The Disagreeable Doctor

An Infectious Disease doctor and his musings about the world

[thedisagreeabledoctor]

Everything has changed. Every encounter is now eyed with skepticism as we mask and gown to enter a room. Patients look to me, terrified about why the infectious disease doctor is wearing full PPE. After all, they just came for a pneumonia, right?

It is hard for me to understand the full extent my life has changed. As an infectious disease fellow I am an essential employee - which means my work has not changed. I go and see patients and do the best I can for them. However, I now do this without vacations, with less oversight and with less support. Many of the attendings have been pulled to help on a system wide, and sometimes global, scale. What remains is the core of our clinical staff - fellow run teams and rotating faculty. Since all “unessential care” has been postponed we have overall fewer consults. But we also have fewer teams and the consults we are seeing on balance are sicker.

I have certainly seen my share of COVID patients. Unfortunately those are the easy consults - continue supportive care. Nothing more to do. I try to reassure them. To hold their hand when I can. But most interactions are happening through phones, windows, and, when in person, behind a thick veil of PPE. It is hard to be reassuring in those situations. I have exercised my skills in goals of care - helping families understand the quagmire that awaits intubating their 83 year old grandpa. We quickly sign off, knowing their patients will languish for 2-3 weeks before ultimately succumbing to their disease.

The rest of my patients are just as unfortunate. Young 20 somethings with surgical disasters. IV drug users with Staph bacteremias. Homeless HIV patients who can’t afford their meds. I worry even more about those who aren’t coming in. Who have mild symptoms but think they will tough it out until the stay at home order is over. The elderly who have no one checking in anymore. There will be a reckoning down the road - not just of those lost to COVID but of those lost to diseases that did not get care during the time of COVID.

This was already the hardest year of my life. No one anticipated we might add in a pandemic. But at the end of the day I don’t complain out loud. I am healthy. I am employed. And I have something to offer in a time where many feel helpless. Everything has changed. At the end of all this, that’s all I can wrap my head around.

[thedisagreeabledoctor]

Trying not to feel

I held it together until I got to my car. But away from other doctors and nurses and the harsh fluorescent lighting and aseptic corridors I cried. They were harsh, ugly tears. It was not because I had a bad day - I survived plenty of those. It was not for the rejection I continue to face each day or this year long consults rotation without weekends or holidays. What finally got me was a young lady who died before her time.

I met her a week earlier in the ICU, where she was admitted for fever, pancytopenia, acute renal injury and liver failure. Without disclosing too much history, I can say she was an immunosuppressed patient and I was called to evaluate her for atypical infections. Despite how sick she was in the chart, I found her in good spirits. Her mother stood as a sentinel at her bedside, swooping in to expand on symptoms when the patient tried to minimize.

“How long have you felt ill?” I inquired.

“The past few weeks...”

“Well for several months she has had mysterious symptoms,” her mother interjected.

The interview proceeded in this manner, the story unfolding as an amalgam from the patient and her mother. But as the puzzle came together I realized this was not an infection - her symptoms fit better with a rare autoimmune blood disorder. Despite this I continued to follow, interested in the case overall.

As I typically do, I tried to learn about who my patient was, the context of her beyond her illness. She had recently moved across the country to live with a family member, which seemed like a new start of sorts. She was an aspiring artist, currently working on commission. We bonded over video games and movies. She reminded me so much of my sister, another young woman trying to find her place in the world.

She declined quickly. I returned from a day off to find her encephalopathic and unresponsive. Her liver could not keep up and her kidneys failed to the point of requiring dialysis. Her porcelain skin had grown yellowed and jaundiced. Her breathing was agonal and labored. Despite broad antibiotics, steroids for her presumed autoimmune disorder and vasopressors, she teetered on the edge between life and death.

After a few days of this tension - the balancing act of machines and medications supporting her physiology - her family began to face harsh realities. Ultimately her family decided to withhold further aggressive care. She passed very quickly.

Each day I am confronted with death. I can typically handle this with mental acrobatics, compartmentalizing the bad and reiterating the good. A regular dose of alcohol also helps to sterilize the emotions. But this one hurt - perhaps because she was so young, perhaps because I saw so much of my sister in her, or perhaps because as medical providers we had so little to offer. Regardless of the reason, she remained constantly on my mind in the days to follow, like an anchor holding me to the emotions I try so hard to quell.

