Saturday, July 30, 2011

Weekly Whine: Bank of America

Back when I was a naive little freshman college student, my parents helped me start up my own bank account in the town where I was going to school. There was a Bank of America right on campus on they were offering some good no-fee deals to clients under age 19, so I opened up an account there.

It was fine while I was in college, but at some point around when I graduated, they made up some rule that if you didn't have over $2,000 in checking, you had to pay like $20 per month. So began a frustrating ritual of trying to keep over $2,000 in my checking account because I was too lazy to just close the account.

I was just a poor med student then and it was hard to look at a bank account with $2,000 and desperately need money, yet not be able to touch it.

One day, I had $2,021 in the account. I needed money, so I withdrew $20, thinking I would still be safe. Except unbeknownst to me, the ATM fee was $2.50. So I was a dollar and fifty cents below the cutoff. I didn't realize this error or replenish the account for about three months, and I was furious that I had just lost $60 over nothing.

I angrily went to the nearest Bank of America branch and angrily told them I was shutting down the account. They tried to dissuade me with temptations of fee-less accounts, but I didn't believe them. I closed the account.

Six years later......

I got a letter from a collection agency saying I owed like $70 to Bank of America. They said that the bank was going through their old files and collecting accumulated fees on dormant accounts. Except I didn't have a dormant account. I closed my account six years earlier, which is why I had no money in their bank and had not received one piece of mail from Bank of America in that time until this letter from the collection agency.

It's a good thing they had pissed me off so much that I vividly remembered closing the account.

I had to call Bank of America. It took them a while to find my old account, because I couldn't remember my address in med school. And also because it had been closed six years ago. Which they quickly confirmed.

They called off the collection agency goons and I followed up to confirm my credit wasn't being ruined by a nonexistent bank account.

The whole thing made me furious, much more so than the first time. Were they just sending collection agencies after everyone who'd ever had an account with them, hoping that it was a small enough amount of money that people would get spooked and just pay it? Considering how hard it was for them to find my account and how easily they confirmed it was closed once they did, I find it hard to believe they legitimately thought I owed them money.

Anyway, good job, Bank of America. I will never open an account with you ever again. And I will tell everyone I know how much you suck.

Friday, July 29, 2011

The 5 Different Kinds of Consults

Wanted to make a cartoon out of this, but just couldn't make it work. So here it is, in boring prose:

The Five Different Kinds of Consults

1. The "Out the Door" Consult
"I've got a consult for you. We're trying to figure out how to manage this patient's meds while they're in the hospital."
"Okay..."
"But you need to see them in the next ten minutes because they're about to go home."

2. The "Afterthought" Consult
"So I've got this patient... he's pretty sick..."
"It's five o'clock. Is it OK to see him tomorrow morning?"
"No, he needs to be seen now. He's sick."
"So why did you wait till 5 to call? Never mind, what's his MR number?"

3. The "Just Because You're Here" Consult
You sit down to eat your lunch...
Someone at table: "So what service are you on now?"
You: "_____ Consult."
Someone: "Oh really? Hey, I have a consult for you..."
You: "No, you don't."

4. The "I've Blessed You With a Consult" Consult
"So I've got a really interesting patient for you..."
"Uh.. thanks?"

5. The "Least Important Consult Ever" Consult
"So I've got this patient. He's septic with pneumonia and he's been intubated. His oxygen sats are in the 70s and he's got pus filling his pleural space. He's also got heart failure."
"What's the consult for?"
"I think he has osteoarthritis is his knee."

Wednesday, July 27, 2011

Tales From Intern Year: How to call a consult, Part 2

My experience attempting to get one of my ICU patients chemo:

"Oncology consult."
"Hi, I'm the intern on Black Medicine and I'm calling about the onc patient you're following, Mr. Murphy. We got his meta-port in and we'd like him to get chemo today."
"Oh, okay. In that case, just call the chemo pharmacy and tell them to start the patient's chemo."
"That's all I have to do?"
"Yes."
"Nothing else?"
"Yeah."
"Okay, great."



"Operator."
"Hi, can you please transfer me to the chemo pharmacy?"
"Huh?"
"Uh... the chemo pharmacy."
"I can transfer you to the inpatient pharmacy."
"Uh... fine."



"Inpatient pharmacy."
"Hi, can you please transfer me to the chemo pharmacy?"
"You mean you don't want to talk to us?"
"Uh..."
"Okay, I'll transfer you."



"Chemo pharmacy."
"Hi, this is Dr. Fizzy from Black Medicine and I'm calling because we want to start chemo today on Mr. Murphy. I called onc and they told me to call you and let you know you could start."
"All right. We need to have the chemo orders faxed over here."
"What? Onc told me I just have to call you and that's all."
"No, we need those orders faxed over. What time do they plan to start?"
"I don't know."
"We need to know what time they have to start."
"Why?"
"Because the medications need to be coordinated with the chemo nurse's arrival."
"Chemo nurse?"
"Yes, you have to contact a chemo nurse. A regular nurse can't administer the chemo."
"Oncology told me I just have to call you and that's it."
"No, we can't send the medications without the orders faxed and a chemo nurse."
"Okay, I'll call back. Just give me your number so I don't have to go through two operators again."



