he had all the information on the instruction sheet, he just didn't take the time to format it in a readable way. Even I couldn't figure out the sheet, and heck, I'm a doctor. But he probably fell into the same trap I do, having to discharge ten patients in a morning, typing furiously, dealing with the interruptions of pages needing to be returned, residents updated, patients seen.

I never realized the sheer volume of work that goes into being an intern. I was a good medical student, and a good sub-intern, but it is impossible to know what all is entailed in being a doctor, in being an intern, until it is your signature on those late night medication instructions, your fingers entering all those discharge orders, your head running on empty because you've been awake for 30 hours.

Probably I will never be a success in my own eyes. But when I make stupid mistakes, like today in rounds, actually forgetting to write down half of a patient's chemistry panel and asking my resident for the numbers in the middle of my presentation, in front of the cardiology fellowship director, it is easy to sink farther in my own estimation than usual, even. Sigh. The only positive I can think of is the fact that I'm learning the hard way, which tends to make a more lasting impression. I just don't want to destroy my chances of success here before I even start.

Maybe that obsession isn't entirely gone.

First call

So my first call night came off relatively well. Though in medical school I thought it the limits of my ability to follow four patients at one time, on this particular 30 hour shift I admitted five, learning all their complicated stories at one time, and without the safety net of an intern above me basically doing the work. I had honestly not realized that it was possible to remain in motion for 30 hours. Not even once did my head hit the pillow in my call room. But it wasn't as horrible as I had feared. The only patient who died was one whom we had transitioned to "comfort care," as the family had recognized the inevitable. And I was able to handle all the questions I was paged without needing to bother the senior. But nevertheless, at about 4am, I had pretty much decided that I picked the wrong field, or at least the wrong specialty. Very few laboratory chemists work 30 shifts as part of a group hazing ritual.

The uneasiness continued to morning rounds. I had not gotten a chance to do more than write down vitals and say "hi" to my patients, by no means getting a thorough exam on each of them, before it was time to start.

My fears were rapidly dispelled. About halfway through my first presentation, my attending stopped me and presented the most welcome piece of constructive criticism I've yet heard. He said "stop. I have no doubt that in three years, you're going to be one of the strongest residents in the program, but you're presenting like a medical student." He then proceeded to tell me exactly how to present as an intern. Noted. Afterwards though, the fear came back, as the fellow drew me aside as said "Dr. Ricker was complimentary, but just remember that your presentations were only acceptable for being the first week. If you are still presenting like that at the end of our weeks, we're going to have problems." Also noted.

Long white coat

Today I put on my long white coat for the first time, along with my name tag with the initials "MD" after my name. Then I put my stethoscope, notebook, pocket reference books, pens, pen light, EKG calipers, rubberstamp, and spare paper in my pockets, and walked into the conference room to start my intern year. The first thing I noticed was that the coat wasn't appreciably lighter than it had been in medical school, and it had the added pain of stretching down to my knees. The second thing I noticed was that the notebook in which I have been writing immensely useful hints, like the REAL number for radiology, the outline for writing up a stress test, and the proper way to evaluate half a dozen common problems, the notebook I've been working on since third year of medical school, had disappeared somewhere between my car and the door of the conference room. But it is long white coat.

Not exactly a stress-free way to begin my intern year. But, as if in sympathy, the schedule worked out very much in my favor. I wasn't on call, so after relatively brief rounds, I was sent on my way rejoicing, and given tomorrow off. I can only complain by saying, I'm about ready to begin, already, and no, I didn't find the notebook on the way back to the car. Sigh.

Hiatus (mostly) over

What, without asking, hither hurried whence?
And, without asking, whither hurried hence!

Orientation is finished. I'm not sure how these things work at other hospitals, but it seemed to me that my orientation consisted of a solid two hours of information crammed into two weeks of lecture. The obligatory instructional lectures on our computerized records system, kindly lectures about the importance of sleep, etc. And then the barbecues, dinners, lunches with residency directors, fellowship directors, directors of directors...I can say with certainty that I'm thoroughly oriented.

Which isn't to say I don't feel more than a little nervous. One of our lectures was on the importance of teaching the medical students rotating with us, and I got to thinking, given the slacker attitude of my fourth year, I'm really only about 6 months ahead of the fourth years students in learning, maybe 3 if you count the extensive attrition of knowledge that remains unused for an extensive period of time. I want to go into cardiology (I think) and my EKG reading skills are still not the greatest. The words "electrolyte management" still bring a cold sweat to my forehead.

