Wednesday, December 17, 2008
First of all, it was a busy and brutal night. From the time we opened for admissions at 2pm and until midnight, my pager was going off nonstop. The ER certainly had a non-stop supply of patients that needed to be admitted.
And by "needed to be admitted" I mean patients for whom the easiest thing for the ER to do would be to admit them because they were feeling a little too ill to be at home (or a lot too lazy to want to return home). The ER definitely could have discharged them, but because ER doctors are too spineless and unconfident, the patients were admitted to the hospital. Honestly, a quarter of patients admitted to internal medicine teams are admitted for so-called “social” reasons, referring to reasons like those I’ve just mentioned.
Therein lays my biggest gripe -- to put it politely -- with the night and with the field of internal medicine in general. We get dumped on. We have to admit every patient. We accept every patient the ER decides to admit to the hospital; or every patient from a surgical service that no longer has a surgical issue; or -- and this is the one I absolutely hate the most -- every patient presenting with a surgical problem that the surgery team who’ll tend to it is just too lazy to admit.
(As an example, I just admitted a young man with several neck masses that he had noticed over the last several weeks. He had no other medical problems and was completely stable; and somehow the ENT teams decided he would be better served on a medicine team. All I do every day is look for the latest recommendations by ENT. Seriously, talk about lazy and work-avoidant doctors.)
Ridiculous admissions like these make me hate what I do. Yes I hate what I do, I really do. I feel that if one wants to be an inpatient internal medicine doctor, one must have a pushover personality. There is no other way to survive each day without feeling discouraged and powerless. Fortunately I will be sub-specializing with a fellowship and thus hopefully avoiding such lame admissions in my future career, but I am not sure I can survive another year and a half of this. Each new admission boils my blood and makes me resent even more the patient population at large.
Anyway, let's go back to my night of call. Lucky me, that was only my first night of call this month ... and I have four months of wards left this year. At least I'm paid well.
Monday, November 17, 2008
More importantly they cluttered up the page, which I like to keep very clean and uncluttered.
Let me know if anyone is horribly distraught by their absence.
Sunday, November 16, 2008
(Many people currently will also argue that the physical exam is obsolete, being rapidly replaced by lab tests, imaging, and other fancier technology. Personally, I don't entirely disagree.)
One of the most important parts of the exam, however, is the mere task of inspection, which involves just looking at the patient. This simple act can provide volumes of information. I feel a patient's hands, and in particular their fingernails, are very telling and provide useful information that the patient herself will not reveal. Here are a few findings I have observed over the last few years.
Dirty nails -- It doesn't take much time or effort at all to maintain fingernail hygiene, so if a patient has clean and trimmed nails it is inconclusive. However, nails that are ungroomed and dirty usually suggest clues about the patient's underlying social history, such as a broken or non-existent housing situation (e.g. as an extreme, being homeless).
Clubbing -- A classic, and the most medical of all these. Clubbing is the buildup of material at the proximal part of the nail bed, giving them a very exaggerated curvature. Often a sign of occult lung disease or cancer, if you notice clubbing consider evaluating the lungs in some detail. I once had an old man present with a set of very vague symptoms. When I noticed his hands and toes had severe clubbing, I started a workup that revealed metastatic prostate cancer.
Long fingernails -- Subtle, but in my view, very telling. I have noticed that long, unclipped fingernails often indicates someone with psychiatric issues. A mind fraught with psychosis or depression has more pressing issues than clean fingernails. Again, it doesn't take much to maintain one's fingernails, so when I see this I wonder if the patient is mentally sound.
One long, groomed pinky fingernail -- Historically this was a trait of gangster bosses, drug dealers, or the like, who proudly displayed a long and groomed nail to signal that they were white collar, and not a manual laborers who used their hands to make a living. Today, it means you're a douchebag. While this finding doesn't provide true medical information, it is always good to know when you're dealing with a douchebag.
Anyway, with that said, regularly scheduled programming will now resume. Stay tuned!
Tuesday, November 04, 2008
Monday, October 13, 2008
I know that I -- in my vast bitterness -- have insulted patients many a time, insulted nurses many a time, and insulted fellow doctors many a time as well. However, no one tops the following people in terms of sheer, absolute dumbness (for lack of a better word).
(In case you require a medical-related reason to watch this video, just imagine the blood pressure effects of listening to the people featured in this video.)
Tuesday, October 07, 2008
The police also ordered everyone in the hospital to refrain from using their cell phones for some reason ... whether it was because the signals might interfere with their communication, or perhaps even because the signals might activate the suspicious package, no one was sure.
Better yet, they also made us turn off our pagers. So while this entire event was a tense and even frightening situation, it was almost worth it to be free of our digital leashes for several hours!
Oh, and it wasn't a bomb.
