Axis Deviation

Start of Fellowship

2010-07-03T21:19:00.000-07:00

Today marked the first day of fellowship, peoples. No more internal medicine ... from now on, your Axis will be in cardiology fellowship training. What will this mean for us?

For me, it will mean finally being in the specialty I enjoy. It means no longer dealing with patients with issues that are beyond the sphere of my interest. No more dealing with social issues and where to place patients upon discharge. And most importantly no longer am I the Plan B (or C, D, or worse), in terms of the service to whom patients should be admitted when no other service wants them.

For you all -- for those very reasons -- it might mean this Axis might just be happy for once, which, in turn might mean blog posts that aren't quite as bitter and venomous.

Who knows? We have several years to find out. Stay tuned.

Residency, By the Numbers

2010-06-30T22:16:00.000-07:00

Years of residency	3
Months of residency	36
Days of residency	1094
Number of them I spent overnight in the hospital	223

Most hours worked at a time	36
Most hours worked in 48-hour period	40

Number of pts I admitted (approx)	~1500
Number that died under my watch	Small handful

Number of pages received	TNTC
Number of times I threw my pager into the wall	0 (!)

Number of lumbar punctures	12
Number where I shook the needle because of a page	2

Number of patients in my clinic panel	110
Number who I truly liked	2

Number of pelvic exams I did	36
Number I enjoyed	0
Number of times I pinched a cervix	1 (so sorry)
Number of times I performed the "whiff test"	1

Number of times I converted my PPD	0

Number of needle sticks	1 (pt HIV negative, whew)

Number of lawsuits	0

Number of days left of residency	0

Nasty

2010-06-11T18:04:00.000-07:00

I stepped into an elevator at work today just as another patient joined me. It was only the two of us. He was in the hospital for, among other things, ulcerative colitis, and thus was having large amounts of bloody diarrhea.

A few seconds into the ride a loud rumbling noise emerged from the depths of his GI tract, prompting a look from me in his direction. He proudly clutched his belly and announced, "Sorry, I've got gas!" When the elevator stopped on his floor, he walked out wearing nothing but his hospital gown ... which, at this time now, was dripping multiple globs of light brown watery stool with each forward step.

As if that weren't bad enough, while walking out myself, I accidentally stepped in one of his disgusting puddles.

I spent the next hour at a nursing station with every anti-infective spray, cream, and wipe that they had. You can find my shoes in the garbage.

Nasty.

She Had a Cold

2010-05-11T18:41:00.000-07:00

I was in clinic today talking with a new patient, a fairly healthy 40-year-old woman, and as part of my routine sexual history I asked if she had ever had a STD (sexually transmitted disease). She responded with "I had something a few years ago, but it turns out she had a cold." I did not understand at all what she meant, so I asked her to repeat herself, to which she again said "She had a cold."

I had no clue what she was talking about. I had no idea who "she" was. I assumed I was simply zoning out while the patient was talking earlier and thus must have missed who "she" was. Thinking the patient may have been referring to a female sexual partner, but not wanting to appear as if I hadn't been listening, I casually asked her "Oh, your female partner?" and she again responded with "No, she had a cold."

Still without a clue as to who had this cold, I then asked "You mean your doctor? So your doctor had a cold?" and she again said "No, she had a cold."

I was about to lose it. Who is she? Who had this cold?

I finally blurted aloud, "OK who are you referring to?"

She then pointed with both hands to her crotch and said, "SHE had a cold!"

Oh. Ohhh. Her. Well excuse me. Couldn't you simply have given her a name and made this easier from the start?

I did laugh, though ... and yes, in front of her.

(And no, I still have no idea what she meant by "a cold".)

Scrubs, the Huffington Post, and Me

2010-05-05T19:19:00.000-07:00

Recently I came across this Huffington Post article. Yes I know I am reading it one year and four months after it was published, but that aside, it reports how the television show Scrubs will be returning for what ended up being its ninth and final season.

Obviously I was excited -- both at the time and also currently -- to read about Scrubs, for as many of you know I am what may be considered a fan. But what was even more thrilled was that they mentioned one of my posts in their article! I had reached the end of the first full paragraph, which finished with:

Scrubs remains the most realistic medical show on television according to most actual doctors and nurses.

With intense curiosity I clicked on that link, which very unexpectedly brought me to my own article. Apparently I'm "most doctors or nurses" ... me, yours truly, your favorite Axis.

I wish I had come across this in a more timely manner, but this delayed surprise isn't so bad. Unfortunately, Scrubs has since come to an end (even after a brief and weak effort at resurrecting itself with a newer version involving medical students) so all I have of that unique show are memories ... and great articles like this.

25 Things I Didn't Do Before I Entered Medicine

2010-02-22T21:08:00.000-08:00

Wake up before 8am.
Go to sleep after 2am.
Look forward to sleeping nearly every night.

Wear a shirt and tie to work.
Shave more than three times a week.

Stick my finger up peoples' butts.
Ask people how many people they’ve slept with.
Ask men to tell me about their erectile dysfunction.
Ask for men to show me their penis.
Dread seeing vaginas.

Be able to tell police officers what to do (in the hospital, at least).
Talk with police officers.
Talk with prisoners.

Slam the phone on people.
Hate pagers.
Hate anything that beeps.

Drink at home, alone.
Want to drink this much.

Be thankful I am alive.
Hope that certain people would die.

Struggle for money.
Dream of money.
Despise people with money.
Despise people.

Wish I didn't enter medicine.

Holidays Are Over

2010-01-15T15:57:00.000-08:00

Now that Christmas and New Years have come and gone, there is only one thing I can say ... thank goodness the holidays are over. I cannot be thankful enough. I was unlucky enough to have to work on Christmas Eve, Christmas Day, New Years Eve, and New Years Day. And for most of them, notably New Years Eve, I had to work night shifts.

I used to love the holidays. I loved the Christmas decorations on the streets, Christmas music everywhere, and the feel of the weather (yes it's California, but still). This job, however, has gradually eroded my passion for the holidays (among most other things in life), and this year sealed the deal.

Working through the holidays, and those four days in particular, was dreadful. Putting in my thankless slave labor hours while watching my friends and family get time off -- some of whom got two weeks off! -- was extremely discouraging and depressing. I absolutely dreaded going to work each evening, I was grumpy with co-workers in the hospital (many who reciprocated for similar reasons), and I found patients extra hateful. What kind of person prefers to be in the hospital on Christmas Day as opposed to home. Who thinks "instead of opening presents or spending time with family let me go to the hospital, complain, and get attention"? Those people are not sick in body, they are sick in mind.

Holiday season 2009 was the worst I have experienced ... and I sincerely hope no future holiday season tops it.

The Best Things in Life

2009-11-16T14:04:00.000-08:00

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

2009-09-05T21:38:00.000-07:00

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

2009-07-08T17:10:00.000-07:00

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

2009-04-21T10:39:00.000-07:00

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

2009-04-08T22:59:00.000-07:00

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

2009-04-07T22:54:00.000-07:00

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

2009-03-30T00:29:00.000-07:00

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

2009-01-27T22:23:00.000-08:00

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

2009-01-25T20:35:00.000-08:00

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

2009-01-09T16:42:00.000-08:00

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:

Husband -- the "high maintenance" type (wants to be updated every day about the latest plan regarding his wife's care).
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).
Son -- a lawyer ('nuff said).

Can you imagine a worse patient family?

I Hate Internal Medicine

2008-12-17T21:56:00.000-08:00

Last night I was on call for the first time as a resident on the wards (i.e. general medicine inpatient wards, the basic/core inpatient rotation in internal medicine), and more than ever do I hate being a resident in internal medicine.

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.

Ads Are Gone

2008-11-17T20:13:00.000-08:00

Just an note on a minor update to this site's design: I decided to take down the Google Adsense ads that used to be on the sidebar. I felt they were not very relevant or useful, especially since they displayed ads mostly about hospitalist positions.

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.

It's All In the Hands

2008-11-16T22:35:00.000-08:00

Much of the training to become a doctor involves the physical exam. This is the time-honored skill of performing tasks like listening to the heart and lungs, palpating the abdomen, feeling for pulses, etc.

(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.

Resuming Post-Election Life

2008-11-16T21:18:00.000-08:00

The election is over, and thank goodness. I can now get some sleep without stressing over whether America will have sense enough to vote the right person into office. For the first time in a long time (8 years, in case you were wondering), I can say I am proud of my country.

Anyway, with that said, regularly scheduled programming will now resume. Stay tuned!

Election Day!

2008-11-04T07:25:00.000-08:00

Go vote peoples (if you already haven't)!