I am pleased with my intern classmates though. Generally they seem a pretty sharp bunch, which will be important as we watch each other's backs through this next year.

One thing is certain though, my uneasiness will be rapidly dispelled. My first two months are the hardest rotations of intern year so I should be well on my way to at least an intern's level of confidence by the end of that time. At least, I'll find out, starting at 7am tomorrow morning.

Steak and residency

Captain Jack Aubrey, the chief character in the Master and Commander series I just finished, is a nearly invincible sea captain. He takes undermanned and underarmed ships against nearly insurmountable odds, and succeeds where no one else can. Part of of his success is being able to tell what his opponents are thinking, as he views with practiced skepticism the subterfuge of his opponents. Once off the water though, he is rather more gullible than other men, and at one point in the series he spends nearly his entire fortune on a shady mining venture.

In crafting such singular, but realistic characters, Patrick O'Brian is portraying that facet of our nature which can make even the most cynical man or woman a sucker, given the right circumstances. For "Lucky Jack" Aubrey it was a mining venture. For me, it was the door to door steak salesman.

I view most salesmen with a skepticism I usually reserve for other drivers on the highway at rush hour: generally they want something I have and they're willing to use any amount of deceit to get it. Drivers want my place in the left lane, salesmen want my money. So the pest control guy, the "I'll paint your house number on your curb for the fire department" guy, and the bottled water guy all left my house empty handed. But Joe, the friendly guy from the steak and meats sales company, had a different tactic: flattery. See meat is a bit like wine, in that you can spend a ridiculous quantity of time and effort learning all the cuts, what part of the cow they come from, how best to use them, etc. And if you've devoted just a little time to this, like I have, and someone makes you feel that your knowledge is pretty extensive, like Joe the meat man does, and you have a pretty strong need for affirmation of your intelligence, after say, starting residency orientation that day and freaking out over the fact that you don't remember anything you've learned in the past four years, like I have, then the situation is dynamite. For your wallet that is.

It fairly makes me long for residency, when I won't have time to be at home and get suckered by such tactics. Of course, as I mentioned above, the orientation process, in which we get accounts for the electronic medical records system, sit through lectures on our responsibilities as interns, and get to know our classmates, is slowly driving home the fact that I'm a doctor, and that means I'm going to work harder than I ever imagined possible for the next several years. It hadn't really sunk in until one of the nurses, making sure my N95 mask (for tuberculosis) had a good seal, called me "doctor." Always before is was just a shorthand, or a compliment to my competency as a medical student. Now it is real, and I don't feel ready. I'm just hoping none of my patients know Joe.

Schedule!

I haven't yet received my official schedule, but my residency program has a online application to check call schedules for the month in advance, and so I've discovered at least the beginning of my year. It looks like I start on inpatient cardiology, which is, as regular readers of my blog know, both my intended specialty and one of the hardest rotations of the intern year. Despite the fact that I want to end up in that specialty, I'm quite nervous about starting there. It's a bit like the first day of school. Except I don't remember Math Expressions being as thick as Harrison's. And Mrs. Simmons was pretty uniformly encouraging.

Looks like I follow cards up with the MICU, so I'm starting with a bang here. A huge part of me doesn't want to embarrass myself and wants to start off with a great impression, but the realistic part of me quietly insists "this is the first month of your intern year. You're going to look like a royal idiot no matter what you do." A major consolation is that my schedule appears to be a bit front loaded, judging from those two months, so maybe the later rotations will ease off. And it also looks like call on cards has gone from q3 to q4, so I might get a little sleep. Orientation starts next week, so I'll find out for sure soon.

Random things

I was tagged a couple of times in the last month with the random things meme, but given the sporadic nature of my posting lately and the uninspired state of my muse, I'm not sure I can reach eight facts. We'll see.

1. I'll start with the fact that I am now a homeowner. It's a surreal state, to be sure, but a regular paycheck with the promise of relatively certain financial solvency in the future makes me a fairly good candidate for lending money to, apparently. This new purchase actually accounts for much of my silence on the blogging front lately, since there are a myriad little things to be done in a house which can be (and were) safely forgotten in an apartment. My concerns over how to afford a house are somewhat assuaged by the fact that it is an investment, and additionally I won't be around enough to spend any money these next three years anyway.