Following her death I cried alone in my car. In the days that followed I tried to talk to other fellows and to attendings, but everyone was too busy fighting their own mental battles, rushing each day in the hopes of making it home at a reasonable hour. With enough distance I was able to again compartmentalize, shoving the sadness deep down. Maybe with a little more time I will stop wondering about all the art she did not produce; all the video games she did not play. Maybe eventually I will be able to stop wondering who this woman would have been if she had found her way.

[thedisagreeabledoctor]

Miracle Hunter

For the last 2 hours I have poured over his 9 months worth of records, typing up his history, notating positive cultures, and reviewing the numerous admissions punctuating his life over the last year. He went from independent and working to barely able to stand. A year ago he was living independently - now he has moved back with his mother, relying on the 24/7 care she provides.  Each clinic visit he looks more defeated.

As much as we want to blame the HIV, that is no longer the issue. The virus, vanquished by his potent anti-retroviral therapies, has retreated and now lies dormant somewhere deep inside his body. But the damage has been done. His immune system has not rebounded and bacteria grow inside him unchecked.

Despite months of antibiotics, he only gets worse. I know because I have seen him through most of it. The worst of it. The last time we spoke did not end well. I struggled to look him in the eye while explaining we were out of treatment options. I choked on my words and the truth dawned on him. There may not be any more admissions. There may not be any more pills or IVs.  We were heading off the reservation - out of the realm of evidenced based care.

I retreated for a day. Dwelling on my inability to provide a solution - after all, infectious disease doctors are often the ones to put people on hospice. But tomorrow I will see him again, as he drags himself across town to our appointment. Our last conversation weighs heavy on my mind. 

We are back to the drawing board. I type this up, in between reading papers, trying to find a new battle plan. Hospice hangs in the air, just beyond our line of site. We both know we may be heading there, but as long as he is willing to keep showing up I am willing to keep spending my extra hours hunting for a medical miracle.      

[thedisagreeabledoctor]

The Ritual

The phone rings. And rings. And rings again. Then there is the familiar message: YOU HAVE REACHED A VOICEMAIL BOX THAT HAS NOT BEEN SET UP.

I hang up.

This has become a ritual. Every few days I scroll through my EMR message inbox, falling upon her most recent lab values. Her HIV viral load is in the thousands, her CD4 count below our threshold of detection. She reached out to me just a few weeks ago in crisis - a new rash of perfectly intact vesicles had marched across her skin along her left bra line. She had called the after hours line, begging for relief from the burning pain.

I met her a day later in clinic to confirm the diagnosis. As the exam unfolded I gently prodded her about her missed appointments. I inquired about the prescriptions that went unfilled. I implored her to let us help.

She did her best to explain to me the pain that came with seeking healthcare. She had grown up in an unstable home, making attempts at her life while barely into puberty. Next had come the meds. So many meds. She despised the pills, the establishment, the white coats. Despite attempts to eliminate her past, each medical visit required her to cart in her many suitcases full of emotional baggage. 

We talked for an hour. I felt like I was scaling the walls she had built, slowly getting through to the person on the other side. I wrote her a script and made a follow up for a week later. She thanked me, promising me she would come back to get back on her antiretroviral meds.

She never showed. My nurses called and called, attempting to connect her back into care. We tried family and friends. But she was gone, back out into the world until the next time she suffered so badly that she could not stay away.

She is now part of the ritual. My rotating list of phone numbers that I try time and time again. Every few days I call, hoping today might be the day she has a voicemail box. Today might be the day she picks up.

[thedisagreeabledoctor]

My Medical Existential Crisis

Who am I? Who do I want to be? These are questions I have spent a lot of time contemplating lately. In many ways these should be easy questions and yet they are some that I have struggled with a lot. My crisis isn’t the typical existential crisis of young adulthood but rather - where and what do I want to do with my life as a doctor?

I chose internal medicine as a residency because it had a wide breadth and offered the opportunity for subspecialty. For most of medical school I was convinced I would be an infectious disease specialist. Those dreams still exist, but as the applications for fellowship grow nearer I am finding myself torn. I honestly love all medicine in a way that is hard to explain well.

