The Best Things in Life

I saw one of my favorite patients today. He is a 30-something-year-old guy with a history of diabetes for the last seven years who has been doing a great job over these last few years of keeping his diabetes very well-controlled. He takes his meds on time, calls in for refills when they start to run out (a rarity not to be underestimated among patients!), and has been very compliant with his routine visits. Like any diabetic, despite maintaining a good diet most of the time, he occasionally gets tempted by very sugary and starchy foods, but for the vast majority of the duration of his chronic illness he has done a great job of showing restraint.

This visit, however, he had news for me. Apparently a new bakery moved in next door to where he worked, and he fell under the spell of some tantalizing cakes they made. Initially he did not even notice the cakes. Then one day he had to go in for a non-food related reason and his interest was slightly piqued. Soon things escalated to the point where almost every day he would walk in and ask for a tiny sample of a cake. That was a few months ago. These days he was at the point where he'd ask for a slice on a daily basis. He still took his meds; he still measured his sugars; but now he was also having a generous slice of cake ... and frequently too.

So he finally succumbed. Despite his initial strength, his many years of good diabetic control, and full awareness of the consequences, he bought an entire cake and went home to eat it. Not just eat it ... scarf it down. From what I hear, he really enjoyed it. It seems that before this bakery, he had not touched cake in many years. And now, he tells me, he splurged three nights in a row, one cake each night.

After this encounter, I couldn't help but think why is it that the best things in life have the potential to be the most dangerous? Not only are they not free as the adage suggests, but they really are the most harmful, whether physically or emotionally or financially. I am not only referring to sugar, salt, fat, and other tasty foods, but other entities in life as well (e.g. excessive money, extreme sports, a neighbor's wife.) Our brains seem naturally wired to crave that which is bad for us. Or maybe it's just we covet that which we can't have. I don't see how this helps with natural selection. In fact, I bet some grand designer up above designed this system intentionally and must love observing us.

Back to my patient, he has now radically thrown off his blood sugar readings and who knows what sort of complications he may face down the line. He is regretful, although he really did enjoy it in the moment. He claims he will be back to good behavior, but we shall see.

Anyway, I don't know why I even wrote this entry.

New Interns

That time of year is here: the brand new interns ("baby interns", if you will) started a few weeks ago in the hospital. I have been looking forward to this day for nearly one year now, as last year I was on an outpatient rotation during the start of the academic year and thus did not get to interact closely with the new interns. It didn't take long, however, to realize why most senior residents dread this day.

I met my two new interns on a Sunday, a day on which our team was on call. So not only did these poor interns -- essentially just fourth-year medical students -- have to start their internship on a weekend, but they had to start on call and stay overnight in the hospital. It was a whole new world ... a whole new, brutal world that didn't care about weekends, holidays, or "after hours".

The rest of the day was spent orienting them to the hospital, describing the way things work in the hospital, and providing them with an overview of day-to-day operations. In addition I had to teach them how to use the VA computer system, which is intuitive and joyful to use once you know the basics, but those basics take some time to learn. Juggling all this while receiving annoying calls from the ER for patient admissions made for a very busy and oftentimes trying day. The day was an exercise in patience, disguised as a fresh start for a group of frightened newbies.

Most surprising, although it shouldn't have been, was watching the interns' clinical skills in action. Understandably, they had not interacted with patients in many months, nor had they made any sort of oral or written presentations in that same time. The minutes of the day where I wasn't teaching them how to order medications or learn the phone system, I had to work on how to present a basic H&P. And by "basics" I mean just that. I spent more than one sitting explaining how one first presents the history, then the exam, then labs, etc. Those basics.

On a final note, just when I was thinking the next day how it couldn't get any worse, of course it did. I soon met two very young guys who introduced themselves as my new third-year medical students. In case you are not familiar, that means they were fresh-as-can-be, had-never-set-foot-in-the-hospital-before, hearts-still-racing-from-waking-up-at-7am medical students. Interestingly, though, while at times the new interns seemed like seasoned pros compared to the new medical students, much of the time they were very similar: new, scared, learning, and above all overwhelmed.

Looking back, despite some of this grumbling, the mere novelty of the week and its participants made it an exciting one me. I am glad I was present to welcome the new interns and students, but it is not something I want to repeat as a resident. Hopefully, as a fellow, I will be slightly shielded from them ... by the poor residents.

Fellowship Match

Match Day for fellowship was a few weeks ago, and dear readers, your Axis got his #1 choice!