2. As a continuation of #1, I am inordinately proud of the fact that I managed to put up a respectable set of shelves in my garage, without instructions, manuals, or advice.

3. I meet most of the criteria for obsessive compulsive disorder. Go figure.

4. Despite #3, I still have difficulty closing cabinet doors. I figure, I'm going to open them again anyway, so...

5. This vacation thing is getting old. I may rue the day I said that eventually, but I haven't done anything really taxing in three months. Once residency starts, I plan to work until the day I die.

6. Despite what my mother says, having a good stereo system is more important than having a good dining table.

7. Ditto a TV.

8. I write about two blog posts for every one that ends up being posted lately. Mostly because the lack of inspiration keeps the quality down, and the beautiful weather outside keeps the volume down. Here's hoping I can get back into regular posting despite residency starting (at least the orientation) in about two weeks.

Nathan, MD

Trust me, I'm a doctor.

Pleasant diversion

In this, our penultimate week of medical school, the administration has planned for us a variety of classes. Nothing serious or stressful, just refreshers on medical-legal ethics, lectures on how to give appropriate feedback as interns teaching med students, cap and gown distribution, etc. Everything is done by noon, and I think it's mostly a way for our faculty to pull everyone together for one last moment of bonding before we scatter to the winds.

The highlight of the morning came from the feedback/basic educator lecture, in which our learned teacher put up the following slide regarding learning environments, which he called the Starling curve of learning climate as it affects medical students, particularly in lecture:


Then this evening a group of us went to a local pro baseball game, and I was struck with how odd it is to have a classmate from California tell you, gesturing with one hand while the other holds a beer, in between cheers as he tells a story in his very relaxed, almost surfer-dude accent that "this lady had like a lymphogranulomatous vasculitis or something." I realized, again, that all of us are just human, and though we've crammed a ridiculous amount of information into ourselves over four years, and we've changed a great deal in some ways while doing so, we still take that information and apply it with the humanity we brought here, accents and all.

Little to do, little to say

I'm shockingly unproductive in the blogging sense lately. I think Medstudentitis put the reason quite succinctly in her latest post. If you don't do anything, you haven't got much to say. This is obviously even more true when your blog is ostensibly about one topic and you haven't had anything to do with the topic in weeks.

I have managed to do a lot of reading though, getting through all twenty of Patrick O'Brian's Aubrey/Maturin novels in the past three weeks. When I think how many pages that is, I stop wondering why my eyes have seemed to burn at times lately. But they are absolutely some of the best books I've ever read. I got to the end and wanted to start over. I think I'll read the rest of O'Brian's books first.

And I found a new band, called "A Fine Frenzy", and since they haven't come out with a complete album yet, I'll postpone writing a real review. I'll just mention that going to her website and listening to a few tracks is worthwhile. And if you have iTunes, she has four songs available for download. I have them all.

So that's all for now, hopefully with my last two weeks of classes and graduation coming up I'll have something to write about soon. 15 days to go.

Last Class

The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course,not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.

Today was the last academic requirement of my medical school career. It wasn't particularly taxing, simply my final meeting with the professor guiding my last month of reading, but it was rewarding. I had finished reading the two biographies of Osler, along with a volume of his essays and speeches, and then I closed this month of Osler-mania by reading the man's favorite book, Religio Medici, by Sir Thomas Browne.

Much of Osler's writing is directed towards medical students, so in reading his works, I regretted not discovering him sooner. (And if you're a medical student or about to be one, you should drop everything and read Aequanimitas and The Student Life today.) But Thomas Browne is not writing to anyone at all, the work is a sort of confession, as he explores his thoughts on God and life. It is also highly worth reading, and though some parts of it are quite dated, the charitable reader will find much to learn from. Browne was a physician in England, who wrote his book in 1635 (though it wasn't published until later) just before he turned 30. At this point in his life, he had learned 6 languages and studied medicine in all the great schools of Europe. But the book is much more about his relations with God and man than with his profession.

Returning from Browne to Osler, it is easy to see the echoes of the great 15th century doctor in his protege 300 years later. Many of the same thoughts, much of the same style. It is easy, reading him, to see why Osler would state "No other profession can boast of the same unbroken continuity of methods and of ideals. We may indeed be justly proud of our apostolic succession." If the profession is deep, it is also broad, and Osler would say in another place "medicine is the only world-wise profession, following everywhere the samee methods, actuated by the same ambitions, and purpusing the same ends." Both these ideas can been seen, nascently, in Browne.