For example, when I rotated on neurology I wondered if I had not made a mistake in picking medicine. I loved it! And the attendings could tell. Many asked if I wanted to switch into neurology. But when I thought about it, there was no way I would want to do that. I would miss the rest of medicine - every other organ system.

That is how it has been for every specialty. Each rotation I dive in head first and come out wondering if I should chose this one thing as my career path. Yet, just days into the next rotation, I find the feelings evaporate and give way to a new adoration for what ever I am doing in the moment.

To my friends this is a silly problem to have. I could likely do any specialty. My board scores are strong, as is my CV. But I am frozen by the choice, terrified of choosing the wrong thing.

My current list of candidate careers is short. I could continue being an internist, working both in and out of the hospital. I would be a master of many things but an expert in nothing. The rewards would be strong patient relationships and lots of hard work that is generally not recognized or rewarded. I could enter palliative care and/or geriatrics. This would allow me to help people when they are perhaps the most weak and vulnerable, in a state where they may have been written off by other providers. Unfortunately, many of these patients will not be diagnostically interesting. Finally, I could continue on the path I set on - infectious disease with the possibility of adding critical care. This is a specialty filled with some of the brightest people, many of whom value knowledge and diagnostic challenges more that money. Infectious diseases is one of the only fellowships you go into to make less money. 

I believe that each of the above professions is noble, in that few people are lining up to do them. Despite the coaxing of many mentors, I do not see myself as pursuing any of the more lucrative or coveted specialties (*cough* GI and Cards *cough*). As money is not much of a motivator, I am left to choose between the merits of each field and the type of life I want to lead. I continue to debate many things, such as whether I want to be primarily inpatient or outpatient, whether I want to be a consultant or a primary care giver, etc.

Ultimately there is probably no right or wrong answer. Yet my anxiety has me retracing each pro and cons list. A major factor in this decision is also my partner, who is vying for her own fellowship. My choice also has to weigh in whether or not it will allow us to be together (i.e. I would have to match or take a job where she does). I recall each step of my journey feeling like this (which med school, which residency, etc.). Yet the process never feels any easier.

So I will go back to my original questions to ultimately decide. Who am I? Who do I want to be?

[thedisagreeabledoctor]

It’s not your ulcer

“I am not a diabetic. Look, this morning my blood sugar was 193 and I hadn’t even eaten anything. That’s not diabetes.”

“Ma’am, that 100% is diabetes.” This conversation quickly became a stalemate between ignorance and my inability to explain her diagnosis in a way she would accept. In fact, every conversation I had with her went this way. She was perhaps the most obstinate and oblivious patient I had ever met. And she was my patient. 

She had come in with the worst foot ulcer I have ever seen. It tracked all the way down to the bone, meaning an amputation was likely in her future. According to her, the ulcer had started a couple days before and she had never had an ulcer before in her life. I used my years of medical training to quickly deduce that a) there was no way that ulcer happened in a few days and b) she most definitely had two very bad looking ulcers on the other foot. When I pointed that out she became upset, telling me they were just split calluses, not ulceration. Every attempt to diagnose and explain the diagnosis was refuted by her “intimate knowledge of her own body.” 

The next several days were some of my most frustrating. I was called to her room for numerous reasons, including refusing insulin (because she wasn’t diabetic), refusing dressing changes (because she was allergic to the dressing), complaining that the hospital food was inedible and rotted, and yelling at nurses about their inadequate care. Each time I walked to the room and took my verbal lashings. I listened. I empathized. I did everything I could to put myself in her place and see the fear she likely felt about losing her foot. 

None of that was enough.

I am not sure if I have ever truly hated a patient. But with her, I came close. Despite my ill-feelings I spent hours coordinating her care between multiple surgical specialties, all of which wanted to pass on taking a non-compliant diabetic, vasculopath to the OR. Podiatry, vascular, and orthopedics all subtly yelled, “not it.” 

Several days into her hospital stay I expressed my frustration to my attending. “They are not your ulcers,” he replied. I looked back, confused, as he continued. “They are not your ulcers. If you care for every patient’s problem as if it were your own, it will destroy you. She got herself into this and she has to bear some responsibility for getting herself out. If she refuses to take our recommendations as to her care, there is nothing we can do. There are times you have to step back and separate yourself from the patient.”  

