Irrelevant Process

This is why I don't like religion and everyday business mixing

2012-01-19T18:17:00.001-06:00

Jessica Ahlquist is a teenager who fought against blatant display of religion in her public school. She won, with the court finding those displays unconstitutional (it's sad that you even have to take someone to court about something as clear cut as that). Now, her community is treating her like a second class citizen. Freedom From Religion Foundation wanted to send her flowers and not one of the four florists in Cranston, RI wanted to deliver to her. Somehow your religious views make it ok for you to not do your job (and discriminate against others). These 4 florists have been added to the list: Twins Florist, Floral Express, Flowers by Santilli and Greenwood Flower.

Asshole doctors: Less common, but still around

2011-11-08T18:21:00.006-06:00

I am on a surgery rotation now and one attending I work with is a complete asshole. Now, surgeons are suppose to have a reputation of being assholes, but after a rather benign surgery experience in medical school (the worst I got was just not being acknowledged), I thought it was a thing of the past. For the most part, it is. However, there are still some physicians around who still perfectly fit the arrogant asshole stereotype.

Despite having gone through medical school, I do not know the intricacies of the types of prostheses or the indications for these types of prostheses. When an attending hears that I am not familiar with those types of equipment, they could respond in one of four ways: 1) Teach me the differences, 2) Direct me to someone who could teach me, 3) just tell me what to order, or 4) Sigh, yell at me for not understanding him, ask where I went to med school and why they didn't teach me that particular fact. Guess which one I got today.

At some point in the past, that type of response was the norm. I suppose it was somewhat of an effective way of teaching. It scarred residents enough to force them to remember it. Today, though, with the hospital working more like a system of individuals, each with their own expertise and responsibilities, rather than a boss that (thinks he) knows everything and his underlings. Today, people don't take to kindly to being treated like an underling. The nurses, physician assistants and administrative people who work with this physician just plain don't work as hard or as effectively because this guy is an asshole to everyone. To me, it doesn't really matter. I ignored most of what he said because I'll be leaving this hospital and won't be seeing him ever again. If I were to see him again though (perhaps as a radiologist), I'm not sure I'd go out of my way to make his life any easier (I just might do the opposite, as long as it doesn't harm patient care). If you're arrogant or an asshole in a hospital, it doesn't matter how experienced, educated or well-qualified you are, your co-workers that you depend on will make your life much, much harder.

Open discrimination

2011-10-11T08:44:00.004-05:00

Another one to add to the list. This hotel freely discriminates against those that don't believe the owner's religious beliefs. Richard Dawkins' reservation was canceled once the owner him on The O'Reilly Factor. Actually, if I include all companies that have owners that watch The O'Reilly Factor, it would probably be a perfectly accurate list of religion-laced businesses that I would want to keep my money away from.

General medicine is generally frustrating

2011-10-07T09:04:00.003-05:00

Not because the medical decision making is difficult or the patients are a mystery. It's more that I spend most of the day doing work that really shouldn't be part of my job description. A typical medical admission is like this:

1. The ER or outside hospital has already diagnosed the patient, my job is to put in the basic orders to get them admitted and write a summary of what brought them in. Then, whether they came in with a diagnosis or not, consult a specialist and wait for their recommendations.

2. Fix their electrolytes, heart rate and maybe start them on some broad antibiotics while waiting for the specialist to see them.

3. Specialist sees them, gives recommendations, and I put in the recommendations into the computer system.

4. Wait for the patient to get better or wait for the specialist to tell me they can be discharged.

5. Figure out where they're being discharged to. Call medical offices to make them appointments. Call nursing homes, long-term care facilities to see if they'll take them.

6. Summarize everything that happened to the patient during their hospitalization.

Every once in a while, I feel somewhat like a doctor when I am answering patient's questions.

All important things, but, as you could see, there is very little actual medical decision making. It's very rare that I am reading up on various medical conditions and thinking about what tests to perform to figure out what's wrong with my patient.

Oh well. Glad I won't be doing that for the rest of my life.

You are what you eat

2011-09-09T17:32:00.005-05:00

Blood just drawn from a patient with pretty extreme hypertriglyceridemia with triglycerides of near 10,000. There's more fat than blood in this patient's veins.

Update on sign out

2011-08-18T09:44:00.003-05:00

OK, now that I've got some more experience on my belt. I gotta say that sign outs really aren't that bad. First, every morning the entire team rounds on every patient on the service, so even though I'm not managing every patient, the fact that I may be responsible for the patient at some other time gives me incentive to pay close attention. The fact that I have that incentive to pay attention has the added benefit of learning about a patients condition without doing all the busy work. The second reason why sign outs aren't that bad is that we're all getting better at effectively presenting patients to each other and writing effective notes. This is a skill that takes some time, but each week it gets better and better. So, now I'm willing to say that shorter hours and more sign outs (in the long run) is better for patients and residents than an overtired resident managing patients. Numerous studies have shown that sleep deprivation severely affects cognitive performance. So, I'd rather have fresh residents who need to spend some time getting to know patients versus an overtired, cognitively impaired one that knows their patient really well.

Signing Out

2011-08-16T12:31:00.001-05:00

With the new work-hour rules for medical interns, the ICU is no longer a place where every 4 days an intern spends 30+ hours in the hospital. I'm glad for the rules. 12-18 hour days are bad enough. However, what it leads to is a lot of passing patients from one resident to another, which, in turn, leads to a general lack of ownership of a patient. It used to be that you admitted your patient to the ICU and for the next 20-30 hours, stabilized them and figured out what was wrong with them. You knew their history inside-out and knew how to manage them and what to look out for. Now, you may admit a patient, but 6 hours later, you've signed the patient out to the next intern. The sign-out is a five minute conversation relating the patients history, status and what to anticipate. The receiving intern know very little about the details of the patient and has to essentially start over. This leads to lots of information falling through the cracks. I recently got handed a patient that had been in the ICU for several days. He was stable enough to be transferred, which meant, I write out the discharge paperwork. Since I didn't know the patient, all of it is based on previous notes. I have to trust that those notes are completely accurate and thorough enough or something important about the patient could be missed. Unfortunately, many notes are neither completely accurate nor completely thorough.

It's a choice between having overtired residents who are prone to make mistakes or this. I'm not sure which is better.

The ICU

2011-08-09T20:03:00.003-05:00

So, I finally get a day off from the ICU today. It's not bad, but there have been a few situations where I felt like I was biting more than I could chew. This is the place where the sickest patients go. It's pretty scary to be playing doctor with people who are just barely hanging on to life. Just a few hours ago, a patient of mine passed away. He crashed in front of my eyes and I can't help but look back at every order I made (or didn't make) to see if it could have been prevented. What's worse is that I can find things that really could have caused him to crash. I suppose this is the reason why the learning curve is so steep. If you don't pick it up quick, lives will be lost.

The fact that I, as someone who hasn't had any meaningful responsibility in a hospital, suddenly am seen by others (patients, nurses, family members) as an expert whose every wish will be carried out (if it's correctly entered in the computer) is terrifying. What's worse is that there never has to be a backup. Yes, there are other interns, residents and attendings, but there is a lot of on-the-spot decision-making that falls on me. Most of it is harmless, but there are times (especially at night) that it can irreversibly affect a patient's health. There are many orders I've put in that I am not confident of (or as a fellow intern said about an order a nurse suggested to her, "I don't know what it was, but I ordered it"). Things go very quickly, there's high patient turnover, and people die (signing your first death certificate is a pretty strange feeling).

I've only worked in the ICU for 7 days, but it's felt like a month. It's an experience where you learn a lot, but it wears you down. I'm glad I'm getting the experience, but I know it's not for me.

Lost in the ICU

2011-08-07T22:07:00.001-05:00

Talk about getting slammed! Working in the ICU doesn't leave much time for anything else. I should have known that when a fellow intern said that I should take care of all my bills before starting the rotation. I will try to have an update sometime soon.

Frustrating Patients

2011-07-22T19:30:00.010-05:00

My attending and I have a pretty good relationship. Good enough that we can have a back and forth about politics (typically a no-no in the world of medical education and "professionalism"). He tends to point out my leftist tendencies and I point out his right-winged nuttiness. After 3 weeks of working in his clinic, which serves a rather impoverished part of the state, I can see his point of view.

Nearly half his patients have their healthcare covered by the state. This is great, but it seems like those same patients tend to do the worst at taking care of themselves. I don't mean eating right and exercising. I could understand if they didn't have the resources to do that. I mean they ignore doctor recommendations, then get an exacerbation of their disease, get admitted and have a hospital work-up that costs tens of thousands of dollars, get better, then go back and ignore every recommendation made to them. It's frustrating for a physician when a patient who is unemployed (and has no trouble with transport or any responsibilities at home) misses important appointments repeatedly or a patient who has all their medications paid for not taking them. Yes, some patients with good insurance also fall into this pattern, but from my admittedly short experience so far, it's a nearly universal pattern with those that are under the public health plan (and my attending agrees). One assumption I could make is that they have trouble following recommendations because they have a lot of other problems in their lives, but it's hard to tell if that's the case.

No, fear not dear readers (both of you), I'm not becoming a Republican (though my attending keeps on telling me that it's a matter of time). Rather, I think that there needs to be a shift in healthcare resources. Covering expensive medications and procedures is great, but I'd rather give those up for increased education of patients and more access to social workers. Preventative care looks great on paper, but in the real world, it only goes as far as patients know to take it.

Refill on the Vics

2011-07-15T09:14:00.004-05:00

So two weeks into a non-academic community setting, I've learned what the real world is like. I'm not so surprised by fact that there are a lot of patients who are addicted to narcotics. I'm more surprised by how there are so many doctors that are feeding their addiction. It's so easy for a patient to find a doctor that will prescribe them some heavy-duty narcotics without too many questions that things that I learned in med school like counseling, pain contracts and limiting refills just plain doesn't work. If legitimate doctors to try to manage their patients' chronic pain without overly relying on narcotics they risk losing the patient and likely the patient's other chronic medical conditions won't be taken care of. Or, they can just write the refill to bring them back and make sure that they have their diabetes, high cholesterol, heart disease, asthma, etc. under control. It's a hard decision to make, but many of the patients in this area just won't see a doctor unless they need their pain meds refilled.

Slow Start

2011-07-03T12:58:00.004-05:00

So, I'm officially a doctor. July 1st was supposed to be a mind-numbing experience where I get thrown into the medical system, overwhelmed with things to do and actually get to feel like I'm making a difference in people's lives. Unfortunately, I feel like I've gone back a few years. I start with a primary care rotation. Primary care is not my thing, but I can appreciate the value of health maintenance and getting to know patients and I was looking forward to actually acting like a primary care doctor. To my surprise, I find out that all I do is shadow a physician while he sees his patients. It's worse than 3rd year. At least then I got to see patients beforehand. The clinic I'm at doesn't have electronic records, so I can't even read about the patients. I go in not knowing what's going on and about 30 seconds later come out not knowing what happened. The physician knows his patients and doesn't really need to go into the details that I would have needed in order to diagnose and treat (actually, I'm a little wary of how quickly he goes through patients). It's a complete waste of time. All I can say is that at least I get paid for it.

Last day of vacation

2011-06-21T12:46:00.004-05:00

After nearly 3 months off, I'll finally be getting back to the medicine mindset with the start of intern year tomorrow (actually, it's just orientation tomorrow, the real intern year won't start for another week or so). I'm a little worried (ok, terrified might be a more accurate description). I've been calming myself down with the thought that lots of people have been through the same thing and have done fine, but with a 3-month break, I'm sure I'll be a little rusty. I suppose I took a 4-year break from medicine during graduate school and did ok when I got back into things, but med school is not the same as being an actual doctor who's orders actually get carried out. I was thinking of spending some time studying medicine, but there's little motivation to pick up a book and I figure that anything I could have learned on my own during the break would be minimal compared to the vast amount of information I'm about to get forced down my throat.

My mindset right now consists of many conflicts: I'm looking forward to actually starting work (I'm getting tired of being home all day), but at the same time, I know I won't have much of a chance for a break for a long time. I'm excited to see patients, apply my knowledge, try to help people and maybe have some fun along the way, but I'm also terrified I might make a mistake and hurt someone. I'm looking forward to meeting new people, but I'm afraid that they actually might know medicine. I'm terrified that I won't be able to handle the workload, but I'm calm because life at the community-hospital based intern year that I'll be going through won't be anything close to that of the academic-hospital based interns that I got to vicariously live through during my recent sub-I. I'm hoping for starting with something light so that I can get my bearings before getting slammed, but at the same time, I want to get the tough months over with before I get burnt out.

I figure it's no use worrying too much about it. It's not like I can change anything.

Setting up shop in a parking lot

2011-06-17T12:33:00.006-05:00

So, after a crazy month, I officially have my MD and have moved to where I will spend my intern year. I'm excited (and scared) for it to start. Orientation is next week, I'm sure you'll hear about it.

