Why I dislike Psychiatry...

I started this post on last day of my psychology rotation. Let me start off by saying that I have IMMENSE respect for everyone that works with the mentally ill. They serve in some of the most thankless, poorly understood jobs in the world. While I'm sure I'll look back wistfully on the days where I got to sleep in until 8AM, psych has been one of the most tiring rotations of the year for me personally. I despise it and here's why:

Your patients are behind a locked door
There are some people who are just downright incapable of functioning
within society. They drive with their eyes closed, they hear voices
telling them that their neighbor is going to get them, they're bizarely dressed/unkempt/disorganized in their behavior, they're incapable of fitting into the "norm". I'm not talking about the Emo crowd that is sad because life
sucks (though their overly tight jeans do make me nervous at times). Pretty often, they're the kind of people that you'd see and cross the street to avoid because you don't feel safe. Basically your spidey-senses are telling you to stay away from them...but you still have to sit down across a table from them and try to understand where they are coming from.

Now it's not It's pretty hard to convince a patient to talk to you when you're behind locked doors. The therapeutic relationship is almost prisoner-jail keeper and I spent about 75% of my time in an adversarial role with my patients. Atleast medical patients know that they're sick, they know that they need your help and willingly accept it. Inpatient psych is kind of like trying to sell the iPhone to an isolated tribe in the amazon that has never had contact with modern man...some of them are in awe and accept willingly, while others would rather spear you and go back to their little world.

The need to fit everyone into a diagnostic box
There were some brilliant folks who sat around and thought about the way that people think. Freud had his Id, Ego and Super-Ego to explain every conscious act as the interaction between the competing forces of the unconscious world. While brilliant, it's not much more than a load of crap that he made up and wrote down while toking the ol' opium pipe. Nowadays we rely on those so-called "neurotransmitters" that become "imbalanced" and cause a person to act "crazy"...OK, that I can buy because it's scientifically based, peer reviewed research and corresponds to treatments that work.

But then we have the DSM-IV QS. It is the biggest piece of crap in the world created by psychiatrists for the express purpose of diagnosis and billing. While it is quite comprehensive, the Diagnostic and Statistical Manual makes diagnosis of patients a simple checkbox process. While it works for some people, it gives the absolute wrong impression of how we view individual psych patients and the agony that is individualizing their treatments.

The patients don't always get better
Granted, I was just doing in-patient psych, but these people have some scary things going on in their heads and we give them a couple pills and boot them out the door as soon as they're no longer a threat to themselves and others. It wasn't really satisfying to wonder "what did we actually do for this person" at the end of a 6 week stay or "what if I run into this guy on the street" or "what if her voices tell her to close her eyes while driving again and I happen to be in the other lane". Most people will stop their meds at some point and bounce back. Others just get stuck in a state institution somewhere. It's not like a STEMI or an appy or pneumonia where you can manage the acute problem and send the people on their way...they need extensive rehab to fit back into society, which they usually cant afford. It's sad.

The understanding of the diseases sucks
Sure you have Freud's theories and the neurotransmitter models, but be don't really understand the entirety of what's going on. That makes it tough to effectively design therapies and meds to fix the problem. And the side effect profiles are nasty too...


But on the bright side, I got pretty good at talking to crazy people, their families and other health care providers...

OB/GYN

I really thought I was going to despise OB/GYN. We're talking angsty, pit-of-the-stomach dread...not just the "oh man this is going to suck alot". I basically thought I was plunging back into the surgery-type dread of not wanting to get out of bed.

It turns out that it's really a lot of fun. It may have been a product of the wonderful people that I worked with in the lovely private facility with the largely private patient population, but it was a nice mixture of everything (Surgery, primary care and babies). Things that I will be taking with me for my future EM career:

1) Pelvic Exams- they're not fun for anyone, but they're not too bad once you've done a bunch of them...except with discharge, those are always bad.
2) SVD's are horrifying- Anyone who thinks that the act of birth is beautiful watches WAAAAY too much TLC or has never seen a birth. Then there's the smell...ohhh that smell of rending flesh, blood, poo and amniotic fluid...ugh.
3) Epidurals are good- You have not heard a blood curdling scream until you've heard a "natural birth." Oh good lord, every time one of those niave primips would walk through the door I would just roll my eyes and try to avoid that delivery room. I definitely learned how to sell the epidural though...something about 20+ hours of labor (aka the worst pain imaginable) without pain control made the case itself.
4) Some women just don't know when they're pregnant- it may be unfathomable to you, oh virgin teenager in the ED with your parents, but your 4 month amenorrhea and weight-gain in the uterus area kind of tipped me off.
5) Drugs and babies don't mix- Just because your first two kids were fine despite your eight-ball a day coke habit doesn't mean that this one will be. Or yes, your baby will be ok, he's just going through withdrawl from your vicodin habit...you can visit him in the NICU. And my favorite: You do realize that you'll probably want an epidural because your nasty pot-habit has caused your child to tip the scales at around 10 pounds...
6) Juno was the worst movie ever in terms of creating mis-conceptions about pregnancy
7) DIC (or disseminated intravascular coagulopathy) is scary shit...
8) intrapartum hypertension+proteinuria=magnesium
9) Don't rupture the cyst- or to quote my favorite attending "If you rupture this f---ing cyst I will literally kill you." For the record, I felt it when before she went to ultrasound.
10) Acute pelvic pain= rule out ectopic pregnancy, ovarian torsion, hemorrhagic cyst rupture, physiologic cyst rupture and PID.

I would have considered OB/Gyn as a career, but if I had to be surrounded by hormonal/pregnant/OCD women for the rest of my career I'd lose it. Never mind the patients...;)

I'm a bad blogger

So it turns out that I've been a very bad blogger over the past several months. I guess what it comes down to is spotty internet access at one clinical site and just straight up boredom on my psych rotation...and now that it's coming to a close I figure that I should probably write at least something down to show that I'm still alive.

I've just been feeling like there isn't much to write about on a day to day basis. I'm much less distressed in the clinical world and as my third year comes to a close over the next several weeks, I'll be looking back at what I've done, reflecting on how it's going to impact my near future and untimately my career/personal life.

But boy do I have stories when I get around to writing them down...these people are crazy.

Stay tuned

Hiatus

Sorry for the long Hiatus...I've been secluded away on OB/GYN away from my apartment. Between spotty interwebs access (leading to lost posts), sleep deprivation and about 30 other excuses, I haven't really had time or energy for writing much. But now the shelf exam is looming, so it's time to procrastinate.

Now when I say secluded, I mean I've been living a semi-monastic lifestyle for the past 5 weeks of the rotation. Considering that I quite litereally live in the hospital...I'm not at all suprised. But hey...it's free and I was able to sublet my apartment for a decent amount...can't complain too much. I also just got my first digtal camera (thank you Circuit City for closing), so it's time for a look inside of the monastic, semi-deprived life of the Bostonian in NY. Enjoy.

Here is the semi-anonymous hospital...if it weren't for the stupid banners touting how amazing the hospital is (and it is), you'd probably just think it was some ugly federal building.

Here is the tiny little dorm room that I've called home. Note the bottle of scotch sitting on the window sill, the lappy and general clutter everywhere. I'm in study mode...back off.

Here's the reverse view of the place...yeah I'm messy, so what. You try working my hours...;)

Anyway, I have a few posts in the chute and Psych coming up next so I'll have some decent content over the next 6 weeks or so...enjoy

Third year...

Being a third year is kind of like being a chameleon. You have to quickly adapt to your service and blend in seamlessly or risk being killed on your evals. You can never get too comfortable though; just as soon as you get used to catching babies, you have to go talk to crazy people in another hospital with a different group of people judging you on a completely different standard. Different ancillary services, different nurses, different charts, different abbreviations, different living conditions...very little carries over. But then again, you're a chameleon...you change your colors and fit in.

In the midst of this constant, whirlwind of change, you're forced to decide on where you'd like to direct your life and all you get is a short exposure to one service in one hospital. All it takes is a couple of miserable residents or a really bad day, and you've cut a career choice out of the picture permanently. Or maybe you have two options in front of you that you like equally in your experience, but you not enough information to choose between the two. Or maybe you liked nothing. Whatever the case, you have to make a career choice pretty soon.