Seriously. No seriously.

If you need help finding your polling location, go to voteforchange.com.

The Dumbest People Ever

2008-10-13T21:53:00.001-07:00

Peoples.

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.)

Silver Lining

2008-10-07T21:38:00.000-07:00

There was a bomb scare in the hospital today. A suspicious package was found and the hospital went into emergency mode. It was actually an impressive event, where all of a sudden the hospital police and city police department came rushing through the floor and very unceremoniously shoved us out of the wing ... and then proceeded to evacuate all the patients too!

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.

The ICU Resident

2008-09-21T18:45:00.000-07:00

I am now a real resident. The last several months I was on a research rotation, which kept me very busy ... not as busy as a clinical rotation, but even more so in another sense, in that I spent all my free time (home or at work) thinking about my project.

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!

Sorry For the Hiatus

2008-09-10T00:04:00.000-07:00

Residency life overtook my life the past several months. I will start posting regularly again, starting very soon. Thanks (if you're even reading this!)

Looking Back At Internship

2008-07-13T21:53:00.000-07:00

Internship is over. Done. I still can’t believe this year is over. While definitely not unbearable -- it was in fact very manageable -- it was among the most exhausting and busy years of my life.

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.

Internship Is Over!

2008-06-24T11:48:00.000-07:00

Title says it all! I can't believe this year is finally over. Sorry for the paucity of posts lately, but stay tuned ... more coming very soon.

Asshole Patients

2008-06-04T18:03:00.001-07:00

See if I ever ask you -- out of genuine compassion (a rarity in the hospital) -- if there is something I can do to help you sleep more comfortably, as you looked uncomfortable. Normal people don't respond to such compassion with yelling and barking out "Is it against the rules to sleep like this?"

Just for that I'm making you NPO until you leave AMA.

Some of My Favorite Things

2008-05-14T17:45:00.000-07:00

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.

Good Nurses
"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.

Dumbest Page Ever #2

2008-04-27T08:59:00.000-07:00

(Seeing how I established a Dumbest Page Ever, it is natural that another page would try to steal that title.)

I was woken up to receive this page at 5am:

"Doctor, doctor, patient is very sleepy. He is arousable but then falls asleep again."

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."

Outside Hospital

2008-04-22T13:51:00.000-07:00

I just came across this hilarious YouTube clip depicting an advertisement that touts the infamous "outside hospital". "Outside hospital" simply refers to any hospital that is not your own -- the hospital you work at, that is.

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".

Grand Rounds 4:30

2008-04-15T22:28:00.000-07:00

The latest Grand Rounds is up at Women's Health News, where yours truly is among the featured posts. Take a look, as she did a great job putting it together.

Job Benefits

2008-04-10T16:20:00.000-07:00

There are some definite benefits to being a doctor that I have noticed in the less than one year I have been working in this field -- other than the “main” benefit of helping people. Here is a short list I compiled.

Fewer Clothes
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).

Weekdays Off
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.

Job Security
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.

Cheaper Bills
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...).

Credibility
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.)

Buffing and Turfing

2008-03-25T21:25:00.000-07:00

I can’t believe that I am fixing people. When I say that I don’t mean it in a I-am-so-honored-to-have-the-ability-to-heal-people way, but rather in a What-the-hell-am-I-doing-that-actually-makes-people-less-sick? sort of way.

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.

Birthday

2008-03-18T21:21:00.000-07:00

I recently turned 30.

It's hard to believe the next "big" age for me is 40, when really I feel 12 at heart.

Squeezing Blood From a Turnip

2008-03-02T20:16:00.000-08:00

I received a fancy-looking envelope from my medical school a few days ago. Without a clue as to what it would contain, there I opened it to find a letter. A very formal letter. One that proceeded to ask me to donate money to the school.

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.

My Priorities

2008-02-28T02:02:00.001-08:00

There's a sick patient in the emergency room right now. He will either be admitted to me or go straight to the ICU. His vitals look horrible,and he's guaranteed to die tonight.

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.

How To Be A Good Patient

2008-02-21T20:50:00.000-08:00

Throughout medical school and residency, we are continuously taught how to be a good doctor. We are taught doctors should be professional, knowledgeable, well-read, and culturally competent (although I still don't know what this ridiculous concept means), all while nothing is expected from the patients.

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!

You Are Crazy If ...

2008-02-05T21:28:00.000-08:00

Every physician has their "oh no" patient. This is the patient with the medical condition that you just cannot bear to deal with, typically because you don’t fully understand their condition and don’t know how to effectively manage it. As an example, gastroenterologists would probably consider patients with irritable bowel syndrome (IBS) as their “oh no” patient. There probably is a legitimate origin causing the symptoms of IBS, but we just haven't discovered them yet. As such we cannot offer good treatment, thus making interactions with those patients difficult and unsatisfying.

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?

Dumbest Page Ever

2008-02-04T19:25:00.000-08:00

Capping off a miserable day filled with endless obstacles more pages than I have ever received in one afternoon, I get paged by a nurse saying how a patient was refusing his medications. This didn't bother me per se, but I was annoyed that she didn't specify which med. I returned her page and asked which med it was, only to hear that it was a pain med. A pain med. A PRN medication. She was paging me to tell me a patient was refusing his prn pain med!

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.

Feces and Food

2008-01-22T20:24:00.000-08:00

Our hospital is pretty big. It has almost 400 beds, spread over 12 floors, with 4 wings on each floor. And the hospital is nearly always crowded, with its over 100 housestaff and nearly 500 other employees. Like I said, pretty big.

And now, all of a sudden, the hospital seems incredibly small ... unusually and suffocatingly and uncomfortably small. Not smart.

Dumbass Patient

2008-01-09T02:39:00.001-08:00

I am on call right now and was walking to my call room when I heard a loud banging on the doors on the opposite side of the hospital (this hospital has a big open-air inside, much like a hotel, making it easy to see from one side to the other).

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.

Merry Christmas, Sicko

2007-12-26T19:31:00.000-08:00

I was on call on Christmas day and night. Initially I expected it to be a calm night with an empty emergency room, however, I soon realized it was the complete opposite.

The ED was full of people seeking medical attention for what I considered trivial reasons: a sore throat, a wound check, or best of all, a medication refill. It was truly surprising. Were these issues that important that they couldn't wait another day? Did they really find it preferable to be in a sterile, crowded emergency room than at home with their family or friends enjoying a nice Christmas evening?

I do realize that half of these people were likely homeless and were thus looking for a warm place to spend the holiday, but that doesn't explain the other half. To them, I simply wanted to yell at them to go home and leave these minor issues for a later date ... thus giving them, and me, a less hectic Christmas.

Merry Christmas, welcome to the hospital tonight.

Halfway There

2007-12-20T22:07:00.001-08:00

I almost forgot: today marks precisely the halfway point of this retched year!

Only 26 more weeks of being at the bottom of the ladder. Only 26 more weeks of scutwork and paperwork. And most importantly, only 26 more weeks of pre-rounding.

Not that I'm counting or anything ....

Holiday Dinner, Hospital Style

2007-12-20T21:39:00.001-08:00

I had a special holiday dinner here at the hospital tonight, and the food was actually pretty tasty. Even more amusing was having the CEO of the hospital in the cafeteria, serving us food. And to top it off, we all got gifts!

This is my second holiday dinner served by the hospital -- first Thanksgiving, now Christmas. I suppose I could be saddened how my workplace (and not mama) is serving my holiday dinners, but it's ok ... at least it was festive.

Paradigm Shift

2007-12-07T21:27:00.000-08:00

One Week Ago
The Caribbean is not enough. This island isn't quite as good as I expected it to be. The beaches are too crowded, there aren't enough beaches, the sun is shining too hard, and I'm getting bored just sitting on the beach reading all day long. I feel I should be more productive with my life.

Today
I am a complete idiot. I would give almost anything to be back on that beach (in fact, I would give almost anything to be anywhere but the hospital). I cannot believe I was unable to fully appreciate a Caribbean island -- any Caribbean island -- when it was filled only with beaches and sun and large an abundance of lazy days. I knew how miserable the hospital was, and I knew I would have to return to that hell within a few days, and I still couldn't fully appreciate it. Now look at me ... I've spent 40 of the last 48 hours in this hospital. Damn.

Doctor Doctor!

2007-12-04T16:18:00.001-08:00

Here on vacation, thoughts flow much more freely over drinks. My surgical intern friend and I spent half an hour describing the annoying text pages we get in the middle of the night, all regarding very important -- rather: "important" -- topics. (Note: this is not meant to ridicule or take a swipe at nurses. It is how we amuse ourselves to get through the misery of this year.)