In the meanwhile, Mrs. mxh has started her job as a pharmacist. She works one day a week at a pharmacy in a sketchy part of town and it turns out that the doctors there are more sketchy than the patients. There are a few doctors in that part of town that are notorious for prescribing large amount of narcotics, a lot of the times without even seeing the patients. The only thing that comes out of their primary care clinics is narcotics prescriptions and their patients have a suspicious pattern of getting new prescriptions too soon. What really makes it bad, though, is that one of the doctors has a habit of just hanging out at the pharmacy and writing prescriptions for narcotics in the parking lot! Yikes! This isn't something new either, it's well known among pharmacists in the area. Why do these people still have jobs? Why isn't the state medical board stripping their licenses from them? Why aren't they arrested?

Part of the problem is that not too many people report them. But, I think, a major problem is that medical boards are notorious for not punishing their own. Medical schools emphasize fitting in and keeping the status quo. If you bring up a problem, it's better that it is discussed quietly. I think this attitude carries on to medical boards. If they punish a doctor, it'll make the news and that type of attention is something that medical boards don't like. If they ignore a problem, then everything will go an as it has. So far, it's been working, but some day, the narcotic ring that these two physicians are running will make front page news and the state medical board will wish that they have dealt with it sooner.

More bad journals

2011-05-16T22:56:00.006-05:00

Synthese - Apparently criticism of intelligent design is frowned upon.

Psychology Today - Racism dressed up as science in the form of an essay by a regular contributor to their website called "Why are black women rated less physically attractive than other women?" Yes, it was quickly removed, but the fact that it was written in the first place is disturbing. How can this guy have evidence that "black women are objectively less physically attractive than other women"? Has he seen Halle Berry?

Both are added to the list.

Torture still doesn't work

2011-05-03T12:27:00.005-05:00

I expected the right to give all the credit of Bin Laden's death to Bush (even though he said he doesn't care about finding Bin Laden), but I'm pretty upset that they would try to rewrite history by saying the information leading to it was because of "enhanced" interrogation techniques. Torture is inhuman and the fact that half the country supports it is the most worrying sign about our future. This analysis shows how Cheney and the rest of the criminals in the Bush administration are completely wrong about torture helping the US get Bin Laden.

If your doctor is praying to heal you...

2011-04-20T19:56:00.010-05:00

... you haven't got long to live (or you should find another doctor). Time to add to the list of science journals that have little regard for science. Here's a presidential address published in the American Journal of Surgery entitled "Can prayer help surgery." Unfortunately, the answer is "yes" (or more like, "No, but I'll say yes anyway"). Despite the fact that the author acknowledges that there is no scientific evidence that prayer works, he decides to add the old religious line of "What if those results are the will of God?" Really? Hell, I should have just responded to all the tough questions I got from reviewers by saying "It's the will of God. Who are you to question it?" This presidential address makes a mockery of science. The field of surgery is already decades behind the rest of medicine and Dr. Schroeder of St. John Hospital in Detroit (along with the American Journal of Surgery) just sent it back a couple of centuries. (uggh, I'll be working in a Catholic hospital next year, hopefully I don't run into these types)

Once again, I have to say that if any physician claims that their successfully treating a patient was God's doing, they should give up their salary.

Gotta bring back the Jesus surgeon picture. It makes me wonder why a surgery residency is 5 years. It must take that long to not get creeped out by Jesus giving you a shoulder message while helping you with surgery.

(PZ Myers has a better evisceration of the address and Orac discusses how ethically and scientifically inappropriate it is).

Stupider than I thought

2011-04-15T10:00:00.007-05:00

I already mentioned how Arizona sucks... but this new bill (that was just passed) that requires presidential hopefuls to "prove" their US Citizenship to get on the state ballot is incredibly stupid. Accepted forms of proof includes a "long-form" birth certificate (because Hawaii only releases the short-form to the millions of nuts that have been asking for it) or, get this, at least two other forms of accepted proof such as early baptismal certificate or circumcision certificate. Are you serious? Some shady religious nut can forge those in a second. I keep on thinking this country can't sink any lower, but I get proven wrong over and over again. Let's hope that the next piece of legislation doesn't do away with the whole birth certificate thing and instead require a baptismal certificate.

Translation: A black man with a funny-sounding name couldn't possibly be an American.

House of God

2011-04-09T22:33:00.010-05:00

With my time off, I recently started rereading Samuel Shem's House of God (must read for any medical type that hasn't read it yet). A novel about an intern learning the truth about how things work in the hospital. It has a lot of dark humor in it, but there's a lot that (even as a med student), I could tell is based on a grain of truth. For example, the type of patients you see at the hospital. You'd think that they'd be a cross-section of the population, but they aren't. I assume it's because those with repeat hospitalizations aren't exactly your average Joes. Upon meeting the patient who hides under the covers whenever his discharge is discussed or the patient that wants to keep his rectal tube in because he's too lazy to get out of bed to go to the bathroom, I was immediately reminded of the characters in the book. I wouldn't like to get to the point where I think about my patients as GOMERS or follow the Fat Man's Laws, but at least some of my experiences with medicine so far say that I may have to face days where it'll get close.

Here are the Fat Man's Laws (courtesy of Wikipedia):

GOMERS DON’T DIE.
GOMERS GO TO GROUND.
AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
THE PATIENT IS THE ONE WITH THE DISEASE.
PLACEMENT COMES FIRST.
THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM.
AGE + BUN = LASIX DOSE.
THEY CAN ALWAYS HURT YOU MORE.
THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

I would really like to think that #12 isn't true.

The Scramble

2011-03-30T21:43:00.004-05:00

So, luckily, on Monday, March 14th, I got a one-liner email (with the ridiculous subject of "Did I match?") that said "Congratulations! You have matched." But not everyone was as fortunate. The people who don't match, if they want to find a position for the next year, have to go through "the scramble", and it really is a scramble. I helped out someone with the scramble and thought I'd share (or more like remember it for myself by putting it here). Here's the timeline:

March 14th 6:30 PM - meeting with the dean of students. Very somber mood in the room. Some are near tears, others are angry, others are happy that they only have to worry about a prelim year and others (like me, who have matched and were there only to help) are trying not to look people in the eye. The dean goes through the process. Seems like a very involved procedure that depends on timing. Hard to know what'll happen at 10 AM the next day.

March 15th 9:30 AM - the dean hands out the list of residencies that had open spots after the match. The number of spots range from 1 in very competitive fields to hundreds for the preliminary surgery year. They're separated by specialty and by state. Everyone had 30 minutes to plan where they will call first. I helped my indicate which programs she is interested in on the centralized match website.

March 15th 10 AM - The scramble officially begins. We hit submit on the computer and simultaneously call places that aren't participating in the computer system. The computer system was very slow, so in about 5 minutes, gave up the computer and went to calling everyone. Calls went one of three ways: 1) Busy signal, 2) Answering machine or 3) actual person responds. If a person responds, we rattled off a prepared one-liner about who we are and what we want and asked what they need to consider us. The response was either to take our phone number and say they'll get back to us or (a few times) actually start a mini-interview.

March 15th 11:30is AM - All the states my colleague wanted to match to were contacted, one promising phone interview was done, but no response yet. We started calling the less desirable locations (while redialing places that hadn't gotten back to us - and accidentally calling some places that already took our name down).

March 15th 12:00 PM - Got a phone interview (5 min) at a decent program in a not-so-great location. They want information faxed... quickly faxed over something like 15 pages.

March 15th 12:45 PM - Decent program gives my colleague an offer! Quickly look over the curriculum and location (seems like a decent part of the not-so-great city and the curriculum is actually pretty nice).

March 15th 12:50 PM - Accept the offer.

March 15th 1:00 PM - Still calling places while waiting for the contract to get faxed over.

March 15th 1:30 PM - Contract is in, it's signed and faxed back. It's official!

March 17th 11:00 AM - Go through the match and pretend to be surprised when you open the envelope.

Whew! It's a rush, but it's a mess. Students at our school was lucky because the dean had paper printouts of the open spots. Apparently, the centralized computer program was down, so many students across the country did not have access to the list until hours later. Some in this situation just cold called every program. Eventually, people were able to get a list emailed to them from the matching program. By then many of the more desirable open spots were taken.
It's a terrible system, but luckily, from what I've heard, it'll be more civilized next year. I believe they'll have mini-matches where, in a calm manner, students can research and take their time applying to programs and, just like the normal match, rank the programs they're interested in and the programs do the same. Later in the day another "match algorithm" is run and students get matched. Any that are left over go through a second round of it.

Matched

2011-03-22T22:10:00.004-05:00

Match day came in went. Having it in the middle of the internal medicine sub-internship (where I get to pretend to be an intern) makes it hard to digest. I matched into a pretty decent prelim year. The only reason why it wasn't ranked first was because I didn't want to move twice. I matched into my first choice for radiology. Very excited to be stepping out into the real world.
On a side note, I got a chance to help out with "the scramble," where students who didn't match frantically call programs that didn't fill their spots in order to find a job. It's a bit chaotic and this year it was a disaster to many across the country. I'll go into it (and the sub-I) in future posts when I catch up on some sleep (5 hours in the last 65 is just not enough).

Another fake journal

2011-03-06T20:57:00.007-06:00

Journal of Cosmology. Another fake science journal to make the list. As the title of the article reviewing it says "Aliens riding meteorites." Need I say more? OK, I will. Here's a description of the field of cosmology according to the journal's website:

Cosmology is the study and understanding of existence in its totality, encompassing the infinite and eternal, and the origins and evolution of the cosmos, galaxies, stars, planets, earth, life, woman and man.

Hey, I study something that fits in there, so I'm a cosmologist! Clearly everyone would be interested in this journal.

Not so:

The interdisciplinary Journal of Cosmology is devoted to the study of "cosmology" and is dedicated to those men and women of rare genius and curiosity who wish to understand more and more about more and more: The study of existence in its totality.

Man, now I kind of feel bad about putting PLoS One on my list.

Glad we're vaccinated

2011-02-26T22:14:00.007-06:00

Passenger on flight from Baltimore to San Diego had infectious measles, officials warn

With all the recent flying, I'm glad my one-year-old is fully up to date with his vaccines. As the San Diego County health officer said, "Measles is so contagious that if one person has it, 90% of the people close to that person who are not immune will also become infected."

By the way, I had an interesting discussion with an autism expert recently and he concluded that with more and more evidence that signs of autism are detectable well before the age of one (and the likely development of techniques to detect autism in infants in the near future), the anti-vacciners will have to come up with another excuse for putting their kids at risk of getting terrible communicable diseases.

Computer overlords

2011-02-23T21:56:00.007-06:00

Oh, no. NPR, you did it again. I've said before that journalists make terrible science reporters, but this is just bad. A computer beat two Jeopardy champions pretty easily. It was an interesting game to watch and an amazing feat of technology, but Martin Ford, a computer programmer and writer decided that winning at a game show is enough evidence to show that computers can take over medicine, emphasizing on radiology. He said, "Radiologists basically focus on looking at visual images from medical devices — things like X-rays or CAT scans, that type of thing. Now, machines are getting much better at analyzing that type of visual information."

Arrgh! Radiology is not just looking at images. It isn't even just pattern recognition. It's putting together information from a vast number of sources (patient history, previous scans, pathology, physical properties of the imaging technique, variances in image acquisition, positioning of patient, etc.) To be an effective radiologist, you can't just look at every image with the same formula (if you can, who needs a radiologist?). That's a start, but personal experience at interpreting images and intuition about what the image and patient history points to adds a lot. It's that intuition that looks more closely at an image or orders a different view that makes the diagnosis.

I don't doubt that computers will eventually able to do this, but just because one won at Jeopardy, doesn't mean that it can start replacing radiologists. In reality, if computers get good enough to accurately interpret all types of images (at least with the same accuracy of radiologists), then they'll be good enough to take an effective history, perform a physical exam, order and interpret appropriate lab tests, perform procedures or even surgery and prescribe medications. The only medical specialty that would be safe is psychiatry (that is, until it starts using real science also). I don't see that happening in my lifetime, and if it does, we'll be living in a pretty different world.

Looking back at the match process

2011-02-04T18:48:00.013-06:00

It is not necessary to read this book.

OK, so we're finally getting towards the end of this crazy "match" process to get into a residency program. I think I've got my rank list down and I'll find out where I end up in March. Now that I've got about a month to wait, I could reflect back on the process. Here are some general thoughts:

1. Interviews
Interviews were a lot of fun and, at least in radiology, almost completely stress free. Those interview preparation questions that the school provided us with were pretty much useless. The conversation-like interviews I had with faculty really helped me get to know a program and helped me let them know the kind of person I am. The few "standard" interviews I had were very awkward for both parties and probably not very helpful for either (especially, the one where one faculty member was interviewing two applicants at once). Some quick points: At first I started reading about the faculty at the institution, but I gave up on it pretty quickly. I never had to bring it up and the casual conversations we were having were much better. Buying and carrying a leather portfolio was useless. I never had to pull out a CV or research paper. I lost it half-way through the interview process and never bothered getting another one. There will be "illegal" questions (especially, "where else are you applying?"). I also once got asked what religion I was ("none" was the response, in case you were wondering).

