Incidental findings

Difficult patients

2011-12-15T18:00:00.000-05:00

I am often told that I have a lot of 'difficult patients', which is code for other doctors hate them. Sometimes, I agree with this assessment. Not all of my patients are the nicest people. However, it's also disappointing to know that a lot of folks I see are labeled as difficult because they want to be involved in their own care. And I think it's shameful that we discourage that.

I had a patient say to me last week something very nice: 'You're my favorite doctor because you always tell me things honestly and straightforward. I can trust you.'

It is a nice compliment to me, but such a sour turn on the profession. The default used to be that physicians deserved to be trusted, whether we deserved it or not. Now, a doctor is viewed as special because of such a basic piece of human interaction.

Privileged #4 - Thankful

2011-08-27T23:28:00.002-05:00

On ICU call, sometimes it can get pretty awful, and this night was terrible. It was 3 AM, and I had just finished admitting a patient to the ICU who has gone into respiratory failure, when a code was called overhead. It was a bad scene. The patient was roughly 300 lbs, lying face down on the floor. He had apparently tried to go to the bathroom and never made it. Usually the nurses would be in the midst of CPR by the time I arrived, but they couldn't even roll him over because of his size.

It took 4 guys to muscle the patient onto his back so we could finally check for a rhythm. Of course: pulseless electrical activity. PEA is a really painful code, not because it is difficult or complicated, but because it is so frustrating. Everything on the monitor looks right, except that your patient is dead.

We ran the code on the floor, since we didn't have the strength to get him to a bed. After 20 minutes of futility, I called the code and paged the patient's attending. As I waited for the call back, one of the floor nurses grabbed me. The patient's wife was here.

At the nurses station sat a willowy, elderly lady. She was wearing an overcoat, a light blue lace nightgown, and pink house slippers. The nurses gave her a cup of that terrible coffee ubiquitous to every hospital unit, but she could barely hold onto it. It was singularly the most pathetic sight I had ever seen in the hospital to that point in my life.

I took her to the conference room and sat her with a couple nurses. They held her hand while I explained what happened. Her husband got up in the middle of the night and had a sudden heart attack, likely (hopefully) dying instantly. We made every effort to bring him back, using shocks and chemicals and CPR, but nothing worked, and we declared him dead (As an aside, when you tell someone that their loved one is dead, you must be tragically blunt sometimes. Denial is a powerful thing).

Tears were already pouring down her face. I told her the nurses were getting her husband cleaned up, and she could visit with him shortly. She had no questions, no accusations, just tears. I sat with her for a few minutes, and then excused myself to leave. The nurses had her well in hand, offering tissues and hugs. Before I could leave, she stopped me to say one thing: "Dr. Ifinding, I know that you didn't know my husband at all, but I just wanted to thank you for doing all that you could to save him. He's a good man and would've appreciated it."

I stopped by later that night to finish some charting. She was still there, weeping at her husband's bedside, holding his cold hand, whispering softly to him.

This code hurt for so long. It hurt because I had failed this patient and failed his wife, and then to have her thank me, it was salt on a wound. As a resident, the sight of her sitting next to his body was painfully seared into my mind. But when I think back on this now, I am so touched by this whole event. It must've taken so much courage for her to thank me, when she had so little to be thankful for. And it was such a beautiful thing to see, a wife crying over her dead husband. It was a display of love that far outshone the most joyous wedding. Words cannot convey how utterly heartbreaking a sight this was, but at the same time, how grateful I am to have seen it.

Privileged #3 - kindness

2011-05-29T23:30:00.000-05:00

In my resident clinic, I had a patient who was an asshole. 100% asshole. He was mean and rude to doctors and staff. He had a hard life, harder than most, and suffered severe disabilities from his medical condition. He had bounced around the medical system, and found his way to my clinic.

I picked him up because one of the other residents unceremoniously dumped him on me. The other resident knew him and had him in the hospital, but feigned total ignorance when he bounced back to the hospital, and so I took his case. I realized a week later that this was a dump, and was I ever pissed off. But I took the patient into my resident clinic, because I will never turn down honest work.

In clinic, he was instantly trouble. He was rude and mean to the staff and other physicians. He complained bitterly about everyone. My attending advocated dismissing him from the clinic. I picked an alternate plan: I would be nice.

And so he would come in every 8 weeks or so and I was nice. He was rude and abrasive to me, and I returned kindness. He cursed and scowled, and I reassured. He was hateful and self-loathing, and I was empathetic. He railed and complained, and I listened.

And for three years this dance continued until my resident clinic ended. At his last appointment, he was quiet and thoughtful. He shook my hand and thanked me for helping him. He left, saying good bye to the staff by name, and thanking them for helping him recently with a prescription issue. One of the staff came up to me afterward and said, 'I can't believe that's the same Mr M! When he started here, he was such an asshole!'

For me, it was such a special moment to see the power of kindness, and that it is possible to do good in this world. I did nothing special for him except show him kindness and compassion, and that was all it took. You can do good in this world too, if only you can remember that in order to do good, you must be good.

"Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that." -Martin Luther King, Jr.

Privileged #2 - Happy birthday

2011-05-15T23:00:00.000-05:00

In the ICU, it is sometimes easy to forget that we are dealing with people. There are tubes and machines and alarms, and somewhere in all of this is a human who can't talk, can't move, and can't proclaim to us their humanity.

I had a patient during my residency who was in such a predicament. She was without any family or friends. She had no visitors. She was in severe septic shock from pneumonia, unconscious and barely clinging to life. Her legal guardian told us, "If there is any chance of recovery, you should proceed. If it is futile, then stop."

Futile? Who's to say what is futile? Is futile a 5% chance of survival? Is it 1%? Is it 10% but with permanent, neurologic damage? We settled on some criteria and proceeded. If she showed any improvement, we would continue aggressive measures.

She only worsened. Each day I came to the hospital hoping for some sign, but every day was worse than before. Finally, the day came where we all agreed her care was futile. That day happened to be her birthday.

There was no one there to celebrate or wish her well, no cards or decorations. The nurses got some cake from the cafeteria, and we sang happy birthday. Then I wrote the orders, the nurses turned off the vent and pressors, and I closed her eyes and declared her dead.

That afternoon spent with the nurses was such a special moment. Without friends of family or anyone to mourn, we took a minute to celebrate her life, even as it ended. Because being a doctor means never forgetting that life is beautiful, and although no one else treasured this life, we did.

Privileged #1 - How are you?

2011-05-14T23:30:00.000-05:00

One of my most memorable patients was a wonderful lady with floridly metastatic, unresponsive to treatment, triple negative breast cancer who developed subsequent cardiomyopathy from chemotherapy. She had an EF of <10% and during the course of her hospitalization underwent multi-organ system failure from end organ ischemia. To translate this into normal speak: she had the worst possible breast cancer, with the worst possible response to treatment, and the worst possible side effects.

I was only an intern but I had to give 'the talk.' I sat her family in a conference room, went through the facts of her case slowly, and gave my assessment: she had two terminal conditions, both of which we could not fix. The family cried, and the oncologist piped up about radiation, or another round of chemo if we could get her heart back, or something ridiculous. I ignored him completely. I sat there for five painful minutes while they cried and asked me "Why?!" Once you have done this a few times, you realize that as much as a family wants the answer, you do not have it. Bad luck? Fate? God's will? There is no right answer to this question, only tissues and holding a hand.

The family consented to weaning off vasopressors (medications to elevate blood pressure), and with her loved ones at her bedside, we turned off all the supportive measures. I declared her dead about 30 minutes later. As memorable a moment as this was, it was not the most memorable.

The privileged moment came one day earlier. The oncology attending had just met with the family and discussed keeping their hopes up as well as future chemo options. It was a pep rally, to be sure. I was eating lunch at the time. My senior resident asked me to check on the labs, so I headed back to the ICU, and ran into the patient's sister in the hallway. I said, "Hi! How are you?" with a little wave.

She looked at me, and managed say, "I'm fine, tha-" before bursting into tears. She collapsed to her knees in the hallway, and I had to help her into a chair. I got her some tissues and sat with her for 15 minutes. We joked a little about some funny things her sister had said. After regaining her composure, she looked at me directly, and asked, "Dr ifinding, is she going to die?" I told her that we should get her family together and talk about this, leading to the family meeting the next day.

I am still amazed that this small, chance event of saying hello could be so profound. It was the opening she sought, the chance to ask the question everyone had avoided. She just needed a chance to ask. And it made me realize that even the smallest interactions can have big impacts.

I also felt very honored by the trust placed in me by this family. I was the wet-behind-the-ears intern, but they saw me every morning doing my job, and that was enough for them, because being a good doctor means that you are someone worthy of trust.

Privileged

2011-05-13T22:00:00.009-05:00

In today's world of medicine, I think that people forget that being a physician is a privilege. There are plenty of things in life that you earn with hard work and skill, and medicine requires those things too, but it is a unique privilege to be a physician. We are asked to do things to people that are painful, we are told things in confidence, we are asked to make life or death decisions. We are the ones who have to tell the family that their loved one is now dead.

I have had a lot of fun writing the "Don't be a doctor" series, but I think it might be nice to write something a little more inspirational, and so I am going to embark on another series of posts, about moments I was privileged to witness in my medical career.

You'll have to excuse me for repeating some post content. I have undoubtedly blogged about some of these events before.

(1) How are you?
Even the smallest interactions can have big impacts.

(2) Happy birthday
We took a minute to celebrate her life, even as it ended.

(3) Kindness
It is possible to do good in this world.

(4) Thankful
She had so little to be thankful for.

How do you know?

2011-04-23T19:05:00.000-05:00

Perhaps the most common question I receive on this blog is a simple one: how did you know you should be a doctor? Well, I have written no less than 4 times on that subject, and posted a litany of reasons why to avoid medicine.

But the truth of the matter is that there is no way to know for sure. Is there any way to know for sure about any career decision until you've already made it? What I can tell you is this: all the reasons YOU think you would be a good doctor are bullshit. Total 100% crap. Because I had the same thoughts, and it just wasn't true.

I want to help people. I'm compassionate. I care. I had a grandfather who was really sick. Blah blah blah. This is all trite garbage, and doesn't cut to the heart of the matter.

In high school, I decided that I would consider being a doctor. Instantly, my teachers were enthusiastic. They thought I'd be an excellent doctor, as did a few college professors and a boss or two. What did they know? They didn't see my transcript. They didn't read my admissions essay. They knew nothing about my motivations.

In truth, being a good doctor is not one quality, but a myriad. It is compassion, but it's also conviction, empathy, faith, indignation, professionalism, perseverance, reverence, charity, dedication, hope, intelligence, skepticism, forgiveness, anger, and so much more. It is a whole subset of skills and traits that you don't know you have at the tender age of 18.

I realize now that all those encouraging words from my teachers and superiors, it was because they could see in me things that I could not see in myself. I wanted to become a doctor because I thought it would change me, make me different. They saw that the other than some coursework and a stethoscope, I didn't need to change a thing.

I needed that

2011-04-22T18:30:00.000-05:00

I saw a patient today, and had some bad news. We talked about what we can do and how to approach it, but ultimately, things are getting worse, and we'll have to see if we can turn things around or not.

As I finished up, he said to me, "Dr ifinding, you gave me all kinds of news today that I didn't want to hear, but I'm glad you were the one telling me."

Thanks, dude. You have no idea how much I needed that.

Quality improvement

2011-02-19T21:15:00.000-05:00

Our length of stay is too long. That means on average, we are keeping people in the hospital longer than we should, given their diagnosis. But we will be penalized for bounce backs, which is where a patient is readmitted within a month. So, we need to get people out earlier and ensure they don't come back. Our A1c's are too high. We are not keeping diabetes well enough in check. Our blood pressures are not well enough controlled. We are not getting enough yearly mammograms.

Quality improvement can be frustrating at times, because there are so many places where a quality standard is being imposed, either now or in the future, and many of these standards have no evidence whatsoever that they actually improve patient outcomes.

So let's be honest here. These goals are not to improve quality. They are to save cost. There's nothing wrong with that. We waste a lot of money in health care and trimming our expenditures is reasonable for any business. But I resent the idea that I am not delivering quality care because I don't hit some arbitrary target, or document something so some quality maven can review it.

A few years ago, I had a patient with HTN and diabetes who was passing out frequently. So I changed his meds so SBP was >140 and A1c was >8.0, and he hasn't passed out since. I think he would say that he's getting quality care.

Liar

2011-01-29T18:30:00.000-05:00

I have a patient who is a liar. He is telling me a story to get pain medications. I don't have any proof he is a liar. He has no incriminating evidence that I can find. There is no labwork that I can do to prove his pain one way or the other. Without evidence, I am inclined to give him the pain meds. I am willing to play this game. All he must do is play the game with me.

Instead, the staff catch him with secret pain meds not prescribed by me, and eating meals from the cafeteria when he swears that he can't keep anything down. All he has to do is play along, and even that, he can't do.

And that is the sad fact about addicts. He has me beat, and still, he cannot stop himself from ruining it.

Leukemia is an asshole

2011-01-27T21:03:00.000-05:00

I am currently reading 'The Emperor of All Maladies' by S. Mukherjee, MD. It is a biography of cancer. I got 20 pages into the book before I had to put it down and walk away for a while. It is tough to read. Only last week I had a patient die from acute leukemia, so it hit close to home, but this book struck a nerve with leukemia. I hate leukemia.

I do not hate diabetes or hypertension. In fact, I love them. If you remember the movie 'Backdraft' there's a nice quote: "the only way to truly kill it is to love it a little." There is a certain love of the pathologic. When I see something going wrong, I know what it is. I know why it does the things it does. I do love it a little.

But acute leukemia I hate with a burning passion. If leukemia was a man, I would kick him in the crotch several times, and then let him get up, and kick him again in the crotch, and then pee on him. THAT is how much I hate leukemia. I hate leukemia because it is totally unfair. It picks on little kids. It strikes hard. It is relentlessly fast. It is cruel. It doesn't care if you've been a good person. It wants you to suffer, and it makes you suffer in all sorts of horrible ways. It is an asshole.

You would be right to say that this is not unique to leukemia. Certainly, sepsis is similar in its tenacity. But with sepsis, it only asks for a cure. If you can treat with the appropriate antibiotic, then the cure is delivered. All I must do is keep the patient alive long enough for the foreign pathogen to be removed.

Acute leukemia is entirely different. In order to kill it, you must also try to kill your patient. You must play a game of chicken: if you swerve, leukemia wins and your patient dies, but if you stay straight, you may kill leukemia but also kill your patient in the process. All the odds are already stacked against you, but instead of other cancers where you think and plan, you must act now. So you destroy what remains of the bone marrow. You pour toxic substances throughout the patient's system. You push the patient to the very edge of death, and sometimes over. And in the end, all that buys you is a 20% shot at being alive after 5 years?

Fuck you, leukemia.

(Of course, prognosis for acute leukemias vary by many, many factors)

Don't become a doctor #16 - I've got a secret

2010-12-20T23:27:00.004-05:00

Confidentiality is a legal requirement in medicine. There are only a few relationships where your conversations are protected by law: your spouse, your priest, your lawyer, and your doctor. We are entrusted with private information, and we have to protect it.

There are exceptions, instances where for the welfare of another person or the general public, we must disclose information, but otherwise, we are bound by professional duty and law to keep our information secret. Generally, this prohibition covers medical illnesses, medications, frailties, personal identifiers.

But that's just the tip of the iceberg. Patients have told me things, dark and secret things, long hidden, told to no one on the face of this earth but me. I have heard stories of rape and incest, physical and emotional abuse, spousal arguments, infidelity, greed, maliciousness and cruelty. I have had a husband and wife come in separately for STD screenings. I have had wives come in with injuries from their husbands. I have had patients tell me about being sexually abused as children.

When someone tells you a secret like these, you will not know how to feel. There will be anger and outrage, pity and sadness, compassion and anxiety. And as a doctor, you will want to fix the problem. But that is not what has been asked of you. You were asked to keep a secret, and that is all.

If you cannot live beneath the burden of all these secrets, then maybe medicine is not for you. But it is these secrets that make medicine into an art.

As as aside, if there is one thing that I hate, it is the abuse of children, and if it were possible to hate one particular form of child abuse more than others, it is child sexual abuse. Morality aside, the health consequences are staggering: insomnia, PTSD, eating disorders, sex disorders, anxiety, depression, substance abuse, anger and impulse control issues, headaches, chronic pain, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, asthma, obesity have all shown higher rates in victims of child sexual abuse.

Please don't infringe on copyrights

2010-12-19T16:43:00.000-05:00

To all those who would republish or compile my blog, please be aware that all rights are reserved. That means no repackaging, no republishing, no copying except fair use.

Just a snapshot

2010-11-30T23:30:00.000-05:00

One of the truly frustrating things about being a doctor is that it's hard to really understand someone's life. We only get to see little glimpses into a patient's life, like looking at a single frame of a movie and trying to tell its plot.

I had this experience recently with a patient. He is smart, pleasant, has a good job, and attractive (I'm not gay, but in my humble assessment). And he is single. I feel like if he is single, what are my chances? He has every advantage over me in the dating world, and he's striking out. Is he a jerk at home? Is there something else there?

I had another patient who is having marital issues because of his medical problems, and I don't get it. I found him to be really pleasant and engaging. I can't believe someone like him would have relationship issues over medical things.

It's tough to understand these situations, and I am picking relationship stuff because it's relevant to me, but I have no doubts that there are answers. It's just that I don't have them, and it's not my place to ask. But it's unsatisfying to go home and know that there is a whole side of a patient's life that I don't know and probably never will.

Cruel summer

2010-08-19T00:02:00.000-05:00

This has been a hot summer, and as a result, we've seen sickle cell patients running into all kinds of trouble. Sickle cell is an annoying disease in that everything can set off a crisis. If it's too hot or too cold, too much exercise or not enough, dehydrated or drinking the wrong liquids... there are so many triggers and they're all common sorts of things.