The fellowship matching process is identical to the residency matching process, which is nice for the sake of familiarity but painful because it involves repeating a long, expensive, and tiring process.

Matching for fellowship was exciting mostly because it indicates that residency will soon end and I will begin training in a field I am actually interested in, cardiology. A third year of medicine residency lies ahead of me, but the end is now in sight.

Exciting and motivating as it is to see that end now, it reminds me yet again that I have will have had to wait several years before I can be immersed in the field of my true interest. Unlike my counterparts in, say, neurosurgery, urology, obstetrics/gynecology, psychiatry, or radiology, all of whom started training in their fields immediately after medical school (save one year of internship, of course), I have to suffer through three long years of general internal medicine before reaching cardiology. Three years of low back pain, diarrhea, runny nose, GI bleeding, and countless other symptoms/illnesses that I simply do not care about. It's hard to be good at what you do when you don't like what you do.

Regardless, the end of general training is near and soon the game of sub-specializing and sub-sub-specializing will start. I will now be Axis, second-semester senior.

Latest Grand Rounds

Check out this week's Grand Rounds, hosted by Diabetes Mine, who did a great job of organizing it. Look out for a post from your very own Axis!

New Design

Axis Deviation is growing up. Throughout its lifetime of nearly three and a half years, this blog has kept the same design. While I have enjoyed the red and grey of old, it is time to retire it and inject a new energy into this blog's appearance. So in the spirit of change, especially since there is no such thing as timelessness on the web, I have changed this site's layout.

Allow me to explain the reasons for choosing this particular template. The theme's block design offers a subtlety lacking in the old theme, which some might deem overly aggressive. I appreciate how the magenta titles contrast the melancholy blue-grey overtones, making the site approachable, pleasing, and even bosomy. Finally, the header's rounded grey squares -- majestically translucent and overlapping -- are delicately spread out, such as might give the effect of confetti blowing into the sky on a warm summer night. Plus it looks cool.

Enjoy.

Clubbing and Coding

Excitement, dear readers, excitement! And outside the hospital, no less ... read on.

In a rare weekend where I had both days off, I went with some friends out of town and then to a club (you know, to read the articles). At one point while I was busy talking, I noticed a large group of people huddled around something across the room.

Automatically I assumed that the "something" was a person so I darted over, pushed my way through the crowd, and then saw a young man collapsed on the floor. Instinctively I jumped in. I didn't even know I had such instincts.

A few muscle-headed security guards were also kneeling down, but I squeezed myself between them. I went straight for the collapsed guy's neck to feel for a pulse, when one muscle head barked that I could not help if I was drunk (which I was not). Normally when a bouncer-type person yells at me I shy away, but this time I barked back that I was a doctor and could help. Immediately -- satisfyingly -- he retreated.

I continued assessing the guy and performed some simple BLS (Basic Life Support). For some reason -- perhaps in the excitement of the moment -- I cannot remember exactly what I did the next few minutes, but I do recall one of the security guards pulling out some gloves from his pocket for his own use, and me snatching it from his hand. I put it on my own, and then he surprised me by offering the other.

Initially I thought the victim had no pulse, so the guards turned to me to see if chest compressions should be started. Just as I was about to nod we tried a sternal rub. The guy immediately started groaning and then he came to. I stepped back and left him to the guards and the newly-arrived medics.

The guy was then wheeled off and hauled away to an ambulance, slurring, belligerent, and all. Good ol' alcohol intoxication.

Any sudden and unexpected situation is an exciting one, but this scenario held special significance. Since medical school or early internship, I have had recurrent daydreams (fantasies?) where I imagine being in a public place when someone collapses, and I rush to the rescue. Whether I do this because of boredom, an overactive imagination, or a latent desire to be a hero -- in one of my dreams I order the pilot of our plane to make an emergency landing! -- this scenario has crossed my mind many times.

Sadly, when the real thing occurred, I wasn't nearly as graceful as in my dreams. In the heat of the moment I had to spend a few seconds reviewing BLS algorithms, and then later I was slightly hesitant to tell people to start chest compressions (which, as mentioned, ended up being unnecessary.) In addition, finding the victim's pulse was close to impossible with loud music pounding in the background and having multiple crowd members yell out idiotic comments does not help one's focus.

Regardless, my work and play don't often mix, so having these two worlds run into one another was definitely exhilarating.