2. Traveling
Holy crap this is expensive. I went to 10 radiology interviews and 9 intern year interviews. Some I drove to, some I flew to. A few places provided a hotel room, most didn't. I kept track of the total cost and I just hit $3000. Add to that the application fees and it gets close to $4000. That's why most people take a loan. A couple of tips: Southwest is awesome (cheap, free bags, can cancel/change without a penalty; it doesn't get better). Renting a car is often cheaper than taking cabs everywhere and it gives you a chance to explore the town. Signing up for frequent flyer and hotel loyalty programs pays off, even if you end up not using the points. I got nice hotel upgrades and free perks (drinks, snacks, higher floor) just because I attached a number to my name. Trying to cluster all the interviews in one region together is nice, but will probably end up to be impossible. TSA sucks, though, I found out that if you freeze your liquids, you can take more than 3 ounces.

3. Research experience
With 10 years of research under my belt, I thought I'd get most questions about my work. Unfortunately, most radiology programs don't care about it (some even see it as a liability in residents). They just want you to check off that box. For example, a top-tier program that has amazing research claimed that all their residents complete a research project during their stay. When I asked how much research time they get, the answer was "7 days a year" (really? It takes me 7 days just to pick a background for my computer station). Something like 75 to 80% of radiology residents go into private practice, so it doesn't matter to them. However, it really hurts the field. With procedures and image interpretation being constantly taken away from radiologists by other fields (cardiologists read echos, vascular surgeons do interventional procedures, ER physicians perform and interpret their own ultrasounds), the future of radiology as a field depends on innovation. When research is shunned by training programs, the innovation will be taken by other departments also.

4. Intern year
So useless. From every radiologist I've heard that it has had no impact on their ability to be an effective radiologist. I applied to lots of intern year programs (some easy, some tough) so that I could live in the same city for both intern year and the radiology years, but it's unlikely that I'll be able to pull it off. That's OK, though. A brilliant comment I heard from a resident was "It's better to lose a weekend moving than to lose every weekend because you chose a tough intern year so that you could stay in the same city." I got some great intern year interviews, but if I could do it again, I wouldn't take location into consideration.

5. Rank lists
People really talk as if there's a strategy to it. There is none, just put the programs in order of your preference. It makes no difference if your number one is a long shot.

6. It's a big game.
By that, I mean that there are specific things that you should do to get an interview or to be considered for a position. These things have no relation to your strength as an applicant, but if you don't do it, your chances at matching may be hurt. For example, there are letters of interest, sending thank-you notes, sending "love letters". Towards the end of November or early December comes a point when you start getting worried about the number of interviews you've gotten and you haven't heard from some of your favorite places. At this point, sending a letter of interest can get you an interview. It really makes no sense (I mean, you applied there, so you're interested, right?), but it makes a big difference to some people. I've heard of a program where they won't interview anyone who doesn't send a letter of interest. I suppose it's to separate people who really want to go to the program from those that are applying to every program in the country (it happens), but if there's an unspoken rule that you must send a letter of interest (after actually applying) to be considered by a program, you might as well make it part of the application process. "Love letters" can go either way. Applicants can tell a program that they will be ranking that program first and programs can tell applicants they are raking them high. What either party says, however, from what I've heard, means absolutely nothing. Programs want to tell lots of applicants that they're ranking them high to get applicants to rank them high, so they can brag about getting their first choices. ... I could go on and on about this, but suffice it to say that the whole process leaves me with a bad taste in my mouth.

7. Med school
It falls to the background. There is no way I'd be able to go to all these interviews and still be on a clerkship. I'm glad I set up my schedule to maximize my time off during 4th year. Speaking of 4th year, the great thing about it is that pretty much everything is self-run. Your grade doesn't matter anymore, so it's all for fun and interest. The bad thing is that, unless you want to have a horrific 3rd year-like schedule, it consists of an awful lot of shadowing. It makes you burn out pretty quickly. Oh well, only a few more months.

Revolution fever

2011-01-30T07:12:00.003-06:00

A lot of people are excited about the overthrowing of dictators in the middle east. Tunisia did it and Egypt is in the process. Some (idiots) are crediting the U.S.'s policy of trying to "spread democracy" in the middle east (starting with Iraq). A called on NPR wanted to credit Bush for Tunisia's revolution, but luckily, the guest shot him down quickly. The guest said that it actually proves the opposite of what Bush was trying to do. You get effective regime change when you don't interfere (Tunisia) and you get failed regime change when an outside force is interfering (Iraq). Whatever the cause, these revolutions are exciting. Although, I fear that something very similar to Iran in the late 1970's will happen. A popular, largely secular uprising will pave the way for an Islamic Theocracy. Let's hope it doesn't.

Not another "miracle"!

2011-01-14T11:32:00.004-06:00

Crazy interview season has kept this blog quiet. Well, I'm done with radiology interviews and only one more intern year interview left. I'll have an update soon. I'm sure no one is left to read the blog, but whatever... I'll vent about the latest "miracle" I heard about. This is from NPR:

BRADY: At times during today's briefing, Drs. Rhee and Lemole were almost giddy. And in undoctor-like fashion, Lemole said Giffords' progress may be partially attributable to outside forces.

Dr. LEMOLE: Miracles happen every day. And in medicine, we like to very much attribute them to either what we do or others do around us. But a lot of medicine is outside of our control, and we're wise to acknowledge miracles.

Dr. Lemole, sir, you are an idiot. A lot of medicine may be outside our control (especially when it comes to recovery from brain injury), but there is no such thing as a miracle. Just because you don't know how something works, doesn't make it a miracle. This is an even less appropriate thing to say when you have no idea what her long-term condition will be. I move that any doctor who attributes the recovery of any of their patients to a "miracle" should not receive any monetary compensation for taking care of that patient. Clearly, they admitted that they didn't do anything.

It's bad enough that an imaginary deity gets all the credit when the hard work of a physician saves someone's life, but it really upsets me when physicians go around accepting that.

(A real miracle would be if the right wing nuts who have been spitting out violent rhetoric for the last few years actually admitted that what they say can affect what another nut does.)

TSA all over T&A

2010-11-24T19:21:00.005-06:00

With all the traveling for residency interviews, the ever-increasing invasion of privacy that is the TSA is starting to become more than just an annoyance. They either get to get to look at you naked (via a body scan) or perform a "heavy" pat down (i.e. grope your genitals... or in some cases, cause your urostomy bag to spill urine all over you). A lot of people are afraid of radiation exposure with the body scans, but (based on how little radiation is emitted by X-rays that can actually see your bones) I'm not so worried about that (though I wouldn't go through them if I were pregnant or had any chance of being pregnant). It's more the invasion of privacy. The government has no right looking under everyone's clothes. It's humiliating and unnecessary. The other option (being groped) is no better. But, if someone is going to take away my dignity, I may as well make them do some work. I'm a little disappointed that the planned pre-thanksgiving protest of refusing to be scanned (and thus, backing up the security line) didn't pan out, but I plan on getting to the airport early just so I could make those useless TSA agents get off their asses and work. Also, I plan on getting them to change to new gloves (who knows how many other people's genitals they've groped with the same glove?).
This is even more upsetting because it really doesn't do much to prevent a terrorist. It's all a show that isn't impressing anyone. It's much easier to do all the work behind the scenes from the moment a passenger books a ticket, but I'm sure the government is afraid that people will think that they aren't doing anything to keep them safe. I'm glad that people are finally starting to protest, but, like with all other steps TSA has introduced, (take your shoes off, no water, etc.), I have a feeling people will fall in line, because it's just easier to.

First interview and rash of rejections

2010-11-12T21:42:00.005-06:00

I recently had my first interview. I had a great time, residents and faculty were both very nice. The interview was pretty low stress. One thing, though, surprised me. The institution that I interviewed at is well known for its research, but I had no comments made about my research and when I asked about research opportunities, each faculty member replied with a quick "yeah, we've got research" and seemed to not be so interested. The tone of the response of one faculty member almost made me feel like I asked an inappropriate question. I understand that in residency it's fairly difficult to work on a real research project and I have no intentions of working on a PhD level project, but I expected at least some acknowledgment of their research strengths.
I feel that most residency programs want a token amount of research in your background, but would rather not have your clinical training soiled with research. As such, someone with a background like mine actually has a big disadvantage. With average grades and boards scores my strength is in my productive research (and recommendations). This leads to a strange situation in which some mid-/lower- tier programs decide not to offer me an interview (I assume because they think I will go to a research heavy institution) and many upper-tier programs decide not to offer me an interview (I assume because of less than stellar grades/boards score). I end up with a small number of fairly random interviews with some of the best and some mediocre programs. Of course, maybe I'm just trying to rationalize a (essentially) random process. Anyway, another week or two of potential interview invitations, but I'm feeling a bit more pessimistic now than I did a few months ago.

People are stupid

2010-11-02T22:12:00.005-05:00

It amazes me how millions of people can be convinced to vote against their self interest. Healthcare? Who needs that? What America needs is a tax cut for the rich. Also, get rid of the estate tax (even though it only applies to people who make millions and I only make $20,000 a year). Oh, and extending unemployment benefits is unamerican (even though I'm unemployed and collecting unemployment right now).

Rural Hospitals

2010-10-27T19:48:00.004-05:00

I recently did a surgery rotation at an outlying hospital. It was labeled a "rural" hospital, but in reality it is only a 30-minute drive from where I live. It was a great experience. Without residents, I actually felt that I was a useful member of the team and in the OR actually got to do more than hold something that I can't see. The hospital only had something like 30 beds and I expected that any patient requiring more than a minimally complicated procedure would make the 30-minute hop to the giant academic center nearby. To my surprise lots of patients there would rather have their complicated multi-organ bowel surgery at the small 30-bed hospital (with only 4 ICU beds). Their main reasoning was that they felt comfortable in a place with familiar faces, where they knew the staff as friends or families of friends, something that they preferred over a giant maze of a hospital where you're known as a diagnosis or a room number. Also, I quickly figured out that the quality of care was the same (if not better, in some respects) than the giant academic center. True, you couldn't get a transplant or brain surgery, but for most procedures that general surgeons (or orthopedic surgeons) do, they're just as good. What's more is that things happen amazingly fast at this small hospital. There were several patients that came in with suspicious breast lumps and within a week had a partial mastectomy with pathology results in and an oncology appointment made. Scheduling several procedures across four different specialties is pretty much not possible in a large hospital. So, even though there's a lot of "outside hospital" bashing in academic centers, for the most part, they're just as good.

Checking email

2010-10-08T19:35:00.005-05:00

Still checking my email for possible residency interviews. It's a very anxiety-provoking process. I check my email something like 20 times a day (I thought having a smart phone would be great, but it turns out to distract me more than help me). It's getting to be a crazy obsession. The plus side is that I've gotten two radiology interviews and four intern year interviews. It's somewhat reassuring, but it hasn't stopped the anxiety (and I did get one rejection from an intern year program).

One thing I'm really glad I managed to do was to take a large chunk of time off in December and January (prime interview season). With the number of interviews I hope to get (and an equivalent number of intern year interviews since I want to be in the same city for both), I will be traveling all the time. Our school only lets us take off one day per week of class for interviews and (by my calculations) I would have to break that rule to fit in the number of interviews I hope to get. Some classmates who don't have the time off are wondering how to deal with this dilemma. Since the med school administration always strictly adheres to their rules (and no amount of logic will let them change it), the best option is to either call in sick or ask your resident/attending and not bother with the administration. Nonetheless, the administration may find out and you'd have to deal with their fury.

Tips to any future medical student:
1. It's best to plow through 3rd year and free up 4th year for easy rotations/research/time off so that you could focus more on residency applications and interviews.
2. When it comes to needing time off, follow the old adage: It's better to take the time off and apologize afterwords than to ask for permission and not get it (because you won't get it).

PLoS One: Not a real science journal

2010-09-22T21:43:00.006-05:00

I love the open-access concept for scientific journals. There is no reason why someone should have to pay $35 to read my papers. PLoS is one of the first and largest open-access science journals out there. Some of their journals, like PLoS Biology, are very prestigious places to publish and have put out many amazing studies. They also have a vigorous peer-review process. Unfortunately, to subsidize publication in their premier journals, PLoS pretty much lets anyone who's willing to pay a couple of thousand dollars to publish anything in their barely peer-reviewed journal PLoS One. Their argument for minimizing the peer-review process (and ignoring the scientific merit of their papers) is that it is reviewed by the global community. Unfortunately, all it does is get a bunch of non-scientists make a big deal of a crappy study for being published in a scientific journal. Don't get me wrong, there have been some nice papers I've read in PLoS One, but they also let in a lot of crap (70% of what's submitted is published), like this recent one about a model for Moses parting the Red Sea, that has absolutely no scientific merit. Because of this, PLoS One made it to my Fake Science list.