Because sickle cell patients have been running into so much trouble, the nurses and physicians are complaining about them and their unbelievable consumption of opioids. I've seen some patients take in enough dilaudid to put down a horse. People accuse them all the time of drug seeking and inappropriate use.

The thing about having sickle cell disease though is that it is rife with chronic ischemic pain. That hurts. It also lowers life expectancy by decades with median age at time of death in the 40's. That sucks.

I hate giving out huge doses of opioids as much as the next guy, but pain is pain, and if I had sickle cell, then I'd want a little more dilaudid too.

Human lie detector

2010-08-02T21:15:00.000-05:00

The show 'Lie to Me' is based on the idea of microexpressions, and if you can accurately see and interpret these findings, then you can be a human lie detector.

I seem to have a knack for this, as I am usually pretty good at spotting the liars, the folks who are outright dishonest about their history of medications usually. But they usually make it pretty easy when they tell me they need 6 xanax a day and oxycontin is the only medication that relieves their chronic back pain.

Knowing when someone lies to you is a remarkably depressing experience. It is one thing to be ignorant of what someone is doing, but to see the lies, that hurts. Still, one thing that people really have a hard time with is the manipulative patient who is actually in pain. I know that he's mean and demanding and wants dilaudid 4mg IV q2 hr, but he is s/p fasciotomy for necrotizing fasciitis. I think he deserves some pain medication, even if he is a jerk.

New design

2010-07-31T21:34:00.001-05:00

I changed the site design in order to make use of a variety of features that Blogger offers. I am sorry if you liked the previous look better. I will be tweaking this from time to time until I like it. Hopefully, the sharing options and fixed width columns will make up for it.

Are you listening?

2010-07-05T20:58:00.000-05:00

One of my patients was raving about me today to the staff. 'Oh Dr ifinding is the best doctor I've met! He really listens and treats me like a person!'

I think it has to be the saddest commentary on the profession of medicine that I was exceptional because I treated her like a human being. It's ridiculous, but we as a profession have really hurt ourselves. If we could just listen for a few seconds to what people tell us, then that would make all the difference. What earned me all this praise from this patient? She didn't want to take insulin more than once a day. That's it.

But there is a trick: she never said anything about concerns with insulin. That part I had to deduce. But is that really so hard to figure out?

backup plans

2010-06-28T00:40:00.001-05:00

When you talk to doctors from my generation, we all had backup plans. I was talking to a colleague, and her plan was to get a PhD in neuroscience. My plan was to work in pharmaceutical development. I was even looking at jobs with a few pharmaceutical corporations, back when my med school app process wasn't going so well. A friend of mine actually got a Pharm D. Another friend pondered social work.

The thing we all appreciated is that being a physician is a privilege and an honor. It's not something you deserve. There was no 'game' or 'trick' to getting into medical school. The entirety of medical school admission can be summed up in one question: why should we let you be a doctor?

Don't become a doctor #15 - Guilty

2010-05-20T22:44:00.003-05:00

Recently, I had a patient who died suddenly and unexpectedly after I had seen the patient in the morning for some muscle aches. I reviewed the case to see if there was anything I could have done to prevent it. Did I miss a lab result? Was there some sign that should have been picked up? Were appropriate protocols and guidelines performed? I was convinced I'd find something, some piece of evidence that would've shown that if I had paid more attention, this person would still be alive. It was preventable and avoidable... wasn't it?

One of the strange things about being a doctor is that, despite all the rhetoric about malpractice and liability, it's hard not to feel guilty when bad things happen. You can't walk away without a little blame. This happened on my watch. We go into medicine to help people, so when shit happens, it's hard not to feel responsible. This person trusted me to protect them from a bad outcome, but it happened, and I didn't even see it coming.

A lawyer friend of mine tells me that physicians are terrible in court because we want to take blame. But shouldn't it be my fault? Shouldn't someone be held accountable? And if I'm the patient's doctor, shouldn't it be me?

It took me a long time to figure out that one of my favorite aspects of adult medicine is that so much of it is lifestyle dependent. When something bad happens, I can go home at night and think to myself it may have been something I did, but it may also have been the patient's bacon cheeseburger lunches for 35 years. There is some amnesty in adult care.

If you are disturbed by the thought that your actions (or lack thereof) could hurt someone, or even kill them, then welcome to humanity. But in medicine, even when you are blameless, you may still find some guilt in your heart. And that is medicine. If it happened on my watch, shouldn't it be my fault?

Bachelor's in pre-med

2010-04-22T23:54:00.002-05:00

I was reminiscing with a friend about the 'good old days' when we were both chemistry students. He's a chemistry professor now, and complains endlessly about pre-meds. He teaches one of those required pre-med courses.

Pre-meds (and medical students for that matter) are pretty high maintenance. 'Is that going to be on the test?' should be the pre-med motto. There's no learning for learning's sake: everything is goal directed. I need to ace biochem so I can rock the MCAT so I can get into Harvard Med so I can get a residency spot in derm so I can do cosmetic derm and rake in a seven figure salary. At no time is there any enjoyment of the process. It is facts and test material and hoops to jump through.

The pièce de résistance is that some schools offer a degree in pre-med. This is, in my opinion, ridiculous. When I was in college, I took all the tough science courses. I took all the sections for real science majors. This is because I wanted my degree to mean something, and feel like I'd accomplished something. I didn't want to spend four years earning a degree in 'pre' anything.

Learning about electron affinity, valence shells, and lattice structures may be entirely useless to me now, but that doesn't mean that it wasn't worth learning. Reading the Iliad was useless too, but I wouldn't give it up either.

EDIT 1/4/11
When I mention a degree in pre-med, I am referring specifically to a Bachelors in Pre-Medical Studies, which is an actual degree offered by some smaller colleges, but not at most universities.
I know that med school has a lot of requirements. I took them too. But part of life is enjoying the process. I enjoyed organic chem. It was fascinating. I took a geology class and loved it. I got a letter of recommendation from my Communications prof for one course that I got a B in. I took 3 or 4 classes that had nothing to do with my 'hard science' major because I wanted to learn. The point of education is to learn, not to earn a grade.
One of the hardest things to explain to pre-meds is that grades and MCATs aren't nearly as important as being a decent and honorable person. And if you can figure out how to convey that information truthfully to an interview committee, then there isn't a med school in the country that wouldn't accept you.

It's not my fault

2010-04-19T23:39:00.001-05:00

Most of the diseases I see are lifestyle related. Diabetes, hypertension, cardiovascular disease, even colon cancer are all heavily influenced by lifestyle. Ultimately, most people earn their way into my care. So, it is pretty frustrating whenever I meet a patient who refuses to take responsibility for their health.

I met someone who took this to comical levels. He had an excuse for everything. No one wrote him prescriptions. He was blacklisted by local doctors. His PCP wrote for the wrong pills. He was never given appropriate dietary advice. He was never told french fries are bad for you. He was told his appointment was for 4 PM, not 3:20 PM. It was our fault. It was his doctor's fault. It was everyone else's fault.

The problem is that I just don't care. People spend so much time worrying about who is at fault, but the only thing I care about are the results. What difference does it make who is to blame? The only thing that matters is that his A1c is 13.6% and is LDL cholesterol is 171.

Your body is like your car: what you do at home has a whole lot more to do with how your car performs than anything a service station does.

Dinosaurs

2010-03-22T21:52:00.000-05:00

I am convinced that the folks in Washington do not understand that primary care is currently an intensely unpopular choice of profession. There have been some massive shifts in popularity of some medical specialties, but the universal theme has been that primary care has waned.

People think it's all about debt burden, but it's not. It's nowhere near that simple. And if you want to prove it to yourself, look at the hospitalist vs the traditional internist. Finding traditional internists (folks who do both clinic and hospital work the same day) are a dying breed heading to extinction. In fact, primary care internists are harder to find in general. And it's no wonder.

Seeing hospital patients in the morning, doing clinic in the afternoons, call every 3 or 4 days, who wants that lifestyle? Compare that to the hospitalist, who is on one week, off the next. A week off is virtually unheard of in traditional practices, but it's the norm for hospitalist work. And hospitalist pays better too.

People fondly remember the days of doctors who do home visits, with a nostalgia entirely unwarranted, and I expect that in our lifetimes, patients will reflect on the days when their regular doctor would see them in the hospital too. But that is going the way of the dinosaurs.

And the true shame of it is that a lot of hospitalists burn out, even with the free time and the extra pay. And that's why I tell people to pick something that makes you happy, because money and lifestyle can't make you happy. It just gives you more time and resources to hate your life.

Match Day

2010-03-18T00:20:00.001-05:00

Thursday (today) is the Match. Students found out on Monday whether they have a spot or not, and the unfortunate had to go through the Scramble on Tuesday and Wednesday, and today, everyone finds out their fate. It is a far more ominous day than any other day in medical school.

I have some patients who have children in medicine or are pre-meds, and they are pushing their kids towards subspecialty careers, which makes me sad as an internist. And the thing that I want to tell them so desperately is that there is no price tag on being happy with your job. I could've been paid far more than I'm earning now, but I love my current position, and I don't want more money. I'm happy now.

So, to all your MS4's out there, I hope you don't get what you want, but that you get what will make you happy. And those two may not be the same thing, but when it is, everything else falls into place.

The toll of medical school

2010-03-08T21:50:00.000-05:00

My New Year's resolution this year was to get back to healthy living. I spend countless hours talking to people about improving diet and exercise, and ways to change lifestyle to improve health. And it's good advice, and some of my patients are quite successful. However, it's advice that I should probably heed.

Before I started my third year of medical school, I ate healthy. I bought fresh produce. Turkey was my favorite meat. I ran a few times a week. I worked out a lot. I was probably in the best shape of my life. Then came clinicals.

Since that fateful July 1st, my health has gone into a tailspin, because after a 30 hour call, I just didn't have the energy to do anything else, muchless exercise. And every year, I've gotten fatter and more complacent. So I have finally decided that it's time to change. And so I am returning to healthy living.

And I think to myself that medical school has taken a considerable toll on my life. I was physically great. I was mentally stable. I was doing quite well. And as much as I enjoy being a doctor now, it's with the knowledge that I spent so much time taking care of medicine that I forgot to take care of me.

Editorial notes

2010-03-06T20:20:00.001-05:00

So, I should note a couple things. I've mostly been ignoring the purpose of tags on posts, but will actually start using them. I will be blogging in 4 main categories: patient care, medical school, first aid, personal life. First aid will be where I dispense unsolicited medical advice. I am hoping that I can start posting once a week, and giving myself some categories will certainly help with that.

EDIT - Make that 5 categories: patient care, medical school, first air, personal life, and careers in medicine.

All apologies

2010-03-01T23:00:00.001-05:00

One of my patients threw a fit. It was really disappointing because I had serious issues with this patient, but this person demanded a personal apology. I did it, and licked my wounds. Truth be told, I don't really care much.

One skill that I picked up in med school during my clinical years was that when it comes to patients, leave your ego at the door. I've had patients yell at me, call me names, disparage me to my face. I just sit there and take it in stride. It's not worth getting angry about.

So apologizing isn't really all that difficult. The only regret I have is that in medicine, the customer is not always right. And it seems like whenever I try to be a good doctor and order tests and medications appropriately, that's when I end up in trouble. And it would be so much easier to just order the needless test, give out the unneeded antibiotic.

But easy doesn't make it right. And the key in all things is whether I can go to bed with a clear conscience.

Empathy is such a simple skill

2010-01-25T23:46:00.001-05:00

A lot of patients like me, not because I'm a good doctor or because I'm terribly friendly. I'm not even all that good at explaining things or 'shared decision making.' My one skill that has pleased my patients is simply that I try to be empathetic.

Many doctors advise caution about getting too emotionally involved with patients, and that it can suck you in, and it gets dangerous. And that's true. Empathy though is a very simple skill, and I think it's really a shame that doctors are so bad at it in general.

Empathy is trying to understand where someone is coming from. I saw someone today who was refusing tests and generally being quite difficult, but her life was spinning out of control with all sorts of new and scary diagnoses, and she was afraid to go further, afraid what the next test would bring.

I am not psychic. I found out by asking her. She told me that she didn't want anymore testing. Why? Because all the testing so far was not good. Well, if I was in her place, I'd be pretty scared to find out what the next test showed too. And I told her that.

I know it sounds trite, but the key to empathy is treating patients like people. Only a doctor could talk to someone about their dead wife, and then in the same breath ask about immunizations. It's no wonder that nurses are generally more appreciated than doctors, and view themselves as patient advocates. Doctors treat disease. Nurses treat people.

I saw a patient today and we talked about coffee for a while, and I think one of the nicest pleasures of being a doctor is meeting all sorts of interesting people. If I had to offer some advice to other docs, it would be that if you stop seeing people and start seeing diseases, it's time to retire.

Doctors say the darnedest things

2010-01-16T21:09:00.000-05:00

When I was a student, we were encouraged to have a 'thick skin' because attendings, residents, interns, nurses, social workers, MA's, PT's, and custodians all tended to lash out verbally at medical students. And it didn't really matter how good you were, or nice, or helpful. Eventually, someone would chew you out for no reason other than you are a convenient person to yell at. People have more scruples about kicking a cat.

I remember the times this happened to me. I was publicly humiliated by one attending at a conference for asking the drug rep a question. One surgeon threatened to make me do M&M, since this patient's imminent death was all my fault. One day I was assigned to eight patients in the morning, and I couldn't see them all before rounds, and the resident told me that I was lazy and useless, and should seriously consider dropping out of medical school. I strongly recall one attending who spent 20 minutes on rounds screaming at one intern until she broke down crying.

So when I graduated medical school, I promised myself that I would not perpetuate this horrible rite of passage. I would be nice. And that's such a noble thing to say to oneself, but in reality, I was just as bad. As a resident, I made no less than two interns cry, and there are a few students who likely went home and blogged about what a jerk I was after getting dressed down by me.

The problem for me is that I expect a lot out of people. I expect 100% all the time. That is the effort that I gave as a student and resident. That is the level I want. But my 100% is not the same as other people's. And it's not like I had to miss my daughter's soccer game or my wife's birthday.

When I finished residency, I promised myself that I would try to be more understanding. Being nice is tough. When you're pissed off, it's hard to turn that into nice. But as long as you're willing to listen and try to understand, even the most withering criticisms can at least be constructive.

Pluripotent

2010-01-02T21:30:00.000-05:00

Don't get me wrong. I never want to go through the hell of med school again. One of my friends was thinking about a second career in medicine, and I honestly think that if I had to go through medical school and residency again, I would quit. It's too hard to do twice.

But there are some things about medical school that I miss terribly, because it's stuff that I can't get back. I remember my first perfectly done suture. It was a vertical mattress, and the tails were just right. I remember following a running suture during a vascular surgery. Afterward, the surgeon told me that he'd never let a med student touch a vessel he was working on, but he trusted me. I miss the excitement of seeing my first trauma, a 20 yr old female MVA, no LOC, FAST scan negative, c-spine cleared. I miss the novel sense of horror upon seeing an apple core lesion on CT abdomen.

But most of all, I miss that moment in medical school when I was not an internist. I wasn't sure what I wanted to do, but I knew that I was capable of anything. It was entirely within my power to pick my medical specialty.

There was a very similar moment that occurred in college. I remember it exactly. It was 6:54 PM and I was getting out of chemistry lab. It was twilight, and as I walked home from lab, I stopped at one particular tree about 40 yards from the chem building. At that moment, I could be whatever I wanted to be in life. I could be a lawyer, doctor, investment banker, veterinarian, librarian, computer programmer... All my life and education had led me to that one point in time where I could choose, differentiate. I was a stem cell.

That is what I miss about medical school. I don't miss the studying or the work. I miss being pluripotent.

Do the right thing

2009-12-26T22:17:00.000-05:00

One of the very first morality lessons we learn in life is that morality is not dependent on observation. Quite simply, we should always do what's right, not just when people are watching. This sounds pretty trite, but in reality, this can be really hard sometimes.

As a resident, I had a patient who was critical, and the family for this patient was so irritating. I just couldn't stand them. And I knew that if I played my cards right, I could convince them to change the patient's code status to comfort care, so the family would get off my back, and I could get some sleep on call.

As a student, I could've written all of my notes without ever examining my patients. No one was checking the accuracy of my findings. Who would've ever known?

And as an attending, I find myself put into dubious situations, where I am presented with disability or FMLA forms or other nightmare paperwork, and it would be so easy to just check off a few boxes and call it a day.

Unfortunately, you can't do the right thing only when it's convenient. And so, sometimes medicine sucks. No one ever said doing the right thing was going to be easy, but it makes it a lot easier to sleep at night.

TMI

2009-12-02T21:30:00.001-05:00

Medicine is all about making decisions, but in the course of medical education, we are never actually taught how to make decisions. It is implied, as if this is a skill that we come born with. But that's not true. You have to learn how to make a decision.

The one thing that so many doctors experience is not a lack of information, but too much. We gather reports, lab tests, x-rays, repeat x-rays, repeat lab tests, consultations, and all in the effort to make a decision. And as we hem and haw, the issue becomes moot. We are paralyzed by information. And suddenly we are second guessing ourselves, and withdrawing previous decisions, favoring another.

And most of the time when we're paralyzed like this, we end up being right by doing nothing. Voltaire said it best: "The art of medicine consists in amusing the patient while nature cures the disease."

If you like to read Malcolm Gladwell, he writes a lot on decision making, and all the things that we use to make a decision, and it is scary to realize that what I had for lunch that day may be more influential to my plan of care than anything in the patient's chart.

Risk averse

2009-11-30T22:26:00.000-05:00

One quality that is great in general internists is risk aversion. In my experience, general internists do not like to take chances. We play it safe. We measure twice and cut once. We are safe people.