My question after finishing this three thousand odd pages of reading (two biographies, two collections of essays, and Religio Medici) was "where to now?" Osler brought the "Jovian and God-like" image of the physician in antiquity into the modern era, demonstrating its continuance in a scientific world. But he finished his practice before antibiotics, before most diseases could be cured, and before the era of "informed consent." How does a physician today take the lessons of Osler and transfer them to a modern world? I have reached the end of a class, but not the end of my learning.

My professor's answer was straightforward. Francis Peabody, MD was a member of the generation of medical students growing up under Osler's influence, and he lived long enough to see the new ideas and conflicts start to arise. He wrote an essay called "The Care of the Patient" which at least framed these questions, taking the philosophy of Oslerian medicine and working it into the new world. It is, apparently, worth much more than the famous closing line "for the secret of the care of the patient is in caring for the patient." So I haven't run out of reading material.

5 reasons

I've been tagged with "5 reasons I blog" by Medstudentitis, so here goes.

1. I started this blog to tell stories. At the time it began, I was discovering that even the most indulgent of friends and family tire of graphic descriptions of hospital life. This was a great way to share.

2. In many ways, sharing the odd and amazing stories that form life in a hospital can seem like showing off. It certainly is an enthralling lifestyle at times, and that exultation can be wearisome to those who do not share it. Here, since I know only the smallest fraction of my readers personally, they cannot think less of me for exulting. And most of you know exactly what I mean anyway.

3. Working in a psychiatry ward, as I was back when this started, can make anyone feel they ought to be a storyteller. However, telling the same story fifty times can be trying, and this was a great way to let all my interested friends get the story without exhausting the teller.

4. As I progressed in blogging, I decided to work through some more difficult issues for me, as a developing physician, through this medium. I certainly learned a lot through writing here, especially the three posts "in sickness and in health," "as long as you both shall live" and "Parenthood" which are linked in the sidebar under "Key Posts". Probably others were just as good, but those are the ones that come to mind.

5. Less of a reason why I blog, and more of what's been going through my mind lately: I've been away from the hospital, in the legendary lull of fourth year medical students, cramming what enjoyment they can into the last few weeks of freedom before we all start actually working for a living, and so I haven't been blogging a whole lot in the last month. I've questioned whether I will start again once residency begins July 1, and if I do, what shape that will take. A commenter here a while ago took exception with one of my posts, believing that I was laughing at a patient's expense. Though I wasn't, it caused me to more closely consider the Hippocratic Oath, specifically the line "All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal." I'm not sure how much of what I do, and how much physicians do in general, "ought not be spread abroad." Certainly, there is a rather considerable precedent for blogging about the hospital, but precedent does not make ethics. If there are any medical bloggers out there who have actually made it this far, I would truly appreciate your input on the subject. I'm not worried about HIPAA, as I've very clearly stated multiple times that all names here are invented, but I do think law is a poor substitute for societal moral pressure, and I'm trying to determine where that lies here.

Slowing down

Osler was a bit of a bore, truly. I got about 300 pages into the 1200 page behemoth of Cushing's work and decided to switch to Michael Bliss's bio, which at 700 something pages seemed more manageable. Cushing wrote to an audience already familiar with Osler, in an atmosphere of hero-worship. Bliss, though certainly not as accomplished a writer, had the advantage of distance in time from his subject, and gave a perspective I could more easily understand. Still portraying a medical hero, surely, but without assuming I already knew why he was heroic.

But as heroes go, I found Osler more demotivating than otherwise. He certainly had an incredible amount of energy and a singular drive to learn everything he could about medicine. And he balanced his pursuits with reading classics and modern literature, so what's not to love? But I think, upon reaching the end of four years of toil towards an almost mythical end, with "MD" on a paper after my name, that I'm a bit demotivated. Certainly, the end is exciting, but I have to re-examine my motivations for coming to medical school. Most of my friends through high school and beyond wanted to go into medicine, or at least we all said we did. I often point to that as the reason I got here at all: peer pressure. Is that going to be enough to sustain me in residency? Time will tell. But reading about Osler, who published over 700 articles in his lifetime, while writing a textbook that would become the standard work for some 50 years, leaves this particular audience feeling inadequate.