Sunday, September 21, 2008
Regardless, even though I was technically a resident, I didn't have any clinical duties or activities. All that has changed now. I am now on my first clinical rotation, and it is in the ICU no less ... and it is quite a rude awakening.
Not only have I been out of practice for several months, I am now thrown into the ICU, where things change by the hour. No more merely doing what I am told (because I’m the one doing the telling). No more nodding along upon hearing the management plan (because I’m the one doing the planning). And no longer do I have the the luxury of possibly having several hours of sleep while on-call (because I’m the one getting paged down to the ER every few hours for their bogus ICU evaluations)! Like I said, definitely a rude awakening.
Especially scary are the nights on call. Since I admit to both the ICU and CCU, I am the only ICU/CCU doctor in the hospital during the night. My first night of call, when I first realized that, was a momentous occasion. It was extremely scary to think that I alone was responsible for taking care of the sickest patients in the hospital. Someone in the ER getting septic? Someone arriving via ambulance with an acute MI (heart attack)? A patient on the floor going into respiratory distress? It’s all me to take care of!
Granted -- and this is the only thing providing an iota of comfort -- the fellow is always available by phone, and not only that but I have to page him for every admission, but I am still the first line. I can no longer face a group of nurses and say “Let me ask my resident”. These thoughts alone were enough to keep my anxiety levels sky high through the night, and to keep me from relaxing even when I had the chance to sleep.
It has been a few weeks now, and luckily -- thankfully -- I can say it is getting a little easier, and I am getting a little calmer. But it is still frightening.
So … all that bitterness and anger from my internship? Well it is now replaced by terror and anxiety. Not sure if that was a fair trade!
Wednesday, September 10, 2008
Sunday, July 13, 2008
Looking back at internship, many thoughts come to mind naturally. On one hand I feel like I learned nothing, but upon deeper consideration, I really have come a long way in terms of personal growth and knowledge.
(As an example, I like to think back to my first few weeks of the year-- where I was afraid to order even a Tylenol -- to the last few weeks, where I had no problem making preemptive orders at night, announcing to nurses and patients alike, “Benadryl 50mg at 10pm, so we can ALL sleep well tonight.”)
Additional thoughts? For one, I did not learn medicine. It sounds odd and impossible, but it is true. I don’t feel like I learned how to heal people. However, I did learn how to write admission order in my sleep, draw little “To Do” boxes and check them off, and, most importantly, how to mask patients’ pain with Vicodin (“page me if you need more”). Middle of the day or middle of the night, I did these with such ease you’d think I had been doing this for years.
And somewhere -- somehow -- amidst all this ridiculousness, patients healed. Or perhaps, they just left the hospital in slightly improved condition, but either way I never felt it was any of my knowledge that contributed to their discharge.
Another unfortunate realization that developed this year is that I don’t like patients. Once again, odd but true, and it began as early as day 2 (on day 1 I was too nervous and enthusiastic to let it bother me.) Patients would describe their symptoms to me (or more accurately, explain in detail every aspect of their health except what I would be interested in), and all I could think about is “I don’t care.” Because I didn’t. I didn’t care about their problems, and as they would talk to me I would silently bet myself if they would stop talking within the next minute. I rarely won.
For me, the patient wasn’t a sick person. They weren’t poor humans seeking my skills in their time of sickness. To me, they were yet another obstacle to me getting sleep or going home. It is unfortunate how much this year has turned me against patients, and much as it may seem otherwise, I’m not proud of it either.
Anyway, regardless of how this year has changed me -- whether to make me more bitter, detached, wise, efficient, whatever -- it was a unique year. I mean, where else can you get on-the-job training that is simultaneously demanding, educational, frustrating, sleep depriving, and low paying? But enough is enough, I am ready to see what being a resident has in store now.
Tuesday, June 24, 2008
Wednesday, June 04, 2008
Wednesday, May 14, 2008
Forget raindrops on roses and whiskers on kittens ... I prefer the following any day:
Post-Call Breakfast Burritos
The only good thing about being on-call and staying in the hospital overnight is the anticipation and feeling of leaving the hospital post-call. And rewarding yourself on a post-call day with tasty, unhealthy food is part of that joy. Breakfast burritos seem to be something all hospital cafeterias prepare, and prepare well. It may be a plate of artery-clogging comfort food, but it definitely feels well-deserved after staying overnight at the hospital.
Patients Who Leave AMA
A patient can leave the hospital at any time they want (with a few exceptions, of course). If it is before the doctors feel they can be discharged home safely, they have to sign out against medical advice ("AMA"). Early in the year when alerted by the nurses that a patient is considering leaving AMA, I used to rush over and negotiate with them to stay. Nowadays, I seize the opportunity to get a patient out. I still rush over ... but this time with the AMA papers in one hand and a pen for them to sign with in the other. Patients think they are threatening us, but in reality they are giving us a gift.