In practice, that means we avoid risky behavior. We go with the established method. We recheck test results. We say things like, 'Don't trust the radiology reports. Look at the films yourself.' In reality, if the radiologist missed it, what chance do I have? We also preach from the rooftops about evidence based medicine. We know what we know. We are applied epistemologists.

But the problem with risk aversion is that I've taken it to another level in my personal life. I am totally gun shy. I like to gamble, but it's nickel slots. I like fine dining, but won't venture past five restaurants. I haven't asked a girl out in five years.

Regardless of the reward, I'm unwilling to take risks, and that is a quality that probably drew me to internal medicine in the first place. I'd be a terrible surgeon. But personally, my life is empty. Without risks, life is shallow and empty. I have no excitement, no joy. It is strange that a quality that helps so much with my professional life can be such a limitation in my personal life...

Thanks

2009-11-26T23:20:00.000-05:00

Sometimes, it's hard to say thank you. But I've got a lot to be thankful for. I've got a great job. I'm doing well financially. My life has achieved a good measure of stability. However, stable doesn't always equal good. One attending quipped to me as an intern, "All vitals stabilize and all bleeding stops... eventually." (For those of you not medically inclined, bleeding eventually stops when you've bled to death, and similarly, vital signs like pulse and blood pressure eventually stabilize at zero)

My life has reached a measure of boredom and stagnation that is difficult to stomach, even for myself. I've become completely still. I have nothing in my life to enjoy or anticipate. I am, in a word, bored.

And I think about what I want, and I just don't know. Should I be thankful that I'm not going through all the heartache I've lived through before, and that I've found a place of emotional stability, or should I be totally dissatisfied that there is no joy in my life?

The answer, as usual, is in between. I am thankful that I have a good job and a life that is calm and peaceful. And I am sad that I am so dissatisfied with it.

Positive teddy bear sign

2009-11-20T19:36:00.000-05:00

If you don't believe me, do a Pub Med search. There is something called a teddy bear sign. It is positive when a patient is found to have a teddy bear at bedside or in bed with them. It usually indicates that the patient is regressing to childhood and also has a high likelihood of non-organic disease. Of course, this only applies to adults. I don't think anyone would fault a six year old for finding comfort in stuffed animals.

However, the teddy bear isn't the only signal that your patient is going to be trouble. Here are some signs that I know of, some of which I've read about, others are my own creation.

Parents Sign is when someone over the age of 40 is found to have their parents at bedside. Always bad news and along with the teddy bear sign often represents mental and emotional regression.

Scrubs sign is when a patient in the hospital is dressed in scrubs, a sure signal that they've spent so much time in the hospital that they start requesting clothing instead of the gowns.

Retrobulbar micturalgia is a screening question used for patients with a 'positive review of systems' syndrome. You ask, "Does it hurt behind your eyes when you pee?" and if the answer is yes, your diagnosis is confirmed.

Radiology sign is when a radiologists marks an x-ray so that even an idiot internist can interpret it.

The radiographic criteria for fibromyalgia are (1) at least 2 MRI scans of spine (count each spine segment, so a CTL scan counts as three), (2) carrying the MRI films and/or reports to initial visit, (3) need for Xanax or Ativan (by name) prior to MRI and CT scans, (4) symptoms in distribution contralateral to radiographic findings. Criteria are met if 2 of 4 findings are present.

Can you think of any others? Most of these are pretty cynical and jaded, but I have to admit are good for a chuckle.

Here's to your health

2009-09-30T20:50:00.000-05:00

There are a lot of opinions about how to improve health care in America, and I won't go into my own partisan views, but one thing is worth mentioning. All the discussion about national health care ignores a very basic fact about being healthy in the US: improving access to health care doesn't actually improve health. It helps with secondary and tertiary prevention (finding disease and preventing complications from those diseases), but it doesn't do anything to prevent those diseases from developing.

Nobody wants to deal with the roots of health disparities, but the ugly truth is that poor people are less healthy than the wealthy. The poor don't eat fresh vegetables or whole grains, don't work their dream jobs, don't live in gated communities, don't run for fun, don't shop at Whole Foods, don't know about trans fats. The poor simply do not have the means to be as healthy as the rich. The poor have less control over their financial future, their living situation, even their own personal safety. All morality aside, the poorer you are, the worse your health.

Having universal health care won't fix that. Improved access and more doctors won't fix that. Changing the Medicare and Medicaid pay structures won't fix that. If being poor is the primary constituent to the dramatic health disparities in the US, then the only fix is to change what it means to be poor and rich. Now, if that sounds alarmingly Communist, that's because it is.

I would argue that Capitalism creates health disparities by creating social inequality, and as such, is intimately tied to how we define ourselves as a nation. Thus, it becomes a fundamental question of identity to ask if we are willing to accept this. Because the alternative is to be socialist.

It gets easier... right?

2009-08-27T22:02:00.000-05:00

I had the chance to talk to a budding medical student last week, and it's strange to see the medical student perspective again. When I was going to medical school, I had a very self-centered experience. That is to say, I did not notice a lot of what was going on around me because I was so focused on what I needed and wanted.

Now that I'm done with the medical education process, I find I have remarkably little sympathy for the plight of the medical student. Everything seemed so dramatic at the time, but the thing about medical education is that every subsequent year is worse. MS2 is worse than MS1. MS3 is worse than MS2. MS4, while easier from the education side, is far worse with interviews and rank lists and the Match. PGY1 is pure hell. Subsequent PGY's are painful for new and horrible reasons. Being an attending is a whole new basket of terrible issues.

So it's hard to be sympathetic when medical students complain about med school. It's like complaining to a major league baseball player that a 70 MPH fastball is hard to hit. Yes, it is, but if you want to go forward, it doesn't get any easier. In fact, it only gets worse.

Caution if hepatic impairment

2009-08-23T22:39:00.000-05:00

I was editing and reposting old entries from the old server, and ran across a post that reminded me of something I'd tried to forget. I had a patient in the ICU, barely holding on to life, with diffusely metastatic cancer, suffering not only from all the complications of the cancer, but all the side effects of the chemotherapy, with cardiomyopathy, neutropenia, anemia, and a host of other terrible side effects.

Even with inotropes [drugs that make the heart beat stronger] and pressors [drugs to increase blood pressure], her systolic pressure was a laughable 60 mmHg. She was having end organ ischemia, and her liver was failing. Her AST and ALT were in the 1000-1500 range. Her renal function was non-existent.

And as a result, we stopped all meds that were toxic to the kidneys and liver. That included her prozac. And every morning that she was conscious, she begged me for her prozac, and I had to tell her that her liver couldn't take it. Her organs weren't working. But she would beg me to give it to her.

Eventually, my attending started the prozac again, despite the miserable state of her liver. 'Ifinding, why not give her the prozac? With everything else going wrong, why not let her have this?' And I felt real guilt. I had been trying to protect this patient from the possible toxic buildup of the drug, but I had taken away the only thing that had made her life bearable. I was worse than the chemo.

And I learned then that the compassionate choice is not always the most medically appropriate, but far easier on the soul.

Gunners

2009-07-12T23:18:00.001-05:00

I have a friend in med school, and he is continually worried about gunners. He's started clinicals and doesn't want to be shown up or embarrassed on rounds. To me, it's quite amusing listening to students complain about gunners, because it's all perspective.

When I was on internal medicine as a student, there was another student on rotation who was always chipping in or talking about some obscure thing he'd been reading about. He knew MY patient's labs, just in case I didn't. It's not like he told me the lab values. He just got them so that if I should falter, he'd have them ready so that he could look good and I would look bad.

But looking back on my surgery rotation, I showed up earlier than everyone, did all my pre-rounding, and helped the interns with pre-rounding, and I volunteered for all the dull procedures. I wasn't trying to shine. In fact, I just wanted to do my time and be done with it, but because I put in the effort, I was always first in line. 'Hey, ifinding has scrubbed in on like five lap chole's this week. He should get to come in on the Whipple.'

I had no desire to do surgery. Scrubbing in on the Whipple was six hours of absolute torture. I wasn't trying to show off or make other students look bad. I just wanted to have a good experience. After the rotation, I found myself complaining about gunners, and one of my friends elbowed me, saying, 'Yah, takes one to know one!' I was shocked, but after a while, I saw it. I'm a gunner too. Being a gunner is all a matter of perspective. We're all gunners.

Countdown to July 1: Attending

2009-06-29T19:54:00.000-05:00

The last July 1st with any significance is after the last year of residency. At that point, a resident (AKA house officer, physician in training, indentured servant, scut monkey, etc.) completes his training and is board eligible. If you ever wondered what BCBE stands for, it's 'board certified / board eligible.'

Uniformly, residents discover that they have a limit to the amount of residency they can take. After a certain point in time, residency becomes intolerable. It is a continual nightmare having your judgment questioned continuously, and having your clinical decision making process derailed by someone who potentially knows less than you. In fact, most residents in their final year may know as much if not more factual medical knowledge than their superiors.

But practicing on your own is a different beast. There's no one questioning what you're doing, but there's also no one to offer advice or reassurance. There's no superior to appeal to.

It is an intensely isolating experience, and all those years of medical school and residency suddenly feel very empty. I thought that I was ready to be an attending when I was done with residency, but what I discovered was that there is no preparation for being your own doctor. At some point, you have to trust that you are right, and that can be hard to come by.

Advice to the new attending:
-Sometimes making any decision is more important than being right.
-Never let them see you sweat.
-Do not pull the 'Who's the doctor? You or me?' card unless you really mean it.
-Most importantly, trust no one.

Countdown to July 1: PGY1

2009-06-27T21:55:00.002-05:00

It is somewhat common knowledge that if you're going to pick a day to avoid the hospital, July 1 is the day. The hospital is awash with not only new interns but also senior residents still green with inexperience. And if you are a PGY1, welcome to Hell.

I remember the day after I graduated medical school, I was driving down the highway and saw a car run off the road and crash. As I drove by, I thought to myself, 'That person could really use a doctor...' Then it occurred to me: OH FUCK, that doctor is me!

The nightmare of intern year has been immortalized in the book, 'House of God' by Sam Shem, and I am sad to say that for the most part it still holds true after 30+ years. Intern year is still the singular worst one year period of medical education.

It is dehumanizing. It is humiliating. It is frustrating. And it wipes away any confidence or boldness carried over from medical school. MS3's complain that they've never felt so stupid as during third year, but that pales in comparison to intern year. At least during third year, your ignorance didn't hurt anyone but yourself. Now, what you don't know kills people.

The training goals of intern year are to learn patient care and disease management. However, what I walked away with was this: I learned what kind of doctor I am. The intern will learn what kind of doctor he is. Is he someone who fudges records? Does he take shortcuts? Does he stay late every day to tie up loose ends? Is he overly confident? Is he gun shy? By the end of PGY 1, an intern will know what kind of doctor he is, and he will spend the rest of his career either accepting that fate or fighting against it.

Some advice for new PGY1's
-If you can, wear scrubs all the time.
-Making friends with the nurses will improve your Rounding-Fu*.
-When you go home, leave the patients at the hospital.
-Make yourself a 'Laws of the House of God' checklist.
-Finally, but most importantly, the most valuable thing I learned during intern year was: sleeping is more important than eating.

*Rounding-Fu: How badass you are during rounds

Countdown to July 1: MS3

2009-06-26T21:23:00.002-05:00

Anyone familiar with the medical education process knows the significance of July 1st. It is the day that everyone moves up a peg. MS2's become MS3's. MS4's become PGY1's. PGY3's (or 4's or 5's) become attendings. There's a lot of significance wrapped up in July 1st.

Third year of medical school is a funny thing. It is an unpredictable experience. It is rough and wonderful and glorious and terrible. It is amazing and disturbing. And the thing about the third year of medical school is that it changes people. At the beginning, everyone starts bright eyed and eager, and by the end, students are profoundly different.

We all imagine that if we were in battle, we would be leading the charge, but what we may discover is that we are the ones hiding in foxholes, shitting ourselves. And that is what you find out about yourself in third year. You find out who you are. You discover if you are vengeful or vindictive, apathetic or aggressive, kind or cantankerous. Your own true nature is revealed.

There are many reasons for this. The MS3 is sleep deprived. He is rotating through different rotations and always a little disoriented. He has not eaten breakfast in 10 months. He has not seen the sun except through patient room windows. He has been constantly pimped about every piece of medical knowledge currently known.

Although we have been trying to change the process of medical education, the MS3 experience is still one of being crushed down, and then being rebuilt better than before: better, stronger, faster. However, that means that some soul crushing has to take place... As nice as it is to be done with the process and look back on MS3 with nostalgia, having your soul crushed is a uniquely painful experience.

Some words of advice to the new MS3:
-Take a shower, no matter what.
-Work hard, play hard.
-No one likes a kiss ass.
-Wear comfortable shoes.
-Your attending wants 3 things from you: honesty, enthusiasm, and diligence (if you have none of these qualities, learn to fake it).

Eating healthy

2009-05-07T11:35:00.000-05:00

I often field questions about dietary supplements and vitamins. What do I think about co-enzyme q10 or high dose vitamin E or beta carotene? Flax seed? Ginkgo? Tons of stuff like that. For the most part, we don't know a lot about dietary supplements. No one has studied these things in any really meaningful way. But in reality, eating healthy is such an easy task that it doesn't require much thought.

If everyone simply did two things, then we as a country would be much healthier. If we (1) ate less, and (2) ate less packaged and prepared foods, we would be miles healthier, diabetes would be far less prevalent, and we would stop being the fattest country in the world.

...but at the same time I'm telling patients this, I have a cheeseburger with fries for lunch waiting for me in my office.

Convince me

2009-04-25T21:51:00.001-05:00

There's a lot of science in medicine. It is often called the youngest science, and rightly so. However, the practice of medicine is quite different from most sciences because it is so intimately tied with dealing with people. And one of the problems with dealing with people is that despite whatever evidence you may have, people need to be convinced.

One of the tremendously annoying things I discovered in med school was immunization of children. So many parents had so many bizarre (and frankly ludicrous) reasons not to immunize their children. After a while, it just wasn't worth fighting over. Now, it's not uncommon to see outbreaks of mumps and measles. Measles is a disease I can't even recognize. I've never seen it.

But immunization is only the tip of the iceberg. I fought over the phone and in person with a patient over the course of a day to agree to have a cardiac catheterization. Once in the lab, they saw left main and triple vessel disease.

One of the things I love about adult medicine is simply that: it's adults. If someone wants to make a tragically bad decision, at the end of the day, if they were properly informed, it's their terrible decision to make, and I can sleep easy at night.

Keeping sharp

2009-03-17T21:30:00.000-05:00

As a general internist, there are a few different jobs that I am trained to do. I am able to see patients in the clinic, outpatient medicine. I am able to see patients in the hospital, hospitalist. I am able to address urgent issues, emergency and urgent care. Not a lot of internists still do emergency, with the rise of emergency medicine as its own specialty. That leaves the hospital and the clinic.

Everyone has their own preferences. Some like the clinic more, others the hospital. I’m not a big fan of hospitalist care. Not that I disapprove. I just don’t enjoy it. I went into medicine for the continuity of care. However, the clinic has its downsides as well. The one true thing though is that if you do one or the other, it’s easy to get rusty. If all you do is clinic work, then the hospital is a pretty intimidating place. There’s a lot of aspects to acute care that are challenging and require a lot of coordination. If all you do is the hospital, then the clinic is really difficult. Results come back in weeks, not hours, and dealing with patients with chronic illnesses is challenging.

The one thing I’ve noticed about myself is that I’m not feeling very sharp with either. I’m losing that sharpness I had in residency in the hospital. I don’t have all the answers. I’m not ‘the man’ anymore. In the clinic, I’m not as sharp as I could be, often taking weeks to take care of relatively simple issues.

To me, it seems like the traditionalist is not a sustainable model. Precious time is split too much, and there’s no expertise. And the shame of it is that I want to be an expert at something.

The things you learn in med school

2009-02-24T22:09:00.000-05:00

When we talk about medical school education, there's the actual didactic material, and then there's the 'hidden curriculum.' For those not familiar with education lingo, the hidden curriculum is a set of norms or values that are imparted to students unintentionally. It is not written down. It is not testable. It is simply something learned through the process of going to medical school.

In medical education, some examples of hidden curricula are that men shouldn't go into OB/GYN, or women shouldn't go into surgery. You should have no life other than medicine. Everything comes second to your medical responsibilities. Sleep is for the weak. There's no crying in medicine.

Sometimes, these lessons are reinforced though things like lectures on professionalism or the patient-physician relationship. Some schools even try to direct their hidden curricula, taking it into the open light, for better or for worse.

For me, I found my own hidden curriculum from medical school. In the process of going through school, I learned a lot of things that med school never intended to teach me, but they're some strong lessons for life:

The friends you make over a bottle of $200 scotch at 4 AM are probably some of the best friends you'll have.

Thanksgiving and Christmas are precious, and when you can't go home for your own family's holidays, then finding a family to take you in is invaluable.

Medical school is some of the hardest work you'll do. Work hard, but play hard too.

While there are many other such lessons, the one that stuck with me is that at some point in your schooling, you will find that you will have to choose to give everything to medicine, or hold back. And you will discover what kind of doctor you really are when you're faced with the hardest choices between what you want to do, and what other people need of you.

Who you need me to be

2009-02-13T21:30:00.000-05:00

One of the strange things about being a doctor is that I play a lot of different roles, and I don't mean administrator or physician or teacher or whatever. I mean that when I meet a patient for the first time, I try to figure out what they need me to be. Some patients need me to be a listener. Some need me to be a father. Some need me to be a counselor. Every patient needs something a little different.