"Oncology consult."
"Hi, I was just talking to you earlier about Mr. Murphy. Now the chemo pharmacy is telling me they need a special nurse and they need to know what time you're going to start.
"Why do they need to know that?"
"Because they have to coordinate it with the chemo nurse."
"Well, we won't know when we're going to start until--"
"Look, can I please give you the phone number for the chemo pharmacy? I can't go back and forth like this. I need to go find a chemo nurse somehow."
"Okay, fine."


Ten phone calls later, the chemo was finally arranged. Then:

"Dr. Fizzy, Mr. Murphy's meta-port is clotted off. We can't use it."

Monday, July 25, 2011

Tales from Residency: Lunch with attendings

When I was in residency, everyone would get lunch in the cafeteria, including the residents and the attendings. Often when the residents were sitting in the cafeteria, the attendings would come over and join us. We didn't like this.

It wasn't that we disliked the attendings exactly. But in residency, all we really enjoyed talking about was how much our program sucked, how much the other residents sucked, how much the attendings sucked, and how much being a doctor sucked. But if the attendings sat with us, what was there left to talk about? Our favorite on Dancing With The Stars?

There was one attending that the residents especially did not like, who I privately nicknamed Dr. Blabber, due to her propensity to talk to patients WAY too much during rounds, especially weekend rounds. Anyway, I remember one day a bunch of us residents were in the cafeteria eating and Dr. Blabber walked into the cafeteria with her tray.

Resident #1: "Don't look at her! Don't make eye contact!"

Resident #2: "Oh fuck, she saw us!"

And approached our table and things became SILENT. The last thing I wanted to hear during my lunch break were some condescending comments from Dr. Blabber. Like if we started bitching about some inappropriate consult, she would start asking about the consult and say, "That consult must be staffed NOW."

Then one of the residents came up with a brilliant idea. "You can't sit here," he said. "We're having a resident meeting."

I felt a little guilty about that one. And moreover, we couldn't do it every day. Of course, now that I'm an attending, I feel new sympathy for those attendings, but at the time, it seemed so unfair that we only got a short lunch break and we were forced to spend it making awkward conversation with attendings.

Sunday, July 24, 2011

Weekly Whine: Bad Roommates (Part 2)

As nutty as my roommates were in college, my med school roommates were much more irritating.

I lived in a four single-bedroom dorm suite in med school. It was a suite in that we shared a kitchen, but there was really no common area, aside from a small table with two chairs in the kitchen. I lived there for about two and a half years and roommates would come and go, some med students, most not med students. But the craziest roommate I had was a med student. We'll call her Teresa.

Teresa was an MD/PhD student in my class, and she didn't move in to my suite until some time during second year. She was very quiet, but always seemed nice enough. But as a roommate, she was odd and sometimes slightly frightened me.

She and I shared one of the two bathrooms and she was really odd about her bathroom use. With prior roommates, we had worked out some kind of system for the toilet paper, or else one of us would just replace it when it got used up. But Teresa insisted on carrying her toilet paper around. So I would hang toilet paper on the roll and she would bring hers into the bathroom with her. I was honestly OK with her using my toilet paper, but I guess she didn't trust me or I don't know what.

She also had this habit that drove me crazy: whenever she was done in the bathroom, she would leave the light on and shut the door. I have no idea why she did this, but it wasted electricity and always made me think there was someone in there. Finally, I just started bursting into the bathroom when I needed it, because I was sick of knocking on my own bathroom door every single time.

She also would not let me leave dishes in the sink. I was hardly a slob who left tons of dishes in the sink, mostly because I only OWNED two plates and two cups. So I simply didn't have many dishes to leave in the sink. But I would put, say, a cup in the sink, and I'd come back an hour later to find that Teresa had removed it from the sink and placed it on the kitchen counter. Every single time. Why did she do this? I still can't figure it out.

OK, but this was the frightening part:

As I said, I only had two plates and two cups. Additionally, I only had two forks. I had lunch earlier in the day with my boyfriend and we'd used up both forks, and I was feeling lazy and didn't want to wash them before dinner. So I did something really, really, really horrible and I borrowed one of Teresa's forks. Seriously, I don't know what I was thinking.

I did clean the fork after using it and then put it in the drying rack. Then later that night, Teresa banged on my bedroom door.

Teresa: "Were you using this fork?"

Me: "Um... what?"

Teresa: "I found this fork in the drying rack. Were you using it?"

Me: "I... I'm not sure."

Teresa: "Because this is MY fork."

Me: "Oh. I didn't realize. I, um, found it in my dishrack." (Lie!)

Teresa: "It was in your dishrack???"

Me: "Yeah, well... maybe someone put it there."

Teresa: "Wow, that's really strange."

Me: "Uh.. I guess. I don't know."

Teresa: "I've been knocking on everyone's doors trying to figure out what happened with the fork."

Me: "Uh... I'm sorry. I didn't realize it was yours."

Teresa: "See how the handle is white? All the utensils that look like that are mine."

Me: "Oh, okay. I see."

Needless to say, Teresa and I never became great friends or had any heart to heart discussions during our tenure as roommates.

Friday, July 22, 2011

Tales From Residency

Attending: "Where was the level of your spine injury?"

Patient: "I think it was C-12."

Attending: "Uh..."

Patient: "No wait, I think it was B-12."

Attending: [hysterical laughing] "That's a vitamin!"

Thursday, July 21, 2011

Tales from Med School: Pay It Forward

When I was in med school, about 16 of us were at a Chinese restaurant to celebrate a friend's birthday.