Doctor doctor, please change Colace order from tid to bid. (really, this needs to be done at 4am?!)

Doctor doctor, FYI: pt's blood sugar is 78, pt asymptomatic. (don't ever again page me to tell me pt is asymptomatic)

Doctor doctor, pt's systolic blood pressure is 85, shall I give metoprolol? (no, which is why I wrote parameters to hold if SBP<90)

Doctor doctor, pt is nauseous, please write for Zofran. (who are you? what pt is this for? how about a callback number?)

Doctor doctor, pt doesn't feel well. please advise! (yup, we've gotten these!)

Luckily, laughing helps wash away the tears.

Hello from the Caribbean

2007-11-28T15:53:00.001-08:00

Greetings from the Dutch Caribbean! Believe it or not, I had no clue this island (or most of the others here) was Dutch-owned until I arrived here. Believe it or not again, I also had no clue where this island was (just off the coast of Venezuela). Pretty exotic locale for a simple little intern like me ...

Sitting on the beach with a tropical drink in hand is MUCH preferable to being in the hospital. I don't ever want to step foot in there again, and I am already dreading my return. My friend -- a surgical intern -- feels exactly the same way and more.

Only a few more days until paradise ends ... time to take advantage of it!

Happy Thanksgiving

2007-11-22T08:07:00.000-08:00

There is absolutely no doubt in my mind what I am thankful for this Thanksgiving: not having to step foot into the hospital for two weeks. Yes, two weeks! Today marks the beginning of my two-week vacation, and I have no intention of getting near that damn hospital. I plan to take full advantage of this vacation, starting with turning off my pager followed immediately by a one-week trip to the Caribbean.

Driving home from the hospital this morning was also great, as the freeways were completely empty. It was the perfect opportunity to test out my new car's handling ... as well as its 0-100mph time.

OK, Happy Thanksgiving everyone!

My Pager

2007-11-15T05:21:00.001-08:00

If it goes off one more time within the next five minutes, I swear I'm
gonna throw it against the wall. I can't put my head down for a few
minutes without this annoying ass little box beeping loudly and
startling me.

Ideally, I'd put my pager AND the patients in a box ... and send them all away.

Random Thoughts 2

2007-11-03T21:36:00.000-07:00

I am in the CCU these days (cardiac care unit, i.e. ICU for heart patients) and am consistently working 15+ hour days most days of the week. It’s amazing how quickly this sort of schedule can eliminate most of your free time and kill any semblance of a social life.

Being in the CCU, I am part of the code blue team and thus have to carry an additional pager … bringing my waistline to a total of two pagers (which also tends to pull my scrubs down). For the first few minutes, wearing both pagers made me feel cool. Then I felt like an ultra-dork. And now all I feel is double the anxiety and terror since I am attached to two leashes that can easily and quickly ruin my night.

I hate nurses who useless send "FYI" pages. I often get text pages that say “FYI: pt X has blood sugar 85 and is asymptomatic”. If he’s asymptomatic, why page me?! I swear, if I get another one of these pages, I’m paging them back next time I’m in the bathroom saying “FYI: I'm taking a crap. But asymptomatic.”

I bought a new car! New new, not new used. As much as I loved my old car, this new one makes the grieving process much easier.

It is Saturday night, and I am home alone. Granted I'm on call tomorrow and need to get sleep tonight, but still ... could I be a bigger loser?

Life Sucks

2007-10-28T03:37:00.001-07:00

It's 3:35am and I'm admitting my third rule out MI patient tonight. This morning. Whatever.

This is why, when med students ask me what field to go into, I say "business".

Clinic Inefficiency

2007-10-17T19:59:00.000-07:00

Another clinic day, another day of incompetence. We residents each have one afternoon a week devoted to our own continuity clinic -- in other words, our own primary care clinic where we have our own panel of patients. They are my patients, and I am their doctor.

More precisely, I am their slow doctor. Starting my very first clinic day, I quickly realized that I am very inefficient. We are typically assigned three to four patients an afternoon, and since these patients are all new for us we are allotted one hour per patient -- as opposed to the 30 minutes we get once they are return patients. Despite all this time we get, I still am extremely pressed for time trying to see the patients, presenting them to our attending, returning to finish up with the patient, and then typing up my note ... or at least the first half of it.

No matter how much I struggle to quicken our encounter, I cannot finish in time. Their endless complaining and my endless attempts to “briefly” touch on each of their complaints makes the clock jump forward faster than I believe. I try to rush things, but I still finish at least 15 minutes late each time. Add to this the fact that many patients arrive late, and you can easily see why I leave clinic around 7pm, even though my last patient is scheduled for 4pm.

This situation is both discouraging because I feel so incompetent, and also irritating because I try hard to be efficient ... only to end up failing.

So, all you practicing doctors, I reach out to you ... how do you do it? How are you able to handle your schedules with so many patients, and on a daily basis too? How do you deal with so many patients? the patients with 10+ problems? the patients who don’t stop talking? How do you see them in the 15-30 minutes of a typical clinic office visit? I can barely keep up with my schedule of 3-4 patients, despite the fact that I’m given over twice as much time as most practicing clinicians.

More importantly, how do you not get tired seeing patient after patient, all immediately after one another? Does it get easier? I really hope so, because at this rate I definitely will not be able to see enough patients to remain financially solvent in the future ... student loans aren’t paid back at four patients a day, you know.

Continuing to Sicken Our Veterans

2007-09-25T22:39:00.000-07:00

For those who are not familiar, the VA (or Veterans Administration) hospital is the government-provided healthcare system for US military veterans. Considering it is a governmental organization, it actually provides great healthcare. Residents in my program rotate frequently through the local VA.

Anyway, today I saw a sign in the VA cafeteria that said “Continuing to Serve Our Veterans” next to a photo of a discounted meal combination consisting of a greasy hamburger, fries, and soda.

Continuing to serve veterans? Ha! First the government fucked up our veterans’ lungs by packing cigarettes into their lunches, and now they’re continuing to ruin their cardiovascular system by only serving nasty, greasy hamburgers and fries in the cafeteria.

I love it. Thankfully the veterans don’t have to pay for their bypass surgeries.

Eating My Words

2007-09-07T19:57:00.000-07:00

You should never challenge the higher powers ...

Remember how I said in my previous post that "there are very few ways" to have this golden weekend of mine ruined? Well "very few" is a bigger amount than I thought.

I walked out of the hospital -- post-call, again -- into the parking lot, only to find my car gone. As in, not in the spot I had parked it in the day before. Not in that spot or any spot for that matter. It is a weird feeling walking into a parking lot expecting your car to be in a very specific spot (since I park in the exact same spot every day), and another car is in its place.

I walked around, stunned, for about 15 minutes, before I realized it had probably been stolen. This was the last thing I needed on a post-call day. Come to think of it, this was the last thing I needed ever.

Anatomy of a Lousy Labor Day Call

2007-09-02T20:47:00.000-07:00

Nothing like a black weekend to ruin a holiday weekend. Read on:

Saturday, 7am.
I arrived at the hospital. The radio started playing a song I really like so when I got out of my car in the parking lot, I kept the keys in the ignition to keep listening to the song as I got my belongings together. But then I slammed the door shut ... with the keys still in the ignition. After ten minutes of prying at every car door and worrying about how this could ruin my morning, I remembered I had a spare key in my wallet. Potential bombshell averted.

Saturday, 7am – Sunday, 3pm.
I endured a grueling night of overnight call. On top of getting slammed with patient admissions – apparently Labor Day weekend drives people to the emergency room in hordes – I had to cross-cover 21 other medicine patients. Nothing more enjoyable than being kept awake all night by a patient going into respiratory failure with no urine output, especially when the sign-out reported "Nothing to do". While that patient didn't die, my cell phone did.

Sunday, 3pm.
Done with my night of call! I walked to my car, turned the key, and heard nothing. No engine sounds, no nothing. In that effort to rescue my locked-in keys the previous morning, I had forgotten to turn off my headlights. With a dead cell phone and no other car in sight to help me, I trudged back to the hospital in order to call AAA.

Sunday, 3pm – 5pm.
I waited alongside my car, with nothing to eat or read, wearing goofy green scrubs, for two hours. Just as I was about to return to the hospital to call AAA again -- what a day to have my cell phone battery drained -- they showed up. One new battery and $120 later, I was on my way back home.

Talk about a comedy of misfortunes ... at least I have this upcoming golden weekend to look forward to. There are very few ways to have those ruined.