I was fortunate. I had found my niche before third year began, and it still feels right after several months. I feel bad for all of those who have no idea at this point.

Home for the holidays

After working my butt off without a full week off since July, I'm looking forward to just hanging out with the fam and being a normal, non-medical student person for a little while.

I almost always enjoy my ride home...until I'm stuck driving on the "clear" day between two snowstorms (it snowed the entire way) on the same day when people from the southern states are all of a sudden trying to drive in the snow for the first time in who knows how many years. I only saw 4 accidents on the way and they only added 45 minutes to the ride, so it could have been alot worse...

I actually miss the Massachusetts winters. There's a routine that happens around a snowstorm, life slows down a little bit and there's a clear priority to the days affairs: get the snow out of the way and go about life. It's almost automatic, ingrained on my soul from my formative years. It could be 3 inches or 3 feet...life goes on as normal. In NY, life pretty much stops for a few inches of snow, everyone on the roads looses their mind. In DC, it takes about half an inch of the white stuff to cripple the nation's seat of power. I came home to about 6 inches on the ground and then we had about 10 more that fell on top of that...so it's a nice wintery change of pace up here. I've already hit the local ski resort up once which was great, though there's something that seems wrong about skiing corduroy the day after 10" of snow fell (but it's the east coast...I can count the number of days I've skiied powder on one hand).

I haven't really been in my usual holiday spirit this year. I think it's the all consuming nature of school coupled with the girlfriend and family being far away, my classmates being spread all over the tri-state area and my roomate being depressed because his girlfriend moved back home for the forseeable future. Despite my case of the Bah-Humbug's, I spent 6 hours of yesterday shopping for everyone with my youngest brother. I'm almost finished, just the girlfriend's mom and niece to shop for. I have to head up for their traditional Christmas Eve Party, which is always interesting since it's the only time that I interact with her massive extended family. Then it's back home for christmas day and then to upstate NY/Canada for a bachelor weekend including the world famous Dinosaur BBQ, a venture into Canada, the Pats-Bills game...and probably lots of heavy drinking in there too. I imagine we'll probably also end up in a canadian strip club at some point (which is always interesting). Then it's back home for new years in Boston with a few of the college buddies and the GF. Then I have 3 days to recover, ski and get ready for OB/GYN to destroy my sleep cycle/personal life.

Merry Christmas to you all! Until 2009...
~Bostonian

A little too close to home...

I had the lovely opportunity to spend 3 days in the NICU of my hospital. Being an ex-30 weeker with APGAR's below 5, I was a little hesitant to begin this rotation to say the least. It brought up a lot of personal feelings that I didn't know were there...like a deep appreciation for the docs and nurses that worked on me...I would have never known that I was such a giant pain in the ass for so long. There's also a sense that all of that is worth it.

It's also immensely sad to see young familes go through that kind of ordeal...I could never imagine the anguish that my parents went through over 25 years ago watching my pediatrician code me in the delivery room...I guess I turned out all right. I feel a deep attachment to the field and a fondness for everyone in the unit. It's truely a wonderful profession that they practice.

At the same time, I had this weird identity crisis thing going on every time that I would reach into an incubator to examine a baby with tubes coming out of everywhere. It was like looking back 25 years ago onto what my life was, and could have been. Rounds for the past three days have been a little too personal of an experience for me to even consider as a career option. I wouldn't be able to deal with it the first time I lost a kid...which happens. Having to code a kid in the delivery room would probably be just too much for me to handle.

But at the same time it has alot of the benefits of EM (proceedures, good lifestyle, portable practice) that I like. I just don't think I could hang through 3 years of gen peds only to have to deal while being emotionally invested in those kids for the rest of my life. It just hits a little too close to home for me.

The rest of the week the Peds ED

So I've nearly had just about every bodily substance pass by my general direction while torturing the kiddies for the past 6 days. I've seen everything from perfectly behaved children who don't even bat an eye while you poke them with needles to 4 year olds that require 5 full-sized adults to hold them down to look in the ears. I've seen parents who would do anything to make sure that their very sick children get healthy to some of the dumbest, drug addicted DNA donors that I've ever met.