One of my patients is a university professor, and what he wants from me is advice about the stuff he reads about health. Is there any truth to coenzyme Q10? Is Atkins a good idea? He doesn't want me to tell him what to do, just give him some advice.

Another patient has no clue. She comes to me without any idea of what to do next. You need to lose 10 lbs. You should cut out fried foods. When you can't breathe, you should use your inhaler. I saw one person who just wanted reassurance. He knew and I knew that he was healthy, but he needed to hear it from me. Another needed me to boss him around.

The strange thing is that I am simply me. I don't try to act like someone I'm not. And somehow, that's enough. I think that the quality that lets me do this effectively is that I don't need to be in the driver's seat of the patient-physician relationship. Tell me what you need me to be.

Anhedonia

2009-02-05T20:12:00.002-05:00

In order to truly enjoy something, it has to have some context. It has to be shared. That's why people try not to eat alone or go to the movies alone. It loses its context. And that is the dilemma of my life. I lack context. I have all these emotions... is it hate or love or envy? I can't quantify or measure it. It's like a commercial: it happens, it's over, it meant nothing, and it's forgotten.

When we talk about anhedonia in the clinical sense, this is not it, but I wonder sometimes if this is real anhedonia. Everything is bland and grey and lacking passion, not memorable at all.

I'm not depressed, although my friends seem to think it's within the realm of possibility. I just feel like my life needs more context.

Don't become a doctor #14 - Uncertainty

2009-01-07T22:47:00.000-05:00

The first time anyone told me that something was unknowable was in science class when I learned about the Heisenberg Uncertainty Principle. You cannot know the exact momentum and position of an electron at the same time.

Well, surely, with better tools and more precise ways of measuring... "No, no, no, you don't get it!" My p-chem professor had crazy, uncombed hair and he had missed a button on his shirt. All the buttons were off, so it was hard to take his words seriously. "A thousand years in the future, with the best tools available, we will never know."

Medicine is not without its own uncertainty. And that doesn't sound so bad in an academic sense, but it's not very comforting to patients. How do you tell a patient that you don't know? I don't know what's causing your abdominal pain. I don't know if it's from your heart or if it's acid reflux. I don't know.

As a practicing physician, I've gotten used to it. The students seem to have a much harder time with it. As a resident, I worked with a group of students, and uncertainty was a problem...

"So, is it Buerger's Disease?"
"Excuse me?"
"The case from this week, Buerger's Disease, right?"
"Oh, the case. There's no answer. It's just an exercise."
"But we were supposed to think about Buerger's Disease."
"It's in the differential, but there are lots of possibilities."
"But it's really Buerger's."
"Well, there's no answer."
"How can there be no answer? It's Buerger's Disease!"

In medicine, there are lots of questions where we never get any answers: poorly differentiated tumors, diseases without any diagnostic tests, all sorts of situations without clarity. Sometimes we spend time and energy to try to find the answer. Sometimes we don't even bother. But the truth is that in medicine, there is uncertainty on all sides.

I am the job

2008-12-25T21:35:00.000-05:00

This year, I had the chance to take Christmas off, and I was happy to take a nice long weekend, but I find that I can't stop thinking about patient care items. One of the strange things about being on vacation is that it's not so much a vacation from a location as much as it is a vacation from the profession. No more decisions, I just want to relax. But I realize now that I've done something quite dangerous: I have become the job.

Even in my regular life, it shows. I don't do much outside the medical world. I eat out sometimes. I go to coffee shops. But most of my time is spent simply waiting to get back to being a doctor. Outside of the white coat, I'm not sure who I am.

So, I need to find myself a little and start enjoying life, now that I've got some time to do just that. But how do you go about getting a life? I'm really not sure. If it takes more effort than going to Starbucks, I might be in trouble.

Every now and then...

2008-12-16T20:26:00.000-05:00

I think one of the things that I feared the most about being a doctor was crying. I was very afraid that my patients would cry. I myself am a pretty emotional guy, and I would probably cry too, so I was eager to keep an emotional distance. But one attending I worked with bucked that notion. Why shouldn't I cry? Am I made of stone? Compassion is a noble thing, not to be hidden or suppressed.

And since then, I have tried to be compassionate to the emotional wellbeing of my patients. Call it biopsychosocial if you like. I try to make sure my patients know that it is my job to care for them, not their disease. And most of the time, this is okay, but every now and then, it can be tough.

I had one patient, a very nice lady with fibromyalgia and IBS. I know the data as well as anyone else. Chances are she has a background of abuse or other psychological trauma. But I'm patient and I wait for her to feel comfortable with me. After several months, it comes out one afternoon. She had recently been mugged, and it gave her flashbacks to when she was a little girl, and she was physically and sexually abused by her father. I don't know about you, but it's hard to sit in a room with a woman who is telling you her deepest secrets of being abused and raped and not shed a tear.

We sat in the office crying, both of us, and it was tough, but every now and then, it is good to be reminded that there is more to patient care than titration of meds and diagnostic testing: that seeing her that day and letting her share the deepest secret of her life probably did her more good than all the meds I'd written.

Don't Become a Doctor #13 - You know too much

2008-11-30T22:47:00.000-05:00

There's a phrase in medicine: zebra hunting. When you hear the beating of hooves, think horses, not zebras. What this means is that common things occur commonly, and so when presented with a set of symptoms, look for the common disease first. Even an uncommon presentation of a common problem is more likely than a common presentation of an uncommon problem. If you go looking for the unlikely instead of the obvious, you are hunting zebras.

And that's all well and good until it's your own friends and family. With patients, you can play the odds, calculate the risk, give people choices. With family, you cannot help but assume the worst, because you have seen the worst. It's never a simple cold: it's pneumonia. It's never a headache: it's an intracranial hemorrhage.

You have seen too much. You have been exposed to the worst case scenario on a daily basis. You have seen breast cancer fungate. You have seen ischemic bowel. You have seen everything wrong that can happen to the human body, and the slightest hint of such a fate sets off all sorts of alarms. It is too great a risk to hope for the best.

Having all the knowledge and trying to use it on loved ones, it is paralyzing. It is an exercise in fear. It is reading NTSB safety reports while on a plane flying through turbulence. You can only see the worst possible outcome. And that is part of what it is to be a doctor.

Continuity of care

2008-10-30T20:23:00.000-05:00

I saw a patient whom I had seen 2 years ago. At that time, I told her it was either one of two things. I gave her some scripts and told her to follow up with her primary care doctor for further workup. After 2 years, she came back with the exact same problem, but in the intervening two years, she has seen 4 internists, 3 urgent cares, 2 ER visits, and 2 specialists all for the same problem, and never her primary care doc. I was foolish enough to order records, and I wanted to cry. Every assessment is the same: this is either diagnoses A or diagnosis B. Follow up with PCP.

I had another patient a while back who was on her 6th internist in 6 years. Every internist and every specialist told her the same thing every time, but she only saw each doctor once. Which is no surprise whatsoever. Because we all saw the same things.

Some people think that the more doctors you see, the better. This is, by and large, false. As doctors, we're trained to think of common things first, and so when presented with a certain set of symptoms and findings, we look for the common disease. If you took a room full of doctors and gave us all a set of symptoms, 80% of us will come up with the same diagnosis, regardless of experience or training. Because we find the common one first.

It's like only being able to read the first page of a book. There may be so much more there, but if all you have is one page, what can you possibly know?

Immunized

2008-10-26T19:48:00.000-05:00

I got my flu shot last week, and I am feeling MISERABLE. Usually I am entirely unfazed by vaccinations, but I am ready to collapse from exhaustion. As well, my shoulder is screaming sore. Still, when people ask me if it was 'worth it' to get the immunization, I say yes, because anyone who has to ask has never had the Flu before.

Someone told me the other day that he didn't want a flu shot because he didn't trust the mercury content. WTF? Are people STILL talking about thimerasol?

oops

2008-10-06T16:43:00.002-05:00

I have to apologize. I accidentally clicked to reject all recent comments instead of approve. So to those of you who commented, my apologies.

Brought to you by Ambien

2008-08-28T03:00:00.000-05:00

Lately, I can't sleep. I do my work. I come home. I'm exhausted some days. I eat dinner. I watch TV. I play around on the internets. I go to bed. And I lie in bed for 2 hours. It is utterly frustrating.

I know all about sleep hygiene. I have given this talk a ridiculous number of times. It is advice so trite that most of my patients thumb through a magazine while I give the talk. You've undoubtedly heard it before: set a fixed bedtime and waking time, don't nap, avoid caffeine and alcohol, exercise regularly...

Most of the time I am giving advice to patients, I am being hypocritical, but except for the caffeine part, I actually follow this sleep hygiene stuff, and still! Insomnia! It is utterly frustrating and agonizing. It seems like there should be some way to sleep better, some way that I can relax and get a good night of sleep every time. I wish I knew how.

Don't Become a Doctor #12 - Limited resources

2008-08-08T22:00:00.002-05:00

One of the main principles of medical ethics is something called distributive justice. What it means is that resources should be allocated as fairly as possible, and when resources are limited, they should be aimed towards bringing the greatest benefit for all, not some.

When students think about distributive justice, they often call to mind health care expenditures and waiting lists for specialists. They think of MRI's and other expensive tests. It is a little detached, but the truth is that distributive justice is a harsh reality in medical care.

The easiest example is mass casualty situations. The first rule of triage is treat who you can save. If you can't save them, then don't waste your resources. It's cold, but it's society's competing interest.

But you don't have to have a mass casualty to find limitations in resources. I have been in a lot of tough situations as a resident. I've had a full ICU and patients needing a unit bed. I've had simultaneous codes. I've had three patients all go into respiratory failure at the same time. There are a lot of tough choices to be made there.

Now, most non-medical folks cringe to hear things like that. 'We need more nurses' or more financial support, or more beds, or whatever else. They mean well, but they miss the point. There will always be limits, but the most precious resource isn't any of those things. As a physician, I am the limited resource. My attention is a valuable commodity, and how I allocate it can be the difference in who lives and who dies. That is a tough call to make, and if you want to be a doctor, it's a call you'll have to make.

Heart

2008-08-02T18:30:00.000-05:00

Some days, I worry that I don't have enough heart to do medicine. I worry that I don't have enough compassion for it. I worry that it will burn me out, and I'll find myself resenting my patients and wishing they'd stop bothering me. Everyone looks to the doctor for the answers, and I don't have any answers. I don't have any cures. I can't fix things. I worry.

Compassion isn't something that comes easily. It takes work to try to understand someone's point of view. It takes a lot of energy to see someone else's perspective. It is hard to show understanding in the face of something that you can't understand.

I wish that I had all the answers. I wish that it came easily. But some days, it's a lot of effort just to phone it in. Medicine is hard work. I can see why so many new students are looking to fields like radiology where you never meet your patients. Because there is something very attractive to never getting to know your patients. It would be nice not to become entangled in their lives, and sit up at night wondering if cancer got the better of Mr P, or what I can do to convince Mrs C just to eat. I am paid to care about these things, but a person can only care so much.

Let's shit on the interns

2008-07-10T20:37:00.001-05:00

July in the hospital means one thing: new interns. It's common knowledge that going to the hospital in July is risky business. I know the new interns are here because I can hear the staff complaining. Every third sentence starts, 'Those dumb interns... *sigh*!' To everyone out there bitching about the interns' growing pains, I'd like to say this: STFU!

When I was a new intern, I caught flack from everyone: my attending, my senior, RN's, PCT's, MA's, RT's, EMT's, PT's, OT's, case managers, and even some custodial staff (strangely enough, I never heard a bad word from social work or nutrition...). I discovered one universal truth to being an intern in July: no one has your back.

My intern hell continued until my ICU month. Nurse Battle Axe was taking care of one of my patients. BA had been doing critical care since I was in diapers. The amount of critical care knowledge she would lose in a particularly violent sneeze was still more than I knew. So, when she asked me a question, I assumed it was rhetorical.

"I asked, 'What do you want to do, doctor?'" she repeated. My patient had a blood pressure of 70/30 despite aggressive hydration. I had no clue what to do. So, I sat down and thought about it, and after a little soul searching, I decided to start a pressor.

"Um, can we start dopamine? ... please?"

"Sure, doc!" she replied, and walked into the room, pushed a button on an IV pump, and dopamine was in. BP improved to 90/60. Mission accomplished.

Later, I thought about it, and she must've had the dopamine hung already and the line primed. But she let me make the call. I asked her about it, and she told me, "Dr. ifinding, you know I've always got your back!"

Part of being an intern is painful, and that's just how it is, but it certainly doesn't have to be more painful than it already is. So take it easy on the interns, huh? Or at least don't badmouth them to their face.

This has nothing to do with medicine at all

2008-07-08T22:28:00.003-05:00

I am so disappointed that Petrozza lost on "Hell's Kitchen" tonight! I thought it was not right. He was a real gentleman and after the first few episodes, never had a bad service, whereas Christina continually had bad services right up to the end! And Christina's menu was so unimpressive! Sliders? OMFG, I'm not going to a Gordon Ramsay restaurant for mini hamburgers! Not unless it's a black truffle with fois gras hamburger.

But the thing that really got me was the comment at the end by chef Ramsay when he said that Christina had more potential and time, as she was significantly younger. Well, fuck, if you were going to choose Christina anyway, then why bother? Might as well just cut Petrozza a check and let him go home with some dignity. I mean, Christina had food sent back, which alone was enough for previous contestants to lose.

I think ultimately, looking at their menus, Christina's menu did not have much imagination, and really did not excite me whatsoever. Ramsay's restaurants average $100+ for a three course meal. For that price, the food not only has to be excellent, but imaginative. I got a lot more excited by Petrozza's menu, and would be much more likely to eat off of his menu.

It just seems to me more fuel for the 'nice guys finish last' fire. If I was a chef, I wouldn't work for Christina. It would be like having an intern run the medicine service. Personally, I love when I get a seasoned intern on service.

Humble Pie

2008-06-15T21:03:00.000-05:00

I think that I'll try to post on a monthly basis. I know, I know, once a MONTH? But right now, that's as fast as I can go! And by the way, I'm taking down my old archives 2002-2004. Sorry! Maybe I'll put up some selected posts as a 'best of' kinda thing?

Every step in the medical education process is a humbling one. There's never a safe moment when medicine won't put you in your place. For me, the most humbling part of my medical education was the application process. I was waitlisted to some, rejected by most. My applicant year was extremely competitive, and some of my rejection letters acknowledged that in other years I would've been accepted, but for circumstance.

I lived in fear of my mailbox. I made a large pile of rejection letters on my desk. I was going to burn them once I got accepted, but after several months, my burning plan was lost in self-pity. Two schools were kind enough to reject me via postcard. I that that was the biggest slap in the face, that my rejection was not worth an envelope.

The interviews were even worse. One interviewer actually told me that I had no business applying to med school, and I shouldn't bother to pursue it any further. Another interview, I forgot my tie of all things. The interviewer took one look at me and didn't bother to listen to a word I said.

So, in early June while I was packing up my apartment and getting ready to move back home, I got an overnight express letter: 'Congratulations! Blah, blah, blah. Sign here!' One of my waitlist schools came through.

Now that I'm further along, it's easy to look back on those times with nostalgia, but it's awfully humbling to know that the only reason I got into medical school was because someone higher up on the list said 'No thanks, I can do better.' Thanks, dude. I really didn't want to move in with my mom.

A laugh

2008-04-29T23:12:00.000-05:00

This post is one of the pre-written posts I mentioned earlier. I've been sitting on it for a couple months, trying to tune it up, but at this point, I give up.

Sometimes, laughter is good medicine. Sometimes, when faced with horrible situations, the only way to deal is to throw up your hands and chuckle.

One month on ICU, I had nothing but nightmare calls. My first call I had four patients code in a row, nearly back to back, and all four expired: four emergencies, four families destroyed, four tense situations full of panic and fear, over 80 minutes of sustained adrenaline with no release, on top of an already busy ICU call night full of septic shock and DKA.

Codes are agonizing. Only about 20-30% of in-hospital codes survive 24 hours, so it's a situation that destined to have a bad outcome. When I first started running codes, I did not save anyone through my first twelve. I was ready to quit residency. I should've gotten at least three of them to come back, if only for a day.

And then there's agonal respirations. During the code, it's a good prognostic sign, but after the code? It's probably the most horrifying physiologic response I can imagine. Every now and then you hear about someone coming back after being the code being stopped, but for the most part, agonal respirations are like a knife in the back.

And it's bad enough to have a patient die, but then facing the family is that much worse. It's like tearing your heart out piece by piece. It's always the same. The wife drives in to the hospital at 3 AM, still in her nightgown, sitting patiently at the nurses station with a cup of disgusting coffee which she can barely hold onto. And to have to tell this poor woman that her husband of 40 years is dead? It makes me nauseous just remembering.

There was another resident in the hospital who helped me through some of the codes, and in the morning before checkout, we reminisced about our terrible night. He loved vasopressin because you can't chase it with epi for five to ten minutes, so that's five minutes you can sit back and think. That doesn't sound like a lot of time, but if you're running the code, five minutes is a lifetime.

"Man, I love vasopressin. Five to ten minutes? That's half the code right there! It's Code Blue cruise control!" We both chuckled. Not that there's anything funny about watching four lives slip through your fingers, or telling four families that their loved ones were dead. It's just that when you have no other protection, nothing to hide behind, all you can do to keep going is to laugh. Because laughing is breathing, and on some days, it takes all the effort in the world to take that next breath.

Fin

2008-04-20T19:56:00.002-05:00

Lately, I've been writing all my posts on paper and trying to edit them. I've been a little more concerned with my writing style, etc. but I've been discovering that I just don't have anything to say. I'm feeling good about my career and where I am professionally. I just don't have much to say.

And the things I do want to say are all things that I can't talk about for one reason or another. And this is just too restrictive a medium.