Unhappiness

2007-08-31T23:54:00.000-07:00

It's ten weeks into internship, and I feel surprisingly down, bored, and unmotivated. I can barely get through my long days, which consist of pre-rounding on a bunch of patients whose exams and complaints don’t change from one day to the next, ordering a handful of tests on the computer, rounding for at least an hour, trying to track down all those test results, and then dealing with the pleasure of figuring out my patients’ social situations and dispositions since half of them have nowhere to return to upon discharge – except the street, of course. My day is capped off by going home and having no energy to do anything -- read, socialize, or enjoy previous hobbies -- but sleep.

I am depressed that I don’t get to do anything hands-on for any of these patients to help them get well (unlike the surgeons and emergency room doctors who do lots of procedures), and I am completely uninterested in dealing with all the patients’ medical problems (as opposed to just the one acute issue bringing them to the hospital).

I hate spending hours on rounds. I want more doing and less discussing. I don’t care anymore about patients’ social issues. I actually don’t care much for patients anymore either. I don’t want to be shat on by other services. And most of all, I can’t stand to be around the few of my co-interns who are “having a blast” this year.

Although I hope not, I wonder if this entire "journey" is a mistake. Hopefully this is simply the plight of the intern, and not me having chosen the wrong specialty (internal medicine) ... or, the wrong field entirely (medicine).

I Should Have Gone Into Surgery

2007-08-18T20:22:00.000-07:00

Title says it all. But in case you want additional details, here are a few:

They focus on just one problem
While medicine doctors focus on the acute problem during patient hospitalizations and clinic visits, they also have to address ALL other problems (hypertension, diabetes, lower back pain, anemia, etc.) Surgeons, on the other hand, address only their body part of expertise and that’s it. No more optimizing a cardiac patient's complex problems ... and then having to deal with their random bowel incontinence they get once a year.

Their history and physical are focused.
This is the best part. Based on your specialty, you can focus your questions and exam to just that one organ system. Examining the body head to toe gets to be quite tedious and rarely do you uncover a hidden physical finding that changes your management plan. I would love to just examine the abdomen and then be done.

If not altogether unnecessary.
Given how dependent the medical field has become on imaging these days, who cares what the patient complains about. You don’t care as much about chest pain when the echo shows aortic stenosis, and you definitely don’t care if a patient can’t move their arm when an x-ray shows a huge spiral fracture.

They know how long their patients will be hospitalized.
OK, THIS is the best part. Surgical patients fall into one of three categories: pre-op, intra-op, or post-op, and each period usually lasts several days. This is great for morale -- the physician’s morale, that is -- and patient turnover. No more rocks on your service!

They wear scrubs everyday.
I am not as passionate about this reason, but if I could bring my dressing time in the mornings from 15 minutes down to 1, that would be great. Although, I do look pretty good in shirt and tie ... .

Their notes are brief.
No, THIS is the best part, and it's a by-product of the “they focus on just one problem” reason. I would love not to be bogged down by writing notes, which often takes close to an hour with a full load of patients. Surgeon notes are often overly terse, but they convey their message well; on the other hand, medicine notes document every piece of information ever tied to the patient, whether they’re lab values, antibiotic histories, or elementary school grades.

I know some of this might be overly simplified, but it does capture the essence of how I presently see things.

No Longer a Medical Student

2007-08-04T22:51:00.000-07:00

While I know that I'm now an intern, I often forget it. In other words I sometimes forget I am no longer a medical student. I am no longer just a tag-along member of the team that needs to feign non-stop enthusiasm and over-eagerness. I am now the intern, and so I'm one of the "real" team members. I can now behave how I want instead of the way that I think will earn me good evaluations.

As a med student, I would only speak when spoken to, cling to the team like glue during rounds, and make sure not to do anything that wasn't directly related to patient care. Now, I speak whenever I want, I walk away from the team at any time during rounds, and say I receive a text message during rounds ... that's right, I whip out my phone right there and reply back.

I realize I probably sound unprofessional -- and perhaps even assholic -- but whatever, I have earned my new position, I am working hard, and so I enjoy taking these little liberties. It's all I have to get me through the day.

First Night of Call as Intern

2007-07-26T18:53:00.000-07:00

What did I get myself into? It is 6pm and I just got home from my first night of overnight call at the hospital. Yesterday was the first day of this rotation -- inpatient wards, which will be the bulk of my internal medicine training -- which means I was on call my first day. I guess I spoke too soon earlier when I said they hit you fast and they hit you hard.

Starting off the horrible day/night continuum was the fact that I took over the five patients the previous intern had. Taking on patients that you do not know is always difficult, especially medicine patients who have many problems to manage. Then throughout the night I picked up four new patients, each of whom takes awhile to admit because of admission H&P’s (history and physical exams) and admission orders. On top of this was the difficult task of cross-covering every other teams’ patients, which means getting paged randomly throughout the night by nurses about patient X’s tachycardia or patient Y’s diarrhea or patient Z’s itchiness. Itchiness? Come on, just scratch it yourself! When your team is being slammed with patients, prescribing Immodium is hard to take seriously.

On top of all that, add the grueling struggle of trying to keep my eyes open since it had been months since I was last on call -- last November, precisely, in medical school.

And then, post-call, dead tired, and zombie-like, I had to churn out notes for all my patients, none of whom I knew too well. It took me quite late into the day ... so much for the ACMGE mandated 30-hour limitation.

Again, what did I get myself into?

Patient Surprises

2007-07-08T20:27:00.000-07:00

Patients never seem to amaze or shock me. Every time I think I have seen and heard it all -- and I admit I have few clinical experiences to draw upon compared to others -- a patient will come and stun me with his response.

Recently, I was in clinic interviewing a very drunk man who presented with a benign complaint. He reported that he had been experiencing this complaint for several months, so I naturally asked him why he waited so long to present. In very slurred speech he replied that he couldn't return to the state ... because of the federal warrant against him!

I have had many jail patients in the past, but at least they were in restraints because of their crimes. This patient, though, was apparently still on the loose for his deeds ... and I don't know much about the law, but I feel a federal warrant seems fairly serious.

So immediately I distanced myself a few inches from him and made sure to keep a clear path between me and the door. I tried to probe a little and get some details on his warrant, but he really couldn't stay awake long enough. Plus, I quickly deemed he was not much of a threat after all, given that he kept nearly falling off the exam table.

But still, despite the amusement afterwards, it was for a moment one of my more frightening patient encounters.

Dr. DRE

2007-07-02T22:33:00.000-07:00

I think my index finger spent more time inside rectums today than it did outside of them. Not really, but I sure performed a lot of digital rectal exams (DRE) ... in fact, I did more today than I did during my entire medical school career. In fact again, I was such an eager intern that I even gave one of my patients not one, but two rectals. Aren't you proud of me?

Cross Cover

2007-06-27T14:19:00.000-07:00

Shit, they hit you hard and they hit you fast.

It's yesterday. I got back from clinic around 6pm. Although I was pretty tired, I had just enough energy and time to go on a short run. I returned moderately refreshed from the run and prepared a nice dinner for myself ... fresh fish, fresh vegetables, the works. I was eating this dinner and watching a favorite DVD when my pager went off.

The page was from one of our chief residents requesting that I "help out" at the hospital for the night. I was still hoping for the best, but unfortunately upon calling her back I found out a fellow intern had an unexpected emergency. So "helping out" meant "taking overnight call in the hospital for the night."

Oh no you didn't.

Panic set in, as I my mind raced to figure out what to do, both at home (getting rid of my dinner, changing into scrubs, and trying to remember to turn off the stove [which I have a tendency to leave on]) and at the hospital ... after all, it had been 3 months since I'd dealt with patients and 7 months since I had done any inpatient hospital work. I was in no shape to admit new patients at 3am.

The night was demanding but luckily not at all as stressful and intense as it could have been. I managed about two hours of sleep, and since the team had capped (admitted the maximum number of patients) by the time I arrived, there were no new admissions for me. Thankfully.

This was, however, a rude awakening for my system, and quickly made it concrete in my mind that I was an intern. I suppose I should expect much more of this ... just please, not in the middle of dinner.

Internship Day One

2007-06-25T22:05:00.000-07:00

The first day of internship was today. Actually internship began yesterday (Sunday), but I am starting with an outpatient rotation and thus began work today. My hours are set, and I work everyday from 8am to 7pm, mostly in an urgent care clinic. That itself makes my day tiring (there's never a shortage of urgent care patients), on top of the fact that I am now working 11 hour days ... up from zero for the past 5 months!

To top it off, I am also this month's "backup" intern, meaning I have to be available at all times via pager in case another intern gets sick or cannot show up work for any reason. They definitely waste no time making me a slave to my pager.