What I've learned:
-A thorough H&P will pretty much give you the right diagnosis 9 times out of 10...be thorough and cautious.
-Parent's ideas of what constitutes an emergency and what is an actual medical emergency are two very different things
-Schools and daycares are germ factories. Wash your hands or you'll catch a stupid URI that will suck the life out of you.
-Kids puke for almost anything at all: Strep- puke, PNA-puke, Cold- puke, Flu- puke, AGE-puking alot, intusceception- puke, bad mood-puke, poor self image- puke,
-Not every
-Eyes are disgusting...conjunctivitis is gross, eye herpes is perhaps the scariest thing in the world.

Finally, I love the ED...undifferentiated patients, procedures, trauma, medicine, primary care, decent pace to keep me from slacking, a good lifestyle, near-instant access to resources, being the floodgates...it's awesome. Yeah, it's a shitty field in many other respects but I'll deflate that baloon full of niave optimism when the time comes.

NICU next week, with exams...should be a fun week.

Peds ED Night 1

First night in the Peds ED with my favorite attending and tolerable peds residents...it was great!

Favorite Chief Complaint of the night: "Pain in behind" with photographic evidence that I can't make this crap up. Second favorite was "congestion"...mom wanted her kid suctioned for a runny nose...discharged with reassurance.

Snow!

Being a native New Englander, the first snow is something that I've looked forward to every year since I can remember...it always makes me feel like a kid again.

I went out for my weekly long run yesterday on a quiet out-and-back route that takes me by a local pond. There was a decent chop on the pond and it wasn't even frozen over yet. I watched a few ducks diving below the surface and then popping back up into their ripples a few second later. It was a bit windy but overall a quiet December day with the occasional snowflake that would meander out of the sky and land in my eye...always in my freaking eye. I can just see myself now, running next to traffic with my face all contorted into some sort of demented wink to try and melt the snowflake on my cornea. I no longer wonder why passing motorists give me weird looks...though maybe it's the tights.

Anyway, I cruised through the first half of the run without much of a problem through the turn around point. I passed one other runner in too much pink and she let out a quick "hello" between breaths...I smiled and waved. Most runners are a friendly folks and will acknowledge you unless they're in the midst of a full-on tempo run or sprint. I stopped at the end of the path to check my watch and catch my breath for a moment before turning around. Being the friendly runner that I am, I said "good morning" to the lady crossing the street with her yellow lab. She gave me a look of disgust/"why-the-fuck-did-you-just-acknowledge-me" that is quite prevalent in the greater NY area and continued right by me as I tried to get the tightness out of my left calf and get enough oxygen into my brain to calculate my splits (8:29/mi).

All of a sudden I was hit by a C-O-L-D gust of wind and I looked up to see a wall of white absolutely flying down the hill in front of me. I thought to myself, I've never seen a snow squall come out of nowhere like this one.

The white wall enveloped me and I decided that I should get on my way. I felt like the care-free seven-year-old version of me again as I cruised along the path next to the pond, squinting my eyes to keep the snow out and leaving my footprints in the accumulating dust on the path. For those of you that have never experienced a snowfall, the sound of it is amazing. There's a background of white noise from innumerable snowflakes hitting anything in their path, and a muffled quality to the rest of the sounds that you'd normally expect. It's absolutely other-worldly.

I passed the lady with her lab in silence, as is my NY-bound cultural duty, and continued home in the snow with only the syncopated rhythm of my breathing and footfalls to keep me company.

When the hell did I get 16,000 viewings??

The combination of longer hours in the hospital, getting back into running, some peer-advisory stuff, the return of new TV (TopChef and How I Met Your Mother) and Netflix (TM) have conspired to knock the will to blog out of me lately. I've got a few ideas on the brain that might be interesting to share...but I also have my peds shelf coming up in a few weeks.

Apparently people have started to read by blog for some reason or another. I'm not quite sure why...but thank you for looking at the blog 16,000 times. I was playing around with the new gadgets so please note the addition of the followers gadget and my new countdown to the end of medical school...feel free to stick yourself on there and I'll reciprocate!