I have thought about his words a lot since then. In some ways if feels antithetical to my nature to see medicine as a job. But I have also experienced the severe mental fatigue and frustration that comes with trying to help a patient unwilling to help themselves. At the end of the day, how far should we go? How much time should I spend on one uncooperative patient knowing it takes time away from other patients who also need my services? In the end I did step back from the case and allow myself to see my care for her as something closer to a job. I switched off service a few days later and the last I knew she was getting an amputation, though she spent time fighting with surgeons about where they could cut.     

At some point we have to protect ourselves as physicians, despite how mentally strong we believe ourselves to be. This year has taught me a lot of medicine, but it has also challenged me mentally. I am still searching for the coping skills necessary to survive life as a resident and eventually as an independent doctor. Despite the frustration this patient provided, she did allow me some excellent learning in this area. In the end, I have to appreciate her for that.  

[thedisagreeabledoctor]

She

Our relationship is one built on ironies. The first of which was my intentions. I let it be known, early on, that I had no plans for a relationship. This was to be, I tried to stress, a series of casual hook ups. She would arrive late to my apartment, after hours of studying, and we would Netflix and chill long before I knew there was such a thing as “Netflix and chill.” We shared in our med school misery, enjoyed each other’s company, and the relationship flourished. Four years have passed now and casual is not how I would describe our relationship. 

I was the first to say “I love you.” I was the first to offer to live together. I was the first to bring up marriage. On at least two of those topics I was initially rebuffed and her plans for “career first,” the mantra of many women in a male dominated field, guided our path. The idea of a man wanting marriage while a woman did not was hard to explain to my small town, catholic parents. Living together before marriage was hard for her to explain to her conservative, immigrant parents. Somehow, we both survived the experience.

The last year for us has been a struggle as we redefine our relationship in the face of real responsibility and 80-hour work weeks. We spend our days in different hospitals, frequently on different shifts. It is ironic that, despite both being doctors, our jobs do not overlap in the slightest, as she takes care of children and I spend my day with adults. Much of our conversation now occurs in the short window periods where we both occupy the same space - usually while simultaneously finishing notes or reading about a case for the next day.  

Perhaps the greatest irony is that she some how believes that I am the better half. I am a flawed man in so many ways. I am moody, narcissistic, and a work-a-holic. I definitely do not deliver well on all the things she deserves. Meanwhile, she is brilliant, caring, and spends a fair amount of her time ensuring my needs are addressed. Her resolve and dedication to being a good doctor are inspiring. She forces me to be better in ways she does not understand. 

She is not a princess and our relationship is far from a fairy tale. But she is an incredible woman who impresses me daily. This year has been full of difficulties and I often forget to count my many blessings. She is a blessing. She is my love. She is my future. And I could not be more thankful for that. 

[thedisagreeabledoctor]

That Fleeting Feeling

My intern year has progressed in distinct phases. For the first three months I lived in a state of perpetual fear. Each time a nurse would call about something, like Tylenol, I would rewind in my head every possible contraindication. Did I know this patient’s liver enzymes? How much had they already had today? Could they have an unknown allergy? I would freeze up with the constant worry I might unintentionally injure someone.

This uncertainty trickled into everything I did. My admit notes were many paragraphs long, just in case the fact that a patient had a rabbit as a pet in first grade might be useful to the diagnosis of their community acquired pneumonia (#alwaysruleouttularemia?). My exams were extensive and thorough, but I worried about documenting findings or exam signs others had not. I would look at consultant notes and worry that perhaps the boiler plate “regular rate and rhythm without murmurs, rubs, or gallops” meant that the murmur I heard wasn’t actually there.  

Slowly I learned that patients were much more resilient than I had been led to believe by standardized tests. In the coming months I gained some confidence in making decisions, making my own diagnostic judgements, and note writing. My admissions got smoother as I figured out what to ask and how to document it. My orders became less complex as I figured out to properly do a med reconciliation. I began to see complex patients as an entire entity rather than the sum of each problem on the problem list. Perhaps most important for my patients, I began to gain a better understanding of pain medications and my fear of them began to abate.

As we passed the new year, I began to feel like a well-oiled machine. I could knock out admit notes and progress notes without issue. I called all my own consults. I began to have enough procedures logged to be signed off. I was beginning to peak as an intern. Wards became something that was fun instead of frightening. I had time to read about my patients and do some teaching for the medical students. As the weather warmed for spring we began to get off work earlier and earlier.