I am tired so I now have to turn in for the night. More updates to follow ... but I have survived. One day down, 1094 to go.

Medicine Orientation and Overload

2007-06-21T14:42:00.000-07:00

Taking a sip from a fire hydrant -- that's what this week has been like. The orientation for our department was today, and we were bombarded with even more information, and this time it affects us in a very real way (as opposed to the fluffy rules and regulations presented in the hospital orientation, such as effective teamwork, etc.).

We were each handed a heavy packet of items, and quickly the realities of internship started to face us. First, of course, was the pager. Everyone immediately began playing with it, causing a roomful of pagers to start beeping. We haven't even started internship and I already hate that little black box, though I know it gets even worse.

Next was our schedule, which is something we have all been waiting for desperately. Right away the next 12 months of our lives were determined, as were our call nights and holidays (or lack thereof). And I am happy to tell you that I will be on call both Thanksgiving Day and Christmas Day.

Finally, the most awakening part of the packet was a prescription pad. Yes, a prescription pad. I'm barely out of medical school, and I'm being given a prescription pad. My impulse reaction was to think "no, those are for doctors", and then I realized that technically I too am now a doctor.

So with that one packet our futures were rudely whipped into shape. It was definitely an informative, if not overwhelming, day. And it will definitely be a busy, if not painful, year.

Hospital Orientation

2007-06-19T21:09:00.000-07:00

Orientation began yesterday, and it is extremely boring. Mind-numblingly boring. As if 3 hours of welcome from the hospital chiefs wasn't enough, we had to sit through 9 -- yes, nine! -- hours of computer training. Overwhelming doesn't even begin to explain it, as every two hours a new topic or computer system would be covered. By the end of the night, we had learned about four different systems and I remembered zero.

The day was even more challenging as I could barely keep my eyes open, since for some reason I was unable to fall asleep the night before. I had no reason to be nervous, I kept telling myself as I tossed and turned in bed until 3:30am! Not helpful considering I had to wake up at 5:30am. Luckily I slept well the next night.

This week was also the first time the incoming interns were able to meet each other. While the lecture hall format of the day made it difficult to spend significant time with anyone, we mingled some and no one jumped out as being overly annoying or weird. I'm hopeful they will be cool, as this is a group that will be working very closely together the next few years.

Time to give my eyes a rest now ... 9 hours in front of a screen is no small feat.

Waiting Anxiously for Internship

2007-06-14T20:42:00.000-07:00

Life is pretty easy these days as I wait for the start of internship, although the more accurate word might be lazy. My days are filled with watching TV and my DVDs. A large portion of time is also devoted to browsing the web, but I get so bored at times that even the almighty internet cannot entertain me (it is these days that I feel I've visited every site on the internet.) In addition, the dog probably isn't used to me being home this much and so she is slightly confused; I spend a good portion of my day pleading with her not to stare at me.

But as the big day looms closer, I am also starting to get a little anxious. If given the choice I would definitely say I'm excited to start internship -- as opposed to the many people who are dreading it -- but I would also like to delay it almost as long as possible. All of a sudden I am realizing what is expected of me in terms of the responsibilities of patient care.

I keep thinking back to my many interns during medical school and wonder if I can handle those sorts of duties and expectations. I had no problem uncovering problems and communicating them to the intern, but attempting to solve those problems was an entirely different matter ... who knows if I'll even know where to begin. My only comforting thought is that thousands of people have gone through this in the past, and so I too should be able to cope.

And maybe that is why I am engrossed daily in such brainless, non-medical activities ... in addition to passing the time, perhaps I am trying to distract myself from various frightening realities about internship. With that said, time to get back to Boomshine. Watch out, it's pretty addictive!

Paperwork

2007-05-29T15:35:00.000-07:00

They certainly don't waste any time piling on the paperwork onto new doctors.

Just a few days after my graduation I received in the mail a large envelope from the hospital where I will be doing residency, filled with a thick stack of papers that dealt with anything and everything related to my upcoming employment with them. Moreover, most of them were important forms that I feel I should be an "adult" to deal with ... this includes forms such as W-2, W-4, I-9, and many other boring federal and state government papers. They weren't just for show, either -- I had to read and sign each of them!

Most amusing was one of the forms I had to sign where I swore to "support and defend the Constitution of the United States [...] against all enemies, foreign and domestic." I suppose this is because technically I will be employed by the state university system -- aka, the government.

Luckily there also were a few forms that dealt with more fun and exciting issues, as there were some papers detailing my salary (money, finally!) and vacation request forms (4 weeks per year!). I also got to specify how I want my name to appear on my business cards.

Time to get crackin' with these worksheets.

Graduation

2007-05-22T12:30:00.000-07:00

Say hello to Dr. Axis Deviation!

That's right ... I am now done with medical school. The feeling has not quite set in yet, and it probably won't for some time -- I am guessing it will be around the time internship begins -- but it fun to think of myself as a "doctor". Fun and weird, especially since I still consider myself the same goofy kid as before.

With graduation this past weekend, I have also now advanced past the ranks of medical student to doctor. "Doctor". In the morning I was a lowly student, and then all of a sudden I became a doctor, one of the most prestigious professions in the world. Quite a big jump in social status for one day. Let's see if I can handle it!

Back From Traveling

2007-05-18T23:00:00.000-07:00

Yes, it's true. My two months of international travel, sadly, is over. I got a great glimpse of South America (hot beaches and arctic weather) and central Europe (lots of beer and great food), and I hope to return to both places in the future. And unfortunately, no more extensive vacations ... well, ever, probably.

I now have to transition quickly from travel mode to graduation mode, as the next few days will be a whirlwind of graduation related activities, from a pre-graduation banquest and award ceremony to graduation rehearsals and finally the ceremony itself.

Stay tuned for some possibly interesting entries about graduation.

Hello from Central Europe

2007-05-10T10:49:00.001-07:00

(I'd translate "hello" to the local language, but it's way too difficult!)

The travelling continues. I am now -- and have been for the past two weeks -- in Central Europe (Middle Europe? Eastern Europe?) visiting several countries. All these countries are post-Communt, so it is interesting to see how they are trying to reshape their image to more, Western ways. Luckily one is famous for its beer and one for its wine, so already they're fine in my book.

I will soon be returning back home to the states, only to deal with med school graduation and all that is necessary for my relocation for residency. Till then, ahoj!

So What Do You Do?

2007-04-23T13:02:00.000-07:00

I have just returned from nearly three weeks of travel, touring several countries in South America. It was a great trip and I regret not being able to travel longer.

While I still have no medical anecdotes to report, some interesting moments did occur during my trip as a result of me being in medical school. Because I am essentially done with medical school -- graduation is next month, but my classes/clerkships ended last month -- when people asked me what I did, I simply told people I was a doctor. My responses weren't far from the truth at all ... I said I had just finished with medical school and I would be starting internship very soon.

(Interestingly, Americans were intrigued by newly-minted doctors, while foreigners were not.)

Inevitably they would start asking follow-up questions such as what specialty I had chosen, why I went into medicine, and other related topics. These conversations were amusing and enjoyable at first, however, I quickly grew tired of them. After the first few of these conversations I knew exactly what question(s) people would ask next, and all my answers were canned.

I therefore came up with an alternative response to the question "What do you do?" I just told people I was in "healthcare". That usually elicited a response similar to "Oh that's a good field" ... and then the conversation usually ended.

It was great. With this wise choice of words, I evaded that repetitive conversation. It worked great the rest of the trip ... although one woman pried a little by asking "What do you do in healthcare?" to which I responded "I work in a hospital."

It is funny how certain things in medicine are so exciting initially, but whose novelty wears off quickly. Other examples include wearing my white coat (I was so excited the first time I wore it but now I can't stand wearing that short white coat) and having a pager (my first page was exciting, while every single one thereafter was annoying). I can only assume more of these situations will arise in the future, and so I should just accept them now.

Hello from Argentina

2007-04-11T14:03:00.001-07:00

Hola again!

I am writing you all from near the bottom of the earth. While I entered Argentina through Buenos Aires -- which is a great and lively city -- we then flew further down south, to the Patagonia region of this country ... which, if you refer to a map, approaches the bottom of the globe. I am probably upside down compared to most of you (at least those in the US)!

Patagonia offers LOTS of amazing scenery and some of the planet´s greatest outdoor sites. Mountains, glaciers, towers of granite, fjords, it has it all. It is also quite cold here, which is unfortunate since I wasn´t expecting to take this excursion and thus only packed beach clothing. Not wise, but a little 0.4 degree Celsius never killed anyone, right? (OK, it probably does.)

Until next time, chau!