The waiting game

2010-09-15T21:39:00.004-05:00

My applications are in for residencies. Now I play the always-fun waiting game. Actually, with radiology, an intern year in either an internal medicine, surgery, or transitional (short rotations of everything) program is required, so I've got twice the applications and (hopefully) twice the interviews. The two programs are essentially independent of each other, so all of this is further complicated by the fact that I would like to stay in the same city for all programs. With radiology being so competitive, I've got a lot of programs on my list. I'm happy to say that I've got one interview already, although it's only an intern year interview... nonetheless, it seems like all that effort I put into applications is actually producing something.

Just for those that don't know (and for me when I look back at all this craziness), the whole residency application process starts with completing an application at a central computerized program, uploading a personal statement about why you want to go into the field you chose, and uploaded grades, national boards scores, letters of recommendation by your medical school. The application goes out to any program you want to click on. This makes it really easy (but pretty expensive) to apply to a lot of programs. Once the you choose the programs, the waiting game involves waiting for them to download your application, go over it, compare it with other applicants and decide to send you a short e-mail that they like you enough to see you in person. This process can take from a few days after submitting for some programs to several months for others (which results in applicants agonizing over whether they got interviews all through the fall and into the winter). Next, you interview at the programs that choose you. Then, by sometime in February, you make a rank list indicating where you want to end up the most from the programs that interviewed you. Finally, on March 17th (this year), the "match," based on your rankings and the rankings of their applicants by the programs you interviewed at, decides where you'll end up for residency. I still don't know how the match exactly works, but (like almost everything in med school), I'm sure I'll figure it out when I get to it).

Stay tuned...

Wanna look stupid?

2010-09-07T20:35:00.004-05:00

Burn books.

Edit: Make that, if you wanna look stupid, give attention to a nut that wants to burn books. Seriously, that guy not only just increased his influence about 1 million times, but there will be hundreds of copycat nuts out their trying to get their 15 min. I don't care that it's the Koran, it more that the media and the government has elevated this guy's voice to an international level. A simple "who the hell are you" and "who cares" would have shut him up easily.

Chainsaws in the OR

2010-08-28T22:07:00.001-05:00

Nope, I'm not on orthopedic surgery. I am working with a general surgeon who likes some good old heavy metal and his playlist included this classic by Jackyl.

(best quote: [James Dupree - the lead singer] once had been asked, "How the hell can you play a chainsaw?" to which he responded, "How the hell can you not play a chainsaw?")

Just looking at pictures

2010-08-26T21:00:00.003-05:00

Julie Rovner, the health reporter at NPR took a little swing at lazy radiologists by saying that all they do is sit in a room at look at pictures while primary care physicians have a lot of high-stress work. Maybe radiologists have a more cush lifestyle (although, I know a lot of people who wouldn't be able to stand doing what radiologists do), but it looks like Julie Rovner hasn't really researched what radiologists actually do and what merely "looking at pictures" actually means (i.e. invasive procedures, deciding whether someone needs an organ removed, deciding if someone needs a brain biopsy, etc.). Wtf, NPR? Maybe you should hire a health reporter that actually knows something about health.

This just points out the fact that most science/health reporters suck. They are trained as journalists, not scientists, but they have no problems making conclusions about science/medicine without actually knowing what they are talking about.

Best line ever

2010-08-18T21:23:00.008-05:00

The Daily Show With Jon Stewart

Mon - Thurs 11p / 10c

Mosque-Erade

www.thedailyshow.com

Daily Show Full Episodes

Political Humor

Tea Party

John Oliver: You can build a catholic church next to a playground. Should you?

This whole ground zero mosque nonstory, noncontroversy is basically right-wingers being racist and trying find a way to get attention from their failures in time for November, the media gladly complying with whatever they say, and the democrats hemorrhaging votes by feebly attempting to make the fake outrage die down.

Nuclear armageddon

2010-08-10T09:47:00.007-05:00

This is a map of nuclear bomb detonations (that we know of) between 1945 and 1998.

It's worth watching all 14 minutes of it, if only to make sure you never live in the Southwest (of course, the US kicks ass at this game).

Fake science legitimized

2010-08-04T11:12:00.023-05:00

There's a lot of pseudoscientific or grossly biased "studies" out there that pretend to be actually doing real science. That really can't be stopped. Lots of organizations spend a lot of money to come up with "evidence" to back up whatever they like to promote. What upsets me is when these "studies" get published under the guise of actual scientific work. Some of theme are even peer reviewed. The great PZ brought up an example today from the Southern Medical Journal of a study that showed that prayer improves vision by recruiting subjects from a church revival, not blinding and not having a control. If the Southern Medical Journal is a legitimate medical journal, how did this study make it past the editor (let alone through peer review)? Clearly, the scientific process doesn't matter for this journal.

There are a lot of science journals that have been publishing pure crap (I suppose in order to get more readers) and it really diminishes their value. Not quite this bad, but even bigger named journals like the New England Journal of Medicine have been trending towards legitimizing pseudoscience, such as this recent review of acupuncture (discussed by Orac). A few years ago, I actually got in an argument with an editor from the American Journal of Health-System Pharmacy because they published a letter to the editor that used a posting from prolifeblogs.com to support their argument against the availability of over-the-counter emergency contraception. The response I received from the editor was that they can't be selective against the literature their contributors cite (yes you can! And, a blog post can't count as scientific literature).

So, similar to my post on companies that underhandedly promote religion, I want this post to include a (probably) growing list of scientific journals that aren't exactly scientific:

Completely Fake:
Journal of Cosmology
The Open Information Science Journal - accepted a fake paper without review from a couple of people from MIT claiming to be researchers at the "Center for Research in Applied Phrenology" (CRAP) - as long as they sent an $800 check to an address in a tax-free zone in the UAE.

Has Ulterior Motive:
Australasian Journal of Bone and Joint Medicine (sham journal for Merck provided by the supervillain of scientific journals: Elsevier).
The Journal of Global Drug Policy and Practice - funded by the Department of Justice and only publishes "research" that shows that punishing people is the only way to reduce drug use.

Ignores scientific process for publicity/money/religion:
American Journal of Health-Systems Pharmacy
American Journal of Surgery
British Journal of Psychiatry
Journal of Medical Hypotheses
PLoS One
Southern Medical Journal
Psychology Today
Synthese

... and more coming when I get the chance to get to them.

King and King

2010-07-25T13:05:00.006-05:00

We've been going to the library and randomly grabbing children's books to read to mxh jr (he has no idea what they're about, so any book will do), and we happened to grab a book called "King and King," about a prince who needs to get married and can't seem to find the right person. All the princesses don't cut it out for him. Finally, he sees the person of his dreams (and from the title you could guess that it wasn't a princess). Pretty cool. It's about time that children get exposed to all types of relationships and learn that love isn't about gender.

Of course, some people aren't happy to see this book in libraries. The Amazon reviews bring out some less-than-enlightened reviews. And someone tried to sue a school for having the book, claiming that "the book in school constituted sexual education without parental notification." Pretty lame... with that logic, you'd better get rid of every other book that ends with "and they lived happily ever after." Luckily, the judge threw the lawsuit out saying, "Diversity is a hallmark of our nation."

4th year and radiology

2010-07-15T22:13:00.002-05:00

So, I've decided to go into radiology and am starting the last year (#8 - can't believe I've spent nearly a decade here) with a radiology clerkship. Since I last took radiology before 3rd year actually started, now that I've actually experienced a lot of what medicine has to offer, sitting behind a resident or attending while they look at images actually isn't that bad. In a previous post I complained about how med students don't get the most exciting experience in radiology, but I've learned on this rotation, that you actually can. The best way to enjoy radiology is to do it yourself. With 3rd year behind me, I can actually make a reasonable attempt at reading some images. So the advice that I've been given (which works pretty well for me) is to find a free computer in the reading rooms and look through the new studies on your own and try to come up with a diagnosis. Then when the resident or attending go over them, you'll get much more out of their discussion. Amazing how in a few weeks those images that I could make little sense of actually start being somewhat meaningful (I'm looking at you ultrasound).

USMLE Step 2 CS: A waste of $1000

2010-06-29T22:16:00.008-05:00

I recently took the clinical skills (CS) portion of step 2 of the US medical licensing exam (USMLE). It's a whole day of interviewing standardized patients (actors), writing notes, coming up with possible diagnoses and ordering lab tests. It definitely covers what every physician should know. What's upsetting though, is that it's a recently-introduced exam that costs $1295 and has a 96% pass rate (and supposedly 100% at our institution). So essentially, every medical student in the country (something like 15,000 students each year) has to take the exam so that only 600 (most of whom probably also have terrible grades and are unlikely to match into a residency program anyway) could be weeded out. We live in a culture of standardized testing. There are whole industries surrounding it (books, tutoring, computer programs, testing centers, patient actors, etc.). So, its not surprising that the company administering the medical licensing exam would like to add yet another exam for students to take. What's disappointing is that physicians in charge of medical licensing go along with it. Residency programs don't care about your Step 2 CS score and I highly doubt that there will be less dangerous physicians around because of this new exam. My cynical opinion is that someone decided that they could make an extra $20 million each year off of medical students and "convinced" those in charge of medical licensing to go along with it.

Oh well, at least I'll never have to deal with fake patients anymore.

Seven alternatives to evidence-based medicine

2010-06-15T22:16:00.004-05:00

Two more days of 3rd year left... can't wait.

This article is a pretty funny (but in my experience true) description of how some doctors justify their treatment plans. My favorite:

Eloquence based medicine---The year round suntan, carnation in the button hole, silk tie, Armani suit, and tongue should all be equally smooth. Sartorial elegance and verbal eloquence are powerful substitutes for evidence.

Bad science in clinic

2010-05-26T22:17:00.001-05:00

I was very disappointed by my recent preceptor, who's pretty good with practicing evidence-based medicine (even when it contradicts the current trends), at recommending an unproven treatment to a patient. We had a patient with reflux disease who was well-controlled with a proton-pump inhibitor (PPI). He suggested that acupuncture might be a good alternative. Then went on to describe this study, in which patients who failed standard therapy with a PPI were randomized into one group that received a double-dose of PPI and another group that received acupuncture in addition to the standard dose. Surprise, surprise, the acupuncture group got better. This is a terrible study that is doing nothing but comparing apples to oranges. First of all, if patients failed standard therapy, the chances of failing a double dose is pretty damn high. Second, where is the control for acupuncture? How do we not know that the acupuncture group is getting a placebo effect? They could have easily placed needles in the wrong places as a control. Third, this doesn't even apply to the patient we were talking to, she was responding to PPIs. Overall, terrible advice by an otherwise well-informed doctor. At least he described the methods to the patient. Luckily, the patient preferred sticking to her trusty PPI.

The one thing I learned from the paper: In the UK, GERD is called GORD (gastro-oesophageal reflux disease).

In the donut hole

2010-05-21T22:12:00.013-05:00

Ms. X is a 80-something year-old woman with congestive heart failure, high blood pressure, diabetes, rheumatoid arthritis and asthma (among other things). She on about 15 medications that adds up to nearly $4000 a year. Unfortunately, this falls right in the middle of the famous donut hole of Medicare Part D (the prescription coverage part of medicare). I never really thought much about it until I saw how this affects Ms. X. Here’s Medicare Part D’s payment schedule from 2010:

If your drugs cost between $2830 and $6440 per year, you get no coverage, but if your drugs cost more than $6440, you get 95% of it covered by medicare. This makes absolutely no sense to me. I was wondering how the hell this came about and it turns out that it’s the consequence of two separate coverage plans (one clearly made completely independently of the other). There’s Medicare initial drug coverage that covers 75% of all drugs on the formulary from $310 to $2830 (there’s a $310 deductible). Above $2830 there is no additional coverage by Medicare’s initial drug coverage. However, if you have to spend (out of pocket) more than $4550 (that’s your prescription drug costs go over $6440) Medicare’s catastrophe coverage kicks in. At this point, Medicare pays 95% of anything that goes over. Medicare does have an “Extra Help” program that includes coverage of the donut hole, but you have to make less than $16245 a year to qualify (not really much). Ms. X is a widower who rents an apartment in town. She has an income of about $18000 a year. She makes too much to qualify for the extra help. She can’t really afford to pay an extra $60-$80 a month that the extra “gap coverage” insurances cost. Now, I don’t spend much money, but I know that you really can’t do much on $18000 a year, especially if you have numerous chronic medical problems. Ms. X has gotten to the point that she is not eating well, she’s not filling some of her prescriptions and has even resorted to taking her son’s albuterol (he has private insurance) for her asthma.

Luckily, the healthcare reform package that recently passed will start closing this donut hole, but it looks like it won’t be until 2020 before the gap is completely closed. I’m not sure why it should take 10 years to fix it. I’d bet that none of the people who set this system up or who decided that it's ok to wait 10 years before closing the gap have an 80 year-old grandmother who steals their albuterol.

4th year will be sweet

2010-05-20T13:47:00.003-05:00

Just about done scheduling 4th year and it looks like it'll be nice. Right now I actually have 22 weeks off! Of course some it will be taken up by taking the boards and interviewing for residencies, as well as research (and maybe I'll add a few more rotations later on), but it sure will be less hectic than 3rd year has been. What I'm really excited about is the end of working for grades, good evaluations, exams, busy work, etc... I will finally (with few exceptions) be able to spend 100% of my time in the hospital on learning what I am interested in. I kind of wish all of med school was like that.