Then April hit and attendings began to make seemingly innocuous comments like, “I think you are ready to be a senior,” or “you are really operating at a senior level.” Slowly the terror drifted back.

Holy shit, I have to be a senior resident soon.

In just two months I will be responsible for twice as many patients. I will have 24-hour call. I will have two clueless and terrified interns who can’t even prescribe acetaminophen. I will have to stay late for them to finish their 4 page long admit notes. And I will have to answer for their mistakes.

I feel like another intern year might be beneficial. I was just getting the hang of being an intern and I want to hold on a little longer to this feeling of competence.

It is interesting how medical training always works like that. Just as you get comfortable in one setting you are whisked away into another and put back into a situation where you are uncomfortable. Whether there is much intention in that, I am not sure. But that is what seemingly makes medicine such a difficult profession. There really is no such thing as mastery. You just progress up the chain and hope that each year you get better.

An attending recently told me that there will never be a time you can rest and stop studying. If you are practicing right, you will always face new challenges that force you out of your comfort zone.

Dang. I really like this fleeting feeling of competence.  

[thedisagreeabledoctor]

My new lab

The pipette feels comfortable in my hand. There is something familiar about it, despite not using one in half a decade. Even though the lab techniques are slowly re-emerging in my mind, getting dusted off after years of not using them, I feel like an outcast still.  I am, after all, an interloper. A transient that some might regard as a burden rather than a help. And yet, if that is their belief, they have not shown it. In fact the lab has welcomed me with open arms. 

I am currently on break from clinical duties. I am using this time (which is meant for vacation) for research. I was accepted into a virology and bacterial pathogen lab working on a very specific virus that has captured public interest in recent years (in an effort to preserve anonymity I will refrain from details that might make it easier to identify me). Because I am interested in infectious diseases as a possible specialty, I wanted to find an opportunity to do some bench research in the field.  

Though I worked in a research lab in undergrad, this experience seems quite different. The level of science being performed is higher and the expectation of me is also increased - I am, after all, a doctor. The sarcasm of the last statement is likely lost in typed form. Essentially there is a dramatic difference between what I do on a daily basis and what many of my lab compatriots expect of me. They ask in depth questions on cell pathways, which they spend most of their waking hours studying. Meanwhile much of my intern year experience has been spent on documentation.  Much of the things they speak about were lost from my mind after my USMLE Step 1, or perhaps never learned at all. 

Regardless, I am having a blast in this lab. It is interesting to see my own evolution as well. I find myself having much more confidence than I used to. I am willing to dive into the literature in a way I would not have prior to medical school. If nothing else, the process of becoming a doctor has made me into a learning machine, ready to read and absorb information in a way I could not during my undergrad years. And yet I am still not on par with these PhD candidates, whose lives are filled with lab work, figures, and paper writing.

It is a bit hard to swallow my pride and start fresh in a field I am very weak in, especially after spending the last 4.5 years attempting to gain competence in an entirely different field. At times my PI and lab mates talk down to me, unintentionally, explaining concepts I have a firm grasp on. Other times they gloss over things they expect me to know - things I actually have no idea about. In the end I am learning, and re-learning, a great deal. Ultimately I am excited for this new endeavor. I just hope to keep up some lab work when my clinical responsibilities resume.      

[scrubsgif]

[thedisagreeabledoctor]

A medical student was giving me a lot of praise the other day. He asked me how I was able to be such a good intern who always knows my patients (and my co-intern’s), brings up new literature, and takes time to teach the med students. This instantly came to mind. I told him it was hard work, which is true. In truth it’s just being willing to be the first one in everyday, the last one to leave, and lie on your time card so you don’t get in trouble for violating duty hours. True medicine is not glamorous and being a good doctor rarely gets you praise. You have to do it for reasons other than that. At the end of the day most people won’t know if you cut corners. But you will know. And you have to decide what you are willing to live with. 