Greetings from South America

2007-04-05T16:35:00.001-07:00

Buenos dias!

I am writing from the nice beaches of Uruguay. This particular city is where many people in South America -- as well as some Americans -- flock to when it gets hot. It is actually fall here (we are in the southern hemisphere) so the masses of people are no longer here, but with Easter weekend approaching there should be a ton of people visiting for the next few days.

Uruguay is an impressively modern country, with great internet connections, fancy stores, and drinkable water. If it weren´t so far from America, I might consider buying a second home here ... and with prices starting in the $80s for a small apartment, you gotta consider it!

Anyway, we´ll be here for a few more days and then move on to another country. Till then, adios!

P.S. I wish I had taken Spanish in high school. French, unfortunately, is a totally useless language for journeys such as this (as well as practicing medicine in California!)

No More Medical School

2007-03-31T18:10:00.000-07:00

My rotations finished two weeks ago, meaning I am done with medical school. Since graduation is still months away (end of May) that also means I have nothing to do until then. Unfortunately, this weblog will probably suffer temporarily as I have nothing medically-related to report. Fortunately for me, though, this means I have almost three months to play around.

Which reminds me ... I should start packing soon for my trip to South America tomorrow.

Post-Match Day Thoughts

2007-03-29T22:44:00.000-07:00

Now that Match Day is well in the past, I thought I would share some thoughts regarding that entire experience.

When I think about it, that was truly the worst experience I have ever experienced -- at least the worse experience I have participated in voluntarily. Not the overall residency application process, but just Match Day itself.

There is something unusually stressful about this day ... whether it is knowing about Match Day from the very day you enter medical school, or realizing that Match Day is a more significant event than graduation, or just realizing that the envelope you are holding in your hand, once opened, will declare where you will be forced to stay for the next several years of your life (for better or worse) ... whatever the reason, it is enough to turn the sane insane.

What the contents of the envelope reveal is an entirely different story. It is difficult enough waiting for Match Day to arrive, but finding out where on your rank list you were assigned is potentially much more difficult. Unfortunately I tend to set my heart things, and when they don't happen I get demoralized. The same thing occured here -- I was set on my #1 choice and had been planning my short-term future around it; and so when I opened the envelope and saw I was off to #2, I was devastated. It made that day pretty tough when responding to all the people who asked me "Are you happy?"

Anyway, there is a first time for everything ... and luckily this will be its last time too.

Today

2007-03-18T18:12:00.000-07:00

So, 15,252,514 minutes ago ...

or, 10,592 days ago ...

or, 1508 weeks ago ...

or, 29 years ago ...

I guess I was born.

Damn.

This is the last year of my 20s. Next year I will be 30, and next thing I know I'll have osteoporosis and be going to sleep at 5pm.

Match Day

2007-03-15T14:02:00.000-07:00

Matched to my #2 ... not bad, not bad.

Still in southern California (new city, however).

More to come, most likely.

Seattle Grace Hospital

2007-03-13T15:59:00.000-07:00

So I found myself in Seattle Grace Hospital today. For those who aren't in the know, this hospital is the setting of my favorite TV show Grey's Anatomy.

I was invited to give a talk at a VA hospital in the valley ("the valley" is an area about 30 minutes north of LA), and when I arrived I immediately noticed a motorized golf cart labeled with "Grey's Anatomy" driving around the lot. Once I was inside the hospital, there was one section of the top floor filled with camera crews, lighting, screens, and other filming gear. After looking around a bit, I saw that well-known breezeway seen in almost every episode, the concrete pathway leading up to the hospital, and a lot of SGH signs on windows and floormats! I love getting behind-the-scenes and seeing film sets, so I was pretty excited.

(Hm, considering how much I hate this show, I sure talk about it a lot.)

Unmatch Day

2007-03-12T10:50:00.000-07:00

Today is a moderately important day. It is known as "Unmatch Day", the day when all applicants find out if -- but not where -- they have matched to a residency program. It is particularly important for people applying to competitive residencies since there is a good chance they might go unmatched.

For someone like me, however, who is applying to internal medicine, which isn't as competitive (except at top-ranked institutions), it isn't as much of a big deal. Having said that, I was up all night tossing and turning, having nightmares about the worst-case scenario of not matching and getting the dreaded email in the morning.

Lucky for me I received this lonely little one-liner in my inbox this morning:

Congratulations! You have matched.

It was a nice relief. It is also kind of strange when I think about it actually, because this email essentially indicates a job offer. It confirms that I have a job awaiting me in July ... salary and all, as a doctor, no less! That's a little frightening and intimidating.

Now all I have to do it last until Thursday ... which is easier said than done.

Less than One Week Until Match Day

2007-03-11T16:36:00.000-07:00

The big day is quickly approaching. It wasn't until last Thursday -- exactly one week before Match Day -- that I began getting anxious just thinking about the match. I am fine as long as I don't think about it (which is most of the day), however if I think about it my mind quickly works itself up into a state of mild anxiety and stress ... not very pleasant.

I just want Match Day to come and go without having to actually go through it ... in other words, I want to know where I match without having to experience the actual moment where I open the envelope and face what's written inside.

Grand Rounds 3:24 is Up

2007-03-05T23:22:00.000-08:00

I don't like tooting my own horn (or, for that matter, using that phrase), but that latest Grand Rounds is up at GruntDoc. I mention this because one of my posts is included ... so go check it out!

Scrubs vs. Grey's Anatomy

2007-02-28T11:27:00.000-08:00

Abortion. Euthanasia. Stem cells.

These are famous examples of some of medicine's oldest and greatest debates. There is no shortage of passionate people on each side arguing their position, and unfortunately there will likely never be a solution that satisfies both sides.

The times are changing, however, and a new debate is emerging, one that involves medical TV shows. Yes I'm speaking of Scrubs and Grey's Anatomy, both of which have huge and loyal followings. Is it Scrubs, the quirky single-camera show about the life of three residents and a nurse, or is it Grey's Anatomy, the new medical drama about a group of surgical interns?

Never fear, Axis is here to help settle this debate. I will attempt to evaluate this dilemma by using several objective criteria to answer modern medicine's ultimate question once and for all.

Medical Accuracy
Let's start with the easy one. The medicine that takes place on Scrubs is nearly dead-on. Internists diagnose and surgeons operate. Classic stereotypes are explained (e.g. surgeons as knife-wielding morons, ob/gyn's as sorority girls, etc.), inside secrets about medicine are revealed, and the emotional aspects of medicine are well conveyed . On the other hand, in Grey's Anatomy surgeons deliver babies and neurosurgeons do abdominal procedures. Most interestingly, the interns have hours of free time on their hands. Point goes to: Scrubs

The Girls
Elliot and Carla on Scrubs are both fairly attractive and well-fed. On Grey's, while Katherine Heigl is hot (albeit whiny), Ellen Pompeo is so skinny she looks like an ashen grey skeleton ... and Sandra Oh looks like a catcher's mitt with eyes. Point: Scrubs

Attendings
You can't beat Dr. Cox: who else can turn a word with two syllables into six? Who can come up with a new girls name every 10 minutes? In fairness, Dr. McDreamy is unusually popular, both on- and off-screen. Point: tie

Chiefs of Service
This is a tough one. On Scrubs, Dr. Kelso is a scowling money-driven Chief of Medicine who makes everyone's life miserable (especially for Ted, that poor attorney). On Grey's, the chief is Dr. Webber, a big guy who simply plays a generic "stern black man". Point: tie

Humor
Scrubs is overflowing with quirky humor (my personal favorite) while Grey's has none (quirky or otherwise). Point: Scrubs

Drama
But what Grey's lacks in humor, it more than makes up in drama. Grey's Anatomy is not so much a medical TV show but rather a soap opera that happens to take place in a hospital. Medicine is occasionally practiced, but only if an intern can hook up with an attending in the process. The winner here is clear-cut. Point: Grey's Anatomy.

Timeline
Characters in Scrubs progress nicely each year, from intern to junior resident to senior resident, etc. In Grey's, the characters apparently are so dumb that they are still interns after three years. Point: Scrubs

And the winner is: Scrubs.

There you have it peoples, objective proof that you may safely avoid watching TV on Wednesday nights. Anyway, it's time to watch Scrubs ... seeing how it's the better show.

The Flu

2007-02-22T18:14:00.000-08:00

I think I have the flu. I woke up three days ago unable to move a muscle and have since been clinging on to life by a delicate thread. I wish it was just a severe cold, but I guess I have the classic flu symptoms: fever, chills, muscle aches, cough, headache, and fatigue. I'm a mess. I also don't think I've ever slept as much as I have in the past few days, with that first day setting the record: only 3 hours of the day when I wasn't asleep!