Finally, my personal life seems to be more of a concern to me than anything else. I was talking to a resident a while back, and he was telling me that he doesn't have time for his personal life. And from my own experience, I couldn't help but say that you can't just have a professional life. There needs to be some balance. That's something that I'm still missing.

So, for now, I have nothing left to say. And honestly, I was thinking about taking this blog down, but I couldn't do it. I don't know what this blog means to me anymore, so I'm giving it a rest.

Why I love beef

2008-02-01T20:43:00.000-05:00

The story of vaccine is such a good story. Vaccine comes from the Latin word for cow 'vacca.' Why? The first vaccine was created by Edward Jenner. He observed that milkmaids were less likely to catch smallpox. What was it about the milkmaids that made them less susceptible to smallpox? The milkmaids were exposed to cowpox, a similar virus. He rationalized that exposure to the more benign cowpox was protective against the deadlier smallpox. So, he isolated the cowpox virus (vaccinia), injected it into people, and for the first time, people were vaccinated. All thanks to the cow. We don't call it being 'Jennered.' You're vaccinated.

There are other good stories in medicine. Pasteur was discovering germs. Lister was cleaning his surgical instruments. Beyond being good stories though, it's useful to remember their contribution to medicine. Their amazing discoveries are now barely worth mentioning in medical school because they are so self-evident, but that is the sign of a great discovery. It's right under our noses. It's also a good reminder that our current safe boundaries were once unknown frontiers.

Biggest winners

2008-01-31T22:40:00.000-05:00

I was shocked when I saw the TV show, "The Biggest Loser." These people were competing through weight loss, and it was astonishing to see people distraught over only losing 2 or 3 pounds in a week. Healthy weight loss is one pound a week. These people are losing 5 to 10. Healthy weight loss represents a change in lifestyle. It's a marathon, not a sprint.

But even worse was that these folks were crying and feeling horrible about not losing enough weight. Losing weight and being healthy should be a positive, happy thing. It shouldn't be about feeling bad.

One of my patients was upset that in 3 months, she had only lost 5 lbs. but I was happy for her. "If you lose 5 lbs every 3 months, that's 20 lbs a year. You keep it up!" Those are the folks who are winning, nickel and diming their way to better health.

No choice

2008-01-24T23:09:00.000-05:00

As a doctor, my whole life is making decisions. On an average day, I am deciding if I need to start another BP med, whether this lady should be admitted, if this guy needs an EKG, if I want an x-ray or a CT scan, if these medications are safe together, if I should give this patient with drug seeking behavior any more Vicodin. There are a lot of decisions, some of them easy, some incredibly hard. These choices can be the difference between life or death, and can have a huge impact on people's lifestyles or wellbeing. At times it can be pretty stressful.

So, when I go on vacation, it doesn't matter where I go as much as what choices I have to make, because once the pager is turned off, so is my decision making engine. Over one of the holiday weekends last year, I went on a short vacation, and people kept asking me what I wanted to do: when to eat, where to go, what to do, what to buy, what to drink... and finally I said, "No more decisions!" I don't want to make any decisions! Don't give me any choices!

Some people want to go to someplace fancy or unique or whatever in order to relax. For me, relaxing is a chance to get away from making any decisions. I just want to be told what to do. And that is surprisingly wonderful.

Reservations for one

2008-01-20T22:22:00.000-05:00

place setting by paul goyette

One thing I love is good food. I am a bit of a foodie, and I have expensive tastes at times. Whenever I go out to eat, I can taste the good food. It's not too hard to tell when food has been frozen or pre-made. It's even easier to tell when something is burnt.

The problem with a love of food is that I can't eat at nice places. I don't mind eating by myself. I do it all the time. I tend to get a lot of work done when I eat out. And I don't mind going to slow restaurants and generating some easy money for wait staff. However, good places are busy, and busy places don't want to see 'party of one' on their booking. I know places that won't take that reservation.

There are many reasons why. One person's food takes as long as two, so the turnover on the table will be similar, meaning the restaurant loses the revenue of an entree and drinks. The server still gets a tip, but of a lower total. One person (if they're not a pro and bring some homework with them) has nothing to do but watch the clock, so they will notice late service. There are all kinds of reasons why a restaurant doesn't want my business.

But it's a little sad. Every time I go out to eat, it's frozen food, hastily prepared, without creativity or thought. It's depressing. I have to go home to eat well. When you've been single as long as I have, you start to miss things like eating at nice restaurants.

Experience points

2007-12-17T22:29:00.000-05:00

I get a lot of hits from a link in this pre-medical student forum, and reading through it, I was actually quite horrified. My Don't Become a Doctor series is all about the downsides of the practice of medicine, but I didn't think people were actually sitting down and calculating the costs, trying to balance out MBA vs JD vs MD. A word to the wise, DDS wins that contest every time.

The prevailing argument throughout the forum revolves around whether physician compensation is adequate to defray the costs of medical school and residency. I think that you can add and subtract all the dollar figures you wish, but that's not the cost of medicine.

The real cost of medicine is not that I will make only ~$130k as a general internist. The cost to me is that from the age of 21 to 29, I was doing nothing but studying and working. My friends got jobs, got married, bought houses, and in some cases had kids. I did none of these things. My single friends spent their evenings hanging out in the social scene, developed big networks of associates. I don't know anyone outside of health care.

Undoubtedly, you'll say that there are plenty of docs who got married in med school, had kids in med school or residency, and have all the things that I mentioned: a wife, a home, a family, a big network of friends and social support. This is true. But do you think any of those new spouses or new parents wanted to spend 80 hours a week in the hospital away from their families? Many of my friends with kids never saw their child's first words or first steps. As I like to say, one of my colleagues celebrated the birth of his child by taking an afternoon off. I tell people this jokingly, but it's true. He took a half day.

Who cares about the money? Medicine cost me my twenties. I can't put a dollar figure on that. While other people were backpacking Europe, I was scouting out the best spot in the library to study. While everyone else was amassing a treasure trove of experience points and leveling up, I've been sitting at lvl 1.

If you ask me today if it was worth it, I'll say yes. I am doing something that I love, and I am getting paid handsomely for it. I have reached a point in my life where I am finally reaping the benefits of all that sacrifice, but the thing about sacrifice, you have to give up something good to get something good.

Shiny new toys

2007-12-01T20:24:00.000-05:00

CLK + wind turbine by Jasmic

Someone in my hospital bought a new Mercedes CLK AMG convertible. It's almost a crime to be driving it outside in the weather we've been having. Still, it's managed to keep its shine, despite some mud splatter and water spots. I saw it in the physician parking area while I was heading in, and I couldn't help but stop and gawk.

One of my colleagues spotted me in the parking lot and caught up to me. He saw what I was looking at and whistled. "Man, that's a beautiful car." We both stood there for a while, in awe of such a fine piece of German engineering.

When I became an attending, I bought a fancy car. It wasn't too fancy, but certainly was not entry level. In the parking lot, it's very respectable, but clearly shows that I am not a subspecialist. I have nothing to be ashamed of. Considering my salary, it's quite a nice car, but my car's sticker price isn't even half of the CLK AMG cabriolet. This person laid out near $90k and is driving it in winter weather in the Midwest.

Every now and then, I think that I could be making more money. I could be working better hours. I could have an easier life. I have certainly earned it. And when I see something so gorgeous, that I can probably never own, it hurts sometimes. I think my colleague saw me comparing the Mercedes to my car.

"Y'know," he noted. "It's too bad that you can't judge a physician by the car he drives. Then it'd be really easy to find a good doctor." We both got a good chuckle and headed inside.

One of the things that I realized during medical school is that the value of something can seldom be measured with dollars. Doing something I love, that is worth a CLK AMG Mercedes. It's worth a Lamborghini Murcialago. It's worth an Aston Martin DB9. It's worth far more to me than 4 wheels and some metal. I can't really quote scripture and verse, but there is one line from Isaiah (55:2) that I like: "Why spend your money for what is not bread; your wages for what fails to satisfy?"

Sure, I'd like a fancier car and a bigger TV and a fancy house. I'd like a lot of things. But at the end of the day, they are things. And things cannot bring happiness. Joy is doing, not owning.

Attending physician

2007-11-29T22:32:00.000-05:00

I haven't written much about being an attending. Partly that is because I don't want to reveal who I am, but also, I feel like being an attending is a hard thing to get a good grip on. In some ways, it feels fantastic to be done with training, but it seems like it's actually quite a bit more stress.

As a resident, I had interns below me and attendings above me. There were tons of people whose job it was to question every decision I made. There were other residents around who could provide some input. As an attending, it's just me. There's no one else. It feels quite odd not having to run my decisions past someone else. After my first clinic, I grabbed one of my colleagues and talked about my patients. "Why are you telling me this?" he asked. It just felt so alien to make a decision and not have it questioned.

I feel like an acrobat without a safety net. I know what I'm doing. Heck, I'm board certified. But being an attending is an isolating experience. I miss having someone tell me that I'm doing the right thing. Now, I have to question my own decision making. I sit at home at night asking myself, "Did I really need that stress test?" Worse yet, I've already had a couple mortalities, and I can't blame anyone but myself.

But for those of you slogging through residency, let me tell you that on balance I am very glad to be an attending. All this time, all the work, and now I am the one calling the shots. That has a price, and sometimes I don't call 'em right, but now they are my mistakes to make, and that is both scary and wonderful.

This was supposed to be the post where I shit all over emergency medicine

2007-11-27T22:13:00.000-05:00

I wrote a really long, really bitter tirade about my problem with some emergency physicians. It started out as part of the 'choosing a specialty' series, but I realized that my tirade had nothing to do with actually choosing a specialty, but was just my bitterness.

My complaints were not really about ER docs in particular, but were more about doctors who don't care enough to do a decent job. Every field has its flaws. ER is not exceptional in that respect, and it would be unfair for me to single out ER. Someone could write an equally bitter tirade about internal medicine. And in fact, when I was a senior resident, I was far more harsh with my interns who were lazy or tried to pass off substandard work, to the point where I earned a reputation as a hardass.

Maybe an example would make my point better. A friend of mine in the ER, Black Cloud, he is the worst of luck. When I was a resident, he would give me the most admissions, and always the most acute. It was a nightmare every time he was on. But BC always charted accurately, ordered the appropriate tests, and communicated with me personally. I knew that even the sickest patients he called to me were receiving the best care he could provide.

Contrast this with Phoning It In. PII would do whatever it took to avoid work. Charting wasn't done. Appropriate tests not ordered. Consults not called. Cases would be dumped on other ER docs incomplete, and when I came to admit, they had no idea what was going on because PII hadn't given signout. I've had patients of PII's whom I've intubated upon walking into the room because they were seconds away from respiratory failure.

PII was a tremendous white cloud, and calls were easy, but if I had to choose between PII and BC, I'd go with BC every time. Even though the calls were tough, I knew that BC was doing everything he could to take care of his patients. And that's what loving your job is all about.

I will close with this parting shot. I got a LOT of attitude from some (certainly not all) of the ER residents when I was the on call IM resident. They would tell me that IM is cupcake, and imply that they could do my job without breaking a sweat. They would order me around like I was their servant. "You need to admit this guy in 5. The chart's over there. Pfft, I don't know his name, look at the chart! Jeez." This is a direct quote. My favorite call for admission was, "You need to admit this patient. What's wrong with him? I don't know. You're the medicine doc. You figure it out."

To those residents, I want to say that I am now (right now) forgiving you for treating me like shit, but I cannot forgive the disregard you have shown to your patients and the stain you have placed upon the profession of medicine. I was taught that we have a moral obligation to provide the best care for our patients, and I find you lacking.

To all the ER docs out there doing good work and fighting back the tide, thanks. I really do appreciate it, as much as I complain. And it makes me feel fantastic to know that when I send my patients to the ER, they are in good hands.

Choosing a specialty, part 3

2007-11-12T20:03:00.000-05:00

So, this will be the last "choosing a specialty" post. I have been asked to render my opinion on emergency medicine, plastics, ortho, and someone couldn't help but pipe up about radiology. These four specialties probably accounted for the career goals of a third of my med school class. I can't stress enough that these are my opinions, and are likely in no way applicable to you.

The most important thing for me to say is that one should not go into ANY profession in medicine with your primary concerns being lifestyle and reimbursement. Those are shitty reasons to do any field of medicine. You should do what you love. You did not go through eight years (minimum) of school plus another three years (minimum) of training to do something that you hate. You'd be a fool.

I remember quite clearly in college I realized that I could actually do anything. It dawned on me that if I put my heart into it, I actually could do anything that I wanted to do with my life: scientist, doctor, engineer, lawyer. That is a privilege that extremely few people have. How dare you waste that privilege doing something just for the money and hours? If you do not want to make use of such a precious opportunity, there are millions of others who would make better use of it. Please, have a better reason for choosing a career than 'shift work.'

People make fun of ortho. Take the smartest and make em the dumbest. FOOBA. Honestly, I'm all right with ortho. I love ortho consults. I get to manage diabetes and high blood pressure, and I don't have to do a discharge summary? Excellent. I couldn't do ortho after I saw one procedure where they were hammering away at a femur. Felt like passing out. I like wood work. Not too crazy about sawing and hammering people.

Plastics is a funny one. Everyone thinks that plastic surgery is all boobs. In reality, the vast majority of plastics is wounds, skin grafts, minor reconstructions, and hands. If you are lucky, you can do some cosmetics, but you're not going to be on Dr. 90210. I still think it's really cool, but there's far more to plastics than making little ones bigger. But I'm no surgeon, so no plastics for me.

Someone mentioned how I knock radiology, which blew my mind. I actually like rads. I wish I could do it, but I needed the patient contact. What kills me about rads is that a lot of my med school colleagues went into rads for easy lifestyle, money, and 9 to 5 hours, and I loved rads far more than them. I was talking Houndsfield units and reviewing criteria for V/Q scans. They couldn't have cared less. And now, they're radiologists? It kills me.

Now, to emergency. I was trying not to comment on emergency medicine, since my opinion of emergency medicine is toxic at best. Keep in mind that my med school class was part of the "ER" tv show boom in emergency medicine interest. I quite clearly remember having ER parties on Thursday nights in college.

I wrote a very long tirade about ER docs, which had nothing to do with my reasons for not choosing emergency medicine, so I have created a separate post for it. I should mention that I do not counsel students at all about ER medicine. I point them as far away from me as possible.

Personally, I had no interest in ER because I liked having continuity of care, and I despise acute care. It was fun, but entirely without satisfaction for me. Also, what I did enjoy about ER was the primary care. Nearly everything I saw in ER was a primary care issue that if they had seen an internist a week before, they could've probably avoided going to the ER. Instead of leg edema, it was decompensated heart failure. Instead of exertional fatigue, it was acute MI. Instead of abscess, it was fasciitis. What ER made me realize is what these people needed wasn't more ER physicians, but they needed a primary care doc.

And so, here I am.

Vets

2007-11-11T12:18:00.000-05:00

I am finding it harder and harder to write on this blog, as it is very difficult to write and not give away all kinds of personally identifying information. However, I will take this one moment to say thank you to all of our servicemen and women who have given courageously to this country their time, effort, and even their lives. Without the selfless actions of one American GI, my parents would not be alive, and I would not exist.

And I say this for two reasons. (1) Even though we may see our actions as the most trivial of deeds, they can echo throughout eternity. I saved the life of this woman, and I thought to myself: but for the actions of one soldier over 50 years ago. (2) Whatever your political beliefs, please remember that our soldiers have given greatly to this country, putting themselves in harm's way to protect not only our freedom, but freedom itself. That kind of sacrifice should never be forgotten.

I had a patient the other day who was a WW2 veteran. I asked him about his time in the service, and as he was leaving, I shook his hand and told him, "Thank you for your service to this country." He looked at me a little funny, a little nostalgic. He told me it had been years since anyone had paid him such an honor. That's a shame in my eyes.

Choosing a specialty, part 2

2007-10-13T20:30:00.000-05:00

"Hi Ifinding, in a future post, could you briefly describe the negatives that swayed you against other specialties? BTW, I really enjoy your blog. I just discovered it yesterday and can't stop reading it!"

I live to please, so here are some thoughts that swayed me from one specialty to another. Keep in mind that these are thoughts that I had regarding specialties that applied to ME and may not apply to you.

Family medicine: I liked the concept, with regular patients and continuity of care. However, I didn't like taking care of kids, and I didn't like the extreme breadth of disease.

Pediatrics: I don't like taking care of kids. When a 72 yr old diabetic has a heart attack and dies, it's unfortunate, but at least I can console myself and say he had a good run. When a 6 yr old dies, that invariably falls on me. Peds deals with a lot of genetic diseases which are rare, but you can't afford to miss. I hate genetic disorders. Peds has parents. I hate parents.

Psychiatry: while I didn't enjoy adult psych, I really loved child psych. I thought the kids were so precious, and I was absolutely struck by the tragedy of their cases, and how for so many of them, their only fault was being born to shitty parents. However, in the end, I couldn't take the tragic nature of the field.

OB/Gyn: I really liked Gyn. Relatively healthy patients, limited number of interventions, good split between clinic and surgery. I thought it was really neat. The OB part I could've done without, but nothing trumps introducing a mother to her new baby. But so many women didn't want anything to do with me because I was a man, and I wanted to make more lasting connections with my patients.

Surgery: Wow, fun. I really enjoyed the technical nature and the quest for excellence, but the bedside portion was so pitiful. We would do a hemicolectomy for obstruction from metastatic colon cancer, and never talk to the patient about their abysmal prognosis. I didn't want to 'sign off' of a patient who needed help.

Anesthesia: 99% boring, 1% terror. Hate boredom. Hate terror.

Dermatology: I loved derm. L-O-V-E-D. Office procedures, almost entirely outpatient, as much continuity as I wanted, get to see some bizarre and unusual disease mixed in with simple but fulfilling care. If I had the board scores for it, I would've done derm, but I'm just not that smart.