[thedisagreeabledoctor]

Palliative Care Discussions

Mr. Thompson sat in the bed looking fatigued. His yellow skin belied his claims at improving health. A drain snaked out from under his hospital gown to a container full of green-black bile. I was admitting Mr. Thompson, who presented to the hospital for inability to tolerate oral intake for the past 2 weeks. Two months earlier he had presented to his primary care doctor with the strange complaint of yellowed skin. Just a few days later abdominal imaging revealed the mass that was obstructing his bile duct. Shortly thereafter he met a surgeon who explained he was a poor candidate for surgery given his weight, his history of heart failure, and his chronic obstructive pulmonary disease. But, he was told, if his co-morbidities could be better controlled he might be a candidate down the road. In the meantime, they placed a percutaneous cholecystostomy tube to drain the bilirubin that was accumulating in his blood.

For most people, a pancreatic head mass is a death sentence. But Mr. Thompson was holding on to this glimmer of hope that was offered by his surgeon. Now, two months later, he was wasting away, in pain, with the expectation that he might still become a surgical candidate. I gently broached the subject of his prognosis, gauging what he understood. He planned to start exercising to get rid of the excess weight and improve his cardiovascular health. When I asked about his functionality at home he admitted that he had recently been confined to using a walker due to his health. He was convinced that if he got over this hump he might be able to exercise once again.

He actually was losing weight, but not in the right way. With his diagnosis, and resultant failing liver, came anorexia. Despite his obesity, his labs suggested he was malnourished in regards to his protein status. Inadequate protein and malnutrition is also a strike against surgery as wound healing would be poor. As we talked it became clear no one had really explained his prognosis, or at least not in a way he understood.  

So I told him.

In the simplest language, I explained my fears for him – that he would spend the rest of his life planning on a surgery that likely would not happen. That he would miss opportunities with his family or not take advantage of what could be the last months of his life. Certainly I did not wish this for him and I truly hoped he would get the surgery he needed. But, as I explained to him, my motto as a physician was to prepare for the worst and hope for the best. We talked about alternatives to his current care and the role palliative care could place in his life. Until this admission, no one had brought this up to him.  

At the end of our conversation he was visibly defeated. He cried and vented about the hand he had been dealt. I silently listened, offering what I could in support. He thanked me for my honesty and asked to speak with the palliative care doctors. I told him I wanted the surgeons to remain involved as well, and he agreed.

For the rest of the day I worried that perhaps I had overstepped my bounds. I had, after all, only just met him. And I was not an oncologist or a surgeon – perhaps he really did have a fighting chance. But how many people had I treated who received palliative care and hospice too late in their disease? Or worse, how many did I admit that died and never received it at all? Self-doubt plagued me the rest of the day as the argument raged on in my head.  

That night, an hour after my shift ended, I got a page asking me to call Mr. Thompson’s wife regarding our talk that day. I worried she would be upset that I had destroyed his hope and I braced for a hostile interaction as I dialed her number. She answered in a calm voice and asked me to explain what I had told her husband that afternoon. I went through our conversation, allowing space for questions. She patiently listened and waited for me to finish. “Thank you,” she said, finally. “I have watched him go downhill since the diagnosis and I guessed that his prognosis was poor – but no one would tell us. I am so glad someone was finally completely honest.”

Breaking bad news is devastating. There are numerous times I have left a room on the verge of tears or driven home crying. In at least one circumstance I have cried in front of a patient. Too often I hear other physicians dance around the topic of prognosis – which is difficult. No one wants to pin themselves to an outcome or a number. But an educated guess is better than no information at all, which is why we tune into the weather forecast every day. That is exactly how I explain it to patients, trying to predict future health is like predicting the weather. Sometimes I will be right and sometimes I will be completely wrong, but I will never intentionally mislead someone to spare their feelings, or my own. All I can do is offer the information I have and my best interpretation of it.  

When I last checked in on Mr. Thompson, just two months after our discussion, he was still alive but doing poorly. He was readmitted to the hospital and was found to not be a surgical candidate. Palliative care was following him and helping to improve the time he had left. Unfortunately, sometimes when you predict rain, it really does rain.    

[thedisagreeabledoctor]

The Heroism of Incremental Care

We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.

[thedisagreeabledoctor]

When Evidence Says No, But Doctors Say Yes

Years after research contradicts common practices, patients continue to demand them and doctors continue to deliver. The result is an epidemic of unnecessary and unhelpful treatment.