One girl at the table was very loudly relating a story that happened to her during anatomy. Her partners were straightening out the plastic covering on top of their cadaver and she was standing on the other side of the table. Anyway, as her partners shook out the plastic, she ended up getting drenched in "cadaver juice," including getting some in her mouth. Yes, this is what med students discuss during meals.

Anyway, when one of the girls in our party went to get our check at the end of the meal, this older guy who was sitting at the next table told her not to bother, that he was going to pay it.

"You know, there are SIXTEEN of us," the girl told him.

"I know," he said. "My nephew is a med student and you guys work really hard and have enough financial troubles."

So he paid for our entire check.

We were floored. The guy at the cash register told us that the man came in a lot and he was apparently pretty rich. Still, it was such a nice thing to do! I'll never forget it.

I can't help but think maybe someday in the future I'll have the opportunity to do something nice like that for a bunch of young people. Maybe someday when I'm not paying $40,000 per year in childcare.

Wednesday, July 20, 2011

Answers to spellcheck

In case you haven't yet taken my quiz on Microsoft Word spellcheck, you can still do so here.

The words on the list that Word thought were misspelled were:
atrial, stent, extravasated, intubated, embolization, neurologic, arousable, hemianopsia, hematoma, parenchymal, rhonchi, and physiatrist

They get you in the bathroom too

I don't like having my bodily functions restricted, and medicine is a field that tends to do that. For example, medical training often limits when you can eat and sleep. I suspect if there were a way for training to limit breathing, they'd do it.

But worst of all is being limited when you can go to that bathroom. I mean, that's a pretty primal need. One thing I love about my job is that there are three clean bathrooms on my unit. And if I'd like more privacy or those bathrooms are full, all I have to do is walk down the floor and there's another SIX bathrooms away from patient care areas. It's basically heaven to me.

It wasn't always so.

The worst bathroom time during training is during surgery. Since I'm not a surgeon, I only had to tolerate this during med school, thank god. I would refuse to drink anything in the morning so I wouldn't have to pee during the first surgery. Sometimes I'd be so thirsty, so I'd go to a water fountain and just wet my tongue, but not actually swallow any water. It was kind of insane.

When I was an intern, I found it incredibly annoying when I'd get paged while in the bathroom. I remember one call when I was paged overhead while in the bathroom. Apparently, the nurse paged me to my pager first, but she couldn't even wait the sixty seconds for the page to actually make it to my pager before paging me overhead.

When I heard the overhead page, I assumed there was something really important going on, so I came running. It turned out it was about an elevated blood pressure. And the patient in question had had elevated blood pressures all night. I was livid. I started yelling, "You can't even take a piss in this place!" (My finest moment.)

As an inpatient resident, while about 7-8 months pregnant, I was in the middle of working on the rehab unit on a rather busy day, when I got up to go to the bathroom (often an urgent need when 7-8 months pregnant). A nurse saw me leaving and said, "Wait! You're leaving?? Don't go!"

Me: "I'm just going to the bathroom. I'll be right back."

Nurse: "Yes, but first I need you to--"

Me: "Please let me go pee!"

At that point, I heard some other kind nurse call out, "Let her pee!"

I was allowed to pee.

Tuesday, July 19, 2011

Spellcheck

I was writing a history and physical in Microsoft Word (not the latest version though) and I was actually very surprised by some of the words that it did and didn't recognize. It's even harder than telling a My Little Pony from a porn star. Care to test your luck?

(No cheating by typing the words into Microsoft Word!)

Which of these words did spellcheck think were spelled INCORRECTLY?




Sunday, July 17, 2011

Tales from Residency: Ultimate scut

One day during residency on an inpatient rotation, my attending came into my office, "Hey Fizzy, would you mind doing some scut for me?"

He always phrased it like that, which drove me crazy. If you want me to do something on my patient, just tell me what it is. That's the job of a resident. I actually never minded scutwork that much.

But instead of saying all this, I said, "Sure."

"So remember Mr. Jones?" the attending said.

"Um no," I said. "He must have been a patient before I was on service."

"Oh," my attending said. "Well, I need you to call this gym where he wants to get physical therapy, write a prescription for the therapy, and figure out how to send it to them."

I can't say I never did this before, but I REALLY hated it when attendings asked me to write prescriptions for patients who I'd never met, that I didn't know anything about. There was one attending who possibly didn't know how to write orders or something, because whenever we'd be in clinic and the attending would get a note saying some patient he'd seen needed, say, an MRI, he'd hand the note to whatever resident was standing next to him and say, "Order this." I think it's a little unethical.

Therefore, I wasn't thrilled about this particular little piece of scut on a patient I didn't even know. I talked to the social worker about it to try to figure out how to get the prescription over to the therapy place and I apologized for my lack of knowledge, "I don't know this patient at all."

"You're writing a therapy prescription for a patient you never met?" the social worker asked me incredulously. "Wow, that's kind of awkward."

"YES. IT IS."

The kicker was that after spending about thirty minutes working on this, it turned out the patient had met all his therapy goals and didn't need the prescription after all. I think that was the day I solved the mystery of why my attending was at work till 9PM every night.

Saturday, July 16, 2011

Weekly Whine: I'm not cute!!!!

I recently placed a consult on a patient to another service. When I asked the consultant for her opinion on the patient, her response was, "The patient thinks you're really adorable."

Okay then....

Honestly, I can't tell you how often I get told that I'm "cute" or "adorable." It happens with alarming frequency. This is great when the person who thinks I'm cute is that hot guy in 5th period math. Not so great when the person is a patient or an attending. Which it obviously always is because there's no math class and certainly no hot guys around.