I've also started using an add-on for Firefox called Scribefire to write my posts and it's been great so far...just thought I'd share a free utility.

Normal Saline Analgesia

I've been working on the floors of a peds hospital for the past month and I finished up my last call the Saturday before Thanksgiving. I had to cover a new admit with the working diagnosis of "Chest Pain" just admitted last night. Seemed like a strange symptom in a tween, but I'm pretty much open to anything after a few months at the major referral center.

Generally, I like to approach these new patients with an open mind and go through my working differential a kind of slowly since I'm still not the brightest crayon in the box. Her symptoms were refractory to a week of antacids/PPI's and had NO identifiable triggers or patterns. Kid had a normal cardiac workup, normal pulmonary work up, clear films of the chest and abdomen, nothing out of the ordinary on labs. So I go out onto the floors to start the day and I hear what sounds like crying coming from her room...great.


Mom comes running out to ask for pain meds. So I eyeball her...and she looks like she's a little uncomfortable, but not in too much distress. She's able to answer my questions clearly through her distress and "8/10" pain. I get the story from mom and it seems like the kid has these paroxisms of stabbing, non-specifically localizable chest pain for about a week. Kid's not in any distress, so I walk away to see the other 10 patients I was covering. Motrin doesn't touch it. Tylenol #3 puts the kid in a comfortable place...problem solved.

So I sit down to write some notes about and about an hour later I hear screaming coming from the room again and mom comes out looking distressed. I stroll on over to check on the kid...10/10 pain, inconsolable, stabbing pain everywhere in her chest. But she still answers my questions and is distractable. Resident writes for some morphine and the nurse goes in a few seconds later to flush the IV and get some fluids running before she pulls the drugs out of the Pyxis.

On the way back over to the room, the nurse notices that it's unusually quiet on that side of the unit...so she palms the morphine while asking the kid how she's feeling. She feels great now, 2/10 pain. Much better!!! I'll file the normal saline analgesia trick away for the finicky attention seekers later in my career.

The difference between kids and adults when they fake:
Adults seek the rush they feel from morphine hitting their neurons,
Kids seek the rush of everyone's attention falling on them for a brief moment

Just an interesting case that I wanted to share.

The Floors

::Beep beep beep::
That's my watch alarm going off at 5:45...what an ungodly hour. There's a little bit of grey in the sky, but it's still mostly dark outside as I drag my sorry ass out of the warmth of my bed and into the coolness of the autumn morning. I slink into for the warmth of the shower and try to suck every last second of freedom out of the warm streams of water. As I turn off the faucet I think to myself: today is going to suck. That's pretty much how every morning goes when I'm on the floors.

It's not that working on the floors is that difficult. I take a walk through the brisk morning air, watching my breath form a cloud infront of my face, grab my cup of black coffee from the cafe, round on my kiddos and make sure that the on call intern and night nurses didn't try to kill them while I slept. Sign-out is at 7. Team rounds are at 9, Heme-onc rounds are at 10, noon conference is at noon. I write my progress notes how the interns like them, and sign out to the intern by 4 after hiding in a conference room for an hour-or-so trying to read up. It's the sheer monotony that wears down on you. The same people, the same patients, the same notes...

How many times did you poop last night?
Ok, I'm going to listen to your heart now.
Deep breath for me.

It gets to be like a yoga routine: calming, precise...boring.
I get into my flow, feel time slowing down around me, feel like I'm one with the living, breathing organism that is the hospital.

I've never liked yoga very much.

My first BIG miss

One of my sicker kids came up to me in the middle of the day yesterday while I was sitting at the nurses station writing a note. He looked pretty relaxed and like he was doing ok, so I talked to him for a bit while I was writing. Then out of the blue he said "My tounge feels funny. Kind of tingly. It just started a little while ago."

OK I thought, probably not a big deal. So I ask him all of the questions that I can think of relating to electrolyte abnormalities, and it doesn't really sound like a big deal to me. So I tell him so and put it in the back of my mind. Well about an hour later, he's told my resident, the nurses and anyone that would listen that he's feeling tingly all over his body and his hands are getting crampy, and it feels like when his K gets lower. Ok not really a big deal, but this is not good!!! Resident orders a BMP and CXR, and we go to sign out for the night.