But more than just Osler, my motivation for work has been pretty slim. Given the freedom of a month almost entirely without responsibility, I've been desperately visiting all the museums and restaurants the metropolis has to offer that I've missed in the past years while studying. I've been catching up on reading for fun, sometimes combining the two pursuits, sitting outside some particularly interesting animal's cage at the zoo while poring over the Patrick O'Brian novel I'm finishing. (and as an aside, I find that the higher the animal, the more disheartening the sight of them in a zoo. Fish are fine, and the smaller birds seem to enjoy their large faux-jungle enclosure, but I could see in the eyes of an orangutan the same look I've noticed in depressed patients.) All of this has left little time or inclination towards medical reflection.

I have, however, found a place to live at my residency site, begun packing my things, and started the process of saying goodbye to friends, beginning indolently the next step in this journey. 25 days to go till graduation.

Osler on nurses

As I mentioned a while ago, my current rotation, bringing the fourth year to a gradual, relaxed close, is medical history. I've been reading about Sir William Osler primarily. Osler is probably the most famous clinician of the modern age, and eventually, almost any medical professor will quote him. I am reading about him for that purpose, because despite his fame, I knew nothing about the man before arriving here, and my knowledge was still limited to the quotes heading the various dull sets of PowerPoint slides I've suffered through. When I actually finish slogging through Harvey Cushing's 1200 page biography, I'll write something about that, but since it's been quite some time since I posted anything, I thought I'd put something up.

Osler, I have learned, was a remarkably widely interested and learned man. While a professor at McGill medical school in Canada, he also managed to maintain a professorship in the veterinary school across town, conducting basic research and publishing in both fields, all the while maintaining an amateur interest in microscopic freshwater animals, travelling extensively, and nearly singlehandedly sustaining several professional organizations. (though my source of information is Cushing's biography, which is rather more hagiography at points it seems.) So it is probably unsurprising that a man of such parts should give a graduation address to a nursing school. In a collection of essays I'm also reading, I found the follow example of eloquence which will doubtless be appreciated by the nurse readers here. It may bear mentioning that this address was given in 1891.

If, Members of the Graduating Class, the medical profession, composed chiefly of men, has absorbed a larger share of attention and regard, you have, at least, the satisfaction of feeling that yours is the older, and, as older, the more honourable calling. In one of the lost books of Solomon, a touching picture is given of Eve, then an early grandmother, bending over the little Enoch, and showing Mahala how to soothe his sufferings and to allay his pains...

In the gradual division of labour, by which civilization has emerged from barbarism, the doctor and the nurse have been evolved, as useful accessories in the incessant warfare in which man is engaged. The history of the race is a grim record of passions and ambitions, of weaknesses and vanities, a record, too often, of barbaric in-humanity, and even to-day, when philosophers would have us believe his thoughts had widened, he is ready as of old to shut the gates of mercy, and to let loose the dogs of war. It was in one of these attacks of race-mania that your profession, until then unsettled and ill-defined, took, under Florence Nightingale—ever blessed be her name—its modern position.

The entirety of the address is singularly quotable, which is probably why Osler is so often quoted, but if you are interested in reading the rest of what he said, the full text is here.

How doctors think

A short while ago, while listening to NPR, I heard about this book, written by a doctor who both teaches at Harvard Medical school and writes for the New Yorker. I bought it expecting a grand revelation, because as I understood it, the purpose of the book is not only to explore how physicians think, but to help them overcome the shortcomings of the heuristics used in practice. The perspective I got was that it was targeted at both physicians and patients.

I was a bit disappointed. Perhaps the fact that I am in medical school, in an environment keyed to understanding exactly the concepts laid out here, makes me more informed that the target audience. Certainly, to a layperson, much in this book might be shocking. But to someone behind the scenes, it becomes a set of anecdotes similar to dozens I've heard in the last four years, interspersed with familiar teaching points: maintain an open mind, listen to the patient, consider all the options. The condemnations are familiar as well: insurance under compensates primary care, insurance doesn't cover enough, doctors leap to conclusions. All of which is true, but not new.