Here are a few more examples:

1) When I was an intern, there was a nurse who once addressed me as "little one." That was seriously what she called me. My resident was laughing so hard, I thought she was going to pee in her pants.


2) I witnessed the following conversation:

Nurse #1: (to patient) "Your doctor will be in very soon." (to second nurse) "Who's the doctor?"
Nurse #2: (pointing to me) "She is."
Nurse #1: "Really?"
Nurse #2: "Yes."
Nurse #1: "No..."
Nurse #2: "Yeah, she is."
Nurse #1: "Her?"
Nurse #2: "Yes."
Nurse #1: "No.... really? Her?"
Nurse #2: "Yes!"
Nurse #1: "That's so cute."


3) Also during my intern year, our sister team's attending Dr. Brown was in the room talking to her team. They were about to go into the other room to talk, but before they left, Dr. Brown patted me on the head. It was so freaking random! She wasn't even talking to me or dealing with me in any way.

Me: "Uh, why did Dr. Brown just pat me on the head??????"

My resident: "Probably because you're so cute, she couldn't resist!"


4) During residency:

Patient to my attending: "Your assistant is so cute!"

Attending: "She's actually a doctor."

Patient: "Really? She looks so young!"

Attending: "Well, she's a doctor in training."

Patient: "I can't believe someone so young could have gone through four years of college and eight years of medical training."


5) A few weeks ago:

Me: "I feel kind of bad that I keep consulting the urologist so often. I hate to bother him."

Nurse: "Oh, that's okay. He thinks you're adorable."


I don't get it. I seriously don't think I'm all that cute. I'm really not.

Friday, July 15, 2011

Painful blood pressure

I have undoubtedly had my blood pressure taken hundreds of times in my life. Considering I've been to dozens of doctors in my life, been hospitalized or in the ER multiple times, this has really added up. It's not something I ever minded. I mean, who cares about having their blood pressure taken?

However, during a recent hospitalization I experienced the most painful blood pressure cuff of my life.

I had my pressure taken about three times a day. An automatic cuff was used and no matter what arm was used, it was killer on my upper arm and my hand was tingling all over by the time it finished.

I have relatively small girly arms, so I usually have the problem of cuffs not getting tight enough. I've never experienced anything quite like this. I would try to really meditate and relax myself prior to the vitals being taken because if my SBP was higher than 130, they had to take it again.

I finally asked a nurse why the blood pressure cuff hurt so much. She said hospital cuffs always hurt more. Wha?

Thursday, July 14, 2011

What you learn during intern year



Note: This cartoon was inspired by the always wonderful Jess.

Wednesday, July 13, 2011

The Science Fair Project Dilemma

Note: I wrote this when I was 13. I found it recently and thought it was amusing.

Every year since I started kindergarten, I've been required to do a science project that would count for some sort of grade. It was easy at first, since I could come up with ideas such as "Where do birds fly in the winter?" and print this in giant capital letters on a piece of oaktag, writing "SOUTH" at the bottom of the page. Of course, these were the days when a stick figure of the main character was an A-plus book report. Need I say more?

When we are forced to make fools out of ourselves by presenting our science project in front of the entire class, I find that my schoolmates had the same problem as I did. They waited so long to choose a project, they had to resort to choosing one from one of those books called "Easy Science Experiments to do at Home." My easy science experiment was recycling newspaper, only I couldn't get the paper to turn white and it kind of crumbled up when I touched it. I wound up soaking a piece of store-bought paper and pasting it on oaktag as the finished product. Hey, I know I'm not alone on this.

So on the due date of our science project, we all come to school lugging around a folded piece of oaktag (except for those so cheap, they just pasted a bunch of looseleaves together) and a huge box or other sort of contraption. Nobody wants to go first, but nobody wants to bring their project back home.

The first project up is an interesting one. It is related to botany. "My project is called 'Under What Conditions Will Plants Grow Best?'" the student tells us, although this is written very plainly in flourescent rainbow colors on top of the poster. "What I did was I put one plant on my windowsill, one in my freezer, and one on the heater, and every day I measured how much the plants grew. My hypothesis was that the one on the heater would grow fastest because people say that sun is very good for a plant and the heater is like a sun. Only my hypothesis was wrong because the one on the windowsill grew fastest. I made a graph of each plant, but the ones on the heater and in the icebox didn't grow at all, so I just drew a straight line at zero. Any questions?"

Someone in the back raises his hand, "What kind of plant did you use?"

Student: "Well, I'm not really sure because I got the seeds from this old lady on the street. I'm not even sure they were all the same plant, but they're probably some kind of bean plant."

Another hand, "Did the one in the freezer not grow because it was too cold?"

Our little scientist shrugs, "I'm not really sure, because my freezer isn't that cold. I mean, I've had ice cream melt two times in there. It might also have been because I didn't water it."

"Why didn't you water it?"

"Oh," the presenter laughs, "um, I thought that since there was so much water in my freezer, it wouldn't need any more."

The teacher poses a question, "There's something I don't understand. How could you possibly think you could grow a plant in a freezer with no light or water! And I don't know how you came up with that connection between the heater and sunlight!"

"I think I read it somewhere," the student replies, "any more questions?"

When no hands go up, the student takes a seat.

The next kid comes up with a huge poster, titled, "Is Mother Nature a Girl or a Boy?" Underneath is what looks like a picture of a piece of broccoli (a tree, maybe).