Religious companies

2010-05-13T11:24:00.011-05:00

There are some companies, fairly well-known ones, that I never knew attempt to push their religious beliefs on others. I find it pretty frustrating when I'm trying to purchase something and I get a religious sermon. Or an ad for car batteries is talking about God's love. I find it worse than religious organizations and televangelists, because, with them, you at least know what you're getting yourself into. But, I was looking for plane tickets recently and a wandering google search taught me that Alaska Airlines regularly distributes Bible verses with their meals. When common everyday companies, like Alaska Airlines, pushes religion when providing the service that you pay them for, it's insidious and not only offends me, but leaves a bad taste in my mouth. I mean, if I were to give my business to Alaska Airlines or Interstate Batteries (which I have before), I have donated to a religious cause (something which I try to avoid at all costs). They are private corporations and can do whatever they want... I'd just like to know about it so I can avoid giving my money to them in the future. So here's my list that may be growing, of companies I will try to avoid because I'd rather not have my business with them fund proselytizing. A good starting point is from a list made last year here. Another good list is here, but I'm not considering companies that just have owners who are religious and have a spiritual way of making decisions. It's more when employees or customers are exposed to religious propaganda, nonreligious employees/customers are discriminated against or the profits from the company goes to religious organizations.

Alaska Airlines
Chik-Fil-A (aah! Making employees pray and Christian-themed toys in their children's meals... that's pure evil!)
Hobby Lobby
In-and-Out Burger
Interstate Batteries
Florists in Cranston, RI
Forever 21 (owner like to demonstrate his faith by putting a bible verse on bags)

Prometric (testing center was playing Christian radio in the waiting room... not what I want to hear just before I start taking Step 2).
Wyndgate Country Club in Rochester Hills, MI

This is a slow growing list. If you have any additions, please let me know.

Burnt out

2010-05-12T09:17:00.002-05:00

It's official, I'm totally burnt out with 3rd year of med school. The primary care rotation is pretty relaxed, but I just can't get myself to study much or do any of the mind-numbing busy work that we are assigned. I'm glad I don't have something more intense like internal medicine or surgery scheduled now. Luckily, it looks like I'll have a pretty chill 4th year (though I'm not looking forward to taking Step 2 of the boards) and I'm looking forward to the adventure of applying for residencies.

How to lose innovation in your state

2010-05-02T08:58:00.006-05:00

University of Virginia and Virginia Commonwealth University are two other places I am looking into for residency. But, I'm hesitating now because there seems to be a witch-hunt against scientists. The attorney general of Virginia is a grade-A nut who is wasting taxpayer money to "investigate" (i.e. go on a fishing expedition) a climate scientist to see if there was "any breach of ethics" (i.e. can we find anything that makes scientists look bad so I could say my twisted version of reality is right). Besides being completely unethical on the attorney general's part (is he really working for Virginians?), this is a great way to lose scientists in your state. For example, if I go into fetal imaging - something that I really am interested in - I may find something that would not fit with the attorney general's ideas about when life begins, and as a result I risk getting "investigated." You lose scientists, you lose scientific discoveries. You lose scientific discoveries, you lose new and exciting companies. You lose that and you've lost jobs, greater tax income, and a better future for the citizens of your state. But who needs all that, it snowed 60 inches in Virginia last winter, so clearly global warming is a fraud.

Two places I could cross out now

2010-04-27T20:46:00.006-05:00

I am thinking about the long list of places I will apply to for residency in a few short months. The list is growing by the week, but two just got crossed out: The University of Arizona and St. Joseph's Hospital in Phoenix. I figured I don't want to spend 5 years living in a place where I'll be asked to "show my papers."

Out of the psych ward

2010-04-23T20:33:00.007-05:00

Just got done with psychiatry. I had a great time. I was in a general adult ward where most patients were voluntary. The staff was great and the patients were very interesting. What was really cool was that in their short stay of 3 to 5 days, most patients actually got better... not something I thought would happen quickly. What was even cooler was that there were no residents, so I was actually a useful part of the team and my patients were my patients. I got to interview them first, I got to write their admission notes, I got to do their discharges. This is probably the closest I've felt to a doctor.

Just for fun, here's something amusing that happened during the rotation:

Attending (while talking to a crack addict that didn't want to stop): You need to stop smoking rock and get addicted to something else. Like this (shows a picture of his cat). You can start getting high off of this.
...
Me (later): Dr. X do you watch South Park?
Attending: Yes
Me: Do you remember the episode where they get high off of cat urine?
Attending: It's called cheesing.
...
Attending (later, to patient): You should probably ignore what I said earlier about getting high off your cat. It's called cheesing and it's bad.

Taking Oaths

2010-04-19T21:05:00.009-05:00

I thought that the only oath I'd be taking in med school is the Hippocratic oath. But, in more than one rotation, I've had to sign papers that certified that I really did read the reading I was assigned or watched the video I was assigned. It's frustrating on two levels. One is that I find oaths in general kind of useless. If someone is going to do something wrong or illegal, they're not going to have much of a problem lying about it. What's more upsetting though is the paternalistic approach that medical schools have towards their students. If there is a reading or video that is recommended, it should be up to me to decide whether I think it's useful to my education. If I don't find it useful, actually doing the assignment will only waste my time. I believe that we're mature enough to decide what the best way for us to study is. I've had hundreds of exams and know pretty well what works for me. The school shouldn't care (and shouldn't make me sign oaths) that I didn't do a particular assignment.

Of course, the administrators don't really remember being students, so they've implemented things like quizzes that ask questions about topics that were in the readings, but not exactly important to clinical practice or (rumor has it) actually make sure that you've clicked on and watched the entire 26 minutes and 13 seconds of the video that is posted on line. This is what happens when you lose sight of priorities... so, if you'll excuse me, I've got to play another video at 2X speed with the sound muted in the background.

Best burger in baseball?

2010-04-07T21:21:00.003-05:00

I was watching the travel channel and saw this beauty:

A bacon cheeseburger with a Krispy Kreme donut as buns. Looks like I have a good reason to apply for residency in St. Louis.

Someone who shouldn't be a doctor

2010-04-02T15:58:00.004-05:00

Florida doctor opposed to health care law turns away Obama voters

This sickens me. I would hope that other doctors in the area realize that he's an asshole who won't treat his patients equally and refer their patients with urological problems elsewhere.

(part of me thinks, I'm glad that he's advertising his idiocy and losing patients)

Psychobabble

2010-03-31T21:35:00.003-05:00

I just started psychiatry this week and so far, it's been pretty good. I feel pretty comfortable talking to the patients I've had so far (although, they really haven't been out there, so I've got plenty of more chances to feel uncomfortable). Although I'm glad that we don't see much of it in medicine these days, in the 3 short days that I've been on psych, I've been exposed to the psychoanalytic model (Freudian stuff) more than I'd like (including part of our formal lectures). As a scientist who believes in theories based on objective experiments, I find it incredibly hard to believe the ideas in the psychoanalytic model. I mean, it's hard to believe that there are actually trained physicians (though decreasing in numbers) that actually believe stories about things like the "oral phase," the "id versus the ego," or the un(sub or whatever)conscious. It all really sounds like the quack cult psychology books (like The Secret) that Oprah and other daytime talkshow hosts promote. I know that the mind is difficult to understand and we essentially know nothing about where psychiatric disorders come from, but do we really need to make up colorful stories about some sort of hidden internal struggle in the brain? Some ideas may be useful in developing a treatment strategy, but still using outdated ideas and teaching untestable stories seems a little backwards to me.

Patient confidentiality vs. Public safety

2010-03-25T21:32:00.004-05:00

A 19 year old woman came to the ED reporting that she had been raped by a taxi driver. She wanted emergency contraception and wanted to be tested for sexually transmitted infections. She said that she was alone in the taxi, the driver took her to secluded park, raped her and left her at the park. She would not describe the taxi driver, say which company he worked for, or give any details about what happened. She did not want to press charges because she did not want to questioned by the police (she stated that her sister had been sexually abused and went through a terrible time having to relive her experience over and over again after she reported to the police). The attending (and I) were in a conundrum. If what happened to her isn't reported to the police, a taxi driver can very well rape (or murder) someone else. If what happened is reported to the police, we'd be breaking her confidentiality (and making her go through a lot of grief). Eventually, the nurses contacted the hospital lawyers who (probably to save their asses) said that legally we can't break her confidentiality. So, even though it gave both the attending and I a terrible feeling, we let her go and didn't report anything.
Later in the week I talked to a medical ethicist at our institution about this. He didn't say anything clear cut. But, he reminded me that confidentiality can be broken if the information we reveal has a high probability of saving the patient's life or the lives of others. So, assuming she's telling the truth (not sure if she is) and there is a high probability that the taxi driver would rape again (and statistically speaking, it is), ethically we should have reported the incident. Is that right? I'm still on the fence about this. I just hope I don't hear anything about a cab driver raping someone else on the news.

Take back our textbooks

2010-03-12T22:20:00.003-06:00

As expected a bunch of nuts in Texas decided that reality is too liberal and will rewrite history and make up scientific facts to teach students in their public school system. I could say, "who cares it's only Texas", but the publishers don't want to make multiple versions of a textbook and since Texas is one of their largest purchasers of textbooks, the right-winged fake textbooks that they'll make for Texas will be used in other states also. However, I believe we could fight back. The same publishers sell college and professional-level textbooks, and with the insane number of textbooks that I've had to buy in my college and professional school career, I'm sure a huge chunk of the revenue for these companies come from people just like me. So, if professors, researchers, and college students boycott the companies that are complacent in the brainwashing of public school students, I believe we could stop these 11 crazy Texans from robbing the educations of kids from all over the country. (I've tried to find a list of the textbooks that the Texas school board uses, but haven't been successful so far.)

Jenny McCarthy as my pediatrician?

2010-03-11T06:43:00.004-06:00

As I expected, in pediatrics I'd run into some anti-vaccine parents. They were beyond convincing (and perhaps not coincidentally, many of them were chiropractors). However, the other day we saw a patient bring her child for her two-month check-up, when the first shots are given. The mom brought up her concern about vaccines causing autism. The pediatrician said that there isn't any evidence that it's the case. Grandma then walked into the room and said, "oh yeah, I heard that the original study that showed a connection between vaccines and autism was a fraud." (yay! word is going around). The pediatrician then said, "Whenever you hear things like that you should ask yourself, if my child had an ear infection, would I ask Jenny McCarthy for advice or would I go to my pediatrician?" The mom and grandma laughed and said, "pediatrician." The baby got her vaccines and the story had a happy ending... but as I was leaving the room I thought, even though it sounds like a silly question, a lot of parents wouldn't think it's such a funny question. There are plenty of people who would be happy to take the advice of celebrities (and quacks) on their kids' health (not just vaccines) over their pediatrician's.

4 Stages of a 3rd year med school rotation

2010-03-08T20:10:00.000-06:00

1. Confusion: You don't know when to be where. You don't know what you're supposed to do, what you're allowed to do, and what you can't touch. You don't know the right terms for anything. You don't know who to talk to. You don't know where the patients are. You don't know when to leave.

2. Productivity: You got the logistics down. You've gotten to know how the system works. You're actually being useful to the team. You're actually learning from your patients. You know when to go home without asking.

3. Burn out: You're getting tired of the routine. You're getting tired of the busy work. You're less excited about the day. There are less learning opportunities during the day. You look forward to going home.

4. Numbness: Your mind is elsewhere and your goal is to just get through the day. Unless something really exciting happens, you're not gaining much from the rotation. You find ways to get out early.

This is kind of a tongue-in-cheek thing, but for some rotations it's definitely true.

How not to treat your students #3

2010-02-26T17:05:00.000-06:00

Another one for the series.

Resident: You guys can do whatever. But stay in the hospital. We're getting an interesting patient soon. I'll page you guys when she gets here
Students: OK, thanks.

5 hours later, no page... students page the resident... no response, students go home

The next day:
Student: Did the patient get here yesterday?
Resident: Oh yeah, she cam at one (2 hours after he said he'll page us).
Student: Did you get my page?
Resident: Yeah, I already took care of the patient by then.

I know the resident has more important things to think about, but med students really, really appreciate it when someone keeps them in the loop (especially when they say they're going to).

Credit Cards Suck

2010-02-17T22:48:00.003-06:00

The Mrs. just got a letter from her credit card company saying they're starting an annual fee unless she spends a certain amount per year. And, I've heard rumors that my credit card will start charging if you pay your balance in full each month (wtf?). It'll definitely be canceled, but it sucks that our credit suffers because the credit card company decides to be assholes.

