I grow more confused everyday. This is not a trite comment about trying to learn medicine, but rather a problem of great import. Four months ago I was committed to Emergency Medicine. It was almost a given that this was the path for me, but after my first surgical rotation this all changed. I now find myself torn between several pathways all of which would provide me with a fulfilling practice.

Emergency Medicine: Pros – Shift work (read NO call), invigorating and exciting environment, being a generalist and specializing in resuscitation, no start up costs, good mix of procedures, short residency (3 years). Cons – No patient continuity, odd hours, high stress environment, little time with the patient.

Ortho Surgery: Pros – Get to work with my hands, better continuity of care, sweet tools and technology, high pay. Cons – Long hours, highly specialized, long residency (5 years), on call, super competitive residency programs.

Cardiology: Pros – Great mix of clinic and hospital time, ample procedures, good mix of pharmacologic, lifestyle and surgical interventions, good patient continuity, ample time to educate patients. Cons – Long residency (7 years), have to do Internal Med residency first, competitive fellowship, long work hours, on call.

This is an abridged list of Pros/Cons but you get the idea. Part of my problem also lies in the disconnect between my grades and my aptitudes. I could do Plastics or Optho, but I don’t stand a snowballs chance in Phoenix of landing one of those residency spots. My decision is also made difficult because I have legitimate economic considerations. My humanitarian sensibilities are in competition with my economic needs. The two are not necessarily compatible. On the one hand being a physician for the people and on the other being a physician for the people who can pay. Let’s face it, having student loans in excess of 200K churning at a 4% interest rate requires some frugal living even with a big paycheck.

Lots of personalities come together in the health care field. From patients and doctors to volunteers and administrators all walks of life are involved. This of course creates some interesting combinations. Sometimes these combinations mesh together in an almost seemless fashion, and other times the combinations are like oil and water.

I feel very fortunate to get to work with some of these people and personalities. Many of the individuals I look up to are the ones that have mastered the art of medicine which includes the ability to get along with all.

Case in point, today we consulted on a patient in the ED who was transferred from Whidbey Island. He had very typical chest pain on exertion and reported a couple of recent episodes of waking in the middle of the night with pain that stopped after he took his nitro. He is what we would consider a good cath lab candidate.

It was late in the day around 6 so Dr. S called up to the Cath Lab to see if the team was still around. He got off the phone, thought for a moment, then got back on the phone and told the person on the other end to send the team home for the evening. When he got off again he explained it to me like this.

“Our patient is stable. He needs a heart cath, but it doesn’t need to be done immediately. I feel comfortable tucking him in to the CV [Cardiovascular] unit, starting him on a Heparin drip and watching him overnight. The Cath lab team has been working hard all day and could probably use a break. My reason is partly based on the fact that Dr. B is slow and the team would be here an additional 3 hrs. If Dr. L were here I would do it now, because I know he is fast and it would only be an hour. If this guy gets into trouble in the middle of the night we can always call the team back, but for now I am willing to take the risk.” (I will save my balance metaphor for another post)

This is why everyone likes Dr. S. He knows how to allocate resources well, and his experience has given him the skills and knowledge to know when to jump and when to stand back and observe.

It doesn’t really dawn on you until you walk into the room and find that while the person in front of you speaks English they do so only minimally and understand even less. It is bad enough that even the most seasoned English speaking natives don’t understand half of what comes out of a doctors mouth, so to actually add an actual translational component really makes the job of providing quality health care to someone is nearly impossible. It makes me wonder how many things are missed simply as a function of poor communication.

Case in point, a woman presents to the cardiology office today for a follow up. She has a history of cardiac problems and can communicate this okay, but it becomes apparent that she really has no idea what I am talking about when I ask her if she is currently having chest pain and she says, “Yes, to the Uniwersity they took me.” Uh, right so I got some info, but not what I was hoping for so we take what we can get and move forward… “you mean you were taken to the University for chest pain?” “Yes.” Okay, now we are at least making some progress. This goes on for another few minutes, me asking questions and sifting through the responses to find direction. In the end Dr. S and I decide the best course of action is to schedule a treadmill test and an echo to assess the heart. At least this is a language we can understand and we don’t necessarily need to have a conversation to figure it out.

Of course another option, as told by one of my beloved mentors in the ED, is to simply “Carpet Bomb” them with enough labs and imaging studies that whatever it is will show up. Not very cost effective, but sometimes very useful.