In the middle of signout the lab calls back with a STAT BMP showing a K+ in the 7's. STAT EKG is showing PVC's. Insulin + Glucose, CaGluconate and Kaoxalte go in and he's transferred to the PICU...OH SHIT THIS IS NOT GOOD. Long story short, he ended up being completely fine once his K+ was brought down to normal levels and he'll be back on the floors tomorrow.

However, the scary thing is that this kid came up to me and directly presented me with a problem. I brushed it off as something not serious...it didn't sound like Ca+ or high K+ to me...but there he is. I could have nipped the issue in the bud and looked like a superstar, but instead I was a space cadet and blew off someone who was SEVERELY sick. We're not talking "ooops, I missed something"...we're talking OOOPS I could have killed a kid by not saying anything. He could have flipped over into VTach or VFib and collapsed infront of me and I wouldn't have known what happened.

I know that I'm a third year student and that seeing the manefestations of disease are what this year is all about. I know there's a saftey net of 10 physicians, nurses, techs and janitors behind me to pick up what I miss. I know this one turned out to be OK...but what about when it isn't OK?

Great article!

Sorry I haven't posted in a while....just haven't been inspired to write and haven't really had anything interesting.

Just to update, the remainder of neuro went well and I had one excellent preceptor and one medicore preceptor. The excellent doc was one of the best educators that I have ever met. He cared about us learning more than the neuro exam...he wanted to be a role model for us and to educate our entire person...what a breath of fresh air. The other guy just didn't want to do work and blew us off...which was good for studying but bad for learning practically. The shelf sucked, but that's what I expected. Now it's onto peds.

Anyway, I was sent this article by a classmate and wanted to post a link to it: Medical Student Burnout

I'm pretty sure this will be me in about 10 years sitting around with my classmate recalling how miserable I was. The years of my life spent isolated from the real world, real people is starting to wear on me. The single persuit of nothing but medical knowledge is eroding who I am...but I'm too in debt now to back out. Today for instance, I finished my work by 4:30 PM and had to sit around waiting to sign out until nearly 7 PM. In that time I wrote 1 note, discharged 1 patient, attended 4 hours of lecture, and 2 sets of teaching rounds.

Was it a fulfilling day? NO!!!
Did anyone get better because of what I did today??? NO!!!
Did anyone get worse because of what I did today??? I certainly hope not, but I'll find out in the morning I guess.

I've said it a few times in the past, but I had no idea what I was getting myself into. I niavely just convinced myself that I would have no problem being a great doctor because I'm a pretty smart guy who listens and cares a whole bunch. HA...if I had only known. Anyway take a gander at the article, it's interesting to see this doc's look back at medical school. I found it to reflect my feelings many times.

Follow the leader

I'm getting kind of sick of this neurology rotation, but it is providing some valuable insight into the nature of what I want to do with my life. Here's today's episode of frustration:

Yestederday, 4:30 PM: Attending says "I'll see you in the morning. I have a meeting that will be over at 10, give me a call after that"

Today,
8:30 AM- Morning report...2 of our patients are presented by the medical residents, I learn a little bit
9:15 AM- Report ends, go to coffee shop to blow off 45 minutes waiting for attending
10:00- Call attending, who doesn't answer, leave voicemail
10:30: Call attending, who still doesn't answer, leave voicemail with pager number because I know he doesn't remember it
Noon: Attending pages and asks us to meet him in Radiology in 5
12:04: medical students and NP arrive at radiology ready to start the day
12:10: No sign of attending
12:15: Attending shows up, talks to radiologist about golf for 5 minutes, radiologist says the patient's scans are fine
12:20: Go to noontime conference
1:15: call attending to meet, he's still eating lunch...call back at 2
2:00: call attending to meet, says to meet at this patient in 5, head up and print out everything needed for a consult and play 'find the chart'
2:30: Attending strolls onto the floor, sees the patient and dictates his note
3:00: Another consult, med students play 'find the chart' for 10 minutes and then attending does the neuro exam
3:30: Another consult, another game of 'find the chart' but we can't find the patient either...he gives a brief lecture on MG and then we BS about the stock market, iPhones, his kids.
4:00: Patient arrives, he does the consult while we watch
4:30: Called for a frequent flier in the ED...he whines about having to go there, we talk him into going to see her, he says that he'd like to keep it less than 20 minutes if possible
4:52: Finishes dictating his note on a silly CYA consult...
4:53: As we walk out of the ED, "Well that wasn't so bad, I'm glad we decided to go see her. Have a nice evening"