How not to treat your students #2

2010-02-15T13:43:00.000-06:00

I was talking with a few students in the hallway when a resident, who was in no particular hurry, walked down the hallway and literally pushed us away while saying "Outta the way kiddos!"
WTF? Just because you have an MD doesn't make you any more worthy of the hallways than us. (I replied with "Kiddos? I'm probably older than you!")
Later that week we were all sitting in a room with other residents and attendings, when the same resident walked into the room and said, "Med students, get out of your chairs. I need to work." Granted she may have been doing some important work, but she could treat the students like human beings and ask nicely, rather than ordering us to give up our seats as if we're second class citizens.

There are lots of simple things that residents and attendings could do to make med students enjoy their time in the hospital better. The easiest one is to treat them like normal human beings. I hope I'll treat my students better.

How not to treat your students

2010-02-07T13:38:00.002-06:00

I recently worked with an attending who completely ignored my presence. Not too unusual in med school. But,I got pretty upset when the attending responded to every question I asked by turning to the resident and replying to him. He didn't want to stoop so low as to talk to a med student. Arrogant ass.

Radiology as a med student: Not always fun

2010-02-05T00:39:00.000-06:00

Radiology is great and is still on top of my list for what I want to be when I grow up. However, as a med student, it can be pretty boring. Last week I spent some time in the neuroradiology department. My two favorite fields, neuro and radiology, combined. Yet, my 2 1/2 days with them were pretty dull. The problem is that to enjoy radiology, you have to look at and interpret images on your own. Shadowing a radiologist doesn't really make much sense. Basically, you end up looking over someone's shoulder as they quickly scroll through scans and talk to themselves (into their dictation programs). There is very little opportunity to figure things out for yourself. Luckily, during neurology and my other rotations, I've gotten plenty of chances to go through images on my own. So, this post isn't about how I stopped wanting to be a radiologist. I'm just venting about my disappointment about the neurorad week.

About damn time

2010-02-03T22:06:00.002-06:00

The Lancet retracts Andrew Wakefield’s article.

Ten of the original 12 authors of the study retracted their support for the study and its interpretation. In 2004 the Lancet published a retraction. However, it was only a partial retraction, and the study remained as part of the published literature.

10 out of 12 authors wasn't enough to fully retract it?

Peds neuro: Can it tear me away from radiology?

2010-02-01T22:20:00.002-06:00

On my neurology rotation I was assigned to pediatric neurology, and that random assignment might have changed my career plans. I loved it almost immediately. The patient population seems great. The diseases are often very challenging. And each patient is completely different. Granted for a lot of patients there is no treatment. Although, figuring out the mystery of why something is wrong with someone's child does a lot for both the parents and the child. For those kids for whom a difference can be made, the difference is dramatic. It could change a potentially severely disabled child to a normal, healthy child. Also, adding the normal changes that a child goes through as they get older along with the neurological problems they face is an added factor that makes the field interesting. Finally, the research opportunity is limitless. There is a lot that is not known about the conditions that these kids can suffer from. For many of them there is no treatment available. Also, their disorders shed light onto my field of interest, how the brain works and how the brain's plasticity can be used to overcome their deficits.

Will I go into it? Not sure yet. Radiology is still winning, but peds neuro is a quick second. The training in peds neuro is a little strange (for most people, 2 years of peds, 1 year of adult neuro and 2 years of peds neuro - you have to go through two different matches). Also, I'm not completely sure if I really like the pediatric population... we'll see, my peds rotation is next. Stay tuned.

So we've had a national referendum on gay marriage also?

2010-01-22T17:34:00.005-06:00

Apparently the fact that the people of Massachusetts chose a Republican to take over Ted Kennedy's seat means that everyone in the US is against health care. So, by that logic, since Massachusetts has legalized gay marriage, we've had a national decision already made on that also.

I'd rather not do that to my child

2010-01-19T20:47:00.005-06:00

With our new baby came an instruction manual (well, maybe a book that my in-laws got us). It has some good advice, it's mostly fact-based (i.e. it does a pretty good job shutting down the anti-vacciners), but one thing caught me eye. It's about soothing a fussy baby:

Dan, a chiropractor father of a fussy baby, came up with this fuss fixer. Hold baby at his hips and swing him upside down at sixty beats per minute, like the pendulum of a grandfather clock. According to chiropractic research, upside-down swinging has a calming effect.

Yikes... how did that research get IRB approval?

Holy crap!

2010-01-10T11:14:00.003-06:00

I'm a father.

Oh, no! We've qat another target!

2010-01-03T13:15:00.009-06:00

With all the recent talk about Yemen (and Fox News telling everyone that Despite Al Qaeda Threat, US Not Planning to Expand Terror Fight in Yemen - don't click on it, it'll go to Fox News), reminds me that we may be on the verge of "liberating" yet another country that we don't understand. Yemen is a pretty interesting place, the history and politics of which does not fit any of the other oil-rich middle eastern countries. I recommend reading "Motoring with Mohammed" about life in Yemen (it's an awesome travel book by Eric Hansen). Plus, you'll learn a lot about qat (a euphoria-inducing stimulant used daily by the Yemeni).

Gotta love the qat break

At least we're not elephants

2010-01-02T23:27:00.007-06:00

Still waiting for mxh jr. Mrs. mxh is getting pretty tired of being pregnant... but I guess he'll get here when he gets here.

10 month elephant fetus... only halfway to birth

See National Geographic's In The Womb specials for more cute animal fetus pictures.

Everything causes cancer in California

2009-12-24T11:40:00.006-06:00

... so you'd better stay away. The San Francisco environment commission just approved a measure requiring cell phone manufacturers to say that their products may cause cancer. The mayor is expected to approve it. Even though every legitimate scientific study has found no link. The head of the city's "Toxic Reduction Program" says...

Do you wait until you have proof of cause and effect, or do you look for indications from reputable scientific sources?

Apparently what any random person off the street says counts as reputable scientific sources, because every reputable scientific source I've seen says there is no effect of "radiation" from cell phones on human tissue. That's why everything seems to cause cancer in California, but nowhere else.

ps. Merry something-or-another

Breaking News on CNN

2009-12-19T21:47:00.008-06:00

Let's see, what happened today? The entire east coast is getting like 2 feet of snow, the healthcare bill got enough votes to avoid a filibuster, the climate conference in Copenhagen comes to an end, and Lil' Wayne gets arrested for pot possession... and none of these stories make the biggest headline on CNN. Instead it's Can Joel Osteen Help You Pay Your Bills? and the poll of the day is "Should information about women who get abortions be posted online?" WTF?? This is what the media has become? A big advertisement for a televangelist as the major headline and a poll that in a country that supports human rights should be 100% No?? Just when I think that US media can't get worse, it proves me wrong. I think I gotta take a tip from my friend, MadDR2 and give up on the news for a bit.

Reflections on OBGYN

2009-12-18T16:43:00.007-06:00

Just finished the last day of the rotation. I was pleasantly surprised. I thought that I would find absolutely no interest in it, but really, it wasn't what I expected. It is a field that encompasses a wide range of patient populations and covers almost every other branch of medicine. My favorite part was OB. First, from a purely scientific point of view, what happens to human physiology during pregnancy is simply amazing. When looking at an obstetric patient, you might as well forget normal physiology and normal lab values that you learned in internal medicine (for example, the white blood cell count, which is normally below 10,000, with a really bad infection being 20,000, can go up to 30,000 during normal labor). Then there is labor and delivery. It's something that is nice most of the time, but every once in a while it gets very scary and very sad. It's the one time that people are hospitalized for something that is completely normal and the expected outcome is not to make them better, but to make sure nothing goes wrong. Delivering babies is pretty fun, but watching the emotions of the people in the room affected me more. There are some interesting social dynamics in the delivery rooms also (like the patient who wasn't sure who the father was and was waiting until she saw the skin color of the baby before giving her a last name or the woman at 43 1/2 weeks gestation who refuses any medical intervention). Overall, each patient is completely different and OBGYN is a branch of medicine that combines the solving-a-mystery aspect of internal medicine with the get-in-there-and-fix-it aspect of surgery. No, I don't want to go into it, but I definitely had a lot of fun in the last 6 weeks.

8 more hours to go

2009-12-14T00:07:00.004-06:00

I'm on night duty on labor and delivery this week. This is my second night, and although it is cool (I've gotten to deliver a couple of babies), it is pretty damn tiring. I'm actually pretty good at staying up at strange hours and can handle being on call overnight every once in a while, but working nights day after day is not easy to get used to. I'm a med student and don't have nearly as much running around as the residents do. How do they do it? It just seems really dangerous to have overworked and sleep deprived people dealing with emergencies. I guess they get used to it (or learn to sleep during the day better than I can). 5 hours down, about 8 1/2 to go.

Learning Abortion

2009-12-03T21:56:00.009-06:00

We had a pretty interesting discussion about how education about termination of pregnancy fits in with resident education in OB/GYN. According to the accreditation board, no residency program can require that residents participate in a termination of pregnancy. However, all residency programs are required to accommodate residents who wish to learn about and participate in such procedures. This applies even if it's a Catholic hospital/university that provides no such services (and equates such services to murder*). Such hospitals have an agreement with another institution that does provide it. Which means that it is possible that somewhere in the country, an anti-abortion institution has an agreement with an institution like planned parenthood that provides abortion services in order for them to keep their accreditation**. I wonder what the atmosphere was at the meeting that led to that agreement. And, how stigmatized is the pro-choice resident in an anti-choice hospital, if they do decide to take this option? Also, how likely is an interested resident going to take the option if the nearest clinic providing abortions is hundreds of miles away?

Another interesting part of this discussion was that each institution has an unspoken reputation about whether it has a pro-choice or anti-choice lean. And, although it is illegal for them to use the applicants views on abortion as a litmus test, according to the attending we were talking to (who has been intimately involved in national ob/gyn resident education), these institutions do look for clues on the residents' applications about where they stand on the issue (i.e. if they said they were a member of Medical Students For Choice) in order to make decisions on whether to interview them or not. Sounds like a litmus test to me.

* though, in my opinion, they really don't. See this discussion.
** although, some of them do get around it by saying that their abortion training is "limited to patients with medical indications," which can equate to early induction of labor and is not really what most people think of as abortion.

The Intolerant Neutral Planet

2009-11-30T20:38:00.009-06:00

The recent, blatantly racist Swiss vote banning the building minarets is upsetting, but, to me, not surprising at all. This is coming from a country where the ruling party's banners featured three white sheep kicking a black sheet off a Swiss flag with the words "For our security" under it. Although, as a non-white person, I have been subjected to subtle racism before, Switzerland is the only place where I experienced overt racism and the only place where I felt uncomfortable.
Here's my experience. A few years ago, I was at a conference in Germany and afterwords, since I'm into mountain climbing, I decided to make a short trip to Switzerland. I took the train from Frankfurt to Basel and an hour before we got to the Swiss border, I see three border guards enter my train car, talk into their radios and headed straight to me (the only brown person in the car). They asked for my passport. I showed it to them. They then asked to search my bags. Went through both my bags. I had a poster from the conference and they asked to open the tube and took out the poster (tearing it in the process). They then asked why I am going to Switzerland, for how long, who I'm staying with, whether I'm looking for a job, what kind of work I do, etc. They asked me to prove to them how long I'm planning on staying in Switzerland. I wasn't sure how to do this. Eventually, showing a print out of my return flight worked. After 45 min, they let me go and left (no questions to anyone else in the full car). Meanwhile, the entire train is staring at me (the presumed terrorist).
Things didn't improve once I got to Switzerland. Everywhere I went, I got a suspicious look. Especially in stores (every store), where the employees followed me throughout the store (to make sure I wasn't stealing anything, I guess). I started playing a game with them, where I would walk around in circles in the store and watch them follow me, to see how many laps I could make them do.
I was surprised that a country that I've always seen as so benign (so neutral) could be so hateful towards others. I suppose Switzerland's "neutralness" is really a manifestation of it's isolationism and xenophobia.

Zapp Brannigan:

With enemies you know where they stand but with Neutrals, who knows? It sickens me.

An unreasonably natural labor

2009-11-24T18:32:00.004-06:00

Being in OB and expecting a child makes me see many sides of being pregnant and labor. I see pregnancy and childbirth as a natural process and think that there are some physicians who "medicalize" it too much (C-section rates are higher than the should be, people are induced more than they should be, etc.). So, I see the why people would want "natural" childbirth, with no medical interventions (like pain control). But, the extent to which some people take it is completely, in my opinion, unreasonable.

Case in point is a woman who recently delivered at our hospital (she was not my patient, so this is second hand). Things went relatively smoothly and, except for receiving a small perineal tear, she was able to successfully go through labor without any medical interventions. The baby was born relatively quickly and was completely fine. The woman just needed the tear sutured and was otherwise fine. When the resident explained that she will numb up the region around the tear with some local anesthetic before suturing, the woman became angry and was adamant she wanted a natural birth without any "chemicals."

Kind of ridiculous. But, childbirth is a highly emotional time and whenever people are dealing with emotional events, they tend to stop thinking rationally.

Ou se trouve le gerbille hôtel?

2009-11-18T22:40:00.004-06:00

I wouldn't mind going to a rodent-cage themed hotel, but the hamster costumes kind of creep me out.

