please D.O. the needful

med school applicant first second third fourth year osteopathic medical student first year internal medicine resident first-year second year third year fourth year med/peds resident. IM residency faculty/casual pediatrician hobby weightlifter. puppy manager, animal enthusiast. an insatiable appetite for being treated like a human being. inbox open for questions. (links below to streamline posts)

[thescaryjokes]

woah dude you hit your head pretty hard. 2025? president donald trump? "labubu"? haha no clue what youre talking about dude its roughly 1pm august 8th 2004 and we're about to take a chicago boat tour and i heard dave matthews band is in town and

[pleasedotheneedful]

I wrote a long, thoughtful message to a patient's PCP about how her pain was all from osteoarthritis and thus not really appropriate for us to fill her opioid (as a palliative care department, since OA isn't really a palliative diagnosis). But I acknowledged that despite an opioid not being the medication of choice for her arthritis, she'd been stable/retaining functional status on the same limited dose of opioid for years and wasn't interested in seeing pain management because two practices wanted her to undergo procedures when she's not interested in having any additional procedures (and with the widespread nature of her OA, unlikely to be of significant benefit).

I then made a pitch that we could continue to see this patient and offer guidance on opioid management/discuss her goals of care if the PCP was willing to write at her current dose. I mentioned that we do this a lot for Complex Care patients (because we do), so as not to give the impression that I'm passing the buck.

Their response was that they don't manage chronic pain, and if I felt she needed chronic opioids, then I should help her out by referring her to pain management.

Now, it's perfectly reasonable for the PCP to have a boundary and say no. If she'd said "I'm sorry, I don't write chronic opioids in my practice" I'd be much more understanding than "well why don't you help her by giving her a pain management referral" when I already addressed that.

Don't be willfully obtuse when I'm trying to help.

In an effort to be somewhat professional, I said "cool beans" and let my attending know. I feel bad for the patient.

[swinging-stars-from-satellites]

this is, as the kids say, frying me (a glasses wearer)

[aquaiznet]

[pleasedotheneedful]

The things that make this job challenging still sneak up on me.

We had to declare a little old lady unsafe to be discharged home, not only for her safety but for others in the neighborhood (she still drives and scored a 1/7 on her clock drawing test, can't manage her own finances or medications).

Well, some things she told me were true and some were confabulations. Her dog is very real, and I saw that case management had to coordinate with the local humane society to get the dog. Dog's fine and I know this was the right thing to do, but I'm hoping this doesn't end with the patient being separated from her companion for a long time.

[pleasedotheneedful]

food items half eaten and returned to the cabinet: a photographic catalog of weird behavior in the physicians' lounge

[wayfaringmd]

Any tips for a narcoleptic person trying to figure out how to get into premed/medical school?

I’ve spent 8 years getting mentally well and reducing symptoms but I can’t help but still feel a bit out of my depth.

Medicine is a field that proudly declares how little sleep everyone functions on. I sleep 10 hours a night. That has me down to no cataplexy on a daily basis but if I stop getting 10hrs I become more “traditional” in narcoleptic presentation. It’s hard to not feel like I’ll be drowned by other premeds if they ever would find out.

It’s hard to envision surviving the rigorous standards with 10 hours of sleep plus an hour minimum of morning inertia. Of course I’m trying to reduce symptoms further but I don’t know if there are doctors who’ve survived schooling while managing narcolepsy. I don’t know if it’s really possible outside of the hypothetical “anyone can do anything they put their mind to” rah rah positivity.

I’ve never heard of anyone like me actually *doing* it.

I don’t know of any docs or students with narcolepsy, though I had a friend who dealt with it in undergrad. It would be exceedingly difficult to maintain a 10 hour sleep routine in residency and in 3rd and 4th year of med school. I think it could be done in the first 2 years if you’re a very disciplined studier. On certain rotations in residency (depending on your specialty), you will only have the ACGME-required 8 hours off between shifts. I imagine the same goes for some rotations while still in med school, though you may be able to get accommodations in school for it. My best advice would be if you’re really serious about going to med school, look hard into the “lifestyle” specialties like derm, radiology, anesthesia, and others with nicer schedules like psych and ophtho. Those would be the places where you might could make that schedule work. But even in Family Medicine it wouldn’t be do-able.