"What I did for my project," he begins ceremoniously, "is choose ten terms that have to do with nature and I figured out whether it is masculine or feminine in other languages. My hypothesis was that Mother Nature was a girl, but it turned out she was a boy. Any questions?"

"What if a word is masculine in one language and feminine in another?"

He hesitates, "Well, actually, I only used one language."

"What language?"

Another hesitation, "Well, actually, it was pig latin and I made different vowels stand for either masculine or feminine."

"What words did you use?"

The student thinks for a minute, "I used park, tree, flower, leaf, grass, bugs, tree trunk, the little animal squirrel-things, soil, and dog-droppings."

The teacher stands, "That was an, uh, very nice project, and I think that will be the last one for today. In fact, that can be the last one this week. Why don't you all bring your projects home and just bring in a terrarium on Monday. You're dismissed, so go home and try very hard not to come back."

Tuesday, July 12, 2011

Tales from Med School: The Honor Code

Did your med school have an honor code?

Mine didn't when we started. Some people in my class thought we needed one and that it would have all sorts of benefits for us, such as being given extra time at the end of the anatomy practical to look at the pins we weren't sure of. Some people in the class worked real hard and we got our honor code. Hurrah!

Except, not exactly.

We elected an Honor Code Committee to uphold the code. It was great for a little while, but then it felt like they were less of a committee and more like the police. Actually, more like the gestapo.

For example, sometimes we had large lectures that were mandatory, so there was a sign-out sheet in the back of the room. And there were some students who would sign the sheet at the beginning of lecture and then leave. Is this ethical? Not really. But I think it kind of sucks that a friend of mine got turned in by her own roommate for doing this once, and had to stand before the dean. It wasn't like she was cheating. And this doesn't encourage a sense of harmony among classmates who are already competitive by nature.

But OK, maybe you think that skipping lectures is really unethical and she deserved to be turned in. And maybe you're right. But it got worse. By third year, there was one honor code committee member that I was literally afraid to talk to because I was scared of being reported. Our conversations would sound like this:

Him: (casually) "I didn't see you in class yesterday."

Me: "No, I have a bad cold, so I told the professor I wasn't feeling well and he said it was okay to go home."

Him: "Really... you don't LOOK like you have a bad cold..."

Me: "But I do. I swear, you can ask my roommate, I was really sick all day. I SWEAR, FOR THE LOVE OF GOD PLEASE DON'T TURN ME IN!!"

So basically, I was not a fan of the honor committee. Perhaps a med school class doesn't have the personalities to handle the responsibilities of an honor code.

Monday, July 11, 2011

Tales from Intern Year

During my intern year, I learned a very important lesson:

Never let the family of your patient see your very detailed discharge summary, unless they are already out the door. I can do without being questioned on every sentence of my discharge summary.

Wife of patient: (furious) "You doctors keep saying that he has sinus problems, but he doesn't. He can breathe fine. This is a mistake!"

Me: "Where did I say he had sinus problems?"

Wife: "Right here! You wrote he had sinus bradycardia!"

Me: "Sigh.

Sunday, July 10, 2011

Work hour rules

I have some friends still in residency and I've been discussing the new intern work hour restrictions with them. In case you haven't heard, the new ACGME rules restrict interns to working more than 16 hours per shift.

When I was an intern, we did 30 hour calls. After being awake for 30 hours, my brain was really fried, and like studies have shown, I both felt and acted slightly drunk. So I agree that 30 hour calls are not a great idea.

My residency program, trying to be progressive, switched the interns to 16 hour calls at the end of my intern year. So I have some experience with this.

Funnily enough, as much as we hated the 30 hour calls, we didn't like the idea of switching. We didn't like the idea of doing hand-offs and had come to believe that there was education in following a patient through their first 24 hours after admission. Plus we got to be post-call the next day, which was especially nice when we had an easy call where we got 5-6 hours of sleep.

Unfortunately, the 16 hour shifts were kind of a disaster. The big problem was that the interns couldn't get their work done in 16 hours. So instead of leaving by 10PM, they would end up leaving at midnight or later, and not get the requisite 8 hours off before returning to work.... and then have to put in a full day of work the next day.

And it only got worse when the new interns started, who were more slower and more inefficient.

Ultimately, I think the 16 hour shifts are a good idea, but I don't know if it will necessarily make life easier for interns. Unless programs are really strict about getting interns home after 16 hours, I suspect that there are going to be a lot of interns who end up basically working most of the night and then not even being post-call the next day.

Saturday, July 9, 2011

Weekly Whine: Bad Roommates (Part 1)

I've had a lot of bad roommates over the years. I've had a lot of good roommates too. I've had roommates that I adored and made my life so much better. But somehow I remember the bad ones better.

When I started college, the students were assigned freshman roommates based on our interests. That's how I ended up in a suite with five other "science" girls, even though most of the other girls on our floor were English or History majors. By "science," I mean that two of us were math majors (me and one other girl), three were chem/bio (i.e. premed), and the other I'm not sure about but she was definitely taking chemistry.

Despite our "similar interests," we didn't really get along. We were the only room on the entire floor that decided to all live in different dorms next year... and basically, never speak to each other again. Mostly, I thought the premed girls were batshit crazy.

I wish I could remember every detail of their craziness. I wish I had recorded it for posterity, but I didn't. But I do remember that the two that I actually shared a room with had really weird sleep schedules.