From one end to another

2009-11-11T19:04:00.005-06:00

That's what my Pathology attending said when I said I was doing my OB/GYN rotation next. I suppose he meant from one end of life to another (it could have also been from one end of the body to another, since I focused on Neuropathology). I started OB this week. We switch teams every week or so. Right now I'm alternating between an infertility clinic and an OB clinic. I haven't seen enough to comment on (although some of the infertility treatments are pretty clever), but it is nice to be expecting our own baby while on this rotation. It not only motivates me to study a bit more, but it definitely helps relate to what the patients are going through (since I've seen Mrs. mxh go through a lot of the same already). It's also a bit reassuring, since it has made me realize that a lot of the fears and problems that we've had so far are very universal.

Glad I got my vaccine

2009-11-04T07:29:00.009-06:00

Just saw this case on the pathology rotation:

A slightly overweight, otherwise healthy 50ish year-old man, 5 days ago starts feeling tired and gets a slight fever (~100 F). He goes on a trip with some friends and returns 2 days later. At that point he is feeling much more tired, his muscles ache a bit, he is starting to get short of breath and his fever is a bit worse (~102 F). He goes to the local ER where they think he might have H1N1 and because of his worsening shortness of breath he is admitted. Over the next day his condition dramatically worsens. He is intubated, his fever skyrockets (~109 F (!)) and he is transferred to a larger hospital. He dies within 12 hours of arriving at the larger hospital. He is determined to be H1N1 positive.

On autopsy, except for his lungs, all his organs show no signs of any disease or abnormality. His lungs, however, weigh about 1200 and 1300 grams each (normal, i think, is about 450 and 500 grams for left and right lungs). It has multiple areas of necrosis, hemorrhage and consolidation (like a really, really bad pneumonia). What goes beyond a normal pneumonia is that it covers the entirety of both lungs (ARDS) and even goes up the airway to the trachea, which also shows inflammation and hemorrhage.

Yikes!

All you need is brains

2009-11-01T09:12:00.006-06:00

Caught a nice documentary last night on PBS. The Zombeatles... probably the coolest thing on PBS in a while.

You must catch the riveting story of the "Fab Gore"

Cleaning up

2009-10-27T21:52:00.006-05:00

With a (much) lighter schedule, the Mrs. and I decided we should start getting ready for the baby getting here. The first order of business is to make room for the baby. This means throwing a lot of crap away. Most of the "crap" was notes and folders from undergrad and the first two years of med school. I've somehow felt attached to these notes, even though very little of it is useful to me anymore (really, I don't need to hold on to my History of Jazz notes). But they had to go. And as I was throwing things away, I saw my Calculus 3 notes and flipped through it and I was amazed that at some point in my life I knew how to do triple integrals. Then I thought, holy shit, what a waste of time. I haven't used it since and will probably never use it again. Was it all a waste? I wonder how much of my education is a waste?

Done Surgerizing

2009-10-24T09:03:00.003-05:00

As you could probably tell from the frequency of posts in the last 2 months, surgery was not the most leisurely of clinical rotations. But it wasn't too bad. Maybe it is just our school (or just my experience), but the hype over how much work it is and how much pimping is involved is a bit overblown. Yes, it sucks getting up at 4:30 am everyday, but once your there (and awake) most of it isn't "difficult." I rarely got pimped (in fact there was only one time where I may have felt uncomfortable), I was rarely given any scut work and (this may have been a fluke because of some national conferences) I actually had time to read. Still, I quickly decided (after about 4 days) that it's not what I want to do with my life. What I loved about medicine was the opportunity to get a complete mystery and solve it with clues from your history, exam and labs. In surgery (for the most part) that is already done for you. It's a much more get in there and fix the problem kind of job. Don't get me wrong though... most of the surgeries were really cool. There are a lot of clever approaches to fixing otherwise very disabling problems (like making a bladder out of intestines). And there's nothing like cutting apart someone, hacking at bones, chopping up intestines and seeing the person functioning pretty much as normal a few days later. Here are some quick goods and bads:

Goods:
1. Most of the procedures are awesome - something not too many people get to be (somewhat) actively involved in.
2. There actually is thinking involved - surgeons have a lot of thinking on their feet to do when something unexpected happens intraoperatively. It's not just for jocks.
3. Results - for the majority of patients, the surgeries actually work! It's amazing to see the overnight transformation in patients.

Bads:
1. Hours suck - When med students are violating national hour-limit laws, I don't want to know what the residents are doing.
2. Not much to do for the student - unlike medicine where you can follow labs, actively discuss your patient, in surgery the most you get to do is throw a few stitches, hold retractors and get to open your mouth once every half an hour or so. There is a lot of standing around not doing anything, which sucks when you have to get up so early.

Advice:
1. Ask questions, very few people are enough of an asshole to call your question stupid (you'll figure out who those people are and avoid them).
2. Try to do as much as possible, ask (if you actually think you can handle it) if you could do it. This isn't a rotation to be quiet and timid on. You'll have a pretty boring experience if you don't try to actively get involved in whatever the team is doing.
3. Don't kiss ass. This goes for most rotations, but students interested in surgery tend to be the worst. Everyone ends up hating the person (including, I presume, the attending).
4. Don't fret over studying for pimping. Study what is important for your exam, but don't spend hours reading about details of an operation that you'll never think about again. The reputation of pimping is overrated... it is not what you should be worried about.
5. Always have something to read in your pocket. That way you'll read what you need for the day in your downtime, giving you more time to eat and sleep when you get home.
6. Don't volunteer for scut work just because you think it will give you a better grade. It won't and it'll be a complete waste of your time.
7. Have fun. You may never get to experience being in the OR again, so try to make the most of it. This is especially important to remember towards the end, when you're completely burnt out.

Despite the fact that it wasn't too bad... I gotta say, woohoo!! My two (supposedly) most difficult rotations of medical school are behind me. Now I get a relative vacation with 2 weeks of pathology before starting OB/GYN, something I have no interest in, but at least having a baby on the way will somewhat have me caring.

And remember, Jesus is with you... though he'll definitely get yelled at by the scrub nurses

You know you're a racist when...

2009-10-15T19:21:00.002-05:00

you have to tell people how many black friends you have.

Here's what a justice of the peace in Louisiana said after refusing to give a mixed couple a marriage license:

"I'm not a racist. I just don't believe in mixing the races that way," Bardwell told the Associated Press on Thursday. "I have piles and piles of black friends. They come to my home, I marry them, they use my bathroom. I treat them just like everyone else."

Wow! He must really not be a racist, if he thinks that black people are clean enough to use his bathroom.

Liberal Swedish Bastards

2009-10-09T13:26:00.007-05:00

This happens every year. The Nobel Prize goes to some undeserving person for political reasons. It's all a left-winged conspiracy and a big F-U to George W. Bush. I mean what has Willard Boyle done to deserve the Nobel Prize?? Nothing. Sure he invented the CCD, but isn't it a little premature to be awarding him the Nobel Prize? What do Willard Boyle and the psychotic, and (possible) cat-killer Erwin Schrödinger have in common? They both won the Nobel Prize. Clearly it's a sham.

Every year it's the same... Yoichiro Nambu, Peter Grünberg, John C. Mather, all liberal hacks who have gotten the Nobel prize only because those liberal elitists at the Nobel Foundation want to give a big middle finger to George W. Bush.

Surgery

2009-09-11T17:59:00.003-05:00

In medicine, you barely have enough time for TV. In surgery, you barely have enough time to eat and sleep. Not for me.

Although taking this monster out of someone's neck is pretty cool

The end of internal medicine

2009-08-29T16:24:00.008-05:00

Well, at least the end of it for me (for now). Wednesday was my last day of the internal medicine rotation and the last two days were the end-of-rotation exams. The rotation itself was actually pretty fun. There was some waiting around not doing anything and there were times when I felt pretty useless. But, overall, I learned a lot, saw a lot of interesting cases (and a lot of not so interesting cases), got to feel like I was the part of a team taking care of people, and got a chance to get to know some interesting people.
Do I want to go into internal medicine? It's hard to say since I only got to experience what life is like for hospitalists. I only saw the specialists tangentially. I wouldn't want to be a hospitalist (things are too hectic and once you see something interesting, you call a specialist). However, from what I saw on the wards, infectious disease and rheumatology appealed to me the most. There is a lot of detective work in both of them and a diagnosis could quickly lead to an effective treatment (Interestingly, these were the two fields that I felt I was the worst at when it came to exam questions). Radiology is still at the top of my list, but going through a more patient-based rotation does make me consider other options. We'll see as the year goes by.

Some advice...
- enjoy your time, at least with my experience, there really wasn't any pimping. There's no reason to feel stressed.
- don't let your first few days' experience set your mood for the rotation. Every time you have a change there is some awkwardness and confusion. It will also take a few days for your team to get warmed up to you. You'll find your place soon.
- don't feel like you have to stay on the wards forever. If someone tells you to leave, leave... it's not a test. You've got a lot of studying to do, and everyone on your team understands that. If nothing is going on, ask if there's anything you can help with, the answer will be "no", and you could leave.
- Spend extra time with your patients. You've got the luxury to actually spend time with your patients. If they're up for it, spend some extra time with them. The more you know about your patient, the better resource you are for the team (plus, the patient will trust you more than the rest of the team, if they've made a connection with you).
- If your school allows it, try to get some experience in a different hospital. It'll give you a better idea of what's constant and what's variable in internal medicine.
- prepare to feel defeated if you're taking the SHELF (nationally standardized) exam. Holy crap the SHELF exam sucks ass. None of my studying prepared me for that test. Even knowing what the exam was like, I don't think I could have effectively studied for it. It is not a good assessment of how much you've learned on the wards. I've never came out of an exam seriously thinking that there's a possibility I could fail until now. Luckily, everyone else in my class felt the same. And from people who have taken it in the past, the results end up being better than you expect.

Now I get a whole weekend off before Surgery starts on Monday. I start with ENT, then have Orthopedic surgery, followed by a month of general surgery.

Old song, but it's been stuck in my head ever since I saw a patient with Wenckebach heart block last month

Informed consent preventing testing?

2009-08-19T21:32:00.000-05:00

I recently saw a patient that had pneumocystis pneumonia - an infection that pretty much only occurs in immunodeficient people and is an indication for HIV testing. In many states written consent from the patient is required prior to HIV testing. Consent prior to HIV testing dates from the late 1980's when HIV was a new, stigmatized disease that was essentially a death sentence. States enacted laws to protect patients from health care workers testing them for the deadly disease without them knowing. Now, however, HIV is a treatable disease that, if caught early could allow the patient to live a relatively normal life. The greatest barrier in decrease of HIV-related mortality and the decrease in the spread of HIV is knowledge of HIV status. There was a recent study in the American Journal of Preventive Medicine that showed that states with a written consent law have a decreased rate of HIV testing than those without. And another study showed that the cumbersome requirement for obtaining written consent from the patient has discouraged physicians from performing HIV. I personally think that that HIV should not be singled out as requiring written informed consent prior to testing (I think it continues the stigma associated with HIV). Either all testing for sexually-transmitted or blood-borne infections should require written informed consent or none of them should. But, it's pretty bad that physicians are avoiding the test only because they have to obtain written permission from their patients.

Jesus is my co-surgeon

2009-08-16T20:39:00.011-05:00

The hospital that I'm working at now (St. XXXX) is affiliated with the Catholic church. I am not a big fan of mixing religion with anything, but I really think that it's unfortunate that so many church-affiliated hospitals exist. For most patients it's not a big deal and it rarely affects them. Sure, there are crosses in every room, Bible quotes in the hallways, and bright notes on the front of charts saying "Sacrament of the sick given" (apparently that's more important than "Allergic to penicillin"), but I pretty much see that as (really bad) decoration. There are some things, though, that I think are not appropriate in a place that is meant to take care of the entire community (especially since people in this half of the state really have no other choice in a major hospital).

One is that there is a rather long, loud morning prayers on the intercom every day (usually at a time when we're rounding on patients). It's not just, "let's take a moment of silence" or something else equally nonspecific... rather it is usually a five-minute sermon on what Jesus or some saint said. Even though it's a rural part of the country, not everyone is Christian or religious (and they're definitely not all catholic). The last thing I'd want to hear when I'm sick in bed (especially if it's during the five minutes that my doctor is talking to me) is what Jesus wants me to do.

What really bothers me, though, is the fact that church doctrine dictates medical decision making. Catholic-affiliated hospitals (which care for approximately 20% of the patients in the US) all follow the US Conference of Catholic Bishops' Ethical and Religious Directives . Since it affects a fifth of patients in the country, it's a must read for healthcare workers. Some of the more striking parts are:

- #24: The institution ... will not honor an advance directive that is contrary to Catholic teaching.
- #25: Each person may identify in advance a representative to make health care decisions as his or her surrogate in the event that the person loses the capacity to make health care decisions. Decisions by the designated surrogate should be faithful to Catholic moral principles.
- #36: A female who has been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization. It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum.
- #41: Homologous artificial fertilization (that is, any technique used to achieve conception using the gametes of the two spouses joined in marriage) is prohibited when it separates procreation from the marital act in its unitive significance
- #45: Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted. Every procedure whose sole immediate effect is the termination of pregnancy before viability is an abortion, which, in its moral context, includes the interval between conception and implantation of the embryo.
- #47: Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child. (pleasantly surprised about this one)
- #48: In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion.
- #52: Catholic health institutions may not promote or condone contraceptive practices but should provide, for married couples and the medical staff who counsel them, instruction both about the Church's teaching on responsible parenthood and in methods of natural family planning.
- #53: Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution. Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.
- #54: Genetic counseling may be provided in order to promote responsible parenthood and to prepare for the proper treatment and care of children with genetic defects, in accordance with Catholic moral teaching and the intrinsic rights and obligations of married couples regarding the transmission of life.
- #61: Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering.