[pleasedotheneedful]

My wife has narcolepsy without cataplexy, though wasn't diagnosed until she was already in medical school. She was an extremely adept student in general so having these random naps wasn't impacting her scores. Her diagnosis came around the time she started her more intense rotations, by which time she was on modafinil.

As an attending, she targets her modafinil to work days as she builds a tolerance rather quickly with regular use. I'm not exactly sure how this would have gone if she stuck with gen surgery rather than choosing EM.

[pleasedotheneedful]

this hospital is on fire

in the past two work weeks:

the private practice docs suddenly announced they have no coverage for no-doc admissions (patients who come in without a PCP in our system, we normally split them 1:1)

they were able to arrange a fill-in doc at the last minute for a few shifts, but it turns out he's not credentialed and can't actually have patients under him. so several patients went to the floor but had no doc to sign off on admission orders.

we no longer have EP coverage on weekends

a resident in the ED straight up lied to me about an admission. someone with a perforated appy was coming in, I asked if surgery was going to be primary. they went on this whole spiel about how the surgeon is new and still learning the system, so I said okay, I'll help them out. then I get a call from the surgeon's nurse practitioner asking who's admitting the patient, because now my name is on the chart but the surgeon called asking her to admit the patient to him. I call the resident back and they're like "yeah I never actually had that conversation." why lie? just call the surgeon to confirm the dispo. it's an appendectomy, they should have first dibs on admission. I'm here to help but don't take advantage of me/try to slip shit past me or I'll fucking destroy you.

speaking of, orthopedics tried to admit someone to me in the middle of the night that broke their femur after a fall. slated for OR tomorrow. otherwise doing fine, some stable chronic illnesses of aging. I told the ED I'd call ortho directly, and when I asked why they wanted the patient under medicine they was a long pause followed by "well, they have a midshaft femoral fracture, usually there's more going on there..." ok? [no further explanation, because there isn't any CME on traumatic midshaft fractures benefiting from medicine admission] so you'll admit the patient? med house will admit patients for the surgical services, I'm happy to let them know for you. we're open for consult if you have any acute medicine needs. "yeah, I guess--" great, thanks

in two days, we discovered THREE of my patients had improper med recs entered from the pharmacy interns/techs resulting in two near misses and a prolonged LOS.

in one case, the patient alerted us prior to administration.

in the second, the patient missed a few days of a medication but thankfully never got the one that was entered instead because the inpatient pharmacy doesn't carry it (lamivudine instead of lamotrigine)

in the third, the patient had their home meds restarted after their hypotension improved, became hypertensive, and then within a day became VERY orthostatic (albeit asymptomatic). they aren't a great historian but cardiology would discover this dude doesn't actually take any of his home meds, so we're the ones who dumped his systolic pressure. this guy was in discharge status and slated to leave tomorrow.

in all three cases, the med recs indicated that the patients had taken all of the listed meds within 1-2 days of admission when we would discover that, no, they definitely did not.

I'm absolutely not perfect but can we not all phone it in at the same god damn time?

[pleasedotheneedful]

waiting awkwardly at bedside during a very long rapid response for afib/RVR

nursing: here, try blowing into this straw

resident: I don't think it's gonna do anything, he's in afib--

me: sshhhhh it gives the patient something to focus on

...

resident: ohh, I guess that's one of those attending insights huh?

[pleasedotheneedful]

Medicine will sign off. Thank you for the interesting consult.

- a consult that was absolutely not interesting

closing statement on a 60-something who fell over and broke his hip when the wind blew his bicycle over. takes no meds, has virtually no chronic medical conditions. dude is healthier than the patients half his age in the hospital. he was "optimized for surgery" when he got up in the morning.

[pleasedotheneedful]

oh and I should mention they originally tried to get the ED to admit directly to me. when I asked ortho why, there was a long pause and said to go ahead and admit to them, and the attending admitted their clinic was running 90 mins behind so was unable to dig into the chart 👀

cmon guys his blood pressure wasn't even abnormal

[pleasedotheneedful]

Medicine will sign off. Thank you for the interesting consult.