"Duh", you might be saying to yourself. Yes, anything or anyone good is a desirable thing: nurse or otherwise (co-worker, friend, turkey burger). But the difference between a good nurse and a bad one is priceless. Good nurses try to handle unexpected patient situations before jumping to page you, they shield you from patient complaints that don't require your (or anyone's) attention, and best of all, they don't send you really dumb pages. So really, the difference can mean a few extra hours of sleep. To the up-and-coming newbies: identify the good nurses and get on their good side. Their great side. You will appreciate the kickbacks.
Sunday, April 27, 2008
I was woken up to receive this page at 5am:
My ideal response: "I see. Now how about I wake you up at 5am and see how awake you are."
My actual response: "OK, thanks for the update."
Tuesday, April 22, 2008
While it strictly just refers to a hospital, this term actually has much richer connotations. A patient being transferred from an outside hospital usually has had many unnecessary procedures, countless tests, and, most irritating of all, is transferred over with a surprising shortage of records and documentation describing what happened there ... and the very few that are sent are of no help at all. Unfortunately you probably cannot fully appreciate this video unless you have worked or trained at a large -- and probably university-based -- hospital.
The best part is the series of back-and-forth comments at the bottom of the page that viewers have posted, particularly by some very defensive people.
But ... the bestest part? "We'll send the nursing notes".
Tuesday, April 15, 2008
Thursday, April 10, 2008
Dressing half the time in shirt and tie and the other half the time in scrubs makes my shopping bills and cleaning bills much lighter. Luckily, men are not expected to have as much variety in their shirts and ties as they are for their casual and going-out clothes; just observe any guy and within a week you will start seeing his attire cycle. As such, I rarely need to go shopping or do laundry. (Don’t worry, you will always see me clean and presentable).
Granted having no/few weekend days off is miserable, since having a set and regular week is a great way to make it through said week. However, if forced, having weekdays off is not so bad since places are usually much less crowded during the day. A little less hassle in grocery stories, shopping malls, and restaurants is a small, yet helpful, perk.
Not by any means a new observation, but I am starting to appreciate this better. Now that I am (more than) several years out of college, I have unfortunately watched more than one friend get laid off or leave because of dissatisfaction and then unable to find a new job. Luckily I doubt I will ever be in this position. Barring any sort of unethical, unprofessional, or incompetent behavior on my part, it is safe to say physicians of almost any specialty will always be greeted by open positions in nearly any part of the country. So while I struggle with an inflexible schedule and low, low pay now compared to my friends, I like to think that in the end this will all pay off.
One benefit of living in the hospital and having no personal or social life is that there is much less time to spend at home or in a social scene to spend money. As a result I have fewer food bills (since the hospital provides lunch), fewer electricity bills (spending one out of four nights away from home), and less time and money to spend in bars (well...).
Speaking of money, being a doctor gives you immediate and great credibility with financial institutions. I had to interact with several lately, each of which asked for my profession. Upon stating “physician” whatever algorithm their systems used boosted up my reliability. I just received a huge increase in credit limit and nice low interest rates. I realize one’s profession doesn’t make or break financial transactions, but it definitely appears to help. (The above is also true -- to a point -- if you substitute “financial institution” with “the ladies”. But not really.)
Tuesday, April 08, 2008
If anyone has any overwhelming objections to this let me know, but for the time being I am curious to see how it works.
Tuesday, March 25, 2008
Why? Because I feel I do nothing that directly helps people get through their times of acute illness. All I do during my day is order lab work, consult other services, and then follow up on those tests and consults. Then, seemingly miraculously, I get to discharge patients home because somehow their symptoms -- or, more importantly, their lab values -- have improved. I don’t know precisely when in the above process patients actually improve. They come to the hospital sick, I order countless tests, the patient and I both wait for the results, and then I discharge them home.
All this makes me wonder: is this medicine? If so, it is kind of shocking ... especially since I have already seen the inner workings of a hospital before, as a medical student. I cannot help but think of House of God, that classic novel of life inside a hospital during the internship of six new interns. Early on the main character describes this very sentiment, saying:
“This internship is nothing like what I thought it would be. What do we do for these patients anyway? They either die or we BUFF and TURF them to some other part of the [hospital]”His resident then responds with “That’s modern medicine”.
(Turfing is slang for the act of transferring patients to another service, and buffing is the term for fixing up a patient enough so that they can’t return back to your service once you turf them).
Great. Again, maybe this really is modern medicine -- just doing whatever it takes to get patients off of your service. That book, by the way, was written in 1978.