Total time in the hospital: 8.5 hours
Total time doing anything productive: 30 minutes playing 'find the chart', 10 minute lecture on MG, 2 minutes removing socks and performing babinski's= 42 minutes of actual educational time towards the specialty of Neurology.
--------------------------------------------------------

So I think I've made the 'doing' vs 'thinking' decision in my career decision tree. Thinking sucks...I really don't think I could take 30 years of sitting around and hypothesizing what the hell is wrong with patients...I need to have something going on, I need some sort of end-goal directed activity to get through...not just a bunch of people chilling in beds waiting to get better. I need a stack of charts, or an OR schedule, or a patient schedule...this in-hospital endless rounding thing just isn't my cup of tea.

WTF...

There are just certain times when a neuro exam just isn't going to go smoothly and won't be of much value...I was lucky enough to have TWO of those situations today pawned off on me by my attending. Consequently, as of this morning I had done 1 independant neuro exam...so as you can imagine, it went smoothly.

1) A lovely, demented, non-english speaking Pakistani woman presents to the clinic with her son who claims initially that she can not speak, form new memories or remember much from the distant past. Ok...I'm a fairly bright and patient guy, but patience and creativity have their limits. Son acting as translator, I manage to get about 40% of the neuro exam done and have a slight clue that she does have some functional capability. I go back and give my very disorganized, half completed report to the attending who then feels the need reward my performance by mercilessly pimping me on all of the causes of dementia. Anyway, he gets frustrated while repeating the exam and gets frustrated after extracting about half as much as I did out of the lady and gives up...I felt a little bit satisfied, but only a little.

2) There are two consults on the psych ward that the attending wants to avoid: I'm assigned the chronic schitzophrenic found wandering the streets and my classmate gets the lovely, cognitively intact gentleman that's getting discharged in about 10 minutes with a clean bill of health. I'm sort of getting the feeling that I'm not the favorite student on this rotation. My patient's HPI is completely disjointed, his MSE is literally the most painful exercise in futilty that I have every striven to complete...fortunately the rest of the exam was less than painful.

Again...I don't see myself doing this EVER.

Neurology

I'm about 2 weeks into Neuro at this point and I have to honestly say that I could NEVER consider this as a career path. I will admit that my opinion is colored by the service that I'm on (consult based in a private community hospital) and that the two of us on the service have been left waiting for HOURS for the damned attending to show up and pay some attention to us and maybe let us do a consult or two.

I think the most frustrating thing is the thought processes of a neurology attending since the advent of the MRI. In one hand you have the bread and butter Neurological exam: Someone's brain is potentially (whether in reality or not) different from baseline, so you call the neurologist to find out what is functionally wrong with this person's neuraxis, localize the lesion to a level/side/location if possible and then try to figure out what can cause that and devise your treatment plan. On the other hand...you could get an MRI and be done with the logical part.

The scary thing is that the neuro exam can be very wrong...and I've seen it in my short time on the service. We had a lady that came into the ED with what seemed to be unequivocally radiculopathic pain on exam. It looked like classic root compression with some pain and loss of sensory modalities...thanks for the $500 ED copay, do some PT for 6 wks and follow up. Well, within 24 hours she was a paraplegic without control of her bowel or bladder without sensation below the waist, enhancing lesions in the spine consistent with transverse myelitis. What causes it? We don't know 50% of the time. What's the prognosis? We don't know most of the time, but we're hopeful. What are the chances that I won't be bed ridden and incontinent? 60% that you'll improve, we're hopeful. It's tough to sit infront of a family and tell them that you're completely out of control of what is happening to them and you don't exactly know what will happen. I guess this is the most humble and useless that I've felt in a long time.