Radiology: Zero direct patient care. No thanks.

Neurology: All diagnosis, no treatment.

Pathology: The most scientific of all specialties, the greatest arbiter of diagnosis, but the only time I get to work with patients is when they're dead. While I loved the science, I wanted to see patients.

So in the end, I went with internal medicine. I loved the diagnostic challenges, the continuity of care, the limited focus compared to family, the treatment aspects, and the attitude. Internists are generally somewhat anal-retentive folks, and a little OCD. We obsess over tests and meds and things like sensitivity and likelihood ratios. There is a constant fight between the art of medicine and the science. In adult care, we are management kings.

But also, we are a dumping ground. We admit patients spurned by every other service: Gyn, neuro, surgery, when everyone else passes, the patient goes to medicine. While I find this aggravating, I also feel that someone has to look out for the patient.

I came to peace with this fact when I talked to a US Marine a while back. I was marveling at his bravery, enlisting in the branch of the services known for being the first to fight. You don't join the marines to avoid war; you join to get your hands dirty. Rather than be proud of his service, he completely downplayed it. "Y'know, when there's a job to do, someone has to step up and say 'I'll do it.'"

And although I'm not in the military, this is pretty much my attitude towards internal medicine. I did not become a doctor to avoid work. I became a doctor because I felt that I could do some good. And whenever people complain that medicine is a dumping ground, my reply is always that there is a patient who needs help, and if no one else will step up, I will. I have even been so bold as to tell other doctors if they don't want to do what's right, then I will.

And when I die, I hope that people won't say what I nice person I was, or that I'll be missed. What I want people to remember about me is that when I was needed, I always answered. I did not become a doctor to rest on my laurels. I came to work.

Choices

2007-10-07T17:19:00.000-05:00

When I was finishing up residency, I was working with some medical students. One of the students was absolutely gorgeous. She had this wavy, brunette hair that seemed to flow like water. And she had this scent to her that was so intoxicating. I found myself following her unconsciously, completely entranced by her smell.

She had a crush on me too. Sometimes, I don't know these things. My social skills are poor at best. But with this girl, I knew. Her gaze would linger a little too long. She would look down when I was talking to her, afraid to make eye contact. She kept her head tilted slightly, in that kind of daydreaming pose.

I think about this girl every now and then, and the long string of girls like her whom I have met briefly, and then have left my life. Either I was going or they were, never in those ideal circumstances you see in the movies. And so we meet and we part, with the vague notion that maybe we could've done something, but for the timing.

And I realize now that the problem was never the circumstances or the timing or whatever else. The problem was the choices I've made. When you can appreciate the choices you've made in life, it becomes very difficult to avoid reality. I've made some choices, some of which were terrible. And it became clear to me that as unhappy as I've been, it was from my own hand.

People make fun of the second Matrix movie, but there was an extremely profound line in it. The Oracle tells Neo, "We can never see past the choices we don't understand... you've already made the choice. Now you have to understand it."

When I heard this line in the movie, I thought this was so trite. But looking at my own life, I can see now that my life is composed of the decisions I have already made, and the most anxiety, the most angst is tied behind decisions that I have made and never understood. And as I shed light on them, it becomes clear to me the effects of these choices, and how terrible it truly is that we can't change the decisions we've already made.

Because for the last 15 years of my life, I have chosen everything over love. I was scared of love, and I still am. And it scares me because everything I love leaves me. And gazing with a critical eye, I can see that I have made some remarkably poor choices, in order that I could wake up in the morning and not shoot myself, but exorcising all joy from my life.

Now, understanding the choices I've made is all very enlightening, but it doesn't answer the very simple question: will I choose to love? I don't know. It's one thing to see the gears. It's another thing to be a clocksmith.

Choosing a specialty

2007-10-01T23:27:00.000-05:00

Recently, I was talking to a 3rd year student, and he was trying to figure out what to do with his life. He was still a little lost, like most people in their 3rd year. Everything either seems fun or horrible. Everyone expects that moment of, 'This is what I want to do with the rest of my life!' but in reality, few of us get that moment. I can't tell you when I decided on internal medicine. I just did.

I tell most people that they should go with the pathology. Whatever diseases interest you are probably things that will continue to interest you, because the patients can't all be winners. This student told me that he wanted to do ER because he didn't want to see the same thing over and over. I was polite enough not to laugh in his face.

The truth is that every specialty has its bread and butter. For me, that's hypertension and diabetes. For the surgeon, it's gallbladders and appendices. And all specialties have their chronic patients. You can't choose a specialty aiming to avoid these chronic folks or to dodge the routine diseases. The only way to dodge that stuff is to go into a field without direct care: radiology, anesthesia, path...

When I was trying to decide, I posed a simple but profound question to myself: what is my staple diet? Sometimes I get a taste for Mexican, but I can eat rice every day for the rest of my life. And that's what choosing a specialty is like to me. What can I see again and again and always find satisfying? That's the specialty for me.

A new paradigm?

2007-09-26T21:40:00.000-05:00

A friend of mine once considered going to officer candidate school (OCS). Of course, he didn't realize this was for folks who want a commission in the armed services, and when we let him know, he reconsidered. However, I don't think that OCS is a bad thing. In fact, I think that things like OCS are quite useful sometimes.

One thing that I think medical school is lacking is training student doctors what it means to be a doctor. There is the education and interviewing and a lot of other aspects that go into medical education. However, I think that a lot of medical schools lack training in the professionalism and ethical behavior of being a doctor. Certainly every school teaches medical ethics, but it is in the safe environment of a classroom. It lacks the thing that OCS excels at: put someone in a real situation and watch them squirm.

An intern I was working with was managing a patient in the clinic, and I saw the patient on a sick visit, and one look at this poor patient was enough to admit him to the hospital. It was a judgment call, but one that the intern should have been able to make. Why didn't the intern admit?

I was the admitting resident and had 3 admissions from the clinic. None of the residents or attendings had contacted me to let me know. Two patients were having acute CHF exacerbations. One was an acute asthma exacerbation. After seeing these three patients, I transferred one on the cardiac stepdown unit, and one patient went to the ICU. Why didn't any of their doctors contact me about the acuity of their patients?

I think that medical school needs to teach doctors to make good decisions, because if you don't want to make good decisions, you shouldn't be a doctor. Being a doctor is all about making decisions. You may not make the right calls all the time, but you must continually question your decision making process, and evaluate yourself critically.

And after confronting all of the medical personnel mentioned above, several mentioned their poor decisions based on workload. They were too busy to do the right thing, and they all recognized that there was a right decision and a wrong one, and that they had not made the right call. But it took being confronted about it. I wasn't mean or rude. After all, in some cases, I was a resident questioning an attending. But if I didn't confront these folks, would they have learned?

I had a part time job once where my boss was a former marine. Let me tell you, having a marine for a boss is a mixed blessing. It turned a pretty easy job into a LOT of work. But the job had relatively little direct supervision. If I did a shitty job, no one would really know. But I always did my best.

My boss recognized me in a meeting, and I was completely stupefied. What had I done other than what was expected? And I realize now that what I had done was something quite simple, but something worth recognition. Without any desire for reward or recognition, with no one looking over my shoulder, I had done my best, because if I was going to do something, then it should be done right.

And I was talking to my boss about being a marine, and he told me that they teach marines something simple but profound. A marine should always do the right thing, even when no one is looking, because that is the best way to judge a man. And I agree. I think that if you can very accurately judge the character of a man by what he does when no one is looking, and by what he does when he is under pressure. Does he do what is right or what is easy?

I told my marine boss that I wanted to be a doctor, and he told me that I would be excellent. What did he know about being a doctor, I thought to myself. He told me that excellence is all about being excellent in all things. And if I can do a good job with essentially meaningless work, then how much better I would be at something where I can make a difference.

And I'll tell you right now, when I see students and residents, I let them know that you can know Robbins word for word, but that won't make you a good doctor. You measure a doctor by how he cares for his patients. And when I was a senior resident, the folks I came down hardest on weren't the ignorant, but on the lazy. I have no sympathy for laziness or arrogance. How can you ever look at yourself in the mirror if you don't do what is right when someone's life is in the balance?

If I could teach that to a medical student, just one, then that would be enough to change the world.

Where's your stethoscope?

2007-09-19T21:30:00.000-05:00

Nowadays, the new, hot thing is to wear your stethoscope on a belt clip. The ER folks are in love with this, because they typically don't wear lab coats, and the stethoscope can irritate the neck. Moreover, getting that weight off your neck is very relaxing.

What's interesting is that how a doctor carries a stethoscope can say a lot. The way you wear a stethoscope speaks volumes about when you trained. Here are some observations that I have made.

You carry your stethoscope in a doctor's bag: you remember when penicillin was first mass produced. When someone talks about Osler, your reply is, "Osler was an ass." Your day is done and you are likely dead now.

You wear your stethoscope like a tie (your neck between the ear pieces): You speak of the 'good old days' of fee for service, and bemoan Medicare, as you remember the days when it did not exist. The words, "Evidence Based Medicine" make you want to vomit. Still, you try to impart wisdom to the younger generation of physicians who don't know any better. You reminisce of the days when everyone had traditional indemnity insurance, patients did as they were told, and no one thought medical paternalism was bad.

You wear your stethoscope around your neck: You are a new breed of doctor who trained in the HMO/PPO era. This style is the current norm these days. It is a strain on the neck and if your stethoscope is not long enough, it's quite annoying. However, you comfort yourself with the knowledge that medicine is now guided by science and best evidence, and you wear your stethoscope more for decoration, since you have never heard a murmur in your life, and wouldn't know one if it bit you in the ass.

You use a belt clip or keep your stethoscope in a coat pocket: You are trying to be on the cutting edge, the avant garde of stethoscope fashion. But no one is impressed. And everyone secretly laughs at you when you get your scope caught in the arm of a chair or on a door knob.

Of course, I'm joking around, but really, the generation gaps are there. I think it would be really interesting if people started carrying scopes differently. I am all for keeping it in the pocket. Truth be told, our physical diagnostic skills have gone to the dogs, and I no longer see that the stethoscope deserves a place of prominence around the neck.

And by the way, I ruthlessly stole all these pictures with Google searches. Sorry. However, while googling, I did discover there is a whole world of stethoscope fetishes. Apparently, there are some very creative uses for stethoscopes.

Just wanna be loved

2007-09-16T23:51:00.000-05:00

This American Life has once again hit a hot button for me, talking about reactive attachment disorder, which is one of the child psych diagnoses that strikes the most horror in me.

The thing that turned me away from child psych is that it is so absolutely horrible. These kids are absolutely destroyed by forces entirely out of their control. I couldn't deal with child psych because for the most part, the pathology wasn't in the children; it was in the parents. Kids aren't born with reactive attachment disorder. It exists because there are awful people and situations out there, and it is actually possible for a child to grow up without love. The consequences are terrifying.

But one commenter wrote about her own work with foster children, and after listening to the radio program, I got a little hope. Maybe these kids do have a chance. But it takes so much dedication, so much work. And it's hard and scary. I'd like to think I could do it, but I couldn't. My basic pathology is that I desperately want to be loved, not the other way around.

Catharsis: all about being dumped

2007-09-08T22:27:00.000-05:00

[This post has nothing to do with medicine. If you have had your fill of self-pity, go ahead and skip this one.]

There have been a lot of comments about the dumping post. I came up with it while driving. I carry a voice recorder with me. My exact quote: "If I ever get into a relationship again, and it goes south, I'm going to dump her before she can dump me. I'm never going to be the dumpee again."

For years, I've lived in a self-imposed emotional isolation, content to say that the risk of loving was far too great, and it was better to be alone. This was a pretty stupid decision, but I certainly can see the reasons behind it. The problem is that rather than take steps forward, I've gone backwards.

If you want to know why I'm so vicious about being dumped, I'll provide you with some context. One episode that jumps to mind was in college. It's classic soap opera. Girl dumps me for my best friend who was seeing her behind my back. It should speak volumes that I blamed myself for this entirely, and rather than get angry, I tried to keep a friendship with them. Part of my motivation was that my entire social circle was tied into these two. I wasn't about to make all my friends pick sides. So, we tried to be friends still. It was almost unavoidable. My friend lived in the same apartment building.

Friday night came, and I waited to hear from the grapevine what plans for the night would be. And I waited, and waited. My roommate was out on a date, so I was in my apartment alone. I sat by the phone for a while, then started calling around. Finally, I went up to my friend's apartment. One of his roommates was there. They had all been there, my friends, and they had hung out for a couple hours, and then left for a bar or club. Due to some circumstances I won't go into, I was physically stuck at home. Even if I wanted to follow them, I couldn't.

The most absurd part of all this was that in order to get to my friend's apartment, you had to walk past mine. So all of my friends had walked right past my apartment to my friend's, and then later walked past again. And at no point in time while I was less than 100 feet away did anyone think to call or even knock as they walked by.

I think what hurt most was I couldn't figure out if it was out of spite over this breakup stuff, or out of sheer apathy, that I mattered so very little that it had not even occurred to them to see if I was in. Despite several phone messages on a variety of answering machines, I never got a call back or an apology. When I confronted them, they said they thought I wasn't in. As if I had somewhere better to be.

I was so angry that I was throwing things all night. Some things are surprisingly sturdy! I am not an overtly angry person. Most of my friends have never seen me angry, but that night, I was furious. And which was the better option: was it better to have friends who were so cruel or so utterly thoughtless?

I made a resolution right then. I would learn to be happy on my own, because it was clear to me that I could not trust other people to be there for me. It took me a while, but I burned those bridges and left all those people behind. And looking back now, I can see what a terrible resolution that was, and how so much of my unhappiness with life was self-inflicted. It was as rash a reaction as possible, but not a surprise. They abandoned me.

Just last month, I realized that my life is governed by an utter fear of abandonment. It scares the crap out of me. I made a list of all the horrors of my life, and when I looked down the page, it was all the same: abandoned by family, by friends, by lovers. And so, that one night in college, more than anything else they had done (and let's see, dumped, two-timed, ridiculed, mocked... the list continues), spelled the end of my friendship with them, because they had done the only thing I couldn't forgive.

And I'm trying now to forgive, and to let go of all the emotional torture I've self-inflicted. And that hurts, but what options do I have? All this time, I have burned with furious indignation. But there is no reward in that. There is no comfort. My anger will not change the past, and very likely has made absolutely no difference whatsoever in the lives of the people who have wronged me. I can keep holding onto my anger, but for what purpose?

And so, I've decided it's time to move on, and that means facing all this fury and quenching it. And at least acknowledging it is a start. And as angry as I seem about this one Friday night, it is only a crumb in a life full of being left behind. And as much as I am trying to grow as a person and move on from all this turbulence, I know in my heart one thing: if given the choice, I would rather be the dumper than the dumpee.

The litmus test for good health care

2007-09-05T20:40:00.000-05:00

Once when I was a senior resident, I had an intern who was taking real shitty care of one of his patients. He couldn't have cared less about this patient. His notes were sloppy. His management poor. I was cleaning up all kinds of loose ends. Finally, I confronted him.

He hated the patient. He thought that the patient was manipulative and mean-spirited. To say his care for her was dispassionate would be a compliment compared to the job he was actually doing. But hating a patient doesn't give you the right to do a shit job.

"Yes, she's a bitch, but she is someone's mother. And if you took this kind of care of my mother, I would sue you out of spite. And my mother makes this lady look like Mother Teresa."

There are two tests that are quite useful when caring for patients. It becomes very easy to forget that we are treating people and not diseases, because all we see are the diseases, and it's hard to get to know the people. So it's helpful to ask yourself two questions when you feel a little lost in the storm:

(1) Is this the care I would want for my parents? (2) Would my parents be proud of me if they could see what I'm doing?

If you can answer yes to both questions, then you're doing alright. If not, it's time to take a step back.

Flip flop

2007-09-03T09:52:00.000-05:00

When ADOPT came out last year, it was pretty much a home run. Many practitioners were advocating changing guidelines to recommend Avandia (rosiglitazone) as initial monotherapy. I was quite vocal in my disagreement. I think metformin has more favorable effects, blah blah.

Now that rosiglitazone's safety has been seriously questioned, everyone is jumping on the 'TZD's suck' band wagon, which is dragging pioglitazone down with it. I find this very amusing because it kind of typifies the trend in US pharmaceuticals.

I could understand the arguments against Vioxx, a drug made for symptom relief and not much else. Natrecor was disappointing, but it had filled a nonexistent hole anyway. But this Avandia stuff is ridiculous. You can't tell me that optimal glycemic control does not have benefits. We have modeled ALL of glycemic therapy on this idea, that microvascular disease is the consequence of hyperglycemia.

And none of this talk answers a quite serious and obvious question about Avandia. Is Avandia doing something or not doing something? By that I mean is the risk caused by the drug itself or is the increase in heart attacks the same as untreated diabetes? If it's simply the risk of untreated diabetes, well then I'll slap some metformin on top and call it a day. But if the drug is causing heart attacks, that's a different story.

I'm willing to concede cardiovascular disease, but keep in mind that there are a lot of complications of diabetes. Choosing between them is like trading bananas for pears. Is it better to have heart disease or kidney failure? Is it better to be blind or a CHF patient?

I don't like TZD's and I've never been a big fan, but I can't argue with the fact that they work, and work well, and probably are one of the best oral diabetes medications. Since this all came out, I haven't written any scripts, and thankfully I've always preferred pioglitazone so I can at least hedge my bets until we figure out if this is a class effect. But I'd be hard-pressed to say to someone that Avandia was bad for them.

Breaking up

2007-08-31T22:38:00.000-05:00

I was listening to This American Life last week, and the episode was about break ups. It was a strange and amusing episode to listen to, and I know that I have felt the same way at times, but it seems like when we talk about break ups, it’s usually the perspective of the dumpee rather than the dumper. It is the dumpee who is all alone, pining for a nonexistent future.