I should just be thankful that I'm on a rotation where I can afford to take a few days off without serious repercussion. Speaking of this ID rotation, I should also be thankful that I only have the flu, and not one of the many nasty infections I've encountered the past few weeks. Would much rather have influenza than salmonella or cryptococcal meningitis. (But then again, with the way I easily scare, I keep fearing that I have the bird flu).

Anyway, back to the grind (meaning get out of bed, drink juice, take temperature, get back into bed.)

1 Month Until Match Day

2007-02-15T20:30:00.000-08:00

Title says it all. One month -- exactly 4 weeks -- till we find out where we go for residency. I am really looking forward to Match Day ... except that once the day arrives and it's time to open the envelope, I know that anxiety will overpower me, and I won't be able to do it.

Apparently there is also a big breakfast for us that morning (this is probably common to all schools). I don't know about other people, but I will likely be a little too nervous to keep any food down. We shall see.

Rank List

2007-02-14T19:36:00.000-08:00

It's in. Today I submitted my rank order list, which is the next step of this residency application process. Even though the deadline to submit our finalized rank order list is February 21, it was recommended that we submit approximately one week early to avoid overloading the apparently frail servers that become unresponsive the night of the deadline.

My rank list consisted of very few programs and thus was fairly easy for me to create, in that it was easy for me to determine which program I liked best, second best, and so on. It did, however, get me thinking about the programs' end and how they need to rank a large number of applicants. The average internal medicine program interviews 200-300 applicants for about 30 available spots. Assuming they rank most of those applicants -- or even if you don't make that assumption -- that is a lot of people to rank.

Furthermore I cannot imagine how they differentiate their applicants, in particular the ones that are similar. I had minor difficulty deciding my #3 and #4 spots; now imagine a program trying to decide which of their 200 applicants gets what rank. Can they fairly or accurately tell the difference between their #56 applicant and their #57? Differentiating that many applicants seems nearly impossible. I haven't a clue how they do it, especially in internal medicine where the interview -- a seemingly important component of their evaluation of us -- is useless. No hard-hitting questions, no difficult questions, no nothing; just casual chatting. (I suppose this weeds out the social idiots, but really, how many people does that eliminate?)

Anyway, the process is now completely out of my hands and controlled only by the magic that is the matching algorithm. Nothing to do but wait.

For a reminder of how the residency application process works, re-read this post.

Happy Valentine's Day (every day is the 14th)!

First Time With a Foley

2007-02-13T19:35:00.000-08:00

Read this post by keagirl on her blog, UroStream. It is a great and entertaining description of her first time placing a Foley catheter in a patient. The reason I link to it is because this was exactly what happened to me too the first time I tried placing a Foley. I was obviously very embarassed, and my resident who was with me at the time instructing me, was thankfully being very patient ... although I could tell she was feeling slightly sorry for my girlfriend.

Anyway, I was going to write about this experience myself at one point, but I procrastinated and keagirl unknowingly beat me to it. Maybe it's for the better, as she probably describes it better than I could.

Ensuring Professional Behavior

2007-02-10T02:22:00.000-08:00

It's late at night right now, and I just got home from hanging out all night with people from school. We were at a bar, and something on everyone's mind was DUI ... or more precisely how to avoid getting one.

See, today we had a (outrageously long and boring) session on medical licensure, and to make sure this topic was properly shoved down our throats, three middlemen representatives from the Medical Board of California made an appearance to talk to us. In addition to describing their mundane job in great detail (i.e. sifting through thousands of applications a year), they spent lots of explaining how we had to make absolutely sure we were being truthful when reporting any prior offenses ... including but not limited to reckless driving, DUI, and running red lights.

Needless to say many students were a little shocked that these offenses, no matter how distant, would have to be reported, lest their application for a license be denied.

So whereas before, people were not overly scared to get a DUI (they were, but everyone has had a friend at one point who got one), now everyone was just a little more careful with their drinking and driving ... to make sure their behavior now doesn't jeopardize their future career.

That was a lot of words. To sum up: now we're really afraid to get a DUI.

Working Too Hard

2007-02-06T19:22:00.000-08:00

Shoot me now. I just can't do it. I am now back in the hospital for an infectious diseases (ID) rotation, and it is killing me alive. After 2 1/2 months of easy rotations where I never worked past 10am, I now have to work normal hours (aka, a full day). Since these past few rotations were all some version of radiology, I also never had to deal with patients ... it was just me, the radiologist, and a dark room. So not only do I have to work long hours but I have to see patients too. A shame, because I think I've forgotten most of my history-taking and physical exam skills. Luckily the first few patients assigned to me were all intubated, making things much easier.

Furthermore, this is a consult service ... meaning that we get our patients when other services/specialties consult us (i.e. ask for our assistance). This also means that we do not round on our patients until the afternoon -- as opposed to the morning -- which for some reason is the tradition with consultation services.

As a result I have to get to the hospital at 8am, catch up with my patient, which takes less than an hour, and then entertain myself until early afternoon. At that point we proceed to round for about 3-4 hours. Yes, hours. (Rounds could easily be shortened, but our attending is the type who responds to a question with a 10-minute story.) As 5pm approaches I really do want to shoot myself. It is precisely nonsense such as this -- endless rounding, endless talking -- that turns people away from internal medicine.

Relatedly, this is quite reminiscent of my dreadful Neurology days.

At times like this I really wish I were going into surgery, where rounds are brief and focused. Unfortunately I have to look forward to 3 more years of this.

One Year Anniversary

2007-01-30T19:06:00.000-08:00

I just realized that today marks the one-year anniversary of this blog (you might even call it my one-year bloggiversary). No one is more surprised that myself that this weblog has lasted so long, and I am glad it has. The few blogs I have tried to maintain over the years have all died after a few posts, so for me to write fairly consistently for a year is unprecedented for me.

Anyway, thanks for whoever reads my blog, and I'll try to keep up the posts.

Boards Done, Radiology Done

2007-01-26T21:11:00.000-08:00

I took my USMLE Step 2 board exam today. It was much like Step 1 (the board exam that really matters), but more clinically oriented. I dedicated one month of semi-serious studying and that was it. It was a 9-hour test, which is damn long. I haven't sat down and focused all my attention on one thing for a long time (since Step 1, actually) and that made it very tough. More importantly, having taken this test signifies the last test I will take in medical school.

Today also marks the end of my radiology rotation ... more accurately, radiology rotations. After having spent December in neuroradiology and this month in radiology, my "radi-holiday" is now over. I definitely did not learn much over the past 2 months, but I have to admit I'll miss the radiologist lifestyle. Gone are my 1-hour "work" days. The rest of my school year still won't be rigorous, since I only have two more months of rotations, one of which is a research month.

Relatedly, I am also starting to understand part of the reason why internship is so stressful and difficult. After going through the fourth year of medical school, the last half of which is spent mostly doing nothing, it must be a rude awakening to be thrust full-time into the hospital again. Going from slacking to 80-hour work weeks, no free weekends, and a call schedule can't be pleasant for anyone. It is a good thing no one expects much from interns. I hope.

2 Months Until Match Day

2007-01-16T17:38:00.000-08:00

I just realized today that Match Day is two months from now. The big day that dictates where I'll work and live for the next few years is no longer in the distant future ... it's just a matter of months now.

Interview season is also winding down, which means the next step in this residency application process is to create and submit the "rank order list", the ranked list of programs you are interested in. (Where did the time go? I swear, I was just a first year med student recently.)

As the big day gets closer and closer, I also get getting lazier and lazier. Fourth year of medical school really is like senior year of high school. I have been on most of my interviews and so I'm tired from all the travelling. I also have lots of free time but can't find motivation to do anything too productive. I am still in Radiology, which is a joke, in terms of time commitment; simultaneously I am trying to study for Step 2 (the next step of the national boards), which I am taking at the end of this month but not having much luck with my attention span. Life is so slow that I watched American Idol last night (making me realize that Seattle is full of freaks ... a shame, since I love that city).

That's it. Not much else going on in this so-called life.

Happy New Year and I'm Back

2007-01-05T11:18:00.000-08:00

Happy new year everyone!

I know it is a little belated, but I've been busy trying to settle down now that I have returned from my trip abroad. I'm glad to be back, although the trip was lots of fun.

My plane rides, however, were not enjoyable. I first flew 5 hours to Frankfurt, Germany, which was not too bad since at the airport I sat and drank a great beer (Licher). Excellent taste while being served at the perfect temperature (not too cold). Ze germans really know how to brew and serve beer. Even better, this beer was for breakfast ... but don't worry, I balanced it out with a healthy bowl of yogurt and muesli (dubbed "The Fitness Breakfast" in their menu). Great combination. Not a bad way to start off the 5am hour.