We had a LOL of 81 yrs in yesterday that tripped on her dog and hit the floor. The end result was a broken hip that landed her in the ER. While broken bones happen to folks all the time without too much fan-fair, the meaning of a broken hip in an elderly woman spells disaster. The broken hip rapidly becomes a multi factorial problem that typically leads down a path of mental and physical degeneration. It is one of those things in life that is closely associated with the sort of decline that leads to death.

I always find myself wondering if the family realizes the gravity and potential meaning of these sort of injuries and my heart goes out to them knowing that this could possilbly be the beginning of the end for their beloved family member. Of course I am optimistic and offer words of encouragement and hope, but deep down there is a shadow of doubt.

My last patient of my surgical rotation was a woman in her mid 60’s. Nothing notably peculiar about her, she was presenting with possible small bowel obstruction (SBO) which ultimately resolved with a naso-gastric tube.

Before returning home for the evening I stopped into her room to chat with her and to see how she was fairing. After the formalities of “How’s your pain?” and “Have you passed any gas yet?” she asked if I might call her partner and her daughter to give them an update. I was glad to do it and scampered off to the nurses’ station to place the calls. Her partner, I’ll call Gordon, picked up the phone and said hello. I identified myself and apologized for calling so late, but that it was Ms. H who had requested the info be passed along. He was gracious and listened while I ran down the list of tests we had done and the info gleaned from them. I assured him everything was okay and encouraged him to get some rest. After prompting, he assured me he had no further questions.

At the end of the conversation he again asked my name and then added, “I just want you to know that I appreciate this call. I have had two separate families that I have been a part of both with their fair share of sickness and need for hospital care over my 74 years. That said I want you to know that this is the first time a doctor has called me at home to keep me informed, for that you get a gold star. Thank you very much. I think it is you who better get home and get some rest.”

I didn’t quite know what to say. I was flattered, but I was also a bit embarrassed that this was the first time he could ever remember a doctor calling him at home. I thanked him and apologized that my call was the first. I quietly hoped it would not be the last.

It made me reflect on how our profession has progressed over the decades from doctors making house calls to doctors barely interacting with the patient. It made me realize how important and powerful the doctor patient relationship can be and even how important and powerful the doctor-family relationship can be. It is a flame that I will do my very best to keep lit.

I got to place my first endotracheal last week. I totally forgot to post this exciting news. I was stoked! It is very interesting shoving a steel blade into someones mouth while they are not breathing and lifting in such a way to visualize the vocal cords and slipping a tube past them. The whole time you are kinda holding your breath too, because you know your patient isn't breathing and the closer you get to needing to take a breath the closer they get. Anyway, I was sweating it.

The process goes something like this: We give the patient something early on prior to coming into the OR to calm the nerves. Once inside there is flurry of prepwork that requires the patient moving onto the surgical table and getting strapped down. Once there they get an oxygen mask and the drugs are placed into the ready position (often Propofol and Succinylcholine). As these drugs are pushed in we monitor the eye lid reflex. When the patients eyes close we brush the eyelashes, if there is no reflex we give another breath, tape the eyes shut (keeps them from drying out and protects the cornea from a drape brushing them etc.). take the mask off, grab the blade in our left hand, scissor the jaw open with our right, slide the tongue blade into the mouth on the right and sweep to the midline, pull up slightly, hook the epiglottis and pull straight up taking care to not lever the blade and risk breaking teeth. Sometimes the right hand is, at this point, used to push down on the forehead to get a better angle and pull up again until you can see the vocal chords. Once these are visualized (it looks like a V in the throat) the right hand grabs the tube and carefully slides it in past the chords. A bulb is inflated to secure the airway and to minimize and leaking around the tube. The tube is attached to the breathing machine and silk tape is used to secure the tube externally. A piece of cotton is rolled up and placed between the teeth and we finish by checking for breath sounds and monitoring Oxygen saturation.

I didn't get the first patient I tried (not to worry, the anesthesiologist got it quick), but on the second patient I got it. I wanted to jump up and down I was so excited, but I kept my cool and simply told everyone I wanted to jump up and down. Somehow it was enough.

My patients are a good mix of high maintenance Histrionic types that play up the sick role for more attention and seriously sick folks that act like they are doing fine. My current favorite is Mr. W, he is in for an empyema of the lung (basically a big abscess). He recently had chemotherapy for his cancer so his immune system is trashed. We are trying hard to get him cleared up and back on track. One day this week he says to me "it doesn't matter how you start, what matters is how you finish." This was his response after I mentioned that I got a late start on my education.