I can certainly sympathize with the dumpee, seeing as that has been my station in life. Being dumped sucks, and after the last time, I have no desire to go through that again. It is all about being hurt, tossed about like in the wake of a passing ship, and while the dumper is getting on with life, the dumpee is stuck in a continual relationship post-game report.

You know, after a football game, the commentators all sit together and break down the game play by play, finding all the faults and mistakes and errors. “In the 2nd quarter, he was far too clingy and came off as desperate. In the playback, you can see he was doing a LOT of hand holding. I think that this is where the momentum turned.” You get the idea. Maybe you even know what I’m talking about. And inevitably, a sick kind of hypothetical game comes up. Maybe if I did this, it would’ve been different. Maybe if I was better about that...

The sick twist to being dumped is that your own self-worth goes in the toilet. Here this person whom you loved and respected has determined you are unlovable, and so that becomes your own self-image, that you actually deserved this, because who could love you? It takes a long time to get back to even keel, and you dream of the day when everything stings a little less.

I for one am sick of this mental torture. I do not want to ever find myself in that place again, full of anguish and self-pity, tortured by the echo of love. I think that if I am in a relationship I see going downhill, next time I will be the dumper. I will be the one to cut my losses, rather than the one left stumbling in the dark.

I am not a mean person, and I don't relish the thought of hurting other people, but it is an issue of self-preservation. A person can only stand so much heartache in a lifetime, and I've had more than enough.

Dear Rhona

2007-08-28T21:44:00.000-05:00

I listen to a lot of medical podcasts, in an effort to try to keep pace with the changing medical world. I find that the podcast is the perfect bite-sized piece of information and, with an ipod, can be played just about anywhere while doing just about anything. I listen while I cook or clean, and I've been doing okay except for The Lancet, which is a difficult podcast to follow because of the sheer volume.

But recently, I got a most pleasant surprise: the soft, lilting, Scottish accent of Rhona McDonald, a substitute for the regular Lancet podcaster, Richard Lane. I was actually listening attentively. I have never seen this woman before, and know nothing about her, but I have to admit, I've got a little voice crush.

It reminded me of a girl I knew in college who was a very attractive Chinese girl, but the amazing thing about her was that she had this smart British accent. She grew up in Hong Kong, and spoke proper British English. It's funny how something as silly as an accent can carry so much weight in our minds.

Along the same lines, I had one friend who had such a pleasant, wonderful voice, and whenever she talked to me, I felt all warm and fuzzy. I wanted to have her record my answering machine message. I was so enamored with her, just by her voice, but apparently, since pretty girls are my Kryptonite, I never could manage to say more than 3 words to her at a time, and I haven't seen or heard from her in years. But oh, what a voice.

Practical advice for the new MS1

2007-08-26T20:16:00.002-05:00

It's time for the brand new medical students to embark on a long and treacherous path towards being a doctor, and I think of this time as amazing. It is both scary and exciting. It is mysterious but beautiful. It is also one of the first times in your life when you are finally among equals. I thought I might provide a little advice to any MS1's out there on my thoughts about the first year.

On first draft, I wrote about principles and value and being a better human being, and you know what, I don't think you'll need that. You will get it from everyone, and tons has been written about it already. Just google "Advice for new medical students." Instead, I will give some very practical advice.

Unless you have a PhD or were a financial analyst, the first year of med school will be one of the hardest things you've ever done. If you want to do well, you have to ensure that your time is productive.

(1) Figure out how you study best (smarter, not harder). Some need to write it out. Some need to hear it. Some need to read it over and over again. Whatever works best.

(2) If you like to study in the library, you gotta get there early to camp out in a good spot. You have to get a good spot, not only to help you study, but by getting a good spot, your academic cred will go up, and smart people will want to study with you.

(3) Have a study buddy. Not someone you study WITH, but a person you study NEAR. So you can take study breaks together, chit chat. Also, with two people, more chances of getting the good studying spots.

(4) Work hard, play hard. After every test, we'd go to the bar. In med school, that whole waiting till noon thing goes out the window.

(5) Get a study group together. Meet regularly. Our study sessions were great fun, and are some of my best memories from med school.

Enough about studying. Let's talk about life for a minute. You will not have one. So you should take some steps to ensure that your life will not be completely joyless and pathetic.

(6) When you hear about this party or that party, go. Go to every single party. Party hard. Enjoy. You'll need to get all your fun in now, to make up for later.

(7) If you're not studying, you'd better be having fun. First year is all about gas pedal or brake. No neutral.

(8) Have some friends who are just friends, and you don't need to worry about a study session breaking out. I had a group of friends who met every week. It was fantastic fun.

(9) Join a million clubs. It'll help to fill up your non-productive time.

(10) Your med school colleagues will form their entire opinion about you for the next 2 years based on the months of August and September. If you have to be an asshole, don't do it the first two months, huh?

Your expectations of med school have to be a little realistic, and you will find that med school is nothing like any academic activity you've ever done, because it is the best of the best. It's like you've joined the academic equivalent of the Navy SEAL's.

(11) Don't try to show off. No one cares about your MCAT score, because we all know that the MCAT doesn't mean shit anymore. In my class, I was in the top ten for MCAT scores, but I was never again in the top ten for anything throughout the rest of med school. No one cares about the MCAT.

(12) A lot of med schools are pass/fail, but I have heard stories about people not sharing notes or giving out false information to try to game their class rank. This is SO NOT COOL. You will get a reputation for shit like this, and guess what, reputations don't go away so easily any more. Eleven years later, some blogger like me will be writing about how Mousy was such an asshole because she wouldn't let me copy a lecture handout, because she didn't need anything from me, and how much satisfaction I got when she wanted to switch calls with me during 3rd year, and guess what, I didn't need anything from her.

(13) Don't start drama. I have known people who've gotten into fist fights in class, or yelled at a professor. That's just ridiculous. I mean, really.

(14) A lot of schools have a 'med school for dummies' kind of extra study session for students underperforming. Don't make fun of these people. That's just fucking rude. I had to go to one of these sessions. It is already one of the most humiliating things that can happen in med school. Your mockery is not required.

Romance in medical school is possible, and I would encourage you to pursue a love life, but there are some definite pitfalls and caveats to keep in mind.

(15) Med school is a small world, so if you end badly, expect repercussions to follow. And do me a favor. As a guy who was turned down at least twice with the line, "Oh, I'm not going to make the mistake again of dating someone in med school," when you do get into a relationship, don't take out your frustrations with med school out on the other person. Med school is a stressful time, but it's never okay to put other people down to make yourself feel better.

(16) For the guys, most girls in med school are in their early twenties (like you probably are), and are still essentially the same girl who turned you down in college. If you are striking out in the med school world, try the working world. That same 23 yr old girl has developed very different priorities after working for a living. For you ladies, c'mon. Boys never change. We hit our maturity peak at 16. He's not going to grow up and act his age, even if he's going to have MD after his name.

(17) Although most med schools are about 50/50 boy girl now, the number of single men to SINGLE women is still vastly disproportionate. In my class, it was somewhere around 5 to 1. If you like a girl, don't do what I did and wait around. Move quickly, because there are 4 other guys with the same idea.

A little advice for the ladies: dating men in medical school is like car shopping. Do a little research. Figure out what you want from a relationship, what are the deal breakers. Take a test drive. All of med school is your oyster. If you can't find anything good in your class, try one up or one down. However, keep in mind that med school selects against bad boys and heavily favors nice guys. You might want to look outside of med school if dating jerks is your thing.

I have some miscellaneous pieces of advice that don't quite fit into the categories I've set up, but are worth mentioning, because some are extremely practical.

(18) First chance you get, steal a pair of scrubs. If you have access, start wearing scrubs regularly (just not to class). You'll save money on laundry.

(19) Become the 'Go To' guy for something. I had a couple friends who invested in a kegerator. Guess who got invited to every party? Even I had my own 'thing' for med school.

(20) You will be poorer than ever before. Save your pennies. Eat ramen noodles.

(21) Whatever you may think about Drug reps and docs whoring themselves to Big Pharma, the only decent meal you're going to eat for weeks is being provided by the drug rep, free of charge. Swallow your pride and take free food whenever it is offered. You can have standards when you get paid.

That's all I can think of for now (isn't that enough?). I'd be interested to know if anyone else has practical advice for new MS1's.

Death and failure

2007-08-24T19:18:00.000-05:00

[SPOILERS ABOUND. BEWARE!]

I was discussing my thoughts on the book "The Spirit Catches You and You Fall Down" with a friend of mine who also read it. We were both amazed at how something so basic as caring for a sick child resulted in such tragic consequences, and it's no surprise to folks like us. We're both Asian, and we've had our own experiences with the clashes of Western medicine and Asian cultures. Neither of us are Hmong though, and it's a pretty different viewpoint.

But then my friend said something really funny to me. "It's so sad that she died, and it was all from—"

"What? Wait a minute. She doesn't die. In fact, according to the book's website, she's still alive."

"No, she died... didn't she?"

"Umm... no she didn't. She's alive."

In medicine, we equate death and failure. We can't separate them, or at least it's very hard. It's why some oncologists will wait till the very last second before sending someone to hospice. It's why we take worse care of DNR patients than full code patients. Even my previous comment is biased towards life-saving measures. Is it worse care, or is it more appropriate care?

But the truth of the matter is that in the medical field, we have a very hard time dealing with death. I have my own theories. I think when it is our own lives, they have a beginning, a middle, and an end, and although most of us are not seeking out death, we understand that it is a part of being human. And we can be content with that based on our own self-worth, which is the totality of our life's experiences.

When you're a doctor, all you see is a part of that life. You may see the beginning. You may just see the middle. But almost never do you see the whole thing. And so a doctor is not able to determine the value of a person's life based on life experiences or anything substantive. We are left with only one way to judge a life's value: quantity. We try to get people as much time as possible, with the belief that adding days will add value.

And in general, board strokes, quantity is valuable, but only to a point. For example, someone on his death bed is probably not concerned with the performance of his stock portfolio. So quantity is clearly not a definitive measure of worth, and so we as doctors are forced to rely on patients and families to tell us what a life is worth, and when it is okay to cut back on quantity, to give a little quality.

I remember one ICU patient was ready to cash out, so I talked to his son, trying to see if we could change to comfort measures. His son was conflicted. "If it was me, I'd say enough is enough. But my dad, he was real stubborn. He would never give up an inch, and I know he would want to fight to the very bitter end. What should I do?"

I could've talked him into palliation, but that's not fair, because in the end, his role isn't to play God, and neither is mine. It's simply to convey his dad's wishes. "When I talk to families, what I really want to know is what the patient would've wanted. Sounds to me like you've given me the answer. I'm gonna keep being real aggressive, and when you think he'd have hit his limit, then you let me know."

Believe it or not, I'm an optimist

2007-08-21T20:52:00.000-05:00

I keep getting comment after comment about how discouraging I am, and how I'm all doom and gloom. OMG, please, understand one thing: I LOVE my job. L-O-V-E. Every morning, I look forward to seeing my patients. The whole 'Don't become a doctor' series is about full disclosure. It is the price you pay for being a doctor. Do you really want to read another article on how medicine is difficult, but rewarding?

I got a private comment from a reader asking me if medicine really was so horrible, and I felt a little guilty. So for those of you similarly disheartened, fuck this whole series. I have one question for you: are you in love with medicine, or are you in love with being a doctor? Because I love the medicine. I have gotten into arguments with other docs about whether a patient should be on coumadin or not. You have to be passionate about the medicine. Because you will never be passionate about getting mail addressed DOCTOR ifinding, and you'll feel no sense of fulfillment from the length of your white coat.

So for those of you who are not regular readers of this blog, understand that this blog is written for me and me alone. I do not write this blog for other people. It is my fears and concerns and worries. It is entirely about the things in my life that worry me.

And since I'm getting sooooo many detracting comments, I thought that I might give you a little... treat. Here is a quick list of all the things that make me crazy happy to be a doctor. There are so many wonderful things about being a doctor, and it is a super fantastic job, if you can deal with all the negatives.

(1) There are only a few 'sacred' professions. For example, there are only two people that a family will call to the bedside of a dying person: a priest and a doctor. Caring for the sick and dying, that is a very special kind of duty, and I feel so lucky to have met so many wonderful families, under the absolute worst circumstances, and seen just how beautiful love is. Watching a wedding is a beautiful display of love, but it cannot even come close to watching a woman weeping at her dead husband's bedside. That is sacred. We as physicians are privy to so many of these sacred moments: births, deaths, and everything in between.

(2) There are very few professions where science and humanity mix so intimately. You can be the best scientist in the world, but if you can't interact with people, you'll never be a good clinician. In hard sciences, you have to love the science in a vacuum. In medicine, I love the science because of the difference it makes in people's lives.

(3) Medicine is one of very few professions where you meet people from all walks of life. In medical school, I was rounding and we were talking to a patient who didn't graduate 4th grade. When we came out of the room, the attending told me, "Here we are, over 30 years of higher education cumulatively, and we still need to be in touch and accessible to this guy with a 4th grade education. I tell ya, ifinding, it keeps you humble."

(4) It's very easy to find fulfillment in your work. One of my ICU calls was absolutely miserable, and I was complaining to the nurses why does all this shit happen when I'm on call? I was getting crushed. One of the nurses came up to me and said, "Dr. ifinding, it may seem really bad, but we are so thankful that it is you on call. When I finish my shift, I can sleep easy knowing that you're doing everything you can for my patient. If it was me in that ICU bed, I'd want you by the bedside." In medicine, there is no finer compliment. Whenever I feel lost, I think of all the people I've cared for, and it's easy to find the strength to keep going.

(5) I love puzzles and thought games. Sudoku, crossword puzzles, word jumbles, all kinds of games like that. I love to take chaos and make it into order. That is how I know that I was destined to be an internist. Every patient is like a little puzzle. Do you have diabetes? What are the diagnostic features of pneumocystis pneumonia? Every day, I am mentally challenged. It is exciting.

(6) I like to take care of people. I like having my own patients who think of me as their physician. It is so flattering. I have one patient who hugs me every time she comes in. She is such a sweetheart. But on the opposite end of the spectrum, I have a patient who is a complete asshole, who after years of me killing him with kindness, he's become very cordial and pleasant! The nurses were shocked. All this medicine stuff, it's fun, but without the patients, it would be meaningless to me.

That is what I love about medicine. It lets me take care of people. It lets me do my good for the world one person at a time, and I get the luxury of seeing the fruits of my labor. It is, at its core, remarkably selfish of me, and I am not sure how selfish and selfless can exist in the same action, but that is why I love medicine.

Don't become a doctor #11 - perfection

2007-08-18T23:04:00.000-05:00

I was in an elevator one day, and I couldn't help but overhear two neurologists talking (elevator conversations are bad! Even when it's an elevator full of doctors! Don't make me call the HIPAA police!). The only part I caught was one saying, "The PCP really dropped the ball. It was textbook HSV encephalitis."

Just as an aside, herpes simplex virus (either the cold sore or the genital herpes variety) can rarely INFECT YOUR BRAIN, and if you manage to live through that, you'll usually suffer some major neurologic damage.

I was completely stunned at the boldness of the neurologist's statement. But I'm sure that this PCP doesn't need a couple neurologists beating him up. Probably doing a good enough job himself. I know I would.

In medical school, one of my professors told me something wise. "Ifinding, I'll bet you think you should be right 100% of the time, because when you're wrong, people suffer, and maybe die. But guess what? You'll never be right 100% of the time. No one can be. We're human. In fact, you only need to be right 60% of the time. That's what the USMLE says (182 out of 300 on Step 1). I think that the most admirable goal would be 90%. If you can be right 90% of the time, then you'll probably be the best doctor you know. And when you fuck up, then you can say to yourself that you're allowed to be wrong one in ten times."

That's a really easy concept when you're a student, and the only thing at risk are your grades. It's a lot harder when you're trying to decide if it's pericarditis on EKG or an MI. And after a while, you learn painfully that you will be wrong sometimes, and the best you can do is plan for the worst.

So if you can't deal with being wrong sometimes, then stay away from medicine. I long for the days when being wrong meant losing points on my boards. Now when I am wrong, people get hurt, and people die. There aren't many things in medicine that feel worse, but the truth of the matter is that it is unavoidable. No one is 100%. No one.

Don't Become a Doctor

2007-08-17T22:17:00.008-05:00

I have been getting a LOT of links lately, and I appreciate the traffic, but I've come to realize that most of the links are for the 'Don't Become a Doctor' series, which I enjoy writing (I am still writing it), but I can see that there probably should be some sort of table of contents or main link page for ease of navigation and for the sake of links.

I just want to be absolutely crystal clear to the new readers out there, as I have gotten a lot of comments and mail about how pessimistic this series is, and how I must hate my job. I LOVE my job. I could write 40 posts on why someone should become a doctor. That's not the point of this series. Because you don't need help coming up with a list of reasons why being a doctor would be great.

To reiterate the purpose of these posts, I think that people spend a lot of time talking about the admirable qualities needed to be a doctor, and the motivations. We talk about the nobility and altruism of medicine, but rarely do we ever talk about the faults and shortcomings. So, I created this series as a guide, so that the eager pre-meds of the world can see the downsides too. And there are good sides, and it can be great, if it is what you want. But if all you are looking for is prestige and money and an easy life, I hope you might reconsider.

But please don't be too disheartened though. If anything I say actually discourages you from being a doctor, post a comment and let me know. I have no right to take your dreams away. I should be accountable for that. And if your dream truly is to be a doctor, I'll be more than happy to give you a litany of reasons why I think medicine is wonderful.

(1) The very worst in people
You only see the very worst of the world. Those are the folks that need our help.