Painting in physicians' break room. Yeah, Jesus has helpful tips for the surgeon, but when a luxurious long hair from his uncapped head falls in the peritoneal cavity, the patient won't be too happy.

I take (some of) it back

2009-08-09T23:44:00.002-05:00

So a week into my rotation in a more rural setting, I'm feeling a bit better. Last time I complained about several things, the most worrying of which was a lack of effort in teaching by the residents and attendings. I don't think I was being completely fair, since comparing a large academic hospital with a smaller rural hospital is not appropriate. The residents and attendings don't see too many medical students, so it makes sense for them to not know where we fit in the scheme of things. It took a few days, but things are going more smoothly now. Although I don't feel nearly as productive as I did at my home hospital, I also don't feel like the burden that I did for the first few days. Also, I know it's difficult for them, but they've gotten better at thinking about what would be beneficial for a med student to see or do. Hopefully the next three weeks will continue moving in the right direction.

P.S. paper charts still suck

P.P.S. everyone really is a Republican, but the blatant anti-healthcare reform postings have been removed.

More rural internal medicine

2009-08-03T21:12:00.004-05:00

I am now in a different part of the state, in a relatively small town at a hospital catering to small town communities spread over this region of the state. I'm not exactly happy with the differences in how things are run from the major academic institution that I'm used to, but I'm hopeful about what I'll gain here. Here are some differences:

1. Less specialists - there are still consults, but (so far) the consult team seems less like they run the show than they do at my academic institution. Patients with an MI are seen by cardiology, but are not necessarily taken care of by a cardiology-specific primary team. This is good news for me because I will likely get exposure to a wider variety of patients than I did back at home.

2. Slower pace - my service caps at 6!!! That is considered a light day back at home. Also, you can only take patients on your call day!! As a result everything else goes at a slower pace. I thought it would be a good thing to have more time to think about, discuss and care for each patients, but really, I think the result here is that people just work slower. On the bright side, I get out earlier.

3. Teaching - I can't say much about this since I've only been with my team for a day, but people seem less enthusiastic about teaching here. I'm pretty proactive with asking about what's going on with each patient, but it seems like I've had to ask several times to get an answer. When coming up with a plan, the resident and intern usually quickly talk about it (quietly) with each other, leaving me out and forcing me to ask more questions than should be necessary (the lack of electronic charting makes it even worse). Finally, the answers to my questions are usually very short. For example, when I ask "Should we be concerned for a pulmonary embolism?" they say "No it's not a PE" versus at home where they actually explained what argues against it. I feel a lot more like a burden here than a part of the team. Maybe it was just today (or just the specific people I've been working with), so hopefully I'll feel better about it when I get more familiar with how things are run in the next few days.

4. Paper charts - I don't care what people say about electronic charting, but paper charts just plain suck. We live in the 21st century and shouldn't have to hunt around through dozens of pages of poorly written and half-torn sheets of paper to find what we're looking for.

5. Everyone's a Republican - I expect this in more rural parts of the state, but everyone (nurses, attendings, and patients) leans pretty far to the right. I just can't respect a physician who actively watches Fox News in the break room (actually, I fear for their intelligence) and I'm really concerned about the fact that propaganda against health care reform is posted all over the nursing station. It's not fun to work in a politicized environment, especially in such a hierarchical system as a hospital.

Hopefully my opinion of this half of my internal medicine rotation changes in the next few days, but if it doesn't, at least I'll appreciate going back home (even if it is for surgery).

Equal education?

2009-07-29T20:20:00.001-05:00

Throughout third and fourth year of med school, students work with a team of residents and attending physicians either alone or with another med student. At least in internal medicine, each student has his/her own patients and reads up on and follows those patients. Different teams may specialize in different types of patients and even within a single group, the types of patients followed by one student (by chance) could end up being very different from those followed by the other. This leads to a lot of variability in what each student learns from their experience on the rotation. For example, most of the patients that I've followed in my internal medicine rotation so far have had liver disease or a bile duct/gall bladder problem. I've read up on these conditions a lot and think that I'd do a pretty good job at examining, diagnosing and treating a patient with these disorders. But other students on the rotation with me have completely different patients, some have more cardiology patients, others have more kidney patients, and each (I assume) are more familiar with those conditions than I am. I hope that it evens out soon... these practice questions that I've been doing for the final exam really shows the bias in my experience with patients. I switch teams (and hospitals... and cities) next week, so I hope to get some exposure to the type of patients that I haven't gotten a chance to see yet.

btw... (can't believe it's already been a month, only 22 more to go).

Social Health

2009-07-27T19:40:00.007-05:00

3 weeks into medicine now and things are pretty busy, but I'm having a lot of fun and learning a lot. I'm still missing a lot of the knowledge, but I definitely feel more comfortable around the hospital and with patients. One thing I've noticed though is how important social situation is to health. Yeah, it seems obvious, but working in the hospital really opened my eyes about it. Of the dozens of patients I've seen, only two of them have a stable living situation. The major reason behind this is lack of access to healthcare. People who are living stable lives likely have the resources to take care of their health and even if they have a problem that can't be prevented (like a genetic clotting disorder), they can keep a close eye on it and live a relatively healthy life that doesn't require them to be hospitalized much. People who have unstable social situations have bigger things to worry about than why their stomach hurts when they eat or why they're slowly starting to turn yellow. They don't catch their clotting disorder until they get a large clot in a major vessel (i.e. the portal vein) and get life-threatening (and much more costly) health problems like losing their liver. A little early education and a $4 a month drug could have prevented a hospital stay of several hundred thousand dollars and a death in the 20's.

72 hrs later

2009-07-11T01:18:00.005-05:00

So, as I mentioned before, we were told that we'd feel a bit more comfortable about starting the wards 72 hrs into it. Well, I just got back from my 3rd day in the wards and I do feel a bit more comfortable. I've figured out the basics of the computer system and I've gotten a little bit better with rounding, presenting patients and writing notes on my patients. So, after 72 hrs here's my impression on internal medicine (and maybe being a 3rd year med student as a whole):

The goods (in no particular order):

1. Getting to be where the action is.
Yeah, I don't get to actually do much, but each day I do get to closely follow a team of doctors debate and make many potentially life-altering decisions on several people.

2. Applying all that medical knowledge to real people
I finally see how many of those lists and seemingly endless facts finally make some sense. I'm far from being comfortable with them, but at least I get to see them applied to real life. And, applying it to real life goes a long way to putting those facts in memory. For example, knowing that low platelets can be an effect of liver failure is much easier when you've seen that Mr. X, your patient with liver failure needs to get a platelet transfusion before every procedure.

3. Talking to patients
This is actually the most satisfying part of going into the hospital. I get to spend some extra time with my patients and actually get to know them. They're pretty bored and enjoy talking to me. I feel that by spending more time with them, I get to better understand their expectations, fears and frustrations. It never ceases to amaze me how honored I feel when a stranger opens up to me and tells me everything about them.

The bads (in no particular order):

1. I'm useless.
I get to be part of a team of physicians that help make a very sick person well again, but I am completely useless. As a medical student, almost nothing I do has any consequence on the patient's stay, and the few things I get to help with, the team really doesn't need my help. Sometimes I feel like I'm in the way. The only part that makes me feel like I'm actually having an effect is when I get to relay the patient's concerns to the doctors because I get to spend more time with them (see the goods).

2. I don't know anything
This may be specific to me since I took 4 years off between finishing 2nd year of med school and starting 3rd year. I've forgotten a lot of facts. Everyone around me is nice and I haven't pimped at all, but the really easy questions that I get, I still have trouble answering. It hasn't all come back to me yet, but then again it's only been 3 days.

3. Studying
Along the lines as #2 and also specific to the fact that I took 4 years off. I've had no reason to memorize lists of facts in the last 4 years and I haven't bothered finding a good way to do it. I remember at one point in the second year of med school, I would learn the pathophysiology of an entire organ system in a week or so before the final exam. Now, I don't even know where to begin. I'm hoping this comes back to me also.

4. Of course, the hours
No matter what, I can't get used to getting up at 5 am (or before) every day. I've gotta learn to sleep earlier.

In all likelihood, these opinions will change in another 72 hours. Overall, I like internal medicine so far. I'm learning a lot and it's not completely exhausting (yet). We'll see how I feel about it as I get more into it. Stay tuned.

mfp

2009-07-07T21:32:00.003-05:00

All right! 3rd year of med school officially started and with it, after another long orientation, I got my first patient. Unfortunately, because I showed up in the middle of the day, I had to pick up a patient who has already been in the hospital for weeks. This means going through a lot of charts (dozens per day, by various MDs, nurses, pharmacists, therapists, etc.) There are two problems with this: 1) I have no idea how to use the hospitals computer system and have to click around for several minutes before I can get to where I need to go. 2) So many abbreviations! I know that doctors like shorthand, but just with this one patient, there are a dozen abbreviations that I've never seen before. Some even have multiple meanings. I've figured a lot out from context: SBP = systolic blood pressure, but SBP treated with cefotaxime is spontaneous bacterial peritonitis... seems easy to figure out, but when your eyes are glazing over the 24th progress note, its easy to confuse the two. Others, I still have no idea... the google helps, but I'll just have to break down and ask someone about some of them tomorrow.

We were told that within 72 hours most of this will make sense, but I have a hard time believing that. We'll see. Meanwhile, I gotta figure out how I'm going to preround tomorrow morning (see the patient before the residents and attending physician does) and prepare myself to present my patient to the attending (focused, yet thorough - seems like an oxymoron to me).

mfp = my first patient

I am oriented (sort of)

2009-07-06T22:15:00.009-05:00

It's finally here, the first day of third year. Today was orientation day... all day getting lectures about what to expect next year and how to survive through it. For the most part there was nothing eye-opening from the various lectures. A couple of things stood out. One was a discussion on how to get along with others in our "team" (attending physicians, residents, nurses, etc. that we are working with) and how to carry ourselves in the hospital. One administrator stated that we should remember the saying "When in Rome, do as the Romans do." To an extent, I agree with that, but not everyone in medicine provides a good example and we should judge for ourselves what is appropriate in a hospital setting and we shouldn't blindly imitate the attitudes and actions of those above us. (Luckily, another administrator quickly mentioned that we should also be a force of change to make the hospital a better place).

Along these lines, I was pleasantly surprised that the med school and hospital are largely aware that the environment of medical education isn't perfect and seem to be working to improve it. I wasn't surprised by the report (of med schools in general... not just mine) that abuse of students is fairly common. To deal with it, a recent addition to our school is the implementation of an on-line method to report inappropriate behavior or abuse by others in the hospital. The report goes to an ombudsperson who is not a physician and has no relationship with any medical department. Although it is sad that such a system is necessary, it's nice that a lowly student can bring inappropriate behavior to light without fear of reprisal by those above them (something several students I know who have gone through med school before me have complained of).

Anyway, enough with the bad stuff... Tomorrow is orientation for my first clinical rotation: internal medicine. I'm fairly excited to start (though not excited about the hours) and will hopefully be able to relate some of my experiences here (really, more for myself than my three faithful readers, but you guys might find it interesting also).

Well, I guess we've gotta keep it

2009-06-23T23:22:00.002-05:00

Tapes of Richard Nixon discussing his views on abortion were released today. Here's one of his opinions:

“There are times when an abortion is necessary. I know that. When you have a black and a white,” he told an aide, before adding, “Or a rape.”

Only 36 years ago, an American president said this... amazing. Since I'm only "a brown", not "a black," I guess we'll have to keep my unborn child (which, by the way will - hopefully - be born late Dec or early Jan... I'm glad my tough med school rotations will be out of the way by then).

Death comes easy

2009-06-23T00:42:00.004-05:00

I've seen patients whom I knew were going to die and I've seen patients who died after I was in contact with them, but recently, I saw, for the first time, a patient die in front of me. I'm not much of an emotional person, but I thought that it would affect me more. Instead, it felt like nothing. I suppose it could have been the fact that I never got to know the patient (she had been in cardiac arrest for a while before I saw her) or that it was pretty busy in the room with people performing multiple procedures and shouting various orders or that no one else seemed especially moved. Maybe I was too concerned with not messing up the small part I was given to save this person's life. Either way, I suppose a certain amount of detachment is necessary to efficiently (and rationally) treat the patient. I just didn't think that I would reach that state of detachment without even trying.