[thedisagreeabledoctor]

Before you know kindness as the deepest thing inside, you must know sorrow as the other deepest thing. When most people consider the grief endured by physicians in training, they look first to the devastating narratives of patient care—sudden illness, agonizing decline, putrid...

A beautiful essay on the sacrifices made during residency and the realization that it is ok to grieve over those losses.

[thedisagreeabledoctor]

My Last USMLE

I am a few days away from boards (Step 3) and I have hit phase 3, the I don’t care any more phase.  Here is a rehashing of every board exam I ever took... in Gifs.

Phase 1: Procrastination

Phase 2: Trying to study

Phase 3: I no longer care

[thedisagreeabledoctor]

“Do you even understand medicine?”  The words landed like a punch in the stomach.  It was 3:30 AM and I had taken my 4th admit while also managing a patient with SVT and one who was rapidly decompensating.  My senior was visibly stressed and I was the target that happened to be standing in front of her.

We had disagreed on the plan of care for one patient.  And then I had wanted to increase a patient’s pain meds, but apparently my proposal would have been too much.  It was clear that with all that was going on she needed the help of a fully functional resident, not just me, the lowly intern.

Welcome to night float.

They say that night float is where you “earn your stripes.”  In essence, few good things happen at night and the bad things happen quickly.  It is your job to answer pages, triaging what is important and what can wait until the day, and take admits from outside hospitals and the ER.  It is a time where you learn a lot about medicine and yourself as a physician.

I felt tired and worthless.  With each mistake I made my self-esteem spiraled and I became more distracted, making more mistakes.  I started to put orders in on the wrong patient.  I added admit orders that were already done.  I lost a note that I didn’t save.  The night was cascading into an internal chaos, where self-doubt and fatigue brought me to a point of being unable to make decisions.  But I pushed through, despite being reamed by my senior resident.  And somehow I survived.

I went home as the sun rose.  I felt defeated, on the verge of tears.  Was I cut out to be a doctor?  Did I make a bad choice in doing medicine?  Is everyone going to know me as the weak intern?  I slept that day and returned as the sun was setting, the questions still percolating internally.

But that night was better.  As was the night after.  My senior resident apologized.  Life went on and my reviews on the next rotations were extremely positive.  

Being a doctor is not anything like what I expected.  There are so many things they cannot teach you in medical school, the least of which is that you are fallible.  You are going to make mistakes and people are going to be upset about that.  To my knowledge I have never made a mistake that made it to the patient, but one day I know that will happen.  But if you let those small mistakes affect you it will quickly spiral out of control, which is what happened to me.  

Sir William Osler, possibly the most notable figure in American Medicine, spoke about the idea of living in “day-tight compartments.”  He advised to avoid reflecting too greatly on the past and to keep your mind from wandering to the future.  Always keep your focus on the task at hand.  His words echoed in my mind as I attempted to put that night out my thoughts.  We all have bad days, and we must move forward without allowing those days to weigh heavy on our thoughts. 

A fellow that I knew as a medical student ran into me the other day and asked how I was doing as an intern.  I explained that some days were tough and that I sometimes doubted if I was cut out for this.  “The long white coat is a lot heavier than it looks,” he responded.  In so many ways that is true.  But by living in my day-tight compartments I am not going to make it heavier than it needs to be. 

[thedisagreeabledoctor]

How To Be A Good Med Student In The Clinical Years

A doctor once told me that the best instrument we have is medicine is the retrospectoscope.  Basically he was saying that often it is easier to make sense of things when looking back from the vantage point of the future.  This is true of life too.  After being an intern for two months I suddenly understand what things make for a strong med students, and what things do not.  Unfortunately, I feel like I lacked many of the qualities that would have made me a helpful med student.  Though I cannot rectify my own mistakes, perhaps I can pass my advice on to future generations of third and fourth year medical students.  I now present, how to be a good clinical med student:

Show up.  This seems obvious.  When you are there to work, then be there to work.  It is so frustrating when medical students are mysteriously absent all the time (only to be found later in the cafe or cafeteria) or when they are there but totally disinterested in what is going on.  I understand that sometimes as a medical student things get slow - like when the interns are putting in orders and notes or when there is a slow call day.  But at least bring something to read.  Don’t play Pokemon Go.  Don’t spend all day on Uworld.  Make an effort to learn real clinical medicine.