My sleep schedule then was what I'd consider typical for a college student. On weeknights, I'd hang out with friends till midnight or so, mess around on the internet for a half hour, then go to sleep. I'd then wake up 15 minutes prior to my first class the next morning. Weekends or nights of big assignments due, I'd sometimes be up much later.

One of the premeds I roomed with had the sleep schedule of my grandparents. She would go to sleep at like 9PM every night and wake up around 5AM. To study. Every day. On weekends, it was particularly weird because I'd generally be arriving home just as she'd be waking up for the day. She also spoke with zero inflection in her voice. It was sort of like living with Rain Man.

The other premed I roomed with did appear to have a life outside of being premed, but she was also very intense about studying. One thing she used to do that drove me nuts was she'd set her alarm to go off in the middle of the night so that she could study. Like at 3AM, her alarm would go off. And because she didn't really want to wake up at 3AM, she would snooze it a few times. At 3AM. I wanted to murder her.

The second roommate had a nasty temper and the rest of us were all terrified of her, but she only inflicted it on me a handful of times. One of those times was when there was a fire drill in the middle of the night and I failed to wake her up, and apparently just left her there to die. I thought she should have thanked me because the fire alarm in our dorm went off like 4-5 times per month and I wished I could have slept through it.

Anyway, even though I was taking premed classes, I was technically a math major. Near the end of the year, one of my premed roommates found out I was taking chemistry and orgo, and she was shocked that I was considering med school. "That's impossible!" she said. "You're too laid back to be premed!"

She probably meant it as an insult but I took it as a huge compliment.

Part 2 (someday): My batshit crazy med school roommates

Wednesday, July 6, 2011

Tales from Intern Year: Cross Cover, part 2

This is an email we got during intern year from the (usually very nice) intern currently doing the cross cover rotation, just to prove I wasn't shitting you about the sign outs people would give:


A few things that have been stewing that I wanted to get off my chest beforeI have a meltdown and buy a 12-gauge (and I don't mean a needle) and go medical on all of you. They relate mainly to cross-cover etiquette, issues that at this time of year really shouldn't be happening anymore, but for some reason they still are.

1. Pt location: I understand that the staff sometimes randomly moves patients around, and people in EAU going to floor/TCU don't have bed assignments when you sign them out to me, but some patients don't have their locations updated for days. When you ask me to f/u Pulm rec's, the first thing I do is look for pt location. If the signout sheet says TCU, and I go there only to find the pt has been in 3C (and has been there for the last two days), I will be pissed. Usually I am helpful and update the pt location for you on the signout sheet (that's usually _after_ I go to the wrong ^%&*%^$ place). Sometimes I find I have to do that a few times in a row. If that happens, I will be pissed. Why should I have to second-guess your signout sheet, go to a computer, log in, get on MDwebstation, type in pt's MRN, and find the pt's location while all you had to do was spend a few seconds to be on top of the info on your signout sheet? Why should I have to spend an extra 20sec to 2min to find the exact room by scanning the pt chart rack or pt list when all you had to do was spend 5sec extra to input the pt's actual room number instead of the lazyass "TCU" or "4C"?

2. "F/U GI rec's": I have no problem following up rec's, but in the last few days I have noticed several people signing out to me in the afternoon when the rec's were already in the chart by morning. If you want me to f/u rec's you should make sure they are not already in the chart by the time you sign out. If you are post-call, I will let innumerable things slide, but if you are not post-call you've got no business asking me to do your *&&^()*^ job for you. One of you was so blatant about it that when I opened the chart, I saw the consult note on the left side, and lo and behold, your progress note on the right side, dated after the consult note. I was already talking about this today with a previous x-cover, and just now during this current shift it happened to me again. I swear, if this happens again, I will not hesitate to let the offending parties know the deepest darkest feelings of my heart during signout, regardless of how many other colleagues are sitting around in the room waiting to sign out.

3. Picking up signout sheets in the AM: most people are good about this, but some are not. If you don't want to know what I wrote on the sheet, that's fine, but then I will just stop writing on your sheet in the future.

4. "F/U PM P7": do you REALLY need to check a PM P7? If your patient has no previous electrolyte abnormalities, is not on diuretics, is not on massive doses of IVF, is not vomiting, pooping or peeing more or less than normal, maybe you should reconsider that reflexive "f/u PM P7". I've noticed an order of magnitude increase in "f/u PM P7" since my last x-cover rotation earlier last year, and most of them are either stone cold normal or somebody will have something like an iCa of 1.13. Stop the press! Call RRT! Infuse that Ca gluc STAT! Somebody should get me a razor blade and draw me up a hot bath STAT.



Of course, after that email, we were all terrified to sign out. It was almost funny. I watched my co-intern sign out a PM chem panel for him to check and she quickly added, "I didn't want to order it! My resident made me!"

Then a few days later, I was transfusing my patient who had the hematocrit of 7 and I ordered a post-transfusion CBC. I told the cross cover intern I was ordering it, "But you don't have to follow it up!"

"Are you sure? That's a pretty low crit."

"Uh, I think it'll be okay!"

Tuesday, July 5, 2011

Grand Rounds, Vol 7 Number 41: An Ode to Trainees

I attended my very first grand rounds as a third year med student. The talk was given by my former pathology professor to a large auditorium packed with students, residents, fellows, and attendings. I don't remember the topic of the lecture, but I do remember this:

Midway through the lecture, the professor called on me. In an hour-long lecture, he called on one person out of 200 in the audience, and somehow that person was me. I almost choked on my cinnamon-raisin bagel.