Mr. W is the kind of patient that I could just sit and hang out and play cards with and listen to. Never bitches or complains just says, "You know you docs should really get outta here and get some rest." He is also a big college basketball fan and coaches a junior college team. He happens to know many of the great college hoops coaches. He told us a story today about how, when he was a kid growing up (In Indiana home of the Hoosiers I believe) he couldn't wait until he wore a size 7 shoe, because that meant he could get Converse All-Stars. Well one day in the gym he was lacing up a new pair and a grey haired gentleman came in and said "Son, if you don't mind I can show you how to lace those up so they are nice and tight." Well he obliged but didn't give it a second thought. Later he noticed that the same fellow was hanging around watching the practice, so he asked one of the coaches who the guy was. Of course you can guess the punch line "Oh, well, that's Chuck Converse."

I started to realize that people actually read this blog when people started to comment that I had not written in a while. In case you didn't already know I am on my first surgery rotation. The hours are long, but the time goes by quickly for me. I am in Sierra Vista, AZ (look it up on a map) it is SE of Tucson next to Ft. Huachuca Army Intellingence Base.

The doc is a military surgeon and splits his time between the hospital on post (base) and the community hospital. Between the two my day starts at 0530 and ends sometime around 2000 with some study time thrown in for good measure. We round on our patients in the community hospital first and last and in between we do surgery, see new referals and follow up on old ones. It is an enjoyable but long day.

Ever wonder why surgeons make lots of money? Because they work A LOT. I am pretty sure that if Family Docs put in the kind of hours surgeons do they too would be pulling down +250K

Anyway, I will try to post more often.

Today a fellow of 68 came in presenting with a cough that had persisited for a month and then some. He was troubled by the fact that he was no longer getting much sleep at night since it was alway worse when he would lie down. His SaO2 was 91% at rest and after two laps around the office it dropped to 88%. We gave him a breathing treatment to open him up a little and get his O2 saturation up and loosen some of his constricted airways. His cough was dry, but with the treatment he began to spit up some crud. I observed the first of this and was alarmed when I saw that it was very pink. Hemoptysis has a differential that includes among other potentially life threatening problems Pulmonary Embolism.

Well after discussing it with my preceptor we went back in and Dr. F began discussing the list of contenders for diagnosis. When he commented to Mr. W about his concern with the sputum Mr. W retorted, "blood, naw I just had a red Gatorade."

I think I would categorize this profession, especially for us students, as humbling right to the core. The lesson here? Never assume anything and always ask... even when you think you know the answer.

One of my friends, now a doctor, once said, "being a doctor is not who I am it is what I do, it is my job."  I thought about this comment for a nanosecond and retorted "Bullshit!" Now, before I explain why please understand I know what she was getting at, she doesn't want to be looked up to or treated differently simply because she is a physician. This I understand perfectly well. Our culture holds most physicians in very high regard simply based on their education. Sometimes this respect has simply not been earned, and I believe she was cautioning against this sort of cart blanche granted to physicians.

I, however, find that many of the doctors I encounter hide behind this excuse. For those that entered this profession with great idealism and hopes of saving the world my argument is this, anyone dedicated enough to spend a life helping others is changed by this process. You come in a medical student, but you leave a physician and it is who you are. For example, my neighbor stopped in a week ago. She had know idea I was a medical student, but she needed help. She was having a case of shingles but didn't know what was going on. All she knew for sure was that her neck hurt, she was dizzy and feverish and felt completely out of sorts. Up to this point she had only hid behind her blinds and yelled at us for temporarily parking our car outside the garage (ours not hers). Now she presented in need of help and it was my door she came to.

 Now I am as busy as the next guy with studying, work, domestic chores etc, but I dropped this and took her to the local urgent care so she could get the medications etc that I could not provide her. I would like to think that anyone of her neighbors would have done the same, but I saw it as my duty. I mean we could have simply called her a cab, but it seemed like a much better opportunity to get to know the individual from behind the curtain. I tell this story only as an anecdotal account of what I think it means to be a physician. Compassion does not stop when you leave the hospital and it most certainly does not stop when your neighbor, who has always been rude, needs help. Compassion is something that is a part of us as physicians, and if it is not it should be.

As for my friend who says it is just her job. She is simply trying to understate what she does to take our profession off the pedestal that so many want to place it on. If you talk to her you understand right away that she is passionate about what she does and absolutely loves her "job". As much as she and others like her want us to believe that being a physician is what they do and not who they are, I don't think anyone can go through this experience and not have it permeate your soul.