In its defense, the book is probably very good for the moderately informed layman, and rereading the laudatory quotes, I see it is not really intended for a physician audience. Certainly, few patients are familiar with a statistic Dr. Groopman cites early in the book, that an experienced physician reaches a diagnosis within 17 seconds of seeing the average patient. Bon mots like that abound for someone who has seen little or been taught little of the workings of a hospital. And the fact that the author is a writer for one of the better-written magazines of our time is evidence of his style and capabilities with language.

Certainly too, the advice he dispenses to patients may be new, and is valuable. Ask good questions, don't be satisfied with cursory explanations, ask what else besides the diagnosis your doctor has settled on could be the problem.

Overall, I enjoyed the book, but my attention was flagging by the final few chapters as it become clear that the exploration of thought was not aimed at a professional audience. The anecdotes serve as warnings and reminders to me, but no more so than any others I've heard. The exhortations to lateral thinking and open-mindedness are no different than that I've heard from my better attendings. And truly, that probably summarizes what this is: an excellent medicine attending writing out his advice to younger physicians in a format a lay audience can understand. Taken for what it is, on that ground, the book is solid and worthwhile. But fellow med students and physicians: don't bother.

And so it ends

The next time I introduce myself to a patient, it will be as "doctor." Today was my last clinical day for the rest of my medical school career. And so Mr. Jefferson, who is in his 20s and just discovered he suffers from narcolepsy and sleep paralysis, will be the last patient to have heard me introduced as "a medical student in here today."

I was trying, on my drive home after my shift, to remember the first patient I saw in the hospital, just for comparison. But I can't remember him well. I do remember he was an elderly gentleman, with heart failure and a body suggesting no immediate danger of starvation, but I can't place his name.

More instructive, perhaps, is to try and remember how I interacted with him. I can recall my checklist, the 3x5 card crammed with obscure questions I generally forgot. And I also recollect that I had not yet learned the physical exam, so my three quarters of an hour in his room was solely to gather his story.

Most of what I've learned has been piecemeal, I think. Starting back in first year with interviews, progressing to the physical exam, learned in parts with a classmate first, then practiced as a whole on patients, trimmed under the influence of surgery attendings and residents mocking the "medical student exam" for its thoroughness to a cursory affair, lengthened during medicine, and focused when my knowledge expanded sufficiently. I remember first year, picking up a copy of the New England Journal of Medicine, forcing myself to read through an article, understanding half the the words at most. Now I can pick up that same article, and at least understand 95% of the words, usually I can follow the concept, and I'm beginning to think how I would apply that article to my own practice.

Though it is still scary to think of calling myself doctor, to think of being a doctor, to make life and death decisions, it is easier, thinking how far I've come.

The next two months are pretty laid back. A month of reading medical history, and a month of "transition to residency" classes. Then graduation, vacation, and the specter of July 1.

Amy Winehouse - Back to Black

There's a lot to be said for the beer test. As in, which of two people would you rather sit down over a beer with? Certainly this factor played some role in the last American presidential election, though whether of not that was good is completely inseparable from political presuppositions at this point.

But enough about politics. Here's the question for this review: given your choice between the following attractive, brunette, female, Jewish, pop musical stars, who would you rather have a beer with: a)Regina Spektor or b) Amy Winehouse? Now the smart money's on Spektor, because if the British tabloids are to be believed, Winehouse would probably finish off a case, and then belt you over the head with a bottle, just for the hell of it.

But to make judgements on such grounds is not always the best course of action. And just listening to this latest offering from Winehouse is enough to make me want to write a review of it. It's the sort of music that makes me want to use trite music review words, like "rollicking" and "infectious." But I'll refrain.

The music is obviously influenced by Ray Charles and his contemporaries, that era where jazz could still be heard beneath the rock. But there's a modern edge too. So yes, saxophones, piano, and a nod to Phil Spector on the production, but we've got drum loops too. And her voice is pure soul.

There are on iTunes the "Explicit" and the "Clean" versions of this record, which should tell you something about the lyrics. But either way, when the first words on the album are "they tried to make me go to rehab, an' I said no, no, no" you know this is probably not a girl you take home to mom, no matter how poetic she is. She is poetic though, and clever too, stating in the title track "we only said goodbye with words," implying the end of a relationship that was more. In "I'm no good" she is frank about infidelities of her own.

This is the blues, and Winehouse is writing what she lives. But it's hard not to hum along, and it's that invitation to share in her musical catharsis which makes this a great listen.