ALL CAPITALS

THE PAGERS IN OUR HOSPITAL ARE TEXT PAGERS, WHICH MEANS THEY DISPLAY BOTH NUMBERS AND TEXT (LIKE A CELL PHONE DISPLAY). MOST OF THE TIME THIS IS A VERY HELPFUL FEATURE ... BUT NOT ALL THE TIME.

NEVER BEFORE, AT LEAST NOT SINCE GRADE SCHOOL, HAVE I SEEN SUCH POORLY-CONSTRUCTED SENTENCES. FORGET THEIR GRAMMAR FOR A MOMENT, THESE PAGES ARE ATROCIOUS BECAUSE OF THEIR CAPITALIZATION.

WELL OVER HALF OF THE NURSES SEND PAGES THAT ARE ALL CAPS. IN CASE YOU CAN'T TELL, IT IS EXTREMELY ANNOYING TO READ. IT TRULY FEELS LIKE ONE IS BEING YELLED AT. I CAN THINK OF A FEW REASONS WHY SOMEONE WOULD SEND AN ALL-CAPS PAGE:

1) THEY ARE TOO LAZY TO FIX IT
2) THEY AREN'T AWARE OF IT
3) THEY DON'T KNOW HOW TO CAPITALIZE PROPERLY

ACCORDINGLY, I HAVE PREPARED SOME RESPONSES:

1') TAKE A SECOND AND LOOK AT YOUR KEYBOARD. IT'S THE KEY TO THE LEFT OF THE 'A' KEY. JUST PRESS IT ONCE.

2') TAKE A MOMENT TO READ YOUR PAGE AS YOU'RE TYPING IT. THEN SEE POINT 1'.

3') REPEAT 3RD GRADE (OR TAKE IT FOR THE FIRST TIME)

THERE REALLY IS NO REASON NOT TO CAPITALIZE PROPERLY. IF YOU'RE MATURE ENOUGH TO CARE FOR PATIENTS, YOU SHOULD BE MATURE ENOUGH TO WRITE WITH A MINIMAL LEVEL OF SKILL.

It's really annoying, isn't it?

Thank Goodness for Scrubs

Nearly everyone I tell I am a doctor asks almost immediately, “Is your life like Grey's Anatomy?”

It is annoying because 1) it isn’t, 2) I wish it was for the sake of (unrealistic) excitement, and 3) I hate Grey’s Anatomy.

Anyway, the conversation that follows usually goes like this:

Me: “No.”

Person: “Ha ha! So what is it like then?”

And this is where it gets a little annoying. It is difficult to explain to non-medical people what an internal medicine resident or internist does all day long. What I do is not that interesting, and I am sure the average layperson would be downright bored hearing a description of my day-to-day activities. (“I start the morning by reviewing labs on a computer. Then I walk from patient to patient asking them how they were last night. Then I spend the rest of the day struggling with the computer system trying to order a lab, paging consults who never call back, and occasionally doing some procedure that inevitably takes ages to set up for.”)

Non-medical people likely don’t understand the concept of rounding, the importance of ordering and following up labs, reviewing films with radiologists, and most importantly, how the time it takes to perform countless small tasks like these quickly adds up.

Surgeons have it easy here. They could simply say “I do surgery”, and everyone in the world would know what that means. Lucky bastards.

Enter Scrubs. This TV show has done a great job of capturing the realities of internal medicine residency and making it interesting. And because it is a popular show, many people are familiar with it.

I have therefore found the best response to “Is your life like Grey’s Anatomy?” is, “No, it’s actually like Scrubs.” People immediately understand.

Scrubs ... relieving doctors like me from painful conversations everyday.

Fellowship Applications

It's that time of career again. I am now applying for fellowship, which means yet another round of filling out applications, begging for letters of recommendation, and sending lots of money to programs. I felt like I just went through this ... and what do you know, I did.

I am beginning to feel that the rest of my life will consist of this dreadful cycle.

A Catastrophe Waiting To Happen

There is a lady on my service that I admitted to expedite her pre-transplant workup. Her family comes to visit nearly every day, and here is who her family members are:

1. Husband -- the "high maintenance" type (wants to be updated every day about the latest plan regarding his wife's care).
2. Daughter -- the head pharmacist at a nearby hospital (of note, she is not a physician, yet parades around as if she is one, by constantly demanding detailed information regarding her dad's lab values and other numbers).
   
3. Son -- a lawyer ('nuff said).
   

Can you imagine a worse patient family?