I wish I could say I gave some brilliant answer and impressed everyone in the room. I didn't. I was so stunned at being called on that I just sat there in silence, desperately hoping maybe he was actually calling on some pathologist in the audience with the same name as me. Eventually, he moved on.

All in all, not my favorite grand rounds.

But this week's grand rounds are going to be awesome. I'm dedicating it to all the medical trainees that got humilated during lectures, pimped during rounds, or tried to answer three beeping pagers at once.



I've divided the submissions into different categories. We'll start out with the scariest week of the year....

OMG, it's the first week of July!!!!!!!!!!



July is considered the most dangerous time of the year to get sick and Medaholic explains why. Except in my residency, the new interns started in mid-June, obviously a dastardly ploy on their part to turn the system on its head.

We also have GlassHospital talking about first days and transitions and being asked about a rash on the first day of med school. I can relate:



And LicensedtoPill takes us through a typical hospital orientation.


Now some anecdotes...



The always hilarious Dr. Grumpy tells how his former attending dealt with a difficult patient. Go.Treat.Heal explains why med students shouldn't be trusted with sharp objects.

Chris McCulloh tells the story of how he nearly (accidentally) cursed out an attending physician. We have some Q&A's between a trainee and the trainer. And finally, Gizabeth Shyder tells of her experience with rectal exams in training. (Rectal exams = always funny)


Opinions

As it turns out, people on the internet like to give their opinion on stuff. I know, it came as quite a shock to me too. As such, I got a lot of submissions expressing opinions on the medical training process.

For example, are the changes to the MCAT a good idea? What should nurses in training wear? How important is learning a good physical exam? And do women in training need to act like men in order to succeed?

And then there are the opinions on the training process itself, such as should med students be trained like Navy SEALS? Is 3rd year of med school harder than it needs to be? And what about resident duty hours?


Wisdom and Advice



Finally, some bloggers have been kind enough to share wisdom and advice for readers through all stages of medical training:

Pre-clinical: Action Potential shares some hilarious questions she'd like to ask her doctor now that first year is over.

Third year: Diagnosing Chaos shares lessons learned on first day of 3rd year.

Fourth year: Happy Hospitalist weighs in on 4th year rotations he recommends for becoming a hospitalist. Or if you are interested in Family Medicine, this is how Dr. Pullen made his decision.

Residency: 33 Charts has some advice to new interns. Gravity Circus gives advice on how not to sleep through your pager while on call. I could have used this advice when I somehow fell asleep on top of my pager as an intern.

And beyond: And of course, who learns as much as during their first year as an attending?

Lastly, we have a moving post from Solitary Diner about how her father's cancer diagnosis shaped her development as a physician.

That concludes this week's grand rounds. Since I received so many great submissions, I'm afraid I did not include ones that were off topic. If you feel there's anything ultra fabulous that I missed, please leave the link as a comment so readers can view it.

Next week: Check the calendar for updates on who will be hosting.

Monday, July 4, 2011

Tales from Intern Year: Cross Cover

Top 10 Most Annoying Cross Cover Sign-outs

(Just for review, sign-out was when the day teams handed their patients over to me for the night, along with a little blurb about the patient, what could possibly go wrong, and things that need to get done overnight.)

1. The "do my dirty work" sign-out

"I want you to check the cardiac enzymes."
"Okay. And what should I do if they're positive?"
"Hmm.... good question. I guess you should heparinize the patient."
"Okay, is he guaiac negative?"
"I didn't check."
"Damn it, are you signing out to me a rectal exam to do???"

2. The "be the bad guy" sign-out

"This patient is really drug-seeking. Try not to give him morphine."
Later that night...
"Doctor, Mr. K is asking for morphine."
"The team told me not to give it to him so no morphine."
Later...
"Doctor, Mr. K said, 'I want to talk to that doctor who won't give me morphine'."
"I'm not talking to him!"
"He said the team misunderstood--"
"Just give him 1 mg of morphine. I don't have time for this."

3. The "mission: impossible" sign-out

"Make sure this CT gets done."

How do you "make sure" a CT gets done? I tried calling the tech and the radiology resident (neither of whom were easy to reach) and all I got was a vague assurance that it would "probably be done that night". Then at 9PM, I ask the nurse to see if it was done. It wasn't. The reason? The patient refused. If I wanted to get it done, I'd have to go try to talk the patient into it, then fill out a new requisition form and have it faxed, then call the CT tech and explain why the CT was so emergent that it needed to be bumped up on the schedule. Guess whether that CT got done?

4. The "check this lab that I'm not going to order" sign-out

About a quarter of the labs I was asked to check on never seemed to get drawn. If it seemed like an important lab, I would go ahead and reorder it. But PM labs could get drawn any time during the evening, so I felt silly chasing down a random chem panel, especially when there weren't many instructions for what to do with it. By the time I feel absolutely sure that it was an actual oversight and not just a late lab, it seemed like it would make sense to just wait another 8 or so hours till the morning instead of sticking the patient twice.

5. The sign-out that assumes that I know more about the patient than the team does...

"If the patient has a fever above 101.5, you can consider switching the patient from cipro to zosyn."
"What do you mean, 'consider'? Consider based on what? Based on my many years of experience in infectious disease?"
"Well, if the patient...... uh, just switch them to zosyn if they have a fever."