Take initiative to learn.  When I was a third year I would wander the hospital to find learning opportunities.  I made friends with the telemetry nurses and they started a folder of good tele strips to give me each day.  I would go to other teams and see if their patients had good exam findings.  I found the cardiology fellows and asked if they had good patients with murmurs.  There is so much learning that can happen if you are willing to experience it.  Now, referring back to number 1, make sure you always let your residents know where you are.  Personally, I would be ecstatic if my students went to hunt down murmurs rather than playing Pokemon Go. 

Read your patient’s chart.  This can be very helpful and will make you look like a star.  Residents are busy taking admissions and sometimes don’t have the time to hunt down records that are three and four years old.  You can stand out by doing that  Look at a patient’s past hospital notes or their specialty clinic notes.  For example, you might be able to alert the resident that an old echocardiogram demonstrated a below normal ejection fraction, which in turn might change how much fluid the patient is given.  Or perhaps you found that during a hospitalization in the past the patient became delirious and needed a one-to-one sitter.  Find ways to add information in a helpful, non-prescriptive, non-judgmental way.  I guarantee your reviews will benefit.

Read about your patient’s condition.  Even if you just browse Medscape, UpToDate, or some other curated source, make sure you understand the basics of your patient’s primary diagnosis.  If they are there for heart failure, read over the basics of treatment.  If they have autoimmune hepatitis look up some info on diagnosis and prognosis.  These things will get noticed, especially when you ask intelligent questions on rounds.  Do not be like a med student I had who, when asked, reported for 4 straight days that he had not read about his patient’s disease.  He instead responded he was too busy with Uworld so he would get a good shelf score.

See your patients.  I literally had students who, on rounds, tried to present without actually having seen the patient in the morning.  This is a huge no-no.  Get to work early enough to see your patients, review their labs, and their overnight events.  

Practice your presentations.  Even if it is on your own or with other medical students, spend time working on your presentation skills.  Heck, even ask the residents to watch you.  I would be happy to do that for any of my students.  Unfortunately, none have taken me up on that offer and instead bumble through their presentation each day making the same mistakes.  By the end of medical school you need to be able to make a good presentation. 

Spend time working on note writing.  Compare your notes to your residents’, your attendings’, and the specialists’.  Everyone has a different style.  Look at lots of notes to determine a style for yourself.  

Forget all the step 1 stuff you learned.  I find many students perseverate on the terrible stereotypes and patterns they see on step 1.  Not all black people with cough have sarcoidosis.  Not every patient with acute kidney injury needs urine eosinophils.  These are good associations, but realize that step 1 has little overlap with real clinical medicine.  Take those associations with a grain of salt. 

Don’t just look for zebras.  I cannot tell you how many times students opt not to follow a patient because the case “doesn’t seem that interesting.”  The majority of medicine is made up of mundane and common diseases such as heart failure, pneumonia, COPD, cirrhosis, etc.  It is pretty rare to get the exciting cases, like disseminated histoplasmosis or a crazy paraneoplastic syndrome.  A lot of learning can happen on cases that are “bread and butter” medicine.  Make sure you follow those cases too. 

Be gentle to your interns/residents.  The transition from 4th year to being a doctor is swift and brutal.  It is easy to criticize when you aren’t the one taking 5 admits.  Find ways to help your intern/resident, because in return they will help you.  I learned this lesson the hard way my 4th year, when I unintentionally threw an intern under the bus while trying to look smart.  Afterwards she took me aside and reminded me that she controlled much of my fate while I was a student under her.  I learned my lesson and we went on to become very good friends.

The clinical years of medical school are daunting.  You constantly feel like a tap dancing monkey, trying to impress people you barely have time to get to know.  But personally, I am not looking for someone who knows everything about everything.  That’s why you are in school.  The best thing you can get out of third and fourth year is how to do a good history and physical, how to write good notes, and how to triage patients.  The best students are interested, willing to learn, and know their patients well.  If you keep that in mind, the clinical years are much simpler.  I promise, if you follow your patients you will learn much more than just doing qbank questions.   

Best of luck on your clinical rotations.  Don’t make things too complicated.  At the end of the day have fun, treat your patients right, and keep an open mind.  The learning will happen whether you recognize it or not.