- a consult that was absolutely not interesting

closing statement on a 60-something who fell over and broke his hip when the wind blew his bicycle over. takes no meds, has virtually no chronic medical conditions. dude is healthier than the patients half his age in the hospital. he was "optimized for surgery" when he got up in the morning.

[pleasedotheneedful]

[pleasedotheneedful]

I got an email in the middle of this night shift giving me a "reminder" that I need to distribute patients equitably between myself and the teaching service.

I was livid. Not because I'm never wrong, but because I specifically go out of my way to give the night residents options. I'm only 1.5 years out, I still intend to practice like a residents' attending. When I get a bulk of admits I let them pick patients, I'm transparent about when I need their help, and I offer to help them with any issues they have. I ask them at the start of the week how they like to have their shift loaded--some prefer to have the admissions front-loaded, others prefer a steady trickle.

There have been several nights where they get a few more admissions, usually because I'm tied up with a sick patient (like last night) and because the census is skewed such that the nonteaching service has too many patients. At the end of the shift, the night residents and the teaching service are all still under cap.

It's a no-win position. If I go easier on the teaching service, the nonteaching side will blow up and then they'll get all pissed off that I'm not balancing the census.

So all that being said, I told them exactly what I've been doing at work this week. Because did anyone ask? No. They just told me to let them know if I wanted "specific guidance."

Here's some specific guidance, how about you get your asses over here and pick up nonteaching/night shifts with the rest of us? Then I'll care what you think.

I think I might ask for my hours to be cut so I can explore other jobs. This double standard is straight trash. Are all academic places like this?

[pleasedotheneedful]

this is hospital medicine, I'm here to remind everyone to be judicious about how you use your patient's allergy list.

if I go to review the chart and there's an anaphylactic reaction listed to sulfa antibiotics, but a month after that was entered I see the patient received bactrim without issue I will have questions

or if I see a dozen allergies listed with "unknown" reactions and "unknown" severity, with some of those medications having been given without issue *during this very admission* I will be reaching out to you

please document purposefully ty

[pleasedotheneedful]

ED intern: hi, I'm admitting this patient with a GI bleed. they just had colon surgery last week at main campus. there's two units of blood hanging and I think they're stable enough to be out of the ICU me: have you talked to surgery? ED intern: oh. uh. I did not me: would you mind doing that? there's a high chance this is a surgical complication, I would at least talk to our surgeon on call or just bypass him entirely and call downtown.

I checked back in the chart a few hours later, this mf is accepted by his surgical team at main campus. the fuck was I going to offer this patient by accepting him? a continuous chocolate fountain of blood?

this is an intern so there was no reason to take it out on him, but this is emblematic of how little oversight they get. it seems to be specific to our ED. the admission requests frequently come through with no work-up, improper dispo, neglectful management, and a story that leaves me wondering if they even saw the patient. and often when we push back, we're told "well it's not gonna change management"

except it often does if you put any thought into what's happening to the patient. neglecting to evaluate for a head bleed and sticking them on med-surg is begging for an ass whooping after the patient decompensates. the hospital is not just some nebulous get-well zone, it matters not only that they leave your department but that they have access to the correct amount of nursing care.

[iknowthisisnowhere]

PGY2 sucks and I hate everything and I hate this program and I wanna go home

[beingdreeyore]

I definitely remember that feeling.

[pleasedotheneedful]

This still reflects my take away from my PGY4 year

[pleasedotheneedful]

me, watching the teaching service struggle to obtain coverage as I quietly reclaim career fulfillment outside of my employer

there's a double standard I'm noticing here that made me realize chasing this carrot at this hospital is sucking way too much joy from the other aspects of my life and negatively affecting my performance.

look, all I'm saying is I think you'll regret not investing in a deep QB room.

see: NFL teams in Ohio

[pleasedotheneedful]

also very belated shout out to the hospitalist that told my friend they follow my tumblr