There is nothing quite like the feeling of being under the microscope. In medicine this is practically a way of life. For instance, today I got to do an SPE or Standardized Patient Exam. This is basically a role playing exercise that is monitored by actual doctors from behind a two way mirror. The set up is like this, we have one minute to review the chart in a folder on the door. After the first minute a tone sounds and a voice echoes "Student doctor, you are now allowed to enter the room and begin your patient exam. Once inside we have 15 minutes to do a focused history and physical. At the 13 minute mark the voice returns telling us all that we have two minutes, two minutes later it tells us to stop and begin the written SOAP note (read: Subjective, Objective, Assessement, Plan). We have 10 minutes for this task and at the end the doctor standing behind the glass the whole time comes into the room and tells us not only how we did but also what we did well and what we did poorly.

So for the first 15 minutes you sweat and alternate between thinking about this "patient's" problem, and which questions to ask, and how much time you have left, and what you are forgetting. The second ten minutes is spent writing was quickly as possible to get all the info down, only to find out that you have run out of room and are totally F'd because if your note runs out of the margins they won't grade it (Incidentally, this is one of the reasons doctors have such shitty handwriting. Seriously, try writing down a whole H&P in less than ten minutes and have it look legible... not an easy task). Finally, when you are discussing the whole thing with your proctor you realize that you forgot to put down two of the tests that you did during the exam that would have ruled out the thing your proctor is now telling you you should have done.

What I think is most amusing is how different styles play into to how we are graded. For instance if a doctor tends to approach their patients with chit-chat before the exam then they tell you, "You should try to open the conversation with something not medically related to relax the patient." Uh, okay, nice shoes. Or they will say, "You should never turn your back on the patient." Which is fine, but most will agree that you should wash your hands in front of the patient so they can see that you are being clean. The problem arises when the sink is on a wall and the patient is on the exam table, no matter what wall it is on you have to turn your back to the patient.

And so it goes with the hoops and such. We show up in our pressed white coats and ties, shake hands and generally smile to all that came before us knowing that someday we too can call our buddies and say "Doctor." All the sarcasm aside, the real microscope is going to come from within when our patients are in the hospital depending on us to ask the right questions and order the right tests. I just hope this training is enough.

I worked the Basha High School Football game last night, as the team doctor. This went off without incident until late in the second quarter when Mr. S got hit high and hard. The trainer helped him to the sidelines and promptly sat him down. Mr. S was exhibiting classic signs of a Grade 1 concussion (dizziness, ringing in ears, confused facial expression, headache, and some slowed thought processing) After about 5 minutes of monitoring by the trainer I asked Mr. S if his left arm always shook. He said "No, I don't know why its shaking." Next question, "Do you have any pain anywhere? Reply "Yes, in my neck, I can't move my head it hurts too much."

At this point I needed to check my own blood pressure but moved around behind him and began palpating his C-spine. What started as a mild concussion was rapidly turning into a major trauma as Mr. S reported exquisite midline neck pain from the base of the skull to the top of his thoracic spine. Quickly I moved to assess sensory and motor function of the extremities, which were good, but complicated by the new finding of tingling in his left arm.

Of course the pucker factor is now at maximum strength as I am trying to figure out what to do next. Obviously Mr. S needs an xray, but how alarmed should I be, I mean the kid walked off the field? I jog over to the firemen standing at the end of the field and ask if any are paramedics, which I think they confused with EMT, but no matter, I got one of them to come over and look at the kid and concur that he needs to be moved to a more secure setting like, oh Maricopa county's level 1 trauma center.

Within the next 15 minutes he is on a back board and being moved to an adjacent parking lot, placed on a helicopter and flown to Maricopa Co. I barely have time to talk to the now worried sick parents and tried my best to reassure them that this was predominantly a precautionary measure. The unfortunate reality was that their son was leaving on a helicopter, not in their car, and would not be celebrating the win with his friends tonight. Instead he would be spending the night having men and women hover over him assessing whether or not he is safe to send home or needs more attention.

I cannot begin to imagine how most parents must feel when all this happens so so quickly. It just leaves me feeling kinda sick knowing that they are so worried and there is just nothing that we can do until the "test" results get back. I guess this is part of the profession that requires the most compassion and empathy in relating to our fellow humans.

I checked in by phone today. The family was still at the hospital awaiting results from the MRI. Their son was doing fine and was ready to go home by midnight last night, but the hospital was not yet convinced. While I as happy that he was safe I couldn't help but feel guilty that I didn't actually go to the hospital to check up on them in person. I guess I am beginning to understand what it really means to be a doctor.

I have heard it said that being a doctor is not who we are but what we do, I would disagree. Anytime a person invests the kind of time into learning something to the level that a physician does, that thing becomes part of the person. Being a compassionate, empathetic health care provider does not end when the game is over or the shift is done. It is something that you go to sleep with and wake up with each day. I like to believe that it is the skin that surrounds us and the light that guides us.