(2) The doctor is OUT
it is very hard to be emotionally available for the people in your life, because you've learned so very well how to suppress it.

(3) There is no cure
We can't cure crap (literally and figuratively)

(4) A cruel mistress
It finds its way into every part of our lives, and continually pulls.

(5) Thou shalt not opine
Your professional opinion is not something to just throw around or wear on your sleeve.

(6) Laughing at the pain of others
What's the alternative? Go home and cry our eyes out every day?

(7) Thankless
All too often, I've taken exceptional care of someone, and been thanked with curses.

(8) Constant change
Some people like fields that are understandable and consistent. Medicine is not such a field.

(9) It's all your fault
Somewhere along the line, we decided as a society that the buck would stop at MD

(10) Hate me
If you want to be a doctor for the prestige and admiration, you're wasting your time.

(11) Perfection
No one is 100%. No one.

(12) Limited Resources
Distributive justice is a harsh reality.

(13) You know too much
You cannot help but assume the worst, because you have seen the worst.

(14) Uncertainty
In medicine, there is uncertainty on all sides.

(15) Guilty
Shouldn't someone be held accountable? And if I'm the patient's doctor, shouldn't it be me?

(16) I've got a secret
Patients have told me things, dark and secret things...

OCD

2007-08-08T22:45:00.000-05:00

The medical school admission process selects for people who border on OCD. I would be one of those people. The reason why is because medicine is so damned detail-oriented. It's like putting together Lego's, except you read the instructions once, see it done once, and then you're expected to do it from memory. So having people who are a little neurotic sometimes helps.

And sure enough, when I'm doing my thing, I've got it down to a T. I'm ordering 5,000 labs, getting x-rays, quizzing students on the diagnostic criteria for hemochromatosis. Beware my Doctor Fu. I'll check back on things, and I'll hear, "Oh that Dr. ifinding is so thorough!" But where this spills over into my personal life can be a little annoying.

I can never remember if I locked my car. I will go back from my office or from the hospital to check and make sure I locked my car. Even now, just talking about it, I want to go and check. Even worse, my front door. I am always so glad when I have a place where the door automatically locks.

I am always worried that I left my burners going on my range, or left the toaster oven on. Every day before I leave, I have to check both to make sure they're off. This might even sound somewhat reasonable till I tell you that I've been doing this daily, but I wasn't cooking for about 2 weeks. That's right, I was checking burners that I hadn't used in 2 weeks.

I have a pathologic fear someone is trying to page me and I'll miss it. Weekends, at night, my pager is always on. It's really, really hard for me to turn it off. I'm even worse with my cell phone.

And I can't pack like a normal person. I was gone for a weekend, and when I finished packing for the trip, I had 5 days of clothing packed for a 2 days. I had packed sweaters, jeans, boots, and a jacket for 90 degree weather.

I need help.

Systems based care

2007-08-06T23:48:00.000-05:00

A while ago, I attended a social event with some of the support staff. I was actually quite surprised to be invited. After all, the staff and the physicians sometimes don't get along so well, and so there's can be a little tension. We talked quite a bit about the different residents and doctors, and it got me thinking about multidisciplinary care, and how sometimes we judge each other on everything but medical ability.

My mom is a nurse, so she always told me that I have to be nice to the staff, and I should always be on my best behavior, and never mean or rude. She would always remind me of my pediatrician growing up, who was a saint of a man.

So I've always tried to be on my best behavior with the nurses and staff, because they are not paid to put up with attitude from me. And I believe that people who like you will help you. Case and point, when I was rounding in the hospital as a resident, one of the interns was presenting, "The patient hasn't had a bowel movement in 2 days and—"

"Wait a minute," I broke in. "Tracy told me that he had a BM yesterday evening, and now he's got diarrhea! I asked her to send a sample." Sure enough, we walk in the room and there is that wonderful smell of melena. The intern asked me after rounds how I knew the patients so well. "The nurse spends all day with the patient. You should try talking to them."

Anyway, back to my original point, whenever I hear nurses complain about doctors, I'm always surprised, because it is often things that the doctor didn't even realize that have earned him such scorn. There's an asshole surgeon who walks around with a coffee all the time the nurses would mock him and his coffee cup behind his back. When I talked to him one day, he thought that he was beloved.

One social worker thanked me profusely for meeting with a family, because another resident was supposed to do it but was called away. Why was she glad it was me? Because the other resident comes from a culture where you don't make a lot of solid eye contact, so he doesn't look patients or family in the eye. And everyone thinks he's pathologically shy or else trying to hide something.

I have seen excellent physicians hated, and incompetent physicians loved by staff, as well as the converse: I've seen great nurses despised and horrible nurses loved by doctors. It took me a while to realize that our ability to interact productively with other health professionals is a skill in and of itself, and multidisciplinary care isn't something you can just assume (so much so that systems based care is part of all residency curricula). So for my part, I try always to be polite and cheerful, and only to be critical where it's appropriate.

And sometimes, when I'm not sure, I'll call my mom. One time, a nurse called me with a low BP of 87/53 (so obviously a machine value, since people almost always report even numbers or multiples of five), so I asked if she rechecked it. She acted like I asked her to part the Red Sea. "Why don't you get up here and recheck it?"

When I got home, I called my mom and asked her, "This nurse called me with a low BP on a patient, and so I asked her if she rechecked it but—"

"—and she didn't recheck it, right? Well, I'll bet she didn't check it the first time either. The tech probably did. She probably didn't do a manual either. That's just plain lazy." I love my mom.

Truer words

2007-08-05T18:02:00.001-05:00

Hmong in California by yankeepez

I have been reading "The Spirit Catches You and You Fall Down" which is a book about Lia Lee, a Hmong infant with a terrible seizure disorder, and the culture clash between the American medical system and the Hmong people. I am instantly wary of all such books, because 99% of them are about how stupid the American medical system is, and lay the blame squarely at the doctors' feet.

This book is remarkably fair, and showcases the completely divergent cultural attitudes. I was discussing this book with a colleague, and remarked, "This story is horrible. I almost wish it was malpractice, but how much worse when everyone has the best of intentions, and still they cannot do something so basic as care for a little girl."

There are two things about this book that got to me though. One is that the book talks greatly about the Hmong people. It helped me to understand a lot about the Hmong patients I have seen, but the thing that got me the most is how the author talks about Hmong culture, but in reality, I have discovered something on my own quite in opposition to the book.

The problem with immigrant cultures in the US is not just one of assimilation. It is that the culture of the Old World is stagnant. It cannot grow. All change is viewed as corruption from the American way of life, and these transplants who were once the most liberal of their generation become the most rigidly conservative. And for me, the way of life that I was taught I now understand to be archaic. I am a man living a dead culture.

The other bit from the book is a line from one of the Hmong people, Jonas Vangay, a French educated man who helps the Hmong community to navigate the American bureaucracy. He utters this aphorism: "I am always the one who laughs last at a joke. I am a chameleon animal. You can place me anyplace, and I will survive, but I will not belong [sic]. I must tell you that I do not really belong anywhere."

I have never read a line that I have felt is a more appropriate description for myself. And I can't help but think to myself that truer words have never been spoken.

Worth its weight

2007-07-18T21:41:00.001-05:00

While I was going through my safety deposit box, I looked through all the gold I have. It's not much (please don't rob me): a few coins, some jewelry. It's all 24 karat. The reason why is because all my gold comes from my parents. Now, a lot of Asians are obsessed with 24k gold, but my parents are war survivors.

For those of you without Asian parents, gold comes in a variety of purities. 24k gold is the most pure gold available. My parents have never bought anything 14k, with the explanation that it is worthless, fake. And to understand why, you should understand that my parents lived through war. My friends talk about their parents growing up in post-war America, in suburbs or on farms. My parents grew up in a war zone. My parents' stories of their youth involve starving and refugee camps and bombs and explosions.

And so my parents have an acute awareness of the value of things. Paper money is only paper. Credit cards are just plastic. Banks are only buildings. But a can of spam can feed a family for a week, and gold is always valuable. No matter where you are in the world, no matter what the circumstances, someone always is willing to trade for gold.

And it seems strange to me that other people don't grow up with this kind of wisdom. Sometimes, I wonder how much of what I do is influenced by tidbits of knowledge like this.

Safety deposit box

2007-07-16T20:26:00.000-05:00

Vault I by chesh2000pro

Now that I have a J-O-B, and I am officially an adult, I decided to get a safety deposit box to store all those invaluables, like some jewelry and papers.

I went to the bank and signed up for a box. The bank teller and I went into the vault, and we both put our keys into the locks, and I pulled out the box. The teller escorted me to a private room, and I played with the contents, putting this in and taking this out.

And driving away from the bank, I thought it was so funny how much trouble it was: the vault, the locks, the security, the private room. We spend so much time and trouble to guard and protect things. Everything in my safety deposit box, it can't be worth more than a few thousand dollars.

Yet we are so utterly careless with our emotions. We hurt each other so recklessly without a passing thought. We guard things that can be replaced, but we don't protect the things that really matter.

And sometimes, I can see why, because if we could lock our hearts in little steel boxes, then how could we ever give our hearts to each other, share our joys and sorrows? I'm learning, slowly, that I have long locked away my heart, and I have kept it safe, but how can I share my heart if it's hidden away?

Worth a bag of moon sapphires

2007-07-07T23:47:00.000-05:00

So, unless you were living under a rock, you know about LiveEarth, which for you under-rock dwellers is a concert to help promote the cause of preventing climate change. There were a few things offered as simple things you can do to reduce your carbon footprint. These suggestions were (1) changing to fluorescent lightbulbs, (2) using energy efficient appliances, (3) turning off lights and unplugging things when not in use, (4) carpooling or using public transport. Gosh, that looks familiar, doesn't it?

I have to admit, I like Al Gore now. I wasn't a big fan of him when he was running for president, but he's managed to pull a Jimmy Carter, and make a bigger name for himself after politics than he ever did in Washington. I'm pretty impressed, and seeing as we're on the same page about a lot of this environment stuff, he's okay in my book. He has ridden the mighty moon worm, after all.

You're probably wondering what's up with me. Graduated residency. Got a job. Moved. Still in the Midwest. That's pretty much it for personal details.

At arm's length

2007-06-24T22:22:00.000-05:00

In medical school, I remember quite distinctly the day we talked about personality disorders. We discussed schizoid personality disorder. These are the folks who prefer solitude. They are lighthouse keepers or wander the desert. This is in stark contrast to social anxiety disorder, where a person is unable to interact with people, and this inability causes great distress.

I remember this because it was when I realized that I have made some terrible decisions in my life, choices that I am not proud of, in order to wake up in the morning and not shoot myself.

I was recently forced to do a lot of introspection. This is something that I am relatively comfortable with. I keep this blog, I write in a journal, I feel like I am pretty in touch. But surprisingly, putting a voice to my inner monologue was quite horrifying.

In my life, I've had my fair share of romantic disappointments and failures. Couple this with other issues with intimacy and relationships growing up, and somewhere along the line, I decided that I could not take it anymore. I made the quite conscious decision to hold the world at arm's length, to distance myself emotionally from all this turbulence. And without that horror, I've thrived. I've done well in medical school and residency, and I feel like I've managed to accomplish quite a bit in my life.

But it comes at a steep price. Sure enough, I have not had my heart broken in a long time, and I haven't felt that pain again, but the problem is that the pain and joy come from the same place. I have cut myself off from a world of happiness, because the risk of pain was unacceptable.

And I've watched life pass me by from my little castle, with all interlopers thwarted by the high walls and deep moat. And actually, if I am really honest about it, women have tried, some trying pretty hard, to get inside. And rather than welcome them in, I have put up more walls, and closed myself off.

This distance has its pluses. I can unflinchingly deal with most patient interactions. I've had people cry, people yell at me, the whole gamut of emotions, and I have been able to be empathic, and none of it hurts me, because I don't let them get close. They have to work on my schedule. I can deal with patients in convenient 15-20 minute chunks. They open their doors to me, but it isn't reciprocal.

It's too bad that joy and sorrow come from the same place, and that it is our greatest loves who can hurt us the most. I just don't know if I can risk it. I don't know if my heart can take it. I so desperately want to be loved, but the thought of me loving another person is absolutely petrifying.

I portray to the rest of the world a man of confidence, an outgoing and gregarious guy, but at heart, I am none of those things. They are adaptations so that I can operate in this extroverted world. And I think of how wonderful it would be to meet a girl who could cut through all of this façade and get to know the real me, and not this face that I portray to the world. She would tell me, "Hey, it's okay. This is safe, you and me," and I could finally, finally let my guard down.

No touching

2007-06-21T19:45:00.000-05:00

Kilmer Middle School bans handshakes, high fives, hugs.

So, I happened to flip past CNN and Paula Zahn was having a talking head bit about Kilmer Middle School and their policy of no handshakes, no high fives, no hugs, no touching essentially. People are arguing back and forth, and there are all sorts of positions one way or the other.

Rationally, I can understand both arguments. However, in my gut, I found this rule to be outrageous. I went to a private school, and we were reprimanded for NOT shaking hands. Hugs I can understand, but the handshake? The handshake is the most basic unit of human, adult interaction. You might as well ban smiling or saying hello.

These days, the only human interaction I have is shaking hands. If I didn't have that, I might as well be a hermit.

Completely disarmed

2007-06-16T10:55:00.000-05:00

A friend of mine made me blush the other day, which isn't much of an accomplishment, but it made me think a little. I started to tell this story, but thought better of it. But now, I find myself wanting to tell this story. I'm not trying to add suspense. It's actually a terrible story. Anecdote is a better word.

I had a patient not too long ago who was completely gorgeous. She was radiant and beautiful, and it was ridiculous that I would be put in charge of her care. I actively avoided entering the room. She had some problems, and eventually it was far over the intern's head, so it was up to me. It took a while to get things straightened out, but after nearly a week, I still had a hard time looking her in the eyes.

The only point to this story is that this woman could've absolutely had her way with me. If she had told me to give her 4 kilos of Oxycontin, I'd have written the script then and there.

And that was part of why I was avoiding her room. I know my weaknesses, and pretty girls are my kryptonite. I get all nervous and apprehensive. I look down a lot. I am for all intents and purposes quite useless. So I've done some hard work to try to desensitize myself. I made a point to talk to all the pretty nurses in the hospital. I try to smile and be friendly. But still, every now and then, I find myself completely disarmed.

31 flavors and then some

2007-06-09T21:04:00.000-05:00

Interns come in so many different flavors, and it can be hard to be a senior resident. Being a senior is a unique skill, and so I hope that I can provide a little guidance.

the stupid — his fund of knowledge is bankrupt.
the slacker — rounding on time? Not this guy.
the cluttered — Most labcoats have 5 pockets. This 'tern needs more.
the superstar — what I told one of my superstar 'terns: "I love having you on service. I get to eat a nice long breakfast."
the casual — He is completely frustrating in his unflappability. You'd swear he smokes pot.
the procedurist — He is single-minded in his focus to do every humanly possible procedure. But H+P? Pass.
the overwhelmed — One of my interns spent 4 hours doing an H+P. Think about that. FOUR HOURS.
the workaholic — His solution to all problems is work harder. While admirable, not always the best policy.
the earnest — "Well, I didn't document a skin exam because I didn't look at all of his skin, just his head, neck, chest, admonen, and legs." An actual quote.
the overconfident — He does not know what he does not know.
the disrespectful — I had one intern who was so disrespectful that I actually told him, "What makes you think you know anything?" I am not above putting a disrespectful intern in his place.
the unprofessional — All the above, while quirky, are just aspects of all of our personalities. At some point in time, we were all one of these flavors of intern. But without fail, the most dangerous intern is the unprofessional one. From a core competencies standpoint, knowledge can be taught, systems can be navigated, practice based learning speaks for itself, communication can be instructed, but you can't teach how to be professional. One of my attendings said something profound on the matter: "Ifinding, tell me, how do you teach someone that lying is wrong? I don't have a fix for that."

It may sound like I'm hating on the interns, but the truth of the matter is this: if you are an intern, there are only two things that any senior resident are looking for. He wants you to (1) work hard and (2) give a damn. Everything else can be taught. And my favorite interns aren't the smartest or most talented, but the ones who I called at 4AM and still got the job done.

I'm sure that I'm forgetting about some flavors of interns. Feel free to leave a comment with your favorite flavor of intern.

Delightfully tacky

2007-05-31T23:10:00.000-05:00

behind the scenes at hooters by o0karen0o

I know this probably won't endear me to the female readers, but I love Hooters. I would say that I really like the food, but I can hear the outcry already. The food is very good though, and it's hard to get spicy hot American food, but their wings and sauce are HOT.

But the best part about Hooters is that it revels in its tackiness. This is what drew me to Hooters on a beautiful day with a friend of mine, Macintosh. Mac had never been to Hooters before, so we had to go. Our server girl was nice. It's just a fun place to eat.

I actually go by myself sometimes because the Hooters near me has an outdoor patio where few people sit (because indoors are where all the girls are), so if I want to eat outside, there's always a table. It helps that I actually like the food.

My favorite Hooters memory was in med school. Me and Chocolate Thunder went on one of our man dates. We went to the local museum and soaked up the arts. Afterwards, we had to counterbalance all that culture, so we stopped at Hooters for dinner! The waitress thought that was hilarious. I mean, how many people at Hooters just spent a day at the museum?

The confusing thing to me was the table next to us was some guy with his 4 yr old girl and his 60's mother. Overhearing their conversation, he took his mother to Hooters for her birthday. WTF? That just doesn't make much sense. I mean, who takes his mother AND his daughter to Hooters?

If you've never been, I recommend it, because it's one of those places where you feel like they enjoy your presence, and sometimes when you live a solitary life, it's very nice to have someone talk to you for a minute and seem interested. ... I must really be starved for meaningful human contact.