6. The "wrong info" sign-out

The most common thing to go wrong was that the room number is wrong. This was annoying if I needed to go see the patient, but especially if they told me to look up a consult. I hated having to run all the way across the hospital to find a patient's chart and then discover the patient wasn't where they said he was.

One night I had a patient where they gave me the wrong med record number. That was awful, especially since they wanted me to follow up cardiac enzymes on the patient. I was beginning to get upset that they weren't coming back, when I noticed that the record number was wrong. Ugh. If they spelled the patient's name wrong too, I would have been in big trouble.

7. The "no instructions" sign-out

"Here, this intern gave me this sign-out to give to you. The only thing to do is check the CBC on this patient."
"And what should I do with the CBC? Why are they ordering it? What's the cut-off for transfusion?"
"Dunno."

8. The absent sign-out

Several times one team just never signed out to me. This mad me really furious, because I was getting calls all night on patients I knew nothing about. This is almost criminal.

9. The "too much to do" sign-out

"Yeah, so I need you to follow up recs from cards, pulmonary, renal, and rheum on these five patients. Also, I need you to check enzymes and an EKG on this patient, then discharge him if they're negative... you also should go talk to the family and let them know the results, also you need to check a chem panel and CBC on every patient on my list, if this patient rules in, you need to heparinize him and call cardiology, and if this other patient has an abscess on his MRI, I need you to call neurosurgery and tell them to urgently make sure to see the patient."
"That's it?"

10. The "five-page long" sign-out

"Sorry, I have a lot of patients... this is going to be painful."

Sunday, July 3, 2011

Thanks for your submissions

Thank you to everyone who submitted articles for Grand Rounds this week.

(Note that the deadline for submission is now passed. I don't want to again argue with people in other countries who don't seem to understand how time differences work.)

Saturday, July 2, 2011

Weekly Whine: Cultural Competency

Each year in medical school, we had a comedy night, where various students would put on "funny" acts. Anyway, during one of these comedy nights, a student in my class put on a costume for his act that was very inappropriate and racist. I'm not going to say exactly what he did, but you might be able to guess.

The student didn't mean anything by dressing the way he did. He was a nice guy. He was just kind of an idiot. Fortunately, some students in the class stopped him before he could go on stage, so 99% of the school never even saw the costume.

The whole thing turned into a big incident, the result of which our students were "punished" by being forced to take a three day course on Cultural Competency. Because you can't learn to be culturally competent in one day. It takes three whole days.

We all gathered in a large auditorium, and the class opened with a movie. The movie showed this glistening ball and asked us what we thought it was. People were guessing stuff like fetus, frog, planet, etc. It turned out to be a popcorn kernel. I learned a lot about other cultures from that exercise.

Student: "So what were we supposed to learn from that?"

Me: "I think the lesson is, don't mix up popcorn with an embryo."

Student: "Yeah, sometimes when you're watching a baby be delivered, they point to the baby coming out and say 'what's that?' and you say 'it's a popcorn.'"

Me: "I won't do that anymore now."

The next exercise involved us all gathering outside the auditorium and getting different color papers stuck to our backs. Then, without being able to talk or see our own color, we had to find our same-colored groups. That was was kind of fun and also taught me a lot about other cultures.

And that's all I remember from the Cultural Competency course.

Look, I think it's important to respect other cultures. But it's a little ridiculous to think that a three day course (that's really a punishment) is going to teach anything to some racist or ignorant person. My residency was even worse: we had an hour-long lecture on cultural competency and that was it.

I grew up in very diverse part of the country and I'd like to think I'm culturally competent, whatever the hell that means. In school, I had very few friends of the same ethnicity as myself and it wasn't something I thought or cared about. But I'm sure I've also done some things that have been somehow insensitive to a person of another culture, mostly because people are dumb sometimes and I'm a person.

Friday, July 1, 2011

Attacked by a flower!

When I was at work, someone had deposited a basket of very pretty flowers near one of the computers on the wards. Everybody was commenting on how nice they looked and how good they smelled.

I was near the flowers when I was checking some labs and they did indeed smell very nice. However, when I was walking away, I realized that there was reddish-brown pollen ALL OVER the shoulder of my white coat. It looked like someone had popped an artery over my shoulder.

I was horrified and attempted to rub it off, but that just made it worse and left a yellow stain on my white coat. I went to the nearest restroom and dunked my coat in water and managed to at least make the stain less noticeable. Of course, now my coat was sopping wet.

I went to the third floor to see if I could get another white coat, but for some reason they didn't have any sizes besides medium. No larges, no smalls, only medium. And for some reason, the medium coat was WAY too big on me... I felt like I was wearing my Daddy's jacket or something. So I had to choose between wearing a coat that was swimming on me or a coat that felt like I had just been swimming in it. I picked the wet coat. Fortunately, it dried within an hour, but it still looked a little yellow.

Now I have to wash the damn thing. Stupid flower.

Answer to MRI question

Many of you guessed correctly that the problem with the MRI of the thorax posted yesterday was that it was actually a knee. I made the observation a while ago that there was something about axial knee MRI films that looked a little like the chest, so I decided to see if I could fool you guys.

Of course, your clue should have been that since I'm a physiatrist, it makes much more sense that I'd be looking at knee films. The only reason I'd be looking at an MRI of the thorax would be to see the vertebrae. And since there aren't any vertebrae in this knee MRI, that wouldn't do me much good.