So this one isn't quite a notable clinic inspired story, but it does have potential. I was reading a post on another blog and there was reference to eating food items that are past expiration dates or perhaps a little moldy (cheese for instance). This brought to mind an issue that is ongoing between my girlfriend and me regarding the fate of leftovers and expiration dates. She happens to be an orthodox follower of the expiration date. It doesn't matter if the milk doesn't smell bad... the expiration date says its bad. If the left overs have been in there for more than three days forget it.

I, on the other hand, happen to be more pragmatic about such things. If it passes the sniff test taste it, if it doesn't taste bad it isn't, middle finger to the expiration date. Its a calculated risk. I took microbiology so I understand that preformed toxins don't necessarily smell, yada-yada, and there are lots of bugs out there ready to do me in. I am not, however, going to let that risk come between me and chicken cordon bleu that has been in the fridge for five days (okay unlikely that it would not be eaten the next day).

This brings me to another point, reheating. If the said food stuff can be reheated in the microwave, so much the better. To my way of thinking, the microwave is going to kill off a good portion of those pesky bacteria anyway. (note that the views stated here are soley that of the author, and as such the author takes no responsibility whatsoever for your food illness. Further more it is his express recommendation that the reader follow the guidelines established by the FDA on food storage and consumption.) I would also note that if you happen to be in the Geology Dept. at WWU, please leave leftovers in the fridge and let Hiram decide if they are good or not.

Alright, so as a health care provider I am obligated to inform patients about the risks associated with smoking and tobacco. I am a non-smoker so one would think that the idea and sales pitch would be easy. However, I find myself torn between upholding an individuals rights and freedoms and attempting to influence behaviors that are not considered healthy. Everything in moderation is a nice idealistic mantra, but unfortunately once we get started down a certain path it is not always easy to maintain that moderation. To this end I encourage cutting back more often than quiting. I try to add good behaviors rather than simply attempt to subtract bad ones. Curious to know if the world-at-large has any thoughts on this subject? Should I be more forceful in my approach or stick with moderation?

This afternoon we had several patients come in that left me thinking, I love my job. Most were either retired or closing in on retirement and all were characters. The problems were minor, so there seemed a light air about the interactions and lots of laughing and joking. It was a genuinely good time and I think everyone walked away feeling better for it.

I suppose a part of it gets back to a piece of advice Dr. Williams gave me back at WWU. He said, "As long as you are willling to make an ass out of yourself, your students will love you." Having spent time in the classroom, I learned quickly that he was right, but it definately goes beyond the classroom. What all these patients had in common was the ability to find humor in their condition and in their idiosyncrasies, in short they have the ability to laugh at themselves with abandon. I find this to be most refreshing since I embrace a certain amount of light-hearted self deprecation. I am learning a lot from my patients and most of it has nothing at all to do with their illnesses.

I think it may have been Confucious who said, "The man who loves his job will never have to work."

"In terms of general education, poetry and philosophy are of vastly more importance than science." -Conant It has been said that the study of the Humanities is a means to knowing human-kind better. Since we are in the business of humans we would do well to heed this advice and focus on knowing our patients, not just our patients diseases.

We had a 71 year old patient come in today that was having some complications with her diabetes and congestive heart failure. She was a good natured gal, but was tired and annoyed that she had to sleep with 3 pillows under her head and back just so she could breath. The fluid had begun to collect in her lungs again and was keeping her both upright and up much of the night. Well, after some discussion about treatments and changes in her drug "cocktail" we walked with Ms. D down the hall to the x-ray room. On our short walk Dr. F said to her "Perhaps what you need is a young man to take care of you."

"Good heavens," said Ms. D "if any man asks me if I want to go to bed, the first thing I'd do is ask if they were tired too!" Well, we all just roared laughing. Apparently her sense of humor was still solidly intact.

 

 If you have any good doctor-patient stories, please share them.

I am currently working in a General/Family practice clinic. We see on average about 30 patients a day with complaints ranging from Upper Respiratory Infections (URI) to Hypertension (high blood pressure) check ups. What I find most difficult is trying to balance a friendly interpersonal interaction within a time constraint that allows me to get the info I need for a diagnosis, which may include tests and a good history. Mostly I find patients need to talk, which I encourage, but this means I run late all day long. I am certain that with time I will become more efficient, my concern here is that I don't have to sacrifice quality for quantity.

 

Given that I have been healthy and not needed to see a doctor regularly, I would be greatful if anyone cares to share a good story about being in a doctors office, or if you work in health care a good patient interaction. Thanks