I should also mention that at Frankfurt's security checkpoint, I was thoroughly "inspected" (felt up). That guy was poking and rubbing his hand in places that even girls haven't visited. Not at all enjoyable, even with a crowd of people watching me squirm with each new body part being examined.

My next flight -- back to California -- was over 11 hours. Think about that. Think about what you typically do in 11 hours. There is only so much sleeping, reading, watching movies (You, Me, and Dupree), and eating you can do when on a plane before you go stir-crazy, or get a PE. Needless to say, I was very excited when we touched ground, especially since I have a new-found appreciation for life.

In any case, I'm back. The plan for this month: radiology. Yes, last month was neuroradiology, and now it's plain old radiology. After one week, I have realized my schedule will be nearly the same as before. Instead of starting at 9am, however, I start at 8am ... which just means my day is done at 9am. Not too shabby!

Near Death Experience

2006-12-29T09:18:00.000-08:00

I've ever been so scared in my life.

Still here in the Middle East, we decided to take a trip to another city within the country, and so went to a travel agency to buy our tickets. Now in the US, this wouldn't a big deal at all ... just book whatever flight was available or cheap and you'd be set. Unfortunately, here you have to watch out because some flights are aboard the infamous Tupolev planes.

If you're not familiar with Tupolev, read here and here. In short, Tupolevs are Russian-made airplanes that are notorious for crashing. They drop out of the sky like flies. All you have to do is look at one the wrong way and it'll crash.

Anyway we reserved flights that weren't on the dangerous airplane, and we thought that was that. However, on the day of departure, we were boarding the plane when a crew member stopped me to and told me to check in my little carry-on bag. I asked him why, and he said "these Tupolev planes are very small."

Um ... what?

My mom and I immediately faced each other and saw the shock in each other's eyes. We asked the guy to repeat, and he again confirmed that it was the airplane we didn't want -- the one aircraft we went to great lengths to avoid, the one aircraft that determined our travel plans for this little trip, and the one aircraft that prompted us to stay an extra night at that city (to avoid Tupolev flights).

The crew member tried calming us down, and for the most part he did, until I stepped foot on the plane ... and saw all the signs were written in Russian. Not calming. Neither was the fact that this plane was incredibly small, half-filled with broken parts (seats, floor boards, overhead compartments, etc.), and smelled like gasoline. I'm no rocket scientician, but I am pretty sure airplanes shouldn't smell like gas.

Luckily -- thankfully -- our flight was uneventful and we arrived safely. We were flying to the holiest city in the country, so it would have taken one mean God to bring down that flight. (Ironically/coincidentally/unfortunately, we were flying to the same city mentioned in the article above.)

I know this isn't much of a medical post, but I guess it does loosely touch upon some medical ethics ... namely, end of life issues.

Hello from the Middle East

2006-12-24T03:49:00.000-08:00

Greetings from abroad! Yup, that's where I am these days. I came
across an internet cafe and thought I'd drop a quick note.

It is very cold and snowy here. (So to answer the burning question in
your minds: no, the Middle East isn't just sand dunes and deserts.) I
actually love snow, especially since it's a huge change from Southern
California. I am also eating a lot, shopping a lot, visiting people a
lot, and thinking about medicine not at all.

Unfortunately internet access is pretty difficult to come by (not in
the entire country, but just in the neighborhood I am staying) so
another post might not occur until my return home.

Till then ... happy christmas and holidays!

Leaving the Country

2006-12-15T20:36:00.000-08:00

Dearest readers, I am leaving tomorrow for a 2-week family trip out of the country. The region of the world we are travelling to (mentioned frequently in the news these days) has unreliable internet connections, so I doubt I can post from there ... but never fear, I'll be back soon.

Merry Christmas!

Interview Thoughts and Random Thoughts

2006-12-15T20:13:00.000-08:00

Now that my first round of interviews is over, I have a little time to breathe (and focus on my hard days of work on neuroradiology). Here are some recent thoughts I've collected. First, the post-interview thoughts:

I wear a suit to all my interviews, as is expected. My suit is kept neatly pressed all the time, and on the mornings of my interviews I sometimes even walk around the house without pants (a la Seinfeld) while getting ready so that they don't get wrinkled unnecessarily early in the day. Also, I make sure my belts are tied, shoes are polished, and ties are straight. In other words, I make sure I look slick.

Well on one interview a few weeks back, I was interviewing with the program director and sitting directly across from him with no desk between us. I may not have had the world's greatest answers, but at least, I felt, I looked damn good. Of course, nothing ever goes perfectly for me ... because afterwards I went to the bathroom, only to realize my fly had been open the entire time. Man, so close!

I've noticed a mildly interesting association between gender and subspecialty choice. At some point during the interview day when all the interviewees are together in one room, we will be asked in what, if anything, we plan to sub-specialize. The trend I've noticed is that girls are interested in pulmonary medicine while guys are interested in cardiology. (And during the tour at my second interview, these two guy interviewees suddenly disagreed on a minor point about cardiology. They went back and forth a few times and then started geeking out -- they began bickering loudly over this useless point, drawing the attention of everyone in the tour. Not wanting to get caught up in this extraordinarily embarassing show, I quickly dropped back to the girls and starting showing newfound interest in the lung.)

Updates from my night at Days Inn (aka, my night in the ghetto motel). The night actually improved: I figured out how to connect the light switches to the lamps; I got the bathroom light working after flipping the switch on and off about ten times; and most importantly, I was able to jerry-rig (gerry-rig? Jerry-rig?) the curtains so that I had some privacy (I used the clip on my hospital name badge to connect both of the thick curtains to each other so that they covered the majority of the window). However, the best part of the night -- which I failed to mention in my original post -- is that the hotel offered FREE wireless internet. That amenity more than redeemed Days Inn in my eyes.

Here are some other random thoughts collected as of late:

I was at the farmer's market one morning last weekend, standing in front of one of the vegetable stands. This stand had a big box of fava beans, and upon seeing them I told my girlfriend "Ha, some people would die if they ate these", referring to favaism, seen in some G6PD patients (causing their red blood cells to lyse open). Some woman next to us overheard me say this and immediately began asking me "what? why? why?" and freaking out. Not wanting to get into the details with her, I just mumbled something about allergies and walked away.

Financial aid disbursements haven't arrived yet, and tuition is due soon ... because I got a bill from my school for $21,000! That is a lot of money. Paying off my student loans will take a looong 30 years. (My blog entry on the day I finish paying it off will probably be my happiest one ever.)

I finally found out that I passed the USMLE Step 2 CS. I still grumble over the $1000 I had to cough up to prove them I know how to speak English.

Acute Intermittent Porphyria

2006-12-07T20:26:00.000-08:00

I swear the gods are sending me a message.

I think they want me to know about a disease known as acute intermittent porphyria. Why? Because this disease has been thrown in my face non-stop lately. The first -- and last -- time I encountered this entity was when I was studying for the boards. I learned it, took the test, and promptly forgot about it. I assumed I would never hear about it again.

Well the people up above would differ. In just the past week alone, acute intermittent porphyria was brought to my attention FOUR separate times. The first time was during my first interview, where a video providing an overview of the program showed a group of residents discussing a case, one of which had porphyria on the differential. It caught my attention, but only enough to think, "oh yeah, I forgot that existed."

The next time was on the show House, a medical show I occasionally watch, in which porphyria was the cause of the main patient's illness. After this episode I thought "OK, I guess I shouldn't forget remember this disease". Shortly afterwards I was watching an rerun episode of Scrubs, which I watch religiously, and one of their patient's abdominal pain was due to porphyria. This time I figured I had better remember it, having seen it twice in a row now. And finally, on my last interview one of the girls in the group (an extremely annoying one, too) said her previous interviewer pimped her by asking her to name the enzyme deficiency in acute intermittent porphyria.

What is up with this? Why, all of a sudden, am I having this obscure disease pop up everywhere I turn? I feel like Mother Nature is trying to indicate that one of my family members will get this disease ... or at the very least, one of my patients will.

In any case, it's safe to say this disease is permanently ingrained in my head.

In case you're wondering, acute intermittend porphyria is one of the porphyrias, which are a group of disorders caused by abnormalities in the production of hemoglobin (the molecule that carries oxygen in your red blood cells). It usually presents with acute abdominal pain, generally in young women. And the deficient enzyme is porphobilinogen deaminase.

I can't believe I looked this up.