I don't think that I could walk into the hospital every day for the next 30 years to localize the leison, check to make sure I was right on the MRI and then have a role of the dice as to whether I can affect any change in the patient. Not to take anything away from them, neurologists are some of the most brilliant and logical physicians in the hospital dealing with a very complex system. I just couldn't see myself in their shoes.

The business of family medicine

Every day that I walk into the family medicine office that I'm currently assigned to, I'm smashed over the head by the realities of why I could never go into primary care: the business side of medicine.

On the surface, family medicine conjures up warm-fuzzy images of the iconic practice model of a strong doctor-patient relationship that creates a forum for the patient to address all of their concerns and for the doctor to manage the patient's medical problems and prevent future illnesses from coming up. In reality, the whole enterprise is a bit like speed dating: get the patient/date to talk about themselves for a few minutes, drop some one-liners and patient's/date's , give them your number, tell them to call you soon and move on to the next one. Maybe they call, maybe they don't...who cares because I'm gonna see 30 others today.

To continue my god-aweful dating metaphor, the entire venture of family medicine is a bit like the 20-something bachelor's dating scene. You make your game (practice) as attractive as possible by adding on as many bright-shiny things as possible: the bachelor pad (a pimp office with lots of room), the interesting friends (in house cardiologists and endocrinologists), the stylin' wardrobe (custom embroidered white coat) and the reputation ("You should go see Dr. Bostonian, I hear that his 'practice' is enormous. All of his 'patients' that I've talked to have been extremely 'satisfied', but I hear that he his 'visits' are usually less than 5 minutes.") In the background you've got several other things going on...the cougar (the nursing home gig), the druggie (methadone clinic), the groupies (drug reps/speaking engagements) all vying for your time and energy.

Ok, I'm done with the crappy metaphor.

In reality, I've been studying medicine for the past 2 years and I don't have a lick of business sense. There is little-to-no appeal in spending a decade building a practice after all of the hassle of medical training and residency. A lot of people heading into primary care assume that they'll be able to find some doctor that is on the verge of retiring and will just take over their practice...I'm not willing to gamble my well-being on a capital-venture project or some dude deciding to hang it up. I really don't see myself becoming a savvy business person who battles day in and day out to keep his practice in the black by working 3 other jobs so that I can use that money to cover the practice overhead while I wait for insurance reimbursements. It's simply not what I came to medical school to do. I came to learn to practice medicine, not to run a business.

A life more ordinary...

I received the following comment from one of the 2 people who read my drivel:

"Ahem...remember that time you had a blog??
It's like you have a life or something...
:p"

It's not that I have a life all of a sudden, it's that I can't find anything interesting to write about and I've had a pretty awesome pneumonia going on for the past week...just to put that one to rest.
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So surgery ended last Friday with perhaps the most difficult exam I have ever taken. It was my first clinical shelf exam and being such it was full of long-winded questions with some fairly obvious presentations and lots of medicine questions that were complicated by the fact that I haven't had medicine yet...it was rough to say the least but I passed with all of the mediocrity that has been the hallmark of my medical education
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Anyway, I've been on Family Medicine for the past week and it is pretty sweet to be able to sit down with a patient from start to finish, leave at the end of the day with the sun still shining and focus on my non-hospital life again by doing normal person things like buying groceries, sleeping, meeting people for dinner/drinks, and general human life. I was even able to run a few times...that is until I ended up with a cough and a fever that became productive and included bilateral crackles in the lower lobes (God I feel awful). I -gasp- saw the NP at school and she fixed me up with a really nice macrolide and some mucinex without a co-pay or anything and was very nice about adding a few interesting teaching points while I tried to keep my lungs in my chest.

On the navel gazing front, I've decided that surgery is probably not the right choice for a career for me. Having a life outside of the hospital is an incredible thing...I can read, I can eat properly and I can be a nearly complete human being again! So the status quo of EM will be maintained for now.

That's really it...I wish I had something interesting to say. I'll probably not have anything posted for another week or so becaue girlfriend is coming to visit this weekend if I make it until then...I've got a few interesting posts brewing in the back of my mind.