I feel this is the point where the surgeons get to laugh and say, “I told you so”. They always mock internists for doing too much thinking (and rounding) and not enough doing. It is the heart of the rivalry between medicine and surgery, and it’s based in truth. We, as their medicine counterparts, don’t get to solve medical problems directly by fixing them with our hands, but achieve it indirectly via ordering drugs. The immediate satisfaction surgeons feel after a successful procedure is hard to achieve when a patient’s improvement comes as a result of administering a drug.
In any case, the future -- at least the next three years of it -- is looking a little more bleak and a little less satisfying now that I realize I’ll be doing this for 80 hours a week for the duration of my training. Perhaps it will change for the better once I become a resident. Or, perhaps, I’m destined to a life of buffing and turfing.
Tuesday, March 18, 2008
Sunday, March 02, 2008
Are they kidding? It is less than one year after graduation -- graduation from medical school no less, which implies that I am making pennies as my salary -- and they have the nerve to ask for money! However, they did show their generosity by stating that I could spread out donations greater than $25000 across multiple payments.
They couldn't wait a few years before sending me letters to donate. They couldn't even wait one year. And now, because of this one cruel, unsympathetic letter, they shall never receive a dime from me.
Thursday, February 28, 2008
And all I can think about is how I much I hope he goes to the ICU, so I won't have to deal with his paperwork once he dies.
Thursday, February 21, 2008
That needs to change. Patients are as much of a part of their care as are doctors. This sounds obvious, yet you would not believe how uninterested, lazy, and ignorant many patients are. While doctors struggle to adhere to the intense scrutinies of professional requirements (and popular media) many patients do nothing but expect 5-star medical while they sit back and relax.
One thing in particular patients -- all patients -- need to do -- in fact, must do -- is to know their medications. Again, it sounds again obvious, but I am amazed by the number of patients that do not know the details of their medication list. Not just names, but exact dosages, frequencies, and dosing schedules.
It is not sufficient just to know the names of your medication -- although that would be a great start for some of my patients. It is not at all useful to us if you say "I take a little blue pill". Sorry you tool, we don't know what pills look like. We may prescribe pills, but we have no idea what color, shape, or size pills are. So enough of this "a little white pill", "that little square blue pill", or "a really big pill". Pharmacists don't even know that information.
"But doctor", you might say, "my memory isn't good". Or, "I take too many medications to memorize them all". Both are legitimate complaints, but you are not excused. If you cannot remember your med list for whatever reason, then write it down or type it out and -- this part is key -- carry it with you at all times. Yes, all times. You never know when you will have to go to the ER without warning, and have to report this list to your doctors. When your life -- or an improved version of it -- depends on medications, you better be damned sure you know everything about them.
There aren't many situations in this world that are the proverbial black or white; almost everything is grey in this world. Except this. So patients listen up, get involved in your own care, show some responsibility, and learn your meds!
Tuesday, February 05, 2008
As for me, my “oh no” patient is the crazy patient. Yes, the crazy patient. Who is this crazy patient? Here’s a non-exhaustive list of those who quickly get that label. If I know you satisfy one of these, I expect you will be nothing but trouble during your stay at the hospital. So, I’m gonna call you crazy if…
- You have a pan-positive review of systems – in other words you answer “yes” to everything on the review of systems (our flurry of questions to see if there are any other symptoms you're having: chest pain, shortness of breath, constipation, weakness, etc.) This is a classic one. Those of you who answer yes to everything -- or even 3 items -- have nothing wrong with you ... except your heads.
- You have an Actiq (Fentanyl lollipop) in your mouth as you walk in through the door, or as you're talking to me as I interview you.
- You admit to having more than 3 allergies. Very few people are allergic to that many things. Trust me, this is a telltale sign!
- You have fibromyalgia. Don’t even get me started. I am not denying that pain syndromes don’t exist; it’s just that people who like to have this label have lots of other, um, issues.
- You ask specifically for IV dilaudid. If you are my patient and you ask for this, please, just get the hell off my service. Your words scream drug seeker. (And briefly, as long as we’re on the topic of drug seekers, it’s not just me … we all hate you.)
- Finally, the “frequent flyer”. The patient that’s in and out of the hospital every other month, week, or day (yes, day). Words cannot begin to describe how much I loathe you people. Who in the world prefers the hospital to their own home?
Monday, February 04, 2008
I couldn't believe it ... I really couldn't. While I didn't get angry on the phone, I did try to convey my anger with a stern voice. Unfortunately, my logic was completely lost on her.
A prn med ... I still can't believe it.
Tuesday, January 22, 2008
And now, all of a sudden, the hospital seems incredibly small ... unusually and suffocatingly and uncomfortably small. Not smart.
Wednesday, January 09, 2008
So ... I walked over to see what all the banging was -- maybe not the smartest of idea to investigate weird noises in the middle of the night -- and saw that it was a patient, who had locked himself out, after he had walked outside, for a smoke, with his oxygen tank. OK, that's